Otorhinolaryngologia - Head and Neck Surgery Issue 40, April - May - June 2010, pages 20-24

ORIGINAL ARTICLE

Appropriate Antibiotics for Peritonsillar Abscess

A 9 month cohort.
Naveed Kara, Catherine Spinou
Department of Otorhinolaryngology, Ninewells Hospital, Dundee, UK.
Author for correspondence to: Miss Catherine Spinou, Head and Neck Fellow, Head and Neck Tumour Stream, The Royal
Melbourne Hospital, Grattan Street, Parkville, VIC 3051, Australia, Email: Catherine.spinou@me.com

Abstract
Objective: To assess the efficacy of the currently used protocol in the management of peritonsillar abscess in a
tertiary referral centre in the UK.
Methods: A prospective linear study was designed. 78 patients referred with peritonsilar abscess were included.
The choice, duration of treatment, and length of in-hospital stay were recorded.
Results: 52 cases of peritonsillar abscess were confirmed. Cultures isolated only Streptococci in 29% , Mixed
Anaerobes in 27%, with 23% of the cases growing both. Metronidazole was the second antibiotic used in all 30
cases. Patients treated with the appropriate antibiotics had an in-patient stay of 1.8 days while patients over or
under treated had an average stay of 2.4 days (p=0.45)
Conclusion: The use of Metronidazole as a second antibiotic in our practice did not reduce the length of stay
and did not show a significant improvement in clinical symptoms. Given the above findings the authors cannot
recommend the use of Metronidazole as a second routine antibiotic for the treatment of peritonsillar abscess.
Key words: peritonsillar abscess, antibiotics, management, metronidazole.

Introduction
Peritonsillar abscess is the commonest recognised deep infection
of the head and neck that occurs in
adults, and the surgical treatment
options have been well described in
literature(1,2). The first line in-hospital
management however is conservative, and consists of intravenous antibiotics and drainage of the abscess.
Treatment with appropriate antibiotic
therapy is a crucial part of the definitive management.
For many years Penicillin has
formed the mainstay of antimicrobial
treatment for peritonsillar abscess,
but recently the overuse of antibiotics
in the community and the emergence
of beta-lactamase-producing organisms have led to the need for this practice to be re-examined(3).

20

Our aims were: 1. To establish the

patient demographics and microbial
aspects of peritonsillar abscess managed in our department. 2. To assess
the appropriateness of antibiotic management of peritonsillar abscess in
our department and 3. To determine
the role of Metronidazole as an additional first-line treatment for peritonsillar abscess.

Materials and Methods:

A prospective study was designed
and all medical staff dealing with
emergency admissions in our department were informed and participated.
Ethics approval was sought and not
deemed necessary as the study prospectively observed an already established practice within the department.
All patients referred to the ENT de-

partment over a 9 month period with

a suspected peritonsillar abscess
were initially assessed for inclusion
in the study. A positive diagnosis was
confirmed with a positive aspirate and
patients with negative aspirates were
thereafter excluded.
All abscess were drained with needle aspiration. Samples of the aspirate
were sent to the laboratory for microscopy and culture. Blood samples were
obtained and sent to the laboratory
for differential leukocyte counts, Creactive protein levels and Monospot
tests for Epstein - Barr virus. Patients
were subsequently admitted, their vital signs recorded, and they were commenced on empirical antibiotics as
per the choice of the admitting doctor.
Although departmental guidelines existed, no attempt was made to instruct

Figure 1
Patients admitted with peritonsillar abscess

Figure 2
Symptoms at presentation

doctors to follow them strictly and the choice of pharmacotherapy was left to the individual admitting doctor. This
allowed us to observe both the variation in practice and the
results of different treatments within the department. This
data was then collated retrospectively through patient case
notes and the computerised laboratory results, and their
clinical courses were charted.
Results
A total of 78 patients presented to the ENT department
over the 9-month period with a suspected peritonsillar
abscess. This included 39 males and 39 females. The diagnosis was confirmed by a positive aspirate in 52 of the
patients, with an equal sex distribution of 26 males and
26 females. There were 28 (55%) left-sided abscesses 23
(44%) right-sided and no side recorded in one case. The
remaining 26 patients were diagnosed with peritonsillitis
and were thereafter excluded from further analysis. One
patients case notes could not be located and was therefore
also excluded from further analysis. (Fig 1)
Patient age ranged from 11 years to 85 years, with the
mean age of 30.5 (32.2 years for males, 28.9 years for
females). Mean body temperature at presentation was
37.25oC (range: 35.4 oC to 39.4 oC) and the average duration of symptoms quoted in the history was 6.2 days (range:
2 days to 21 days). Odynophagia was present in 92%, trismus in 57% and otalgia in 37%, with only 18% of patients
complaining of the classical triad of all three. The commonest combination of symptoms was that of odynophagia and
trismus, being present in just over half of patients (53%).
(Fig 2)

