A comparison of procaine penicillin with sulbactam-ampicillin in the treatment of peritonsillar abscesses

A systematic review of the role of penicillin versus penicillin plus metronidazole in the management of peritonsillar abscess

BACKGROUND

Peritonsillar abscess is a localised infection in the peritonsillar space. Pus from the abscess can contain anaerobes. Many clinicians prescribe metronidazole in addition to penicillin, but evidence to support this is limited. This review assessed the evidence of benefit of metronidazole for the treatment of peritonsillar abscess.

METHODS

A systematic review was conducted of the literature and databases including Ovid Medline, Ovid Embase, PubMed and Cochrane library. Search terms included all variations of peritonsillar abscess, penicillin and metronidazole.

RESULTS

Three randomised, control trials were included. All studies assessed the clinical outcomes after treatment for peritonsillar abscess, including recurrence rate, length of hospital stay and symptom improvement. There was no evidence to suggest additional benefit with metronidazole, with studies suggesting increased side effects.

CONCLUSION

Evidence does not support the addition of metronidazole in first-line management of peritonsillar abscess. Further trials to establish optimum dose and duration schedules of oral phenoxymethylpenicillin would benefit clinical practice.

Calculated parenteral initial treatment of bacterial infections: Infections in the ear, nose, throat and mouth and jaw area

This is the sixth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the antibacterial treatment of more severe infections of the ear, the nose, the throat and the maxillofacial region, including odontogenic and salivary gland infections.

Metronidazole in conjunction with penicillin neither prevents recurrence nor enhances recovery from peritonsillar abscess when compared with penicillin alone: a prospective, double-blind, randomized, placebo-controlled trial

OBJECTIVES

The objectives of this study were to evaluate the efficacy of metronidazole in conjunction with penicillin in preventing the recurrence of peritonsillar abscess (PTA) and to learn whether metronidazole enhances the recovery from PTA when compared with penicillin alone.

METHODS

In this prospective, double-blind, randomized, placebo-controlled trial, 200 adult outpatients with PTA at our ear, nose and throat emergency department received either penicillin (1 000 000IU) × 3 and metronidazole (400 mg) × 3 for 10 and 7 days orally (combination group, N = 100) or penicillin and placebo (penicillin group, N = 100) after incision and drainage of the PTA. Afterwards they received a symptom questionnaire via e-mail daily for 2 weeks, then weekly for 6 weeks. The primary outcome was efficacy of metronidazole in conjunction with penicillin in preventing PTA recurrence in 56 days; the secondary outcome was ability of metronidazole plus penicillin to enhance recovery from PTA in 28 days. All healthcare contacts were registered during follow-up. Registered on www.clinicaltrials.gov with the identifier NCT01255670.

RESULTS

Of the 200 patients, 20 returned to hospital with recurrent symptoms, 10 in each group (P = 1.00). In the combination group, the mean (SD) duration of throat-related symptoms was 5.6 (5.0) days and in the penicillin group it was 5.3 (2.7) days, values for fever were 1.5 (0.9) and 1.6 (1.0) days, respectively, and those for poor overall physical condition were 4.0 (3.9) and 4.5 (4.9) days; there were no significant differences between groups. The adverse effects nausea and diarrhoea lasted longer in the combination group (P = 0.01).

CONCLUSIONS

For healthy adult PTA patients treated with incision and drainage, metronidazole neither prevents recurrence nor enhances recovery when combined with penicillin compared with penicillin alone, but instead leads to increased adverse effects.

Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess

OBJECTIVES

Traditionally, emergency physicians (EPs) have used anatomic landmark-based needle aspiration to drain peritonsillar abscesses (PTAs). If this failed, an imaging study and/or consultation with another service to perform the drainage is obtained. Recently, some EPs have used ultrasound (US) to guide PTA drainage. This study seeks to determine which initial approach leads to greater successful drainage. The primary objective of this study was to compare the diagnostic accuracy of EPs for detecting PTA or peritonsillar cellulitis (PTC) using either intraoral US or initial needle aspiration after visual inspection (the landmark technique [LM]). Secondary objectives included the successful aspiration of purulent material in those patients with a PTA in each arm, the use of computed tomography (CT) scanning in each arm, and the otolaryngology (ENT) consultation rate in each arm.

