What is the recommended treatment for a patient with tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial (Group A Streptococcus) tonsillitis, prescribe penicillin V or amoxicillin for a full 10-day course; for viral tonsillitis, provide supportive care only without antibiotics. 1, 2

Diagnostic Approach: Confirm Before Treating

Always perform rapid antigen detection testing (RADT) and/or throat culture before initiating antibiotics to distinguish bacterial from viral etiology. 1, 2, 3

Clinical Features Suggesting Bacterial (GAS) Tonsillitis:

• Sudden onset sore throat 1
• Fever >38°C (>101°F) 1, 3
• Tonsillar exudates 1, 3
• Tender anterior cervical lymphadenopathy 1, 3
• Absence of cough 1, 3

Clinical Features Suggesting Viral Tonsillitis:

• Absence of high fever 1
• Lack of tonsillar exudate 1
• Absence of cervical lymphadenopathy 1

Critical Pitfall: Do not prescribe antibiotics based on clinical presentation alone without microbiologic confirmation, as this leads to inappropriate antibiotic use in 70-95% of cases that are viral. 1, 2, 4

Treatment for Confirmed Bacterial (GAS) Tonsillitis

First-Line Antibiotic Therapy:

Penicillin V oral for 10 days is the first-line treatment. 1, 2

Amoxicillin for 10 days is an acceptable alternative first-line option. 1, 2

Dosing for Adults and Children ≥40 kg:

• Mild/Moderate: 500 mg every 12 hours or 250 mg every 8 hours 5
• Severe: 875 mg every 12 hours or 500 mg every 8 hours 5

Dosing for Children <40 kg:

• Mild/Moderate: 25 mg/kg/day divided every 12 hours or 20 mg/kg/day divided every 8 hours 5
• Severe: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours 5

Dosing for Infants <3 months:

• Maximum 30 mg/kg/day divided every 12 hours 5

The full 10-day course is mandatory to maximize bacterial eradication and prevent acute rheumatic fever—shorter courses increase treatment failure risk. 1, 2, 5

For Penicillin-Allergic Patients:

Non-anaphylactic allergy: First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 1

Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 1

Critical Pitfall: Avoid using macrolides as first-line therapy when penicillins are appropriate, as this contributes to antibiotic resistance. 1

Treatment for Viral Tonsillitis

Provide supportive care only—no antibiotics. 3

Symptomatic Management:

• Analgesia: Ibuprofen or acetaminophen for pain and fever control 1, 3
• Hydration: Ensure adequate fluid intake 3
• Warm salt water gargles for patients old enough to perform them 1

Management of Recurrent Tonsillitis

Watchful Waiting Criteria:

Strongly recommend watchful waiting if episodes are: 6, 1, 2

• <7 episodes in the past year, OR
• <5 episodes per year for the past 2 years, OR
• <3 episodes per year for the past 3 years

Each episode must be properly documented with temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test. 6, 1

When to Consider Tonsillectomy:

Tonsillectomy may be considered when meeting Paradise criteria: 6, 1, 2

• ≥7 documented episodes in the past year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years

Important caveat: Tonsillectomy is not recommended solely to reduce the frequency of GAS pharyngitis without meeting these strict criteria. 1, 2

Modifying Factors That May Favor Earlier Tonsillectomy:

• Multiple antibiotic allergies/intolerance 6
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 6
• History of >1 peritonsillar abscess 6

Treatment Failure or Early Recurrence

If symptoms return within 2 weeks of completing standard therapy, consider alternative regimens: 1

Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days 1

Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days 1

Penicillin V with rifampin: Penicillin V 50 mg/kg/day in 4 doses for 10 days plus rifampin 20 mg/kg/day in 1 dose for the last 4 days 1

Important consideration: Quick return of symptoms may indicate chronic GAS carriage with intercurrent viral infections rather than true recurrent bacterial infection. 1 Up to 20% of asymptomatic school-age children may be GAS carriers during winter and spring. 1

Common Pitfalls to Avoid

• Never prescribe antibiotics without confirming GAS infection through testing 1, 2
• Never use antibiotic courses shorter than 10 days for confirmed GAS tonsillitis (except high-dose penicillin four times daily, which is not standard practice) 1, 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 3
• Never perform routine follow-up throat cultures for asymptomatic patients who completed appropriate therapy 1
• Never base tonsillectomy decisions on ASO titers—these reflect past immunologic response, not current infection status 1