What is the recommended dosage of prednisolone (corticosteroid) for treating acute tonsillitis in adults and children?

Prednisolone is Not Recommended for Routine Treatment of Acute Tonsillitis

Corticosteroids should not be routinely prescribed for acute tonsillitis, but may be considered in adults with severe presentations (Centor score 3-4) in conjunction with antibiotic therapy. 1

Evidence-Based Recommendations

For Adults with Severe Tonsillitis

• A single dose of corticosteroids in conjunction with antibiotic therapy may provide benefit in adults with severe or high Centor scoring sore throat (3-4 criteria). 1
• The effect of steroids is smaller when administered by oral route compared to intravenous administration. 1
• Steroids have a considerably smaller effect in typical primary-care populations where most patients do not have severe presentations. 1

For Children with Tonsillitis

• No evidence of significant benefit was found in children with acute tonsillitis. 1
• Studies were not sufficiently powered to detect adverse effects of short courses of oral corticosteroids. 1

When Corticosteroids Are Considered (Adults Only)

If the clinical decision is made to use corticosteroids for severe adult tonsillitis:

• The typical approach would follow dosing similar to other acute inflammatory conditions: a short tapering course over 1-2 weeks. 1
• Based on extrapolation from other acute inflammatory conditions in guidelines, adult dosing would be prednisone/prednisolone 40-60 mg daily for 3-7 days. 1
• Always administer in conjunction with appropriate antibiotic therapy for bacterial tonsillitis. 1

Primary Treatment Approach

First-Line Management

• Either ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms. 1
• Antibiotic therapy should only be initiated when there is high probability of bacterial tonsillitis (particularly Group A Streptococcus), especially in patients at risk. 2
• Use clinical scoring systems (Centor, McIsaac, FeverPAIN) to estimate probability of bacterial infection. 2

Antibiotic Selection When Indicated

• Penicillins remain the treatment of choice for Streptococcus pyogenes tonsillitis. 3
• Amoxicillin and oral forms of first and second generation cephalosporins are drugs of choice. 4
• The course of antibiotic therapy for streptococcal tonsillitis is 10 days. 4

Critical Pitfalls to Avoid

• Do not prescribe corticosteroids routinely for tonsillitis without visualization of the pharynx and assessment of severity. 5
• Do not extrapolate pediatric croup data (where steroids are beneficial) to adult or pediatric tonsillitis—the evidence does not support this. 5
• Avoid using corticosteroids in viral tonsillitis, which is the most common etiology and should be treated with supportive care only. 6
• Most acute tonsillitis is self-limited, with improvement in 7-10 days with supportive care. 5

Special Considerations

• Potential adverse effects of corticosteroids include sleep disturbances, adrenal suppression, metabolic syndrome, weight gain, hypertension, and increased infection risk—even with short-term use. 5
• The strategy of "delayed antibiotic prescriptions" with monitoring for 2-3 days is appropriate and highly effective in doubtful cases. 4
• Topical antiseptic/analgesic agents may provide symptomatic relief and can be used as adjunctive therapy. 4