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==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==
==Medical Therapy==
Treatments of tonsillitis consist of pain management medications<ref>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</ref> and lozenges.<ref>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</ref> If the tonsillitis is caused by [[bacteria]],<ref>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.
===Antimicrobial therapy===
 
*If the tonsillitis is caused by [[Streptococus#Group_A|group A streptococus]], then [[antibiotics]] are useful with [[penicillin]] or [[amoxicillin]] being first line.<ref name="pmid1459378">{{cite journal |author=Touw-Otten FW, Johansen KS |title=Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe study in 17 European countries |journal=Fam Pract |volume=9 |issue=3 |pages=255–62 |year=1992 |pmid=1459378 |doi=10.1093/fampra/9.3.255}}</ref>
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</ref> then [[antibiotics]] are prescribed.<ref>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</ref> [[Penicillin]] is the most commonly used antibiotic.<ref>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</ref>
*Cephalosporins and [[macrolides]] are considered good alternatives to penicillin in the acute setting.<ref>Casey JR, Pichichero ME. Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics 2004;113:866-882.</ref>
 
**A [[macrolide]] such as [[erythromycin]] is indicated for patients allergic to [[penicillin]].
In many cases of tonsillitis, the pain caused by the inflamed tonsils warrants the prescription of topical anesthetics for temporary relief. Viscous [[lidocaine]] solutions are often prescribed for this purpose.
*Individuals who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria.<ref>{{cite journal |author=Brook I |title=The role of beta-lactamase-producing-bacteria in mixed infections |journal=BMC Infect Dis |volume=9 |pages=202 |year=2009 |url=http://www.biomedcentral.com/1471-2334/9/202 |pmid=20003454 |pmc=2804585 |doi=10.1186/1471-2334-9-202}}</ref> 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.<ref>{{cite journal |author=Brook I |title=Microbiology and principles of antimicrobial therapy for head and neck infections |journal=Infect Dis Clin North Am |volume=21 |pages=355–91 |year=2007 |pmid=17561074 |url=http://linkinghub.elsevier.com/retrieve/pii/S0891-5520(07)00026-8 |doi=10.1016/j.idc.2007.03.014 |issue=2 }}</ref>


[[Ibuprofen]] or other [[analgesic]] can help to decrease the [[edema]] and inflammation which will ease the pain and allow the patient to swallow liquids sooner.<ref>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</ref>
====Empiric Therapy====
*Preferred regimen: [[Penicillin V]] PO 10 days or if compliance unlikely, [[benzathine penicillin]] IM single dose<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
*Alternate regimen (1): [[Cephalosporins|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


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 some rare infections may last for up to two weeks.
====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>
*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> 
**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>
***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>
**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>
** 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
** Inappropriate dose, duration of therapy, or choice of [[antibiotic]]


Also using warm water and salt solution, and [[gargling]] may help kill the infection, though it's not a strong treatment.<ref>http://www.mayoclinic.com/health/tonsillitis/DS00273/DSECTION=10</ref>
===Symptomatic Treatment and Pain Management===
*Treatments of tonsillitis consist of [[analgesics]] and [[lozenges]].<ref name="BoureauPelen1999">{{cite journal|last1=Boureau|first1=F|last2=Pelen|first2=F|last3=Verriere|first3=F|last4=Paliwoda|first4=A|last5=Manfredi|first5=R|last6=Farhan|first6=M|last7=Wall|first7=R|title=Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model|journal=Clinical Drug Investigation|volume=17|issue=1|year=1999|pages=1–8|issn=1173-2563|doi=10.2165/00044011-199917010-00001}}</ref>
**[[Analgesics]] can help reduce [[edema]] and [[inflammation]] to allow the patient to resume swallowing liquids.<ref name="BoureauPelen1999">{{cite journal|last1=Boureau|first1=F|last2=Pelen|first2=F|last3=Verriere|first3=F|last4=Paliwoda|first4=A|last5=Manfredi|first5=R|last6=Farhan|first6=M|last7=Wall|first7=R|title=Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model|journal=Clinical Drug Investigation|volume=17|issue=1|year=1999|pages=1–8|issn=1173-2563|doi=10.2165/00044011-199917010-00001}}</ref>
*Topical anesthetics for temporary relief, such as viscous [[lidocaine]] solutions are often prescribed.<ref name="BoureauPelen1999">{{cite journal|last1=Boureau|first1=F|last2=Pelen|first2=F|last3=Verriere|first3=F|last4=Paliwoda|first4=A|last5=Manfredi|first5=R|last6=Farhan|first6=M|last7=Wall|first7=R|title=Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model|journal=Clinical Drug Investigation|volume=17|issue=1|year=1999|pages=1–8|issn=1173-2563|doi=10.2165/00044011-199917010-00001}}</ref>
*Gargling with warm [[saline]] water.<ref name="urlTonsillitis - Treatment - NHS Choices">{{cite web |url=http://www.nhs.uk/Conditions/Tonsillitis/Pages/Treatment.aspx |title=Tonsillitis - Treatment - NHS Choices |format= |work= |accessdate=}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 00:26, 30 July 2020

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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

Empiric Therapy

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]
    • 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

References

  1. ↑ 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.
  2. ↑ Casey JR, Pichichero ME. Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics 2004;113:866-882.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  6. ↑ 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.
  7. ↑ 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. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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. ↑ 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.
  17. ↑ "Tonsillitis - Treatment - NHS Choices".


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