Medication Summary
Drugs used in the treatment of peritonsillar abscess primarily include antibiotics and analgesics. Some otorhinolaryngologists also recommend use of corticosteroids for their anti-inflammatory effect. However, evidence regarding their benefits is inconsistent. Whether these medications are given orally or intravenously depends on whether the patient is able to tolerate orally and whether the patient is being treated as an inpatient or outpatient.
Because the infection is usually polymicrobial aerobic-anaerobic, empiric antimicrobial treatment should include coverage for group A streptococcus, Staphylococcus aureus, and oral flora anaerobes. It can be modified if needed based upon the results of culture or upon the response to treatment. Coverage for methicillin-resistant S aureus (MRSA) is important, especially if drainage is not performed.
Parenteral treatment is given until the patient has no fever and shows clinical improvement. After treatment is converted to oral administration, it should be continued for 14 days.
Antibiotics
Class Summary
Empiric intravenous antibiotic therapy should provide coverage for group A Streptococcus, S aureus, and oral flora anaerobes. The initial empiric can be adjusted if necessary based on culture results if drainage is done. Because not all causative organisms are consistently cultured, antimicrobials effective against these organisms is necessary. This mandates providing coverage against polymicrobial aerobic and anaerobic (including beta-lactamase–producing bacteria) pathogens. Beta-lactamase–producing bacteria include Prevotella, Fusobacterium, Haemophilus, and Staphylococcus species.
For outpatient management, a beta-lactam antibiotic is preferred. Amoxicillin plus clavulanate (Augmentin) is the drug of choice (DOC). For inpatient management, intravenous ampicillin plus sulbactam is preferred. Alternatively, a combination of intravenous ceftriaxone and clindamycin or a carbapenem (ie, imipenem, meropenem) is used for severe or complicated cases. Coverage for methicillin-resistant Staphylococcus aureus (MRSA) includes clindamycin, vancomycin, or linezolid. [33]
Amoxicillin plus clavulanate (Augmentin)
Interferes with synthesis of cell wall peptidoglycan during active replication, resulting in bactericidal activity against susceptible microorganisms. Clavulanic acid is a potent beta-lactamase inhibitor, further broadening the spectrum of activity to include beta-lactamase–producing S aureus and anaerobes (eg, Prevotella species).
For children >3 months, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250 mg chewable-tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Imipenem and cilastatin (Primaxin)
For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity. Provides anaerobic coverage.
Ampicillin plus sulbactam (Unasyn)
Interferes with synthesis of cell wall peptidoglycan during active replication, resulting in bactericidal activity against susceptible microorganisms. Clavulanic acid is a potent beta-lactamase inhibitor, further broadening the spectrum of activity to include beta-lactamase–producing S aureus and anaerobes (eg, Prevotella species).
Clindamycin (Cleocin)
Alternative agent in patients allergic to penicillin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding have been reported to decrease from 95% bound at plasma concentrations < 25 mcg/mL to 85% bound at 300 mcg/mL.
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who are unable to receive or who have not responded to penicillins and cephalosporins or for infections with resistant staphylococci. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.
Linezolid (Zyvox)
Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against staphylococci.
Analgesic agents
Class Summary
Pain control is essential to quality patient care.
Codeine/acetaminophen (Tylenol with Codeine Elixir)
Indicated for the treatment of mild to moderate pain. Contains codeine 12 mg and acetaminophen 120 mg per 5 mL.
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Examination of the oropharynx demonstrates unilateral swelling and erythema of the left tonsil with deviation of the uvula to the contralateral side. Courtesy of Michael Altieri, MD, Medifor, Inc. Used with permission.
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CT scan with contrast demonstrates a 2-cm low-attenuation mass with a minimally enhancing wall in the right peritonsillar region. Associated edema, ipsilateral jugulodigastric lymphadenopathy, compression of the internal jugular vein, and deviation of the airway are present.
