What is the recommended management for tonsillitis?

Management of Tonsillitis

Diagnostic Approach: Test Before Treating

The cornerstone of tonsillitis management is confirming bacterial infection before prescribing antibiotics, as 70-95% of cases are viral and do not require antimicrobial therapy. 1, 2

• Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating any antibiotic therapy 1, 3
• Bacterial tonsillitis presents with sudden onset sore throat, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 4
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 4, 3
• Use validated scoring systems (Centor, McIsaac, FeverPAIN) to estimate probability of bacterial infection when testing is not immediately available 5

Medical Treatment Algorithm

For Confirmed GAS Tonsillitis (Bacterial):

Penicillin V for 10 days is the gold standard first-line treatment for confirmed bacterial tonsillitis. 1, 3

• Penicillin V 250 mg orally three times daily for 10 days (adults) or 30-50 mg/kg/day in divided doses for 10 days (children) 6, 7
• Amoxicillin is an acceptable alternative with similar efficacy 1, 4
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even if symptoms resolve earlier 1, 4, 3

For Penicillin-Allergic Patients:

• Non-anaphylactic allergy: Use first- or second-generation cephalosporins 6, 3
• Anaphylactic allergy: Use erythromycin 250 mg four times daily for 10 days (adults) or 30-50 mg/kg/day in divided doses for 10 days (children) 6, 7
• Alternative macrolides include azithromycin 12 mg/kg once daily for 5 days (children) or clindamycin 3, 8

For Viral Tonsillitis:

• Provide supportive care only—no antibiotics 4
• Use ibuprofen, acetaminophen, or both for pain control 4
• Ensure adequate hydration and rest 4

Management of Recurrent Tonsillitis

Watchful waiting is strongly recommended unless Paradise criteria are met for tonsillectomy. 1, 2

Watchful Waiting Indicated If:

• Fewer than 7 episodes in the past year 1, 3, 2
• Fewer than 5 episodes per year for the past 2 years 1, 3, 2
• Fewer than 3 episodes per year for the past 3 years 1, 3, 2

Tonsillectomy Criteria (Paradise Criteria):

• 7 or more well-documented episodes in the preceding year, OR 1, 4, 3
• 5 or more episodes per year for 2 consecutive years, OR 1, 4, 3
• 3 or more episodes per year for 3 consecutive years 1, 4, 3
• Each episode must be documented with temperature, cervical adenopathy, tonsillar exudate, or positive GAS test 4, 3
• All episodes must be disabling and adequately treated 1

Perioperative Management (If Surgery Indicated):

• Administer single intraoperative dose of intravenous dexamethasone (0.5 mg/kg) to decrease postoperative nausea, vomiting, and pain 1, 4

Management of Treatment Failures

If symptoms persist despite appropriate 10-day penicillin therapy, consider alternative antibiotics that eradicate beta-lactamase-producing bacteria. 6, 9

• Clindamycin or amoxicillin-clavulanate are effective for penicillin treatment failures 6, 9
• First-generation cephalosporins are also effective alternatives 9
• Assess medication compliance before changing antibiotics 1, 3
• Consider chronic GAS carriage with intercurrent viral infections 1, 3

Follow-Up Recommendations

• Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 6, 1, 3
• Do not routinely test asymptomatic household contacts 6

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing—this drives antibiotic resistance and treats viral infections unnecessarily 1, 4, 3
• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis—this increases treatment failure risk and does not prevent rheumatic fever 6, 1, 3
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 3
• Never perform tonsillectomy without meeting appropriate Paradise criteria for frequency and documentation 1, 3
• Do not assume compliance—if treatment fails after oral therapy, consider intramuscular benzathine penicillin G 6