Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute tonsillitis not due to group A beta-hemolytic streptococcal infection

1st line – analgesics

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ACUTE
|
acute tonsillitis not due to group A beta-hemolytic streptococcal infection
1st line – 

analgesics

Acetaminophen can be used for symptom relief.

An alternative is a nonsteroidal anti-inflammatory drug, including aspirin.[24][25] However, aspirin should not be used in children (under 16 years in the UK; age cutoffs may vary in other countries) due to concerns about Reye syndrome.[26]

Patients at home can also use local medications for the relief of their sore throat, including topical lidocaine or other analgesic or mild antiseptic lozenges, oral sprays, gels, and mouthwashes (e.g., warm salt water). Although there is no evidence that these can reduce the duration of their sore throat, there is some limited evidence that they provide symptomatic relief in some patients.[27][28]

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

aspirin: adults: 325-650 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

naproxen: adults: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

OR

celecoxib: adults: 100-200 mg orally twice daily when required

acute tonsillitis due to group A beta-hemolytic streptococcal infection

1st line – analgesics

Back
ACUTE
|
acute tonsillitis due to group A beta-hemolytic streptococcal infection
1st line – 

analgesics

Acetaminophen can be used for symptom relief.

An alternative is a nonsteroidal anti-inflammatory drug, including aspirin.[24][25] However, aspirin should not be used in children (under 16 years in the UK; age cutoffs may vary in other countries) due to concerns about Reye syndrome.[26]

Patients at home can also use local medications for the relief of their sore throat, including topical lidocaine or other analgesic or mild antiseptic lozenges, oral sprays, gels, and mouthwashes (e.g., warm salt water). Although there is no evidence that these can reduce the duration of their sore throat, there is some limited evidence that they provide symptomatic relief in some patients.[27][28]

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

aspirin: adults: 325-650 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

naproxen: adults: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

OR

celecoxib: adults: 100-200 mg orally twice daily when required

Consider – antibiotic therapy

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ACUTE
|
acute tonsillitis due to group A beta-hemolytic streptococcal infection
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Antibiotics are indicated for patients with group A beta-hemolytic streptococcal infection confirmed on antigen testing and/or throat cultures.

Antibiotics are also indicated in patients who are critically ill or from vulnerable populations in which susceptibility to acute rheumatic fever is high (e.g., in South Africa, Australian indigenous communities, Maori communities of New Zealand, the Philippines, and in many developing countries).[13]

Patients who are not penicillin-allergic can receive penicillin V. A single intramuscular injection of penicillin G benzathine can be used in patients who are unable to complete a course of oral antibiotics.[31] One study has shown that penicillin V for five days can be a valid alternative to the 10-day regimen.[34]

One randomized controlled trial of 146 children who had suppurative tonsillitis found that amoxicillin/clavulanate led to a quicker improvement of symptoms than ceftezole (a first-generation cephalosporin that is available only in Asia).[35] 

Choices in patients who are allergic to penicillins include a macrolide (e.g., erythromycin, azithromycin, clarithromycin), a cephalosporin (e.g., cephalexin, cefadroxil), or clindamycin. Due to potential cross-reactivity between penicillins and cephalosporins, patients with a penicillin allergy may rarely have a reaction to a cephalosporin and caution is advised. However, this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[37] For patients at risk of reduced compliance, a short course of high-dose azithromycin has comparable efficacy and bacteriological resolution rates.[30][52]

Oral treatment course is usually 10 days (except azithromycin, which is 5 days).

Primary options

penicillin V potassium: children ≤27 kg: 250 mg orally two to three times daily for 10 days; children >27 kg and adults: 500 mg orally two to three times daily for 10 days

OR

penicillin G benzathine: children ≤27 kg: 600,000 units intramuscularly as a single dose; children >27 kg and adults: 1.2 million units intramuscularly as a single dose

OR

amoxicillin/clavulanate: neonates and infants <3 months of age: 30 mg/kg/day orally given in divided doses every 12 hours for 10 days; children ≥3 months of age and <40 kg: 25-45 mg/kg/day orally given in divided doses every 12 hours, or 20-40 mg/kg/day orally given in divided doses every 8 hours for 10 days; children ≥3 months of age and ≥40 kg and adults: 500-875 mg orally twice daily, or 250-500 mg orally three times daily for 10 days

More

OR

amoxicillin: neonates and infants <3 months of age: 30 mg/kg/day orally given in divided doses every 12 hours for 10 days; children ≥3 months of age: 25-45 mg/kg/day orally given in divided doses every 12 hours, or 20-40 mg/kg/day orally given in divided doses every 8 hours for 10 days; adults: 500-875 mg orally twice daily, or 250-500 mg orally three times daily for 10 days

