Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management

Abstract

More than 120,000 patients are treated annually in Germany to resolve repeated episodes of acute tonsillitis. Therapy is aiming at symptom regression, avoidance of complications, reduction in the number of disease-related absences in school or at work, increased cost-effectiveness and improved quality of life. The purpose of this part of the guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through different conservative treatment options in order to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical management in terms of intracapsular as well as extracapsular tonsillectomy (i.e. tonsillotomy) is the subject of part II of this guideline. To estimate the probability of tonsillitis caused by β-hemolytic streptococci, a diagnostic scoring system according to Centor or McIsaac is suggested. If therapy is considered, a positive score of ≥3 should lead to pharyngeal swab or rapid test or culture in order to identify β-hemolytic streptococci. Routinely performed blood tests for acute tonsillitis are not indicated. After acute streptococcal tonsillitis, there is no need to repeat a pharyngeal swab or any other routine blood tests, urine examinations or cardiological diagnostics such as ECG. The determination of the antistreptolysin O-titer (ASLO titer) and other antistreptococcal antibody titers do not have any value in relation to acute tonsillitis with or without pharyngitis and should not be performed. First-line therapy of β-hemolytic streptococci consists of oral penicillin. Instead of phenoxymethylpenicillin-potassium (penicillin V potassium), also phenoxymethlpenicillin-benzathine with a clearly longer half-life can be used. Oral intake for 7 days of one of both the drugs is recommended. Alternative treatment with oral cephalosporins (e.g. cefadroxil, cefalexin) is indicated only in cases of penicillin failure, frequent recurrences, and whenever a more reliable eradication of β-hemolytic streptococci is desirable. In cases of allergy or incompatibility of penicillin, cephalosporins or macrolides (e.g. Erythromycin-estolate) are valuable alternatives.

A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic

“…[4041] RSAT is an easy and sensitive test that is available at the point-of-care testing and could be utilized to decrease inappropriate antibiotic use. [4243]…”

Immunity‐targeted approaches to the management of chronic and recurrent upper respiratory tract disorders in children

“…Tonsillitis is more common among children than adults. 49,50 In the USA, sore throat accounts for 2.1% of outpatient visits, 51 with a prevalence of bacterial tonsillitis of 15-30% among affected children. [52][53][54] Recurrent tonsillitis in children is defined as multiple episodes of acute tonsillitis in a year.…”

“…According to clinical practice guidelines, the first-line treatment for bacterial tonsillitis should be a narrow-spectrum antibiotic (eg penicillin). 16,49,50 However, some European countries, including Germany, the UK and the Netherlands, only recommend antibiotics in certain high-risk patients. 56 The widely accepted indications for tonsillectomy in children are at least seven well-documented, clinically significant, adequately treated sore throat (defined as "acute pharyngitis, tonsillitis or acute exudative tonsillitis") in the preceding year, or at least five such episodes in each of the preceding 2 years, or at least three such episodes in each of the preceding 3 years.…”

“…56 The widely accepted indications for tonsillectomy in children are at least seven well-documented, clinically significant, adequately treated sore throat (defined as "acute pharyngitis, tonsillitis or acute exudative tonsillitis") in the preceding year, or at least five such episodes in each of the preceding 2 years, or at least three such episodes in each of the preceding 3 years. 49,50 Surgery should also be considered if the episodes are disabling and prevent normal functioning.…”

Inhaled Antibiotic Therapy for the Treatment of Upper Respiratory Tract Infections

“…However, some viral RF cases exhibit complications such as a superimposed bacterial infection that leads to severe and persistent purulent rhinorrhea. (21) Inhaled antibiotics have been considered as a possible (22) These authors enrolled 311 children with a median age of 4.5 years. The participants were divided into two homogenous groups that received either 15 mg of aerosolized tobramycin or 50 mg/ kg/day of oral amoxicillin-clavulanate.…”