Sandbox:Tonsillitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.
Overview
The mainstay of therapy for tonsillitis includes analgesics and antimicrobial therapy. Antimicrobial therapy is recommended among patients with tonsillitis due to bacteria and the drug of choice is Penicillin. Viral tonsillitis is self-limited and usually resolves within one week. Supportive therapy includes salt water gargles and lozenges.
Medical Therapy
Bacterial Tonsillitis
- If the tonsillitis is caused by group A streptococus, then antibiotics are useful with penicillin or amoxicillin being first line.[1]
- Cephalosporins and macrolides are considered good alternatives to penicillin in the acute setting.[2] A macrolide such as erythromycin is used for people allergic to penicillin.
- Individuals who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria[3] such as clindamycin or amoxicillin-clavulanate. Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins.[4]
Antimicrobial Therapy
- Preferred regimen: Penicillin V PO 10 days or if compliance unlikely, Benzathine penicillin IM single dose[5]
- Alternate regimen (1): 2nd generation Cephalosporins PO for 4–6 days
- Alternate regimen (2): Clindamycin or azithromycin for 5 days
- Alternate regimen (3): Clarithromycin for 10 days
- Alternate regimen (4): Erythromycin for 10 days. Extended-release amoxicillin is another (expensive) option
Tonsillitis caused by virus
- When tonsillitis is caused by a virus, the length of illness depends on which virus is involved. Usually, a complete recovery is made within one week; however, symptoms may last for up to two weeks.
Symptomatic Treatment and Pain Management
- Treatments of tonsillitis consist of analgesics and lozenges.[6] and lozenges.[7] If the tonsillitis is caused by bacteria,[8] then antibiotics are prescribed.[9] Penicillin is the most commonly used antibiotic.[10]
- Analgesics can help reduce edema and inflammation to allow the patient to resume swallowing liquids.[11]
- Topical anesthetics for temporary relief, such as viscous lidocaine solutions are often prescribed.[12]
- Gargling with warm saline water.[13]
Complications in treatment
Despite its excellence in vitro efficacy, the frequently reported inability of penicillin to eradicate GABHS from patients with acute and relapsing tonsillitis is a cause for concern. Over the past 50 years, the rate of penicillin failure has consistently increased from about 7% in 1950 to almost 40% in 2000.[14]
There are several explanations for the failure of penicillin to eradicate GABHS tonsillitis (Table 1). One explanation is the poor penetration of penicillin into the tonsillar tissues as well as into the epithelial cells.[15] Other explanations relate to the bacterial interactions between GABHS and the other members of the pharyngo-tonsillar bacterial flora. It is hypothesized that the enzyme beta-lactamase which is secreted by beta-lactamase-producing aerobic and anaerobic bacteria, that colonize the pharynx and tonsils, may “shield” GABHS from penicillins.[16] These organisms include S. aureus, Haemophillus influenzae, and Prevotella, Porphyromonas and Fusobacterium spp.[17] A recent increase was noted in the recovery of MRSA which was isolated from 16% of tonsils, making it more difficult to eradicate this and other beta-lactamase producing organisms.[18] Another possibility is the coaggregation between Moraxella catarrhalis and GABHS, which can facilitate colonization by GABHS.[19] Normal bacterial flora can interfere with the growth of GABHS,[20][21] and the absence of such competitive bacteria makes it easier for GABHS to colonize and invade the pharyngo-tonsillar area.[22] GABHS can also be reacquired from a contact or an object (i.e., toothbrush or dental braces)[23]
- Causes of Antibiotics Failure in Therapy of GABHS Tonsillitis
- The presence of beta-lactamase–producing organisms that “protect” GABHS from penicillins[24]
- Coaggregation between GABHS and M. catarrhalis[19]
- Absence of members of the oral bacterial flora capable of interfering with the growth of GABHS (through production of bacteriocins and/or competition on nutrients)[20][21]
- Poor penetration of penicillin into the tonsillar cells and tonsillar surface fluid ( allowing intracellular survival of GABHS)[15]
- Resistance (i.e., erythromycin) or tolerance (i.e., penicillin) to the antibiotic used
- Inappropriate dose, duration of therapy, or choice of antibiotic
- Poor compliance
- Reacquisition of GABHS from a contact or an object (i.e., toothbrush or dental braces)[25]
- Carrier state, not disease[26]
References
- ↑ Touw-Otten FW, Johansen KS (1992). "Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe study in 17 European countries". Fam Pract. 9 (3): 255–62. doi:10.1093/fampra/9.3.255. PMID 1459378.
- ↑ Casey JR, Pichichero ME. Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics 2004;113:866-882.
- ↑ Brook I (2009). "The role of beta-lactamase-producing-bacteria in mixed infections". BMC Infect Dis. 9: 202. doi:10.1186/1471-2334-9-202. PMC 2804585. PMID 20003454.
- ↑ Brook I (2007). "Microbiology and principles of antimicrobial therapy for head and neck infections". Infect Dis Clin North Am. 21 (2): 355–91. doi:10.1016/j.idc.2007.03.014. PMID 17561074.
- ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
- ↑ Boureau, F. and et al. "Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model." Clinical Drug Investigation 17 (1999): 1-8. - Boureau studied 113 patients who saw 19 physicians in France. Patients were give Ibuprofen 400mg or Paracetamol 1000mg randomly. Pain intensity, difficulty swallowing, and global pain relief were use to measure in hourly increments until 6 hours after patients first dose. The results showed that Ibuprofen better than Paracetamol in all three categories
- ↑ Praskash, T. and et al. "Koflet lozenges in the Treatment of Sore Throat." The Antiseptic 98 (2001): 124-127 - The efficacy of Koflet Lozenges was evaluated by symptomatic relief of pain. The 48 patients were examined by the Physicians and given a scale rating from 0-3. 0 stating no signs and symptoms and 3 being the worse. The results showed patients with pharyngitis 95% of the patient with positive feedbacks. Tonsillitis patients and patients with both symptoms gave 100% positive feedbacks
- ↑ Touw-Otten, Fransje WMM. and Kristen Staehr Johansen. "Diagnosis, Antibiotic Treatment and Outcome of Acute Tonsillitis: Report of a WHO Regional Office for Europe Study in 17 European Countries." Family Practice 9 (1992): 255-262 - 17 European Countries had a minimum of 10 physicians each that participated in a studied that involved 4094 patients that they had seen from Nov 1989 to May 1990. Sore throat, redness and swelling of tonsils, pus on tonsils, enlarge regional lymph nodes, or fever. Bacterial and serology test were performed to determined antibiotics usage. Antibiotics results had 2334 out of 3646 patient using penicillin. 343 out of the 3646 used amoxicillin and 554 out of 3646 used macrolides
- ↑ Touw-Otten, Fransje WMM. and Kristen Staehr Johansen. "Diagnosis, Antibiotic Treatment and Outcome of Acute Tonsillitis: Report of a WHO Regional Office for Europe Study in 17 European Countries." Family Practice 9 (1992): 255-262 - 17 European Countries had a minimum of 10 physicians each that participated in a studied that involved 4094 patients that they had seen from Nov 1989 to May 1990. Sore throat, redness and swelling of tonsils, pus on tonsils, enlarge regional lymph nodes, or fever. Bacterial and serology test were performed to determine antibiotics usage. Antibiotics results had 2334 out of 3646 patient using penicillin. 343 out of the 3646 used amoxicillin and 554 out of 3646 used macrolides
- ↑ Touw-Otten, Fransje WMM. and Kristen Staehr Johansen. "Diagnosis, Antibiotic Treatment and Outcome of Acute Tonsillitis: Report of a WHO Regional Office for Europe Study in 17 European Countries." Family Practice 9 (1992): 255-262 - 17 European Countries had a minimum of 10 physicians each that participated in a studied that involved 4094 patients that they had seen from Nov 1989 to May 1990. Sore throat, redness and swelling of tonsils, pus on tonsils, enlarge regional lymph nodes, or fever. Bacterial and serology test were performed to determined antibiotics usage. Antibiotics results had 2334 out of 3646 patient using penicillin. 343 out of the 3646 used amoxicillin and 554 out of 3646 used macrolides
- ↑ Boureau, F. and et al. "Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model." Clinical Drug Investigation 17 (1999): 1-8- Boureau studied 113 patients who saw 19 physicians in France. Patients were give Ibuprofen 400mg or Paracetamol 1000mg randomly. Pain intensity, difficulty swallowing, and global pain relief were use to measure in hourly increments until 6 hours after patients first dose. The results showed that Ibuprofen better than Paracetamol in all three categories
- ↑ Boureau, F. and et al. "Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model." Clinical Drug Investigation 17 (1999): 1-8- Boureau studied 113 patients who saw 19 physicians in France. Patients were give Ibuprofen 400mg or Paracetamol 1000mg randomly. Pain intensity, difficulty swallowing, and global pain relief were use to measure in hourly increments until 6 hours after patients first dose. The results showed that Ibuprofen better than Paracetamol in all three categories
- ↑ "Tonsillitis - Treatment - NHS Choices".
- ↑ Pichichero ME, Casey JR. The evidence base for cephalosporin superiority over penicillin in streptococcal pharyngitis. Diagn Microbiol Infect Dis. 2007;57(Supplement):S39-S45.
- ↑ 15.0 15.1 Kaplan EL, Chatwal GS, Rohde M. Reduced ability of penicillin to eradicate ingested Group A streptococci from epithelial cells: clinical and pathogenetic implications. Clin Infect Dis. 2006;43:1398-406.
- ↑ Brook I. Role of beta-lactamase–producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis. 1984;6:601-607.
- ↑ Brook I, Calhoun L, Yocum PA Beta-lactamase-producing isolates of Bacteroides species from children. Antimicrob Agents Chemother. 1980;18:164-6.
- ↑ Brook I, Foote PA. Isolation of methicillin resistant Staphylococcus aureus from the surface and core of tonsils in children. Int J Pediatr Otorhinolaryngol. 2006 ;70:2099-102.
- ↑ 19.0 19.1 Brook I, Gober AE. Increased recovery of Moraxella catarrhalis and Haemophilus influenzae in association with group A beta-haemolytic streptococci in healthy children and those with pharyngo-tonsillitis. J Med Microbiol. 2006;55(Pt 8):989-92.
- ↑ 20.0 20.1 Grahn E, Holm SE. Bacterial interference in the throat flora during a streptococcal tonsillitis outbreak in an apartment house area. Zbl Bakl Hyg A. 1983;256:72–79.
- ↑ 21.0 21.1 Brook I, Gober AE. Role of bacterial interference and beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococcal pharyngotonsillitis. Arch Otolaryngol Head Neck Surg. 1995;121:1405-9.
- ↑ Brook I, Gober AE. Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis.Arch Otolaryngol Head Neck Surg. 1999;125:552-4.
- ↑ Brook I, Gober AE. Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis.Arch Otolaryngol Head Neck Surg. 1998;124:993-5.
- ↑ Brook I. Role of beta-lactamase–producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis. 1984;6:601-607.
- ↑ Brook I, Gober AE. Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis.Arch Otolaryngol Head Neck Surg. 1998;124:993-5.
- ↑ Brook I, Gober AE. Recovery of interfering and beta-lactamase-producing bacteria from group A beta-haemolytic streptococci carriers and non-carriers.J Med Microbiol. 2006;55(Pt 12):1741-4.