METHODS

This was a prospective, randomized, controlled clinical trial of a convenience sample of adult patients who presented to a single, large, urban university hospital. Patients were enrolled if they presented with a constellation of signs and symptoms that were judged to be a PTA. These patients were randomized to receive intraoral US or to undergo LM drainage. The US was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the US also performed the needle aspiration. The LM was performed using visual landmarks in a superior to inferior approach until pus was obtained or at least two sticks were performed. Anesthesia was standardized. Patients returned for follow-up in 2 days where a final diagnosis was rendered.

RESULTS

  There were 28 patients enrolled, with 14 in each arm. US established the correct diagnosis more often than LM [(100%, 95% confidence interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also led to more successful aspiration of purulent material by the EP than LM in patients with PTA [(100%, 95% CI =63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)]. The ENT consult rate was 7% (95% CI = 0% to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage rate was 0% for US versus 35% for LM (p = 0.04).

CONCLUSIONS

  An initial intraoral US performed by EPs can reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in the drainage of PTAs with needle aspiration leads to greater success compared to the traditional method of LM relying on physical exam alone.

Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses

Peritonsillar, retropharyngeal, and parapharyngeal abscesses are the most common deep cervical fascial space infections. Most develop secondary to an oropharyngeal or dental infection. Additional factors such as smoking and periodontal disease may also contribute to the formation of a peritonsillar abscess. The CT scan is used to confirm the presence of deep neck abscesses, but its accuracy has some limitations. Adequate drainage with accompanying antimicrobial therapy and hydration are the cornerstones of management. Catheter or needle drainage of these abscesses may provide an alternative to open procedures and is the drainage method of choice for peritonsillar abscesses. However, in selected cases, medical therapy alone, especially in children, can resolve parapharyngeal and hypopharyngeal abscesses. Ancillary use of steroids reduces morbidity in patients with a peritonsillar abscess and there is a limited but useful place for immediate tonsillectomy in the treatment of this disease.

Peritonsillar Abscess: A Comparison of Outpatient IM Clindamycin and Inpatient IV Ampicillin/Sulbactam following Needle Aspiration

In an attempt to assess the effect of antibiotic choice on the treatment of peritonsillar abscess, we compared the clinical efficacy of empiric intramuscular clindamycin and intravenous ampicillin/sulbactam (following needle aspiration of the abscess) in a prospective, randomized study of 58 patients. Patients in the clindamycin group were treated on an outpatient basis, whereas those in the ampicillin/sulbactam group were hospitalized for the duration of their treatment (minimum: 7 days). Comparison of clinical outcomes with respect to the posttherapeutic duration of fever and throat pain and the time to resumption of eating revealed no statistically significant difference between the two groups. These results suggest that intramuscular clindamycin is an excellent choice and can be safely prescribed on an outpatient basis following needle aspiration, thereby reducing both antibiotic and hospital costs.

The role of oxidants and antioxidants in chronic tonsillitis and adenoid hypertrophy in children

OBJECTIVE

To determine the possible role of oxidants and antioxidants in the pathogenesis of chronic tonsillitis (CT) and adenoid hypertrophy (AH) in children.

METHODS

Randomized, prospective, controlled. The study group was made up of children with chronic tonsillitis and adenoid hypertrophy who are to undergo tonsillectomy and adenoidectomy. The control group was constructed with otherwise healthy children with normal ENT examination. The blood levels of antioxidants (retinol, beta-carotene, alpha-tocopherol, laycopene, ascorbic acid, superoxide dismutase, glutathione peroxidase, GSH) and peroxidation products (malondialdehyde) were determined before and 1 month after the operation in the study group and once only in the control group. These antioxidants and peroxidation products were also measured in the tonsil and adenoid tissue that were obtained during operation.

RESULTS

In the study group, the blood levels of antioxidants and oxidant before and after the operation were significantly different when compared to the control group (P < 0.05). In the study group, the blood antioxidant levels increased and oxidant level decreased significantly after the operation (P < 0.05). These levels after the operation never reached those of the control group.

CONCLUSIONS

Oxidants and antioxidants played a significant role in the pathogenesis of chronic tonsillitis and adenoid hypertrophy in children. These children are under significant oxidative stress. Tonsillectomy and adenoidectomy significantly decreased the oxidative stress in these patients, but could not normalize it completely. Further studies are necessary to evaluate their possible therapeutic role in preventing recurrent tonsillitis and treating postoperative patients to help normalize their blood levels of antioxidants.