Treatment of Tonsillitis
Immediate Diagnostic Approach
Test for Group A Streptococcus (GAS) before prescribing antibiotics—only treat bacterial tonsillitis confirmed by rapid antigen detection test (RADT) or throat culture, as most cases (70-95%) are viral and do not require antibiotics. 1, 2
When to Test vs. When to Withhold Testing
Do NOT test patients presenting with sore throat accompanied by viral symptoms including cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal ulcers/vesicles—these patients have viral illness and should receive supportive care only 1
Test for GAS when patients present with suspicious bacterial features: persistent fever, rigors, tender lymph nodes, tonsillopharyngeal exudates, scarlatiniform rash, palatal petechiae, or swollen tonsils 1
Use modified Centor criteria to identify low-probability patients: those with fewer than 3 Centor criteria (fever by history, tonsillar exudates, tender anterior cervical adenopathy, absence of cough) do not need testing 1
First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis
Penicillin V oral for 10 days is the first-line treatment for confirmed GAS tonsillitis, with amoxicillin as an equivalent alternative. 3, 4
Antibiotic Selection Algorithm
Penicillin-allergic (non-anaphylactic): Use first-generation cephalosporins (cefalexin, cefadroxil) for 10 days 3
Penicillin-allergic (anaphylactic): Use clindamycin, azithromycin, or clarithromycin 3
Azithromycin demonstrated 98% clinical success at Day 14 and 94% at Day 30 in controlled trials, with bacteriologic eradication of 95% at Day 14 (compared to 73% with penicillin V) 4
Critical caveat: Azithromycin is FDA-approved as an alternative to first-line therapy in individuals who cannot use first-line therapy, but penicillin remains the drug of choice for preventing rheumatic fever 4
Treatment Duration Warning
Never use short courses of antibiotics—complete the full 10-day course for penicillin/amoxicillin regimens. 3 Follow-up throat cultures are not recommended for asymptomatic patients who completed appropriate therapy 3
Supportive Care for Viral Tonsillitis
Provide symptomatic relief with analgesics, hydration, and rest for viral tonsillitis 5
Over-the-counter options include cough suppressants (dextromethorphan), first-generation antihistamines (diphenhydramine), and decongestants (phenylephrine), though evidence for specific therapies is limited 1
These supportive measures have low incidence of minor adverse effects (nausea, vomiting, headache, drowsiness) 1
Management of Recurrent Tonsillitis
Watchful Waiting Criteria
Strongly recommend watchful waiting if the patient has had fewer than 7 episodes in the past year, fewer than 5 episodes per year for 2 years, or fewer than 3 episodes per year for 3 years. 3, 6, 7, 2
Many cases of recurrent tonsillitis improve spontaneously—untreated children experienced only 1.17 episodes in the first year, 1.03 in the second year, and 0.45 in the third year 6
A 12-month observation period is recommended before reconsidering tonsillectomy, with documentation of all episodes 6
When Tonsillectomy May Be Considered
Tonsillectomy should only be considered if the patient meets Paradise criteria: at least 7 documented episodes in the past year, OR at least 5 episodes per year for 2 years, OR at least 3 episodes per year for 3 years. 3, 6, 7
Each episode must be documented with sore throat PLUS at least one of: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive GAS test 3, 6, 7
Antibiotics must have been administered in conventional dosage for proven or suspected streptococcal episodes 6
Tonsillectomy provides only modest reduction in throat infections for approximately 1 year post-surgery 3
Modifying Factors for Earlier Surgical Consideration
- Multiple antibiotic allergies/intolerance 6
- PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) 6
- History of more than 1 peritonsillar abscess 6
Special Consideration: Chronic Carriers
Do NOT treat positive GAS tests in asymptomatic carriers or those with viral symptoms (cough, rhinorrhea, hoarseness)—these patients harbor GAS but are experiencing viral infections, not bacterial tonsillitis. 3
When to Treat Carriers (Rare Circumstances Only)
During community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis, or invasive GAS infection 3
When patient has family or personal history of acute rheumatic fever 3
Carrier eradication regimen (when indicated): Clindamycin 20-30 mg/kg/day in three divided doses (maximum 300 mg per dose) for 10 days 3
Critical Pitfalls to Avoid
Never prescribe antibiotics without confirming GAS infection—this drives antibiotic resistance and exposes patients to unnecessary adverse effects 1, 8
Never use azithromycin as first-line therapy—it should not be relied upon to prevent rheumatic fever, and susceptibility testing should be performed as some strains are resistant 4
Never recommend tonsillectomy without proper Paradise criteria documentation—many children awaiting surgery no longer meet criteria by the time of operation 6
Evaluate for rare but serious complications: peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome in patients with unusually severe symptoms (difficulty swallowing, drooling, neck tenderness/swelling) 1