Acute tonsillitis treatment
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"tonsillitis" AND "treatment"
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Acute Tonsillitis - Treatment
Aetiology and Microbiology
Acute tonsillitis is caused by both viruses and bacteria, either separately or together. The most common bacterial pathogen is Group A Beta-Haemolytic Streptococcus (GABHS / Streptococcus pyogenes), accounting for 10-23% of cases. Viruses account for the majority, with rhinovirus being most prevalent. Other organisms include:
- Viral: Adenovirus, EBV (infectious mononucleosis), HSV, parainfluenza, influenza, Coxsackievirus
- Bacterial: Fusobacterium necrophorum (5-10%), Group C/G Streptococcus, Arcanobacterium haemolyticum, rarely N. gonorrhoeae, C. diphtheriae
There is no evidence that viral tonsillitis is more or less severe than bacterial - both tend to resolve quickly without treatment in most cases.
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 2
- Tintinalli's Emergency Medicine
Treatment Overview
1. Symptomatic / Conservative (First-Line)
Management is mainly symptomatic until symptoms subside:
| Measure | Details |
|---|---|
| Analgesia | Paracetamol and/or NSAIDs for pain and fever relief. Aspirin should be avoided. |
| Hydration | Adequate fluid intake, especially in children |
| Saline gargles | Soothing, especially in older patients |
| Rest | General supportive care |
Most cases resolve within a few days with supportive care alone.
2. Antibiotics
Antibiotics shorten the illness and may reduce the risk of sequelae (rheumatic fever, peritonsillar abscess). They are recommended if:
- No improvement after 48-72 hours of symptomatic treatment
- Clinical concern about severity at presentation (start early)
Antibiotic of choice:
| Scenario | Drug | Duration |
|---|---|---|
| First-line (bacterial GABHS) | Phenoxymethylpenicillin (Penicillin V) or Benzylpenicillin | 10 days |
| Alternative / penicillin allergy | First-generation cephalosporin (e.g. cefalexin), clindamycin, clarithromycin, or azithromycin | 10 days |
| Penicillin failure | Amoxicillin/clavulanic acid, cephalosporins, or clindamycin | - |
| Severe (IV) | Benzylpenicillin IV or IV cephalosporin | - |
Important: Ampicillin and amoxicillin should be avoided if infectious mononucleosis (EBV) is suspected - they cause a widespread maculopapular rash in ~90% and ~30% of EBV patients respectively.
Penicillin failure occurs in 7-37% of cases. Macrolide resistance is also increasing worldwide. Recent evidence suggests macrolides and cephalosporins may be more effective as first-line agents in some populations.
- Cummings Otolaryngology Head and Neck Surgery
- Bailey and Love's Short Practice of Surgery, 28th Ed.
3. Corticosteroids (Adjunct Therapy)
Corticosteroids (oral or intramuscular) in addition to antibiotics expedite resolution of pain, especially in severe cases:
-
Provide symptomatic pain relief in sore throat
-
A short course is particularly beneficial in EBV tonsillitis with significant swelling threatening the airway or causing swallowing difficulty
-
Should be given in combination with antibiotics, not alone
-
Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 2
4. Specific Situations
Infectious Mononucleosis (EBV):
- Avoid ampicillin/amoxicillin
- High-dose IV penicillin or cephalosporins if hospitalized
- Corticosteroids if significant tonsillar swelling with airway/swallowing compromise
- Antiviral agents (aciclovir) are debatable - consider only in severe cases
Peritonsillar Abscess (Quinsy) - Complication:
- IV high-dose penicillin or cephalosporin
- Needle aspiration of pus or incision and drainage under local anaesthesia
- If EBV excluded and recurrent: consider interval tonsillectomy
5. Surgical Treatment - Tonsillectomy
Tonsillectomy is considered for recurrent tonsillitis. The widely accepted threshold is the Paradise Criteria:
| Criterion | Threshold |
|---|---|
| Frequency (within 1 year) | ≥ 7 episodes |
| Frequency (over 2 years) | ≥ 5 episodes/year |
| Frequency (over 3 years) | ≥ 3 episodes/year |
Children who meet these criteria benefit significantly from tonsillectomy (reduced episodes, improved quality of life, reduced healthcare costs - NESTAC trial). Children with milder/less frequent disease do not show significant advantage over watchful waiting.
There is no evidence of benefit from long-term antibiotics for recurrent tonsillitis.
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 2
Complications to Prevent/Recognize
| Complication | Type |
|---|---|
| Peritonsillar abscess (quinsy) | Local suppurative |
| Parapharyngeal / retropharyngeal abscess | Local suppurative |
| Septicaemia | Systemic |
| Rheumatic fever | Non-infective (streptococcal) |
| Post-streptococcal glomerulonephritis | Non-infective (streptococcal) |
| Lemierre's syndrome | Fusobacterium - thrombophlebitis of internal jugular vein |
Recent Evidence (2024-2026)
Two relevant systematic reviews provide updated guidance:
- An Italian intersociety consensus (2024) on acute pharyngitis treatment in children - PMID 39501298 - supports targeted antibiotic use guided by clinical scoring.
- An umbrella review in Lancet Infectious Diseases (2025) on optimal antibiotic duration for upper respiratory tract infections - PMID 39243792 - supports shorter antibiotic courses may be effective, potentially updating the traditional 10-day recommendation.
These findings are consistent with the textbook guidance but suggest antibiotic stewardship (using clinical scoring tools like Centor/FeverPAIN before prescribing) is increasingly important.
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