What is the treatment for tonsillitis?

From the Guidelines

For tonsillitis, the first line of treatment should be supportive care with over-the-counter pain relievers like acetaminophen or ibuprofen, along with plenty of fluids and rest, as most cases are viral and do not require antibiotics. When considering the treatment for tonsillitis, it's crucial to differentiate between viral and bacterial causes, as this distinction significantly impacts the treatment approach. For viral tonsillitis, which accounts for the majority of cases, supportive care is the mainstay of treatment, including over-the-counter pain relievers such as acetaminophen 325-650mg every 4-6 hours or ibuprofen 400-600mg every 6-8 hours, alongside adequate hydration and rest 1.

Bacterial Tonsillitis Treatment

For cases of bacterial tonsillitis, typically caused by Group A beta-hemolytic Streptococcus, antibiotic therapy is necessary to prevent potential complications such as rheumatic fever or kidney inflammation. The first-line antibiotic treatments include penicillin V (500mg twice daily for 10 days in adults) or amoxicillin (500mg twice daily for 10 days), with alternatives for those allergic to penicillin being azithromycin (500mg on day 1, then 250mg daily for 4 more days) or clindamycin (300mg three times daily for 10 days) 1. It is essential to complete the full course of antibiotics even if symptoms improve before finishing the treatment.

Supportive Care

Additional relief for tonsillitis symptoms can be achieved by gargling with warm salt water (1/2 teaspoon salt in 8 ounces of water) several times a day. This method can help reduce throat discomfort and inflammation. Given the potential for spontaneous resolution of recurrent throat infections over 12 months, as observed in some studies 1, careful documentation and consideration of the frequency and clinical features of throat infection episodes are crucial before proceeding with more invasive treatments like tonsillectomy.

Tonsillectomy Consideration

Tonsillectomy may be recommended for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, with documentation of sore throat and at least one of the following: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A beta-hemolytic Streptococcus. However, the decision to proceed with tonsillectomy should be made after thorough consideration and shared decision-making with patients and their families, emphasizing the importance of appropriate documentation and the potential for spontaneous resolution of symptoms 1.

From the FDA Drug Label

Penicillin is considered by the American Heart Association to be the drug of choice in the prevention of initial attacks of rheumatic fever (treatment of Streptococcus pyogenes infections of the upper respiratory tract e.g., tonsillitis, or pharyngitis). Erythromycin tablets are indicated for the treatment of penicillin-allergic patients. It is recommended that there be at least 10 days’ treatment for any infection caused by Streptococcus pyogenes to prevent the occurrence of acute rheumatic fever.

Tonsillitis Treatment

• The treatment for tonsillitis caused by Streptococcus pyogenes is typically penicillin, but for penicillin-allergic patients, erythromycin is an alternative option 2.
• Amoxicillin can also be used to treat tonsillitis, with a recommended treatment duration of at least 10 days to prevent acute rheumatic fever 3.
• The choice of antibiotic should be based on the patient's allergy status and the severity of the infection.

From the Research

Medicine for Tonsillitis

• The treatment for tonsillitis is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic 4.
• In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years 4.
• Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs, and in case of high probability of bacterial tonsillitis, standard antibiotic treatment is initiated directly or by delayed prescription 5.
• Antibiotic treatment is an option in patients with recurrent acute pharyngo-tonsillitis (RAPT) who have contraindications for tonsillectomy, with clindamycin and amoxicillin with clavulanate being superior to penicillin 6.
• First-line therapy of β-hemolytic streptococci consists of oral penicillin, with alternative treatment with oral cephalosporins or macrolides indicated only in cases of penicillin failure, frequent recurrences, or whenever a more reliable eradication of β-hemolytic streptococci is desirable 7.

Diagnostic Tools

• A variety of diagnostic tools are available, including symptom-based validated scoring systems (e.g., Centor score), and oropharyngeal and serum laboratory testing 4.
• Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS) 5.
• In ambiguous cases, a point-of-care test GAS swab test is helpful 5.

Tonsillectomy

• Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years 5.
• An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients 5.