What is the appropriate management and treatment for a patient with acute tonsillitis, considering the severity of symptoms and potential history of recurrent infections?

Management of Acute Tonsillitis

Initial Diagnostic Approach

For any patient presenting with acute tonsillitis, test before treating—perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating antibiotics, as most cases are viral and do not require antibiotics. 1, 2

Clinical Features to Document

• Bacterial tonsillitis typically presents with: sudden onset sore throat, fever >38.3°C (101°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2, 3
• Viral tonsillitis lacks high fever, tonsillar exudate, and prominent cervical lymphadenopathy 1
• Use the Centor/McIsaac scoring system (≥3 points) to estimate bacterial probability before testing 1, 4, 3

Medical Treatment for Confirmed Bacterial (GAS) Tonsillitis

Penicillin V for 10 days is the gold standard treatment for confirmed GAS tonsillitis, with amoxicillin as an acceptable alternative. 1, 2

Antibiotic Selection Algorithm

• First-line: Penicillin V for 10 days 1, 2
• Penicillin-allergic (non-anaphylactic): First-generation cephalosporins (e.g., cephalexin) 1, 2
• Penicillin-allergic (anaphylactic): Clindamycin, azithromycin, or clarithromycin 1, 2
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even if symptoms resolve earlier 1

Pain Management

• Ibuprofen and/or acetaminophen (paracetamol) are first-line analgesics for pain and fever control 1, 2
• A single dose of dexamethasone may provide additional pain relief in severe cases 1, 2
• NSAIDs such as ibuprofen or flurbiprofen are strongly recommended as adjunctive therapy for moderate to severe symptoms 2

Management of Recurrent Acute Tonsillitis

Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. 5, 2

Tonsillectomy Criteria (Paradise Criteria)

Tonsillectomy may be considered when episodes meet the following frequency thresholds WITH proper documentation: 5

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

Required Documentation for Each Episode

Each documented episode must include sore throat PLUS at least one of the following: 5

• Temperature ≥38.3°C (101°F)
• Cervical adenopathy
• Tonsillar exudate
• Positive test for GAS

Modifying Factors That May Favor Tonsillectomy

Even if Paradise criteria are not met, assess for modifying factors that may favor surgery: 5

• Multiple antibiotic allergies/intolerance
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
• History of >1 peritonsillar abscess
• Severe infections requiring hospitalization

Natural History Considerations

Watchful waiting is strongly recommended because recurrent tonsillitis often spontaneously improves over time. In randomized controlled trials, control groups (non-tonsillectomized) experienced only 1.17 episodes in year 1.03 in year 2, and 0.45 episodes in year 3, demonstrating significant spontaneous improvement 5. This natural resolution pattern supports avoiding surgery in less severely affected patients 5.

Alternative Medical Management for Recurrent Cases

For patients with recurrent acute tonsillitis who have contraindications to tonsillectomy or do not meet surgical criteria, consider: 6, 7

• Clindamycin has shown superior effects in preventing future episodes and eradicating GAS compared to penicillin in recurrent cases 6, 7
• Amoxicillin with clavulanate may be superior to penicillin for recurrent infections 6
• These options target beta-lactamase-producing bacteria that may contribute to treatment failures 6, 7

Follow-Up Recommendations

• Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1, 2
• If symptoms persist despite appropriate therapy, consider: medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics 1, 2
• Document each episode with clinical characteristics, RADT/culture results, days of school/work absence, and quality of life impact using validated tools (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) 5, 4

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing—most cases are viral 1, 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2
• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis—this increases risk of treatment failure and complications 1, 2
• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria—surgery has potential complications including bleeding, pain, infection, and anesthesia problems 5
• Never confuse chronic GAS carriers (who do not require treatment) with true recurrent infections 2