Figure 3
Organisms grown from abscess (n=52)

Blood results for 12 patients and aspirate culture results for 4 patients could not be obtained, and they were
excluded from the relevant analyses. The quantity of pus
obtained on aspiration was documented and ranged from
0.5mls to 15mls (mean: 3.6mls). The mean Leukocyte count
was 15.4x109/L (range: 8-25.2 x109/L) with a predominant
neutrophilia (mean: 11.9 x109/L, range: 4.4-21.9 x109/L).
C-reactive Protein (CRP) was also measured and showed
variable elevation ranging from 18-361 mg/L (mean: 135.1
mg/L). No positive Monospot tests were obtained.
Male patients presented earlier than female patients at
5.1 days rather than 7.3 days. No other significant differences between both groups were noted in presentation,
clinical findings or clinical course. Likewise, a comparison
of patients presenting with left sided or right sided abscess
also showed them to be statistically similar.
Microbiological analysis demonstrated only one respon-

21

Figure 4
Comparison of antibiotic usage and sensitivities

sible organism in 60% (n=27) of the

aspirates and two responsible organisms in 27% (n=11) of aspirates. Thirteen percent of aspirates (n=6) did not
yield any organisms. Twenty nine percent of aspirates (n=14) grew Streptococci only, 27% (n=13) grew Mixed
Anaerobes only, and 23% (n=11) grew
both Streptococci and Mixed Anaerobes. Organisms such as Haemophilus Influenza, Bacillus Urealyticum and
Mixed mouth flora were responsible
for the remaining 8% (n=4). A total of
11 different bacterial isolates were obtained. (Fig 3)
There were no significant differences in age, sex, presenting symptoms,
side of abscess or blood results between those patients with a monomicrobial abscess and those with a multimicrobial abscess. There were also
no differences found on comparing the
different individual organisms.
Twenty patients were treated with
a single intravenous antibiotic regime,
comprising of Augmentin, Benzylpenicillin, Clarithromycin, Erythromycin or
Clindamycin. Thirty patients received
a combination of two different intravenous antibiotics, Metronidazole being
the second antibiotic of choice in every
case. One patient was managed with
oral Penicillin alone.
For the 41 patients on whom all

22

Table I
Length of stay related to treatment
Patients
Numbers Length of stay
Overtreated
8 (20%)
2.6 days
2.4 days
Undertreated 9 (21.5%)
2.3 days
Appropriate
antibiotics
24 (58.5%)
1.8 days

necessary data was available, aspirate

sensitivities were compared with the
actual antibiotics empirically used. Of
the 24 patients (59%) whose aspirates
tested sensitive to Metronidazole, only
two thirds were actually treated with it.
Of the 17 (41%) who did not test sensitive to Metronidazole, half of them had
been treated with it. (Fig 4)
In addition to the initial aspiration
on admission, a total of 11 patients
required further procedures to be carried out. Six patients required a further aspiration, one patient required
incisional drainage, and one patient
required both a further aspiration and
incisional drainage. One patient required two further aspirations and 2
patients underwent a hot tonsillectomy. Patients who required additional
interventions presented later at 7.8
days in contrast to 5.7 days. Over half
of these patients were treated with
appropriate antibiotics. One of the patients who required a further aspiration
was also the only patient who received
steroids as part of their treatment (2
doses of intravenous dexamethasone).
His presentation and clinical findings
were no different from any of the other
patients.
The mean length of stay for all patients was 2.2 days, ranging from 0
days to 6 days. Patients who required
further interventions required a longer

in-patient stay of 3.1 days compared

with 2.0 days for those managed with
a single procedure. Patients who received appropriate antibiotic treatment had a shorter in-patient stay of
1.8 days in contrast to 2.4 days, which
was the average stay of patients either
overtreated or undertreated. Using
ANOVA one way test for 3 independent
samples the comparison of length of
stay between correctly treated, overtreated and undertreated group gave
a p= 0.41. Surprisingly, patients who
were overtreated had a longer stay of
2.6 days, but these numbers were too
small to reach statistical significance.
(Table I)
Discussion
According to a 2002 postal survey,
the average number of peritonsillar
abscess cases seen by an ENT department per year in the UK was 29(2). A
total of 52 patients with peritonsillar
abscess were admitted to our department over the 9 month period, equating to 69 cases per year. This is considerably higher and reflects the fact that
our department was part of a large
teaching hospital.
Two thirds of our patients admitted with a peritonsillar infection were
diagnosed with an abscess, the remainder being managed for peritonsillitis alone. Patients were seen and
aspirated by different doctors, and it

