Tonsillitis

• Brief overview of tonsillitis (inflammation of the tonsils) 
• Common causes: viral vs. bacterial infections 
• Importance of using antibiotics for bacterial infections only 

Tonsillitis is a common disease when the palatine tonsils are inflamed because of a viral or bacterial infection. It's challenging to distinguish between bacterial and viral causes but to facilitate this diagnostic scoring systems such as the McIsaac or Centor score are recommended.  When we are talking about bacterial infection the predominant reason is the “Group A β-hemolytic streptococcus”.  

The Centor score (≥15 years) and the McIsaac score (modified Centor score) used for younger patients (3–14 years) predict the probability of a streptococcal infection by assessing defined clinical parameters. To treat bacterial infections the best option is antibiotics, although antibiotics are ineffective against viruses. 

Bacterial vs. viral tonsillitis 

• Differences in symptoms and causes 
• Importance of diagnosis (rapid strep test or throat culture) 
• Misuse of antibiotics for viral infections 

Is not an easy task to differentiate between bacterial and viral causes in tonsillitis, but symptoms are similar: sore throat, difficulty in swallowing, fever and cervical lymphadenopathy. 

Rapid Antigen Test (RAT) is a practical test used in discrimination between viruses, and bacteria and restricts the use of unnecessary antibiotics as a consequence of the increase in antibiotic resistance, a problem affecting the whole world today. In fact, antibiotics are often still prescribed for children with sore throats even if in most cases antibiotics are not indicated. 

The recommendation is that antibiotic treatment should be offered to patients with three or four Centor criteria (fever, tender cervical lymph nodes, coatings of the tonsils, and lack of cough) and a positive rapid antigen detection test for group A streptococcus. 

Common antibiotics for bacterial tonsillitis 

• Penicillin: First-line treatment, its effectiveness and common usage 
• Amoxicillin: Alternative to penicillin, benefits of broader coverage 
• Cephalosporins: Option for penicillin-allergic patients 
• Macrolides (e.g., Azithromycin, Clarithromycin): For patients with penicillin allergies, pros and cons 
• Clindamycin: For resistant cases or recurring tonsillitis 

Penicillin is the most effective way to treat bacterial infection caused by tonsillitis, it works by targeting the bacterial cell wall, preventing the bacteria from building it correctly leading to the death of the bacteria. 

Amoxicillin has similar effects in the treatment of tonsil inflammation compared to penicillin, they belong to the same antibiotics family and are commonly used in children. Cephalosporins and macrolides are good clinical options to treat bacterial infections in patients with penicillin allergy. 

Considerations for choosing the right antibiotic 

• Allergies to specific antibiotics 
• Local resistance patterns (antibiotic resistance in the community) 

Patient-reported penicillin allergies remain largely unquestioned. More than 95% of patients labelled as penicillin allergic will have negative penicillin allergy testing and tolerate subsequent exposure. In the majority of countries, the current standard of care in adults to verify or disprove a penicillin allergy includes prick and intradermal skin testing, followed, if negative, by the oral challenge.  

Antibiotic resistance is a big problem we have to deal with, the public perceives antibiotic resistance as a distant, societal problem rather than an immediate personal health risk, and primary-care clinicians rarely encounter treatment failures due to resistance, affecting prescribing decisions. Antibiotic use is the main risk factor for carrying and developing antibiotic-resistant infections, but the clinical implications of resistance in common community infections are not well understood. 

Treatment duration and dosage 

• Typical duration of antibiotic treatment (e.g., 7-10 days) 
• Importance of completing the full course 
• Risks of incomplete treatment (resistance, recurrence) 

The effectiveness of β-lactam antibiotics relies on how long the unbound drug concentration in the bloodstream remains above the minimum inhibitory concentration (MIC). The key factors influencing this duration are the dosage and how often the medication is taken. The risk with a shorter regimen might be a lower rate of clinical resolution and microbiological eradication. 

A study¹ shows that a dosing schedule of 800 mg four times daily achieves the desired drug levels more effectively than 1000 mg taken three times daily.  However, reducing the treatment duration could cause fewer side effects, improve patient adherence, cause less impact on the human microbiota, lower total antibiotic use, and reduce drug costs for patients and the community. 

Potential side effects and complications 

• Common side effects of antibiotics (nausea, diarrhoea, rash) 
• Serious complications (e.g., allergic reactions, C. difficile infection) 

The use of antibiotics can cause side effects like digestive problems (diarrhoea, nausea and vomiting, abdominal pain resulting from changes in flora). Antibiotics can disturb the balance of healthy bacteria, which can lead to long-term effects like digestive issues or a weakened immune response.  

Non-antibiotic treatments and supportive care 

• Pain relief (ibuprofen, acetaminophen) 
• Hydration and throat-soothing remedies 

The recommended treatments for symptom relief are non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. If the condition worsens after 2 days or shows no significant improvement within 8 days, the patient should return for further evaluation. Corticosteroids, whether taken orally or via injection, are not advised due to their limited effectiveness in reducing pain. Additionally, the FDA has issued a black box warning against using codeine and tramadol in children under 12 and has restricted their use in children aged 12 to 18 due to risks of breathing problems and death.  

Hydration is crucial in managing tonsillitis, staying hydrated also assists in thinning mucus, helps the body’s immune system function and reduces discomfort of the inflamed tissue. 

When to seek medical attention 

• Recurrent tonsillitis and consideration of tonsillectomy  

Recurrent acute tonsillitis is a condition where a person experiences repeated bouts of bacterial infections in their tonsils, separated by periods without or with minimal symptoms. These infections are specifically focused on the palatine tonsils, and it's important to note that this term only applies to bacterial infections. 

It's crucial to distinguish between 'recurrent acute tonsillitis' and terms like 'sore throat' or 'pharyngitis,' which are often used interchangeably. A sore throat is simply a painful irritation of the throat, regardless of the underlying cause. In practice, it can be difficult to definitively determine if a sore throat is due to tonsillitis. 

A tonsillectomy is a surgical procedure that involves completely removing the palatine tonsils, including their surrounding capsule. This is done by carefully separating the tonsils from the nearby muscles. In contrast, an intracapsular or partial tonsillectomy removes most of the tonsil tissue but leaves behind a small portion to protect the underlying muscles. Sometimes, this procedure is referred to as a tonsillotomy. Another type of procedure, also called a tonsillotomy, involves cutting through the tonsil at the base of the palatal arches, leaving the remaining tissue in place. 

The most frequent and traditional method of tonsillectomy is with metal surgical instruments (cold steel tonsillectomy; tonsillectomy by cold dissection or with a snare/guillotine). Due to the relevant risk of primary and secondary postoperative bleeding and because of moderate to severe pain for up to weeks after surgery, other techniques have been used for decades with the aim of reducing the risk of postoperative bleeding and severe pain.

Summary: tonsillitis and its treatment 

Tonsillitis is a common illness caused by viral or bacterial infections that inflame the palatine tonsils. While it's challenging to differentiate between viral and bacterial causes, tools like the McIsaac and Centor scores can help predict the likelihood of a streptococcal infection. Bacterial tonsillitis is primarily caused by Group A β-hemolytic streptococcus. Antibiotics like penicillin are the primary treatment for bacterial infections, but they're ineffective against viruses. Treatment for tonsillitis often includes antibiotics, pain relievers (NSAIDs and paracetamol), and hydration. In severe cases or recurrent tonsillitis, a tonsillectomy may be recommended.