Best Practice Treatment for Acute Tonsillitis
For confirmed Group A Streptococcus (GAS) tonsillitis, penicillin V for 10 days is the gold standard first-line treatment, with testing required before initiating any antibiotic therapy to avoid unnecessary treatment of viral cases. 1, 2
Diagnostic Approach Before Treatment
Always perform rapid antigen detection testing (RADT) and/or throat culture before prescribing antibiotics to confirm GAS infection, as 70-95% of tonsillitis cases are viral and do not require antibiotics. 1, 3, 4
Bacterial tonsillitis presents with sudden onset sore throat, fever >38°C (>38.3°C for documentation), tonsillar exudates, tender anterior cervical lymphadenopathy, and notably the absence of cough. 1, 2, 5
Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy—treat these cases with supportive care only (analgesia with acetaminophen or ibuprofen, hydration). 1, 2, 4
First-Line Antibiotic Treatment for Confirmed GAS
Penicillin V for 10 days (twice or three times daily) is the recommended first-line treatment for confirmed bacterial tonsillitis. 6, 1, 2
Amoxicillin for 10 days is an acceptable alternative first-line option with comparable efficacy to penicillin V. 6, 1, 2
The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even though symptoms may resolve earlier. 1, 2, 5
Treatment for Penicillin-Allergic Patients
For non-anaphylactic penicillin allergy: Use first-generation cephalosporins. 1, 5
For anaphylactic penicillin allergy: Use clindamycin, azithromycin, or clarithromycin. 1, 5
Azithromycin demonstrates clinical efficacy comparable to penicillin V in pharyngitis/tonsillitis trials, with clinical success rates of 98% at Day 14 and 94% at Day 30 versus 84% and 74% for penicillin V, though approximately 1% of susceptible S. pyogenes isolates became resistant following azithromycin therapy. 7
Treatment Failures and Recurrent Cases
For treatment failures: Consider amoxicillin-clavulanate, clindamycin, or second/third-generation cephalosporins. 5
For documented recurrent GAS tonsillitis within 2 weeks of completing standard therapy, alternative regimens include clindamycin, amoxicillin-clavulanate, or penicillin with rifampin. 5
Evidence suggests clindamycin and amoxicillin-clavulanate are superior to penicillin for recurrent acute pharyngo-tonsillitis in preventing future attacks and achieving microbiological eradication. 8
When to Consider Tonsillectomy
Watchful waiting is strongly recommended if episodes are fewer than 7 in the past year, fewer than 5 per year for 2 years, or fewer than 3 per year for 3 years (Paradise criteria). 1, 2, 3
Tonsillectomy may be considered when meeting Paradise criteria with proper documentation of each episode including temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test. 1, 2
Spontaneous improvement commonly occurs without surgery, with control groups showing reduction to only 0.3-1.17 episodes per year. 2
Follow-Up Management
Routine follow-up throat cultures should not be performed for asymptomatic patients who completed appropriate antibiotic therapy. 1, 5
If symptoms persist despite appropriate therapy, consider medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics. 1
Critical Pitfalls to Avoid
Never initiate antibiotics without confirming GAS infection through testing—this leads to unnecessary antibiotic use in the majority of viral cases. 1, 2, 5
Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS, as this contributes to antibiotic resistance. 1, 5
Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis (except azithromycin's approved 5-day course), as shorter penicillin courses increase treatment failure risk. 1, 2, 5
Never perform tonsillectomy without meeting appropriate frequency and documentation criteria, as this represents unnecessary surgery. 1, 2
Evaluate severe cases with difficulty swallowing, drooling, neck tenderness, or swelling for peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome. 5