is possible that relative differences in

experience may have contributed to
an elevated false negative cohort. It is
also possible that had some of those
patients presented later or had antibiotics not been commenced when they
were, that they too may have proceeded to develop a peritonsillar abscess.
We made no attempt to identify what
antibiotics if any the patients had received prior to admission. Other studies have demonstrated abscesses accounting for between 68% and 82% of
patients presenting with peritonsillar
infections(4, 5).
Several studies have examined the
epidemiology of peritonsillar abscesses and our patients average age of
30.5 years is comparable to their findings, showing a decreasing incidence
with increasing age(6-8). Similarly, we
also did not demonstrate any significant differences in the side of the
abscess(7). While some studies have
shown a considerably higher male
prevalence of up to 3:1, several others
have shown a comparable prevalence,
and we demonstrate a very equal sex
ratio(5-9).
The majority of our patients underwent needle aspiration only, and while
this appears to be the commonest procedure of choice in the United Kingdom(2), many other authors appear to
favour incisional drainage, believing
that it offers a much lower recurrence
rate (7,10). Two (3.8%) patients from
our study underwent a hot tonsillectomy due to a poor response to aspiration and antibiotics alone. A study
from Germany presented a cohort of
76 patients who all underwent a tonsillectomy within 24 hours of admission, and this clearly demonstrates
that therapeutic strategies for peritonsillar abscess remain varied and
controversial(8).
No patients from our cohort tested
positive for Epstein-Barr virus infectious mononucleosis, nor did any
present with bilateral abscess. Other

studies have shown a prevalence of

Epstein-Barr virus to be up to 1.8% and
bilateral abscess have been shown to
present in around 1% of patients with
peritonsillar infection(5-7).
Microbiological analysis of 13% of
our aspirates did not yield any organism, and this is not surprising with
other studies yielding no detectable
growth in 1.6% to 15% of aspirates (7,
8, 11)
. These variations may be in part
due to the geographical differences of
peritonsillar abscess or the differing
diagnostic abilities between laboratories. Some patients may have been
commenced on oral antibiotics prior
to their admission and this may have
contributed to the negative aspirates,
although previous studies have not
shown this to alter clinical course or
microbiological results(12).
The polymicrobial nature of peritonsillar abscess is well described,
and Brook et al have demonstrated up
to 3.1 isolates detected per aspirate(13).
Several studies have looked in detail
at the differing contributions made by
both aerobic and anaerobic organisms,
and have shown them to be jointly responsible for up to 76% of abscess(8,13).
Other studies have demonstrated that
anaerobic organisms alone may be
responsible for up to 84% of abscess,
and more importantly, Beta-Lactamase producing organisms have been
shown to be responsible for 6% to 52%
of abscess(4, 8, 11, 13).
Our patients had an average inpatient stay of 2.2 days. This is in keeping
with the UK average, and considerably
lower than other studies who have
quoted up to 9.9 days(2, 7). Patients who
were treated with appropriate antibiotics showed a slightly shorter length
of stay of 1.8 days compared with the
average 2.4 days for over and under
treated patients. However this did not
reach statistical significance. Other
studies, have also failed to show any
difference in the length of stay with the
usage of different antibiotic regimes(5).

No differences in clinical presentation

were noted between the groups, which
could be used to guide appropriate
treatment or predict outcomes.
Potentially 98% of our patients
could be covered effectively by the use
of both Penicillin and Metronidazole
as a blind empirical regime instituted
on admission. However Metronidazole
did not seem to reduce the length of in
hospital stay unless the correct regime
was used. Since there are no specifics
in clinical presentation which could
help identify the patients with anaerobe abscesses, the blind use of Metronidazole cannot be recommended
from the results of this study. There is
no significant difference in the length
of stay between overtreated, undertreated and correctly treated patients
which could justify the wide use of
Metronidazole as a second antibiotic
for all admissions with peritonsillar
abscess.
This study although prospective in
its design, is limited by a few factors.
Firstly the numbers are small and statistical significance was not reached
even though the number of admissions with peritonsillar abscess were
higher than the national average. It
was designed to be observational and
any bias towards treatment modalities cannot be excluded. A prospective randomised multicentric study of
adequate power will be necessary in
order to address the above questions
with certainty.
Conclusion
Peritonsillar abscess are a relatively common emergency admission
in ENT departments, and therefore are
primarily managed by junior doctors. A
variation in their skills and ENT core
knowledge is to be expected. Moreover
the introduction of hospital at night
teams means that fewer doctors are
competent to perform a needle aspiration out of hours, rendering antibiotics the only treatment modality a
patient may have for up to 12 hours af-