Secondary options

azithromycin: children: 12 mg/kg orally once daily for 5 days, maximum 500 mg/day; adults: 500 mg orally once daily for 5 days

OR

clarithromycin: children: 15 mg/kg/day orally given in divided doses every 12 hours for 10 days, maximum 500 mg/day; adults: 250 mg orally twice daily for 10 days

OR

erythromycin base: children: 30-50 mg/kg/day orally given in divided doses every 6 hours for 10 days, maximum 2000 mg/day; adults: 250-500 mg orally four times daily for 10 days

OR

cephalexin: children: 25-50 mg/kg/day orally given in divided doses every 12 hours for 10 days, maximum 1000 mg/day; adults: 500 mg orally twice daily for 10 days

OR

cefadroxil: children: 30 mg/kg/day orally given in 1-2 divided doses for 10 days, maximum 1000 mg/day; adults: 1000 mg/day orally given in 1-2 divided doses for 10 days

OR

clindamycin: children: 20 mg/kg/day orally given in divided doses every 8 hours for 10 days, maximum 1800 mg/day; adults: 300-600 mg orally every 8 hours for 10 days

Consider – corticosteroids

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ACUTE
|
acute tonsillitis due to group A beta-hemolytic streptococcal infection
Consider – 

corticosteroids

Treatment recommended for SOME patients in selected patient group

In patients with sore throat, a single dose of corticosteroid has been shown to reduce symptoms earlier than placebo.[39][40][41] [ Cochrane Clinical Answers logo ] ​[42][Evidence B] In practice this is indicated in adults and children ages >12 years with severe symptoms who are not immunocompromised or have infectious mononucleosis.[39]  The use of corticosteroids at the onset of fever in patients with periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome has proved effective in several series and case reports and in one randomized clinical trial.[43] 

Primary options

dexamethasone sodium phosphate: children >12 years of age and adults: 10 mg intramuscularly/intravenously as a single dose

OR

dexamethasone: children >12 years of age: 0.6 mg/kg orally as a single dose, maximum 10 mg/dose; adults: 10 mg orally as a single dose

OR

prednisone: children and adults: 1-2 mg/kg orally as a single dose

ONGOING

recurrent episodes of tonsillitis

1st line – tonsillectomy

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ONGOING
|
recurrent episodes of tonsillitis
1st line – 

tonsillectomy

Tonsillectomy may be considered for patients who have recurrent symptoms of tonsillitis that do not become less common with time and for whom there is no other explanation for the recurrent symptoms.[3] In its guideline for children ages 1-18 years, the American Academy of Otolaryngology-Head and Neck Surgery recommends watchful waiting for recurrent throat infection if there have been less than seven episodes in the past year, less than five episodes per year in the past 2 years, or under three episodes per year in the past 3 years.[44] In children, tonsillectomy can reduce days and number of episodes of sore throat in the first year.[45] More benefit was reported in those children who were more severely affected.[46] Tonsillectomy in children is also associated with significant improvements in quality of life compared with watchful waiting.[47] Tonsillectomy is also indicated in children with additional exacerbating factors such as obstructive sleep apnea; peritonsillar abscess; and periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome.[43][44][48] Partial tonsillectomy seems to have similar efficacy with less postoperative pain and bleeding.[49] However, more data are needed to establish which patients benefit the most from this procedure.[50][51]

Consider – antibiotic therapy

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ONGOING
|
recurrent episodes of tonsillitis
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

One systematic review of antibiotics for recurrent acute pharyngo-tonsillitis (RAPT) found evidence that clindamycin and amoxicillin/clavulanate are superior to penicillin in patients with RAPT, with preferable effects on the microbiologic flora and the number of future attacks of acute pharyngo-tonsillitis.[38]

Primary options

amoxicillin/clavulanate: neonates and infants <3 months of age: 30 mg/kg/day orally given in divided doses every 12 hours for 10 days; children ≥3 months of age and <40 kg: 25-45 mg/kg/day orally given in divided doses every 12 hours, or 20-40 mg/kg/day orally given in divided doses every 8 hours for 10 days; children ≥3 months of age and ≥40 kg and adults: 500-875 mg orally twice daily, or 250-500 mg orally three times daily for 10 days

More

OR

clindamycin: children: 20 mg/kg/day orally given in divided doses every 8 hours for 10 days, maximum 1800 mg/day; adults: 300-600 mg orally every 8 hours for 10 days

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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