Tonsillitis medical therapy: Difference between revisions
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====Challenges of Treatment==== | ====Challenges of Treatment==== | ||
Despite in vitro efficacy, there is frequently reported inability of penicillin to fully resolve [[GABHS]] from patients with acute and relapsing tonsillitis.<ref name="pmid17292576">{{cite journal |vauthors=Casey JR, Pichichero ME |title=The evidence base for cephalosporin superiority over penicillin in streptococcal pharyngitis |journal=Diagn. Microbiol. Infect. Dis. |volume=57 |issue=3 Suppl |pages=39S–45S |year=2007 |pmid=17292576 |doi=10.1016/j.diagmicrobio.2006.12.020 |url=}}</ref> | Despite in vitro efficacy, there is frequently reported inability of [[penicillin]] to fully resolve [[GABHS]] from patients with acute and relapsing tonsillitis.<ref name="pmid17292576">{{cite journal |vauthors=Casey JR, Pichichero ME |title=The evidence base for cephalosporin superiority over penicillin in streptococcal pharyngitis |journal=Diagn. Microbiol. Infect. Dis. |volume=57 |issue=3 Suppl |pages=39S–45S |year=2007 |pmid=17292576 |doi=10.1016/j.diagmicrobio.2006.12.020 |url=}}</ref> | ||
*Over the past 50 years, the rate of penicillin failure has consistently increased from about 7% in 1950 to almost 40% in 2000. | *Over the past 50 years, the rate of penicillin failure has consistently increased from about 7% in 1950 to almost 40% in 2000. | ||
*There are several explanations for the failure of penicillin to eradicate [[GABHS]] tonsillitis:<ref name="pmid16251332">{{cite journal |vauthors=Brook I, Foote PA |title=Efficacy of penicillin versus cefdinir in eradication of group A streptococci and tonsillar flora |journal=Antimicrob. Agents Chemother. |volume=49 |issue=11 |pages=4787–8 |year=2005 |pmid=16251332 |pmc=1280135 |doi=10.1128/AAC.49.11.4787-4788.2005 |url=}}</ref> | *There are several explanations for the failure of penicillin to eradicate [[GABHS]] tonsillitis:<ref name="pmid16251332">{{cite journal |vauthors=Brook I, Foote PA |title=Efficacy of penicillin versus cefdinir in eradication of group A streptococci and tonsillar flora |journal=Antimicrob. Agents Chemother. |volume=49 |issue=11 |pages=4787–8 |year=2005 |pmid=16251332 |pmc=1280135 |doi=10.1128/AAC.49.11.4787-4788.2005 |url=}}</ref> | ||
**Poor penetration of penicillin into the tonsillar tissues, as well as the epithelial cells.<ref name="cid.oxfordjournals.org">[http://cid.oxfordjournals.org/content/43/11/1398.full.pdf+html 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.]</ref> | **Poor penetration of [[penicillin]] into the tonsillar tissues, as well as the epithelial cells.<ref name="cid.oxfordjournals.org">[http://cid.oxfordjournals.org/content/43/11/1398.full.pdf+html 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.]</ref> | ||
**Bacterial interactions between [[GABHS]] and the other members of the pharyngo-tonsillar bacterial flora.<ref name="pmid6390637">{{cite journal |vauthors=Brook I |title=The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection |journal=Rev. Infect. Dis. |volume=6 |issue=5 |pages=601–7 |year=1984 |pmid=6390637 |doi= |url=}}</ref> | **Bacterial interactions between [[GABHS]] and the other members of the pharyngo-tonsillar bacterial flora.<ref name="pmid6390637">{{cite journal |vauthors=Brook I |title=The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection |journal=Rev. Infect. Dis. |volume=6 |issue=5 |pages=601–7 |year=1984 |pmid=6390637 |doi= |url=}}</ref> | ||
***It is hypothesized that the enzyme [[beta-lactamase]], secreted by beta-lactamase-producing aerobic and anaerobic bacteria that colonize the pharynx and | ***It is hypothesized that the enzyme [[beta-lactamase]], secreted by beta-lactamase-producing aerobic and anaerobic bacteria that colonize the [[pharynx]] and [[tonsil]]s, may “shield” [[GABHS]] from [[penicillin]]. | ||
****These organisms include ''S. aureus'', ''Haemophillus influenzae'', and ''Prevotella'', Porphyromonas and ''Fusobacterium'' spp.<ref name="pmid6968177">{{cite journal |vauthors=Brook I, Calhoun L, Yocum P |title=Beta-lactamase-producing isolates of Bacteroides species from children |journal=Antimicrob. Agents Chemother. |volume=18 |issue=1 |pages=164–6 |year=1980 |pmid=6968177 |pmc=283957 |doi= |url=}}</ref> 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.<ref>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.</ref> | ****These organisms include ''S. aureus'', ''[[Haemophillus influenzae]]'', and ''[[Prevotella]]'', Porphyromonas and ''[[Fusobacterium]]'' spp.<ref name="pmid6968177">{{cite journal |vauthors=Brook I, Calhoun L, Yocum P |title=Beta-lactamase-producing isolates of Bacteroides species from children |journal=Antimicrob. Agents Chemother. |volume=18 |issue=1 |pages=164–6 |year=1980 |pmid=6968177 |pmc=283957 |doi= |url=}}</ref> 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.