23

ter admission to hospital. This in turn

may give rise to over-expensive and
ineffective patient management. It is
therefore necessary for departments
to regularly audit their own practice to
ensure that while it remains cost effective, it does not compromise patient
care.
Although in practice the results of
microbial analysis of aspirates are
not available at the time of commencing therapy, they can provide valuable information to accurately direct
treatment in resistant or complicated
cases. Our frequent finding of anaerobic organisms as the sole or second
organism in peritonsillar abscess
highlights their important role in their
pathogenesis.
However the use of a combination
of Penicillin and Metronidazole as routine practice, in all patients admitted
to hospital with a peritonsillar abscess
cannot be recommended by this study
as no significant difference in hospital stay and clinical picture were observed.
Summary
What is known about the topic
The average ENT department in the
UK will admit approximately 30 peritonsillar abscesses a year.
Anaerobes are a common finding
when culturing aspirates from peritonsillar abscesses
Needle aspiration, incision drainage,
and hot tonsillectomy have all been
employed as invasive treatment modalities.
Penicillin is the most common antibiotic used for conservative treatment
and Metronidazole is usually the 2nd
antibiotic added to the regime.
What this study adds to the topic
Anaerobes alone or as part of a group
account for 50% of all organisms found
in an aspirate
The use of Penicillin and Metronidazole should cover almost all the
patients admitted with peritonsillar
abscess.

24

No clinical predicting factors for

anaerobic infections could be identified in this study.
The addition of Metronidazole as a
second antibiotic did not reduce the
length of in hospital stay unless the
correct regime was used.
The blind use of Metronidazole as
a second antibiotic in all peritonsillar
abscesses cannot be recommended
from this study.
References
1. Steyer TE. Peritonsillar Abscess: Diagnosis
and Treatment. Am Fam Physician 2002; 65:
93-96.
2. Mehanna HM, Al-Bahnasawi L, White A. National audit of the management of peritonsillar
abscess. Postgraduate Medical Journal 2002; 78:
545-547.
3. Parker GS, Tami TA. The management of peritonsillar abscess in the 90s: an update. Am J
Otolaryngol 1992; 13: 284-8.
4. Muir DC, Papesch ME, Allison RS. Peritonsillar infection in Christchurch 1990-2: microbiology and management. N Z Med J 1995; 108(994):
53-4.
5.Ong YK, Goh YH, Lee YL. Peritonsillar infections: local experience. Singapore Med J 2004;
45(3): 105-9.
6. Hanna BC, McMullan R, Gallagher G, Hedderwick S. The epidemiology of peritonsillar abscess disease in Northern Ireland. J Infect 2006;
52(4): 247-53.
7. Matsuda A, Tanaka H, Kanaya T et al. Peritonsillar abscess: a study of 724 cases in Japan. Ear,
Nose Throat J 2002; 81(6): 384-9.
8. Sladczyk M. Microbiology and antibiotic resistance of peritonsillar abscess. Annual Meeting of
the German Society for Oto-Rhino-Laryngology,
Head and Neck Surgery, 4-8 May 2005. http://
www.egms.de/en/meetings/hno2005/05hno057.
shtml
9. Stegehuis HR, Schousboe M. Peritonsillar
infection in Christchurch 1981-1984. N Z Med J
1986; 99(806): 536-8.
10. Wolf M, Even-Chen I, Kronenberg J. Peritonsillar abscess: Repeated needle aspiration
versus incision and drainage. Ann Otol Rhinol
Laryngol 1994; 103: 554-7.
11. Prior A, Montgomery P, Mitchelmore I et al.
The microbiology and antibiotic treatment of
peritonsillar abscesses. Clin Otolaryngol Allied
Sci 1995; 20(3): 219-23
12. Briner HR. Does antibiotic therapy hinder the
course of peritonsillar abscesses? Schweiz Med
Wochenschr Suppl 2000; 125: 14S-16S.
13. Brook I, Frazier EH, Thompson DH. Aerobic
and anaerobic microbiology of peritonsillar ab-

scess. Laryngoscope 1991; 101(3): 289-92.

9
Naveed Kara,
Department of Otorhinolaryngology,
Ninewells Hospital, Dundee, UK.

:

.
- :
78 .

.
: 52
.
29% ,
27% ,
23% .
.

1,8
- 2,4
(p=0.45).
:

.


.
- : , , ,