Treatment for Nonbacterial (Viral) Tonsillitis
Viral tonsillitis should be managed with symptomatic treatment only—no antibiotics—using NSAIDs or acetaminophen for pain and fever control, with consideration of a single dose of dexamethasone for severe cases. 1, 2
Diagnostic Confirmation
Before initiating any treatment, confirm the viral etiology by:
- Testing for Group A Streptococcus (GAS) using rapid antigen detection testing (RADT) and/or throat culture to rule out bacterial infection before withholding antibiotics 1, 2, 3
- Recognizing that viral tonsillitis typically presents with absence of high fever, tonsillar exudate, and cervical lymphadenopathy—the opposite pattern of bacterial infection 1
- Using the modified Centor/McIsaac score: if <3 points, bacterial infection is unlikely and antibiotics should be withheld 2, 4
Critical pitfall: Never initiate antibiotics without confirming GAS infection through testing, as the majority of tonsillitis cases are viral in origin 2, 3
Symptomatic Treatment Protocol
First-Line Analgesics
- Ibuprofen (NSAID) or acetaminophen (paracetamol) for pain and fever control 1, 2, 3
- These should be provided to all patients with tonsillitis regardless of etiology 1
Adjunctive Therapy for Severe Cases
- Single dose of dexamethasone may provide additional pain relief when symptoms are severe 2, 5, 6
- This corticosteroid approach is supported for acute tonsillitis symptom reduction 5, 6
Supportive Measures
- Adequate hydration is essential 3
- Warm salt water gargles for patients old enough to perform them 1
- Educate caregivers about pain management and when to seek reassessment 3
What NOT to Do
- Never prescribe antibiotics for viral tonsillitis—they provide no benefit and contribute to antibiotic resistance 2, 3, 4
- Do not use broad-spectrum antibiotics even if uncertain about etiology; confirm diagnosis first 2, 3
- Avoid routine use of topical antiseptics as primary treatment, though they may provide symptomatic relief 4
When to Reassess
- If symptoms persist beyond 3 days or worsen, reassess for possible bacterial superinfection 7
- Consider repeat testing if clinical picture changes to suggest bacterial infection 1
- Monitor for development of complications such as peritonsillar abscess, though these are rare with viral infections 5, 6
Duration and Prognosis
- Viral tonsillitis is self-limited and typically resolves within 7-10 days with symptomatic treatment alone 8
- Patients should be counseled that antibiotics will not shorten the course of viral illness 4
- The "delayed antibiotic prescription" strategy (monitoring for 2-3 days before filling prescription) is appropriate when diagnosis is uncertain, but testing should guide this decision 4