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Peritonsillar Abscess: Treatment & Medication
Updated: Mar 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Prehospital care for peritonsillar abscess includes transport with supplemental oxygen.
Emergency Department Care
- ABCs, paying attention to the patient's airway, should be evaluated. If the patient's airway is compromised, he or she needs immediate endotracheal intubation. If this cannot be completed, then a cricothyroidotomy or a tracheotomy may need to be performed.
- These patients are often dehydrated because of their avoidance of food and liquid and will need fluid resuscitation.
- Antipyretics should be administered for elevated temperature, and adequate analgesia should be provided for pain.
- Needle aspiration should be performed to drain the abscess and should provide moderate pain relief. Larger abscesses may require incision and drainage, and if the emergency provider is not comfortable with this procedure, an ENT may be consulted. See Drainage, Peritonsillar Abscess.
- Antibiotics for empirical treatment of a streptococcal infection should be administered. Steroids have been shown in one study to decrease the number of in-hospital days.3
- Patients can be managed on an outpatient basis unless they show signs of toxicity, sepsis, airway compromise, or complications.
Consultations
Otolaryngologist, anesthesiologist for difficult airway management
Medication
Antibiotics are the main component of therapy. Along with drainage of the abscess, antibiotics usually suffice to resolve peritonsillar abscess (PTA). Begin antibiotic therapy prior to needle aspiration and report of culture results. Because of streptococcal resistance of more than 30% and infection with mixed bacterial flora, many practitioners recommend combination therapy of a penicillin and metronidazole (98% sensitivity). Some physicians still use only penicillin initially. Penicillin resistance is reported in 11-65% of patients. In those patients allergic to penicillin, a good choice would be clindamycin. Analgesics and throat washes are recommended. Some physicians report using adjunctive steroids to decrease edema and pain.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Clindamycin (Cleocin)
Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
Oral or parenteral antibiotic for anaerobic or susceptible streptococcal, pneumococcal, or staphylococcal species. Considered to have good absorption into bloodstream in both oral and parental forms.
Adult
150-450 mg PO q8h
1.2-2.7 g IV/IM q8h
Pediatric
Neonates: Not established
Infants and children: 15-25 mg/kg/d PO q8h; 25-40 mg/kg/d IV/IM q8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Penicillin G benzathine (Bicillin L-A)
DOC in combination with metronidazole. Effective in approximately 98% of patients. Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
600 mg (~1 million U) IV q6h for 12-24 h
Pediatric
12,500-25,000 U/kg IV q6h
Probenecid can increase effects; coadministration of tetracyclines can decrease effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Metronidazole (Flagyl)
DOC in combination with penicillin. Effective in approximately 98% of treated patients.
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells of microorganisms that contain nitroreductase. Unstable intermediate compounds are formed that bind DNA and inhibit synthesis, causing cell death.
Adult
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h
Maintenance dose: 6 h following loading dose, infuse 7.5 mg/kg or 500 mg for 70-kg adult over 1 h q6-8h; not to exceed 4 g/d
Pediatric
Administer as in adults
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; known or previously unrecognized vaginal candidiasis may present more prominent symptoms during metronidazole vaginal-gel therapy; >6% of patients have developed symptomatic candidal vaginitis during or immediately following therapy
Nafcillin (Unipen)
Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to PO therapy as condition warrants.
Because of thrombophlebitis, particularly in elderly persons, administer parenterally only for short term (1-2 d); change to PO route as clinically indicated.
Adult
1-2 g IV q4h
Pediatric
50 mg/kg/d IV divided q4-6h
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
To optimize therapy, determine causative organisms and susceptibility; administer more than 10 d of treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection is eradicated
Erythromycin (E.E.S, Ery-Tab, Erythrocin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal (including S aureus) and streptococcal infections.
Indicated if patient is allergic to penicillin.
Adult
15-20 mg/kg/d PO/IV divided q6h; not to exceed 4 g/d
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO/IV divided q6-8h; double dose for severe infection
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
More on Peritonsillar Abscess |
| Overview: Peritonsillar Abscess |
| Differential Diagnoses & Workup: Peritonsillar Abscess |
 Treatment & Medication: Peritonsillar Abscess |
| Follow-up: Peritonsillar Abscess |
| Multimedia: Peritonsillar Abscess |
| References |
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References
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Further Reading
Keywords
peritonsillar abscess, tonsillitis, throat abscess, head and neck infection, peritonsillar abscess treatment, peritonsillar abscess symptoms, peritonsillar space, PTA, quinsy, peritonsillar cellulitis, retropharyngeal abscess, drainage of throat abscess
