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Viral tonsillitis
It is not easy to distinguish viral from bacterial infections. In general, I use the following distinguishing factors although I cannot prove they are scientifically valid. If a patient has a generalised sorethroat, associated with symptoms of an upper respiratory infection such as rhinorrhea, cough, low grade fever, minimal or no cervical adenopathy and no purulent exudate on the tonsils, I feel this is probably viral and will not treat with antibiotics, but use supportive therapy like nasal decongestants, gargles and plenty of oral fluids. If the patient has small vesicles or erosions on the soft palate and/or mucosal surfaces, I am even more convinced of a viral infection. The one viral infection that will present almost identical to bacterial tonsillitis is infectious mononucleosis. These patients may have a fever, cervical lymphadenopathy and exudative tonsillitis. As a consequence, they usually are treated with an antibiotic and the diagnosis is suspected 3 - 5 days later when they do not respond to antibiotics or develop a rash associated with the use of amoxicillin. In these patients, the diagnosis would be confirmed with a monospot test. 

Bacterial tonsillitis treatment: When and how 
Once we have decided that the patient fits into the bacterial tonsillitis category, which ones should we treat and why? 
In the pre-antibiotic era, the complications of streptococcal tonsillitis were frequent and devastating. Even as late as the mid 1950’s, when I was a University student and had to be hospitalised for 3 days with scarlet fever, the police came to my residence to quarantine the household for 2 weeks to try to prevent the spread of the disease. The feared complications were rheumatic fever with joint and heart involvement and glomerulonephritis. In this age of antibiotics when we rarely see these complications, we have become blase about treatment. As already mentioned, the purist would treat only GABHS infections. In the 60’s and 70’s this led to the practice of doing a culture, starting the patient on penicillin and then stopping after 24 - 48 hours if the GABHS culture was negative. Over the past 10 years, a rapid strep test has become available and GABHS may be ruled in or out in 30 minutes, to make a treatment decision. The problem for me was that a 10-day prescription of penicillin was less expensive then a culture or even the rapid strep test. Plus, I felt there were still patients with all the signs and symptoms of bacterial tonsillitis who were GABHS negative, but still quite sick and would respond quickly to penicillin with the ability to return to school or work much sooner. As a consequence, I chose to treat these patients with a 10-day course of antibiotics rather than to do a culture.
What antibiotic should we use and for how long? Since coming to Singapore, I have observed that it is a common practice to treat tonsillitis with 3 - 5 days of penicillin or amoxicillin and then ask the patient to return if they are not better. This came to my attention when I saw a 22-year-old girl who was referred for a tonsillectomy. On a casual history, she stated she had 10 - 15 attacks of tonsillitis treated with antibiotics over a one year period. This would meet almost anyone’s criteria for doing a tonsillectomy, but on more careful questioning, she had only taken 2 -5 days of antibiotics each time and the tonsillitis would recurr in 2 - 3 weeks. There are two problems with this short course therapy. First, it does not protect one from the risks of cardiac and renal complications from GABHS. At present, the American Heart Association and the American Academy of Pediatrics recommend a 10-day course of penicillin V or a single dose of intramuscular Benzathine penicillin G(1). If the patient is penicillin allergic, a 10-day course of erythromycin or Cephalosporins are recommended. Stromberg et al(2) showed in a randomised controlled clinical trial, that 10 days of penicillin had a 9% recurrence rate of tonsillitis within one week versus 30% with 5 days of therapy. The second reason for not using short but frequent course of antibiotics is the rapidly developing problem of drug-resistant bacteria. Although at present Streptococcus pyogenes has not been a problem, it is becoming a major problem with Streptococcus pneumoniae. It is known that low doses and frequent exposures to antibiotics is the ideal media for selecting out resistant organisms.
Finally, in patients with frequent recurrent tonsillitis after adequate courses of antibiotics, one needs to keep in mind the possibility of anaerobic bacteria as a source. Brook et al(3) showed that if one took tonsils at the time of tonsillectomy for chronic recurrent tonsillitis and did sterile core cultures from the center of the tonsil, a mixed flora of aerobes and anaerobes were often found. With this in mind, I frequently recommend a 10 -14 day course of clindamycin for patients with chronic recurrent tonsillitis before considering a tonsillectomy. 

When is tonsillectomy indicated?
What are the indications for a tonsillectomy? At the present time, the American Academy of Otolaryngology  gives  the following  guidelines(4): 1) At least 3 or more episodes of tonsillitis per year despite adequate medical therapy. Each episode must have been characterised by one or more of the following: a) oral temperature >38.2nC;  b) enlarged (> 2 cm) or tender anterior cervical lymph nodes; c) tonsillar exudate; d) positive culture for GABHS; 2) Hypertrophy causing dental malocclusion or adversely affecting oro-facial growth documented by orthodontist; 3) Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications; 4) Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon; 5) Chronic or recurrent tonsillitis associated with the streptococcal carrier state and not responding to beta-lactamase resistant antibiotics, and 6) Unilateral tonsil hypertrophy presumed neoplastic.
 

CONCLUSION
In conclusion, although tonsillitis is a common infection today, the exact etiology may be difficult to determine. When to treat remains controversial, but if one does decide to use antibiotics, the patient should be encouraged to complete a 10-day course of the appropriate antibiotics to minimise recurrence and prevent the complications of GABHS. In patients who meet the criteria of recurrent or chronic tonsillitis, a tonsillectomy would be recommended.