When should I consider prescribing antibiotics for a patient with acute tonsillitis?

Consider prescribing antibiotics for a patient presenting with acute tonsillitis only if there is clinical evidence suggesting a bacterial infection that is likely to benefit from antimicrobial treatment rather than a self-limiting viral illness. This includes patients with severe symptoms, signs of systemic infection, or those at higher risk of complications due to comorbidities or immunosuppression. Immediate antibiotic prescribing is not recommended for most cases, as acute tonsillitis is often self-limiting and viral in origin. Instead, offer self-care advice and consider a back-up (delayed) prescription if symptoms worsen or do not improve. When antibiotics are prescribed, document the reason, planned duration, and discuss the benefits and harms with the patient, including safety-netting advice on when to seek further medical help.

Specifically, assess the severity of symptoms and overall health context; if the patient has signs of severe illness or risk factors such as frailty or chronic disease, the threshold for antibiotic treatment is lower. If the infection appears non-severe and self-limiting, do not issue immediate antibiotics but consider delayed prescribing strategies. Microbiological sampling or point-of-care testing may be considered if it is safe to wait for results before prescribing.

In summary, antibiotics for acute tonsillitis should be reserved for cases with clear bacterial infection signs, severe symptoms, or high-risk patients, with a preference for delayed prescribing and thorough patient communication to support antimicrobial stewardship.

References: ¹,²,³