<ref>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.</ref> | ||
**Coaggregation between ''Moraxella catarrhalis'' and [[GABHS]], which can facilitate [[GABHS]] colonization.<ref name="pmid16849717">{{cite journal |vauthors=Brook I, Gober AE |title=Increased recovery of Moraxella catarrhalis and Haemophilus influenzae in association with group A beta-haemolytic streptococci in healthy children and those with pharyngo-tonsillitis |journal=J. Med. Microbiol. |volume=55 |issue=Pt 8 |pages=989–92 |year=2006 |pmid=16849717 |doi=10.1099/jmm.0.46325-0 |url=}}</ref> | **Coaggregation between ''[[Moraxella catarrhalis]]'' and [[GABHS]], which can facilitate [[GABHS]] colonization.<ref name="pmid16849717">{{cite journal |vauthors=Brook I, Gober AE |title=Increased recovery of Moraxella catarrhalis and Haemophilus influenzae in association with group A beta-haemolytic streptococci in healthy children and those with pharyngo-tonsillitis |journal=J. Med. Microbiol. |volume=55 |issue=Pt 8 |pages=989–92 |year=2006 |pmid=16849717 |doi=10.1099/jmm.0.46325-0 |url=}}</ref> | ||
**Absence of normal bacterial flora and resultant lack of interference on the growth of [[GABHS]], makeing it easier for [[GABHS]] to colonize and invade the pharyngo-tonsillar area.<ref name="pmid6362282">{{cite journal |vauthors=Grahn E, Holm SE |title=Bacterial interference in the throat flora during a streptococcal tonsillitis outbreak in an apartment house area |journal=Zentralbl Bakteriol Mikrobiol Hyg A |volume=256 |issue=1 |pages=72–9 |year=1983 |pmid=6362282 |doi= |url=}}</ref><ref name="pmid7488371">{{cite journal |vauthors=Brook I, Gober AE |title=Role of bacterial interference and beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococcal pharyngotonsillitis |journal=Arch. Otolaryngol. Head Neck Surg. |volume=121 |issue=12 |pages=1405–9 |year=1995 |pmid=7488371 |doi= |url=}}</ref><ref name="pmid10326813">{{cite journal |vauthors=Brook I, Gober AE |title=Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis |journal=Arch. Otolaryngol. Head Neck Surg. |volume=125 |issue=5 |pages=552–4 |year=1999 |pmid=10326813 |doi= |url=}}</ref> | **Absence of normal bacterial flora and resultant lack of interference on the growth of [[GABHS]], makeing it easier for [[GABHS]] to colonize and invade the pharyngo-tonsillar area.<ref name="pmid6362282">{{cite journal |vauthors=Grahn E, Holm SE |title=Bacterial interference in the throat flora during a streptococcal tonsillitis outbreak in an apartment house area |journal=Zentralbl Bakteriol Mikrobiol Hyg A |volume=256 |issue=1 |pages=72–9 |year=1983 |pmid=6362282 |doi= |url=}}</ref><ref name="pmid7488371">{{cite journal |vauthors=Brook I, Gober AE |title=Role of bacterial interference and beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococcal pharyngotonsillitis |journal=Arch. Otolaryngol. Head Neck Surg. |volume=121 |issue=12 |pages=1405–9 |year=1995 |pmid=7488371 |doi= |url=}}</ref><ref name="pmid10326813">{{cite journal |vauthors=Brook I, Gober AE |title=Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis |journal=Arch. Otolaryngol. Head Neck Surg. |volume=125 |issue=5 |pages=552–4 |year=1999 |pmid=10326813 |doi= |url=}}</ref> | ||
** Poor penetration of penicillin into the tonsillar cells and tonsillar surface fluid (allowing intracellular survival of [[GABHS]])<ref name="cid.oxfordjournals.org"/> | ** Poor penetration of penicillin into the tonsillar cells and tonsillar surface fluid (allowing intracellular survival of [[GABHS]])<ref name="cid.oxfordjournals.org"/> | ||
** Resistance (i.e., erythromycin) or tolerance (i.e., penicillin) to the administered antibiotic | ** Resistance (i.e., [[erythromycin]]) or tolerance (i.e., [[penicillin]]) to the administered antibiotic | ||
** Inappropriate dose, duration of therapy, or choice of antibiotic | ** Inappropriate dose, duration of therapy, or choice of [[antibiotic]] | ||
===Symptomatic Treatment and Pain Management=== | ===Symptomatic Treatment and Pain Management=== | ||
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{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category:Emergency mdicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
[[Category:Otolaryngology]] | |||
[[Category:Pediatrics]] | |||
[[Category:Surgery]] | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Esther Lee, M.A. Luke Rusowicz-Orazem, B.S. Maliha Shakil, M.D. [2]
Overview
The mainstay of therapy for tonsillitis includes antimicrobial therapy analgesics. Supportive therapy includes salt water gargles and lozenges. Antimicrobial therapy is usually penicillin, though alternative regimens include cephalosporins, clindamycin, azithromycin, clarithromycin, erythromycin, amoxicillin. Supportive therapy includes salt water gargles and lozenges. There are noted challenges to antimicrobial therapy involving reduced or blocked efficacy of penicillin.
Medical Therapy
Antimicrobial therapy
- 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 indicated for patients 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]
Empiric 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
- Alternative regimen (5): Amoxicillin for 10 days
Challenges of Treatment
Despite in vitro efficacy, there is frequently reported inability of penicillin to fully resolve GABHS from patients with acute and relapsing tonsillitis.[6]
- Over the past 50 years, the rate of penicillin failure has consistently increased from about 7% in 1950 to almost 40% in 2000.
- There are several explanations for the failure of penicillin to eradicate GABHS tonsillitis:[7]
- Poor penetration of penicillin into the tonsillar tissues, as well as the epithelial cells.[8]
- Bacterial interactions between GABHS and the other members of the pharyngo-tonsillar bacterial flora.[9]
- It is hypothesized that the enzyme beta-lactamase, secreted by beta-lactamase-producing aerobic and anaerobic bacteria that colonize the pharynx and tonsils, may “shield” GABHS from penicillin.
- These organisms include S. aureus, Haemophillus influenzae, and Prevotella, Porphyromonas and Fusobacterium spp.[10] 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.[11]
- It is hypothesized that the enzyme beta-lactamase, secreted by beta-lactamase-producing aerobic and anaerobic bacteria that colonize the pharynx and tonsils, may “shield” GABHS from penicillin.
- Coaggregation between Moraxella catarrhalis and GABHS, which can facilitate GABHS colonization.[12]
- Absence of normal bacterial flora and resultant lack of interference on the growth of GABHS, makeing it easier for GABHS to colonize and invade the pharyngo-tonsillar area.[13][14][15]
- Poor penetration of penicillin into the tonsillar cells and tonsillar surface fluid (allowing intracellular survival of GABHS)[8]
- Resistance (i.e., erythromycin) or tolerance (i.e., penicillin) to the administered antibiotic
- Inappropriate dose, duration of therapy, or choice of antibiotic
Symptomatic Treatment and Pain Management
- Treatments of tonsillitis consist of analgesics and lozenges.[16]
- Analgesics can help reduce edema and inflammation to allow the patient to resume swallowing liquids.[16]
- Topical anesthetics for temporary relief, such as viscous lidocaine solutions are often prescribed.[16]
- Gargling with warm saline water.[17]
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.
- ↑ Casey JR, Pichichero ME (2007). "The evidence base for cephalosporin superiority over penicillin in streptococcal pharyngitis". Diagn. Microbiol. Infect. Dis. 57 (3 Suppl): 39S–45S. doi:10.1016/j.diagmicrobio.2006.12.020. PMID 17292576.
- ↑ Brook I, Foote PA (2005). "Efficacy of penicillin versus cefdinir in eradication of group A streptococci and tonsillar flora". Antimicrob. Agents Chemother. 49 (11): 4787–8. doi:10.1128/AAC.49.11.4787-4788.2005. PMC 1280135. PMID 16251332.
- ↑ 8.0 8.1 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 (1984). "The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection". Rev. Infect. Dis. 6 (5): 601–7. PMID 6390637.
- ↑ Brook I, Calhoun L, Yocum P (1980). "Beta-lactamase-producing isolates of Bacteroides species from children". Antimicrob. Agents Chemother. 18 (1): 164–6. PMC 283957. PMID 6968177.
- ↑ 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.
- ↑ Brook I, Gober AE (2006). "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. 55 (Pt 8): 989–92. doi:10.1099/jmm.0.46325-0. PMID 16849717.
- ↑ Grahn E, Holm SE (1983). "Bacterial interference in the throat flora during a streptococcal tonsillitis outbreak in an apartment house area". Zentralbl Bakteriol Mikrobiol Hyg A. 256 (1): 72–9. PMID 6362282.
- ↑ Brook I, Gober AE (1995). "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. 121 (12): 1405–9. PMID 7488371.
- ↑ Brook I, Gober AE (1999). "Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis". Arch. Otolaryngol. Head Neck Surg. 125 (5): 552–4. PMID 10326813.
- ↑ 16.0 16.1 16.2 Boureau, F; Pelen, F; Verriere, F; Paliwoda, A; Manfredi, R; Farhan, M; Wall, R (1999). "Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model". Clinical Drug Investigation. 17 (1): 1–8. doi:10.2165/00044011-199917010-00001. ISSN 1173-2563.
- ↑ "Tonsillitis - Treatment - NHS Choices".