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 inhospital management however is
conserva- tive, and consists of
intravenous
antibiotics
and
drainage of the abscess. Treatment
with appropriate antibiotic therapy is
a crucial part of the defini- tive
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-lactamaseproducing organ- isms have led to

the need for this prac- tice to be reexamined(3).

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 addi- tional
first-line treatment for periton- sillar
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

nee- dle aspiration. Samples of the
aspirate were
sent
to the
laboratory for micros- copy and
culture. Blood samples were
obtained and sent to the laboratory
for differential leukocyte counts,
C- reactive protein levels and

Monospot tests for Epstein - Barr

virus. Patients were subsequently
admitted, their vi- tal signs
recorded, and they were commenced on empirical antibiotics as
per the choice of the admitting
doctor.
Although
departmental
guidelines ex- isted, 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

pharma- cotherapy 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 di- agnosis 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
dura- tion of symptoms quoted in the history was 6.2
days (range: 2 days to 21 days). Odynophagia was
present in 92%, tris- mus in 57% and otalgia in 37%, with
only 18% of patients complaining of the classical triad of
all three. The common- est 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-

Figure 4
Comparison of antibiotic usage and sensitivities

table i
Patients
Overtreated

Length of stay related to

treatment
Numbers
Length of stay
8 (20%)
2.6 days
2.4 days

Undertreated
Appropriate
antibiotics

9 (21.5%)

2.3 days

24 (58.5%)

1.8 days

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
per- cent of aspirates (n=14) grew
Strep- tococci only, 27% (n=13) grew
Mixed Anaerobes only, and 23%
(n=11) grew both Streptococci and
Mixed Anaer- obes. Organisms such as
Haemophil- us Influenza, Bacillus
Urealyticum and Mixed mouth flora
were responsible for the remaining
8% (n=4). A total of 11 different
bacterial isolates were ob- tained.
(Fig 3)
There
were
no
significant
differenc- es in age, sex, presenting
symptoms, side of abscess or blood
results be- tween those patients with
a monomi- crobial abscess and those
with a mul- timicrobial abscess.
There were also no differences found
on comparing the different individual
organisms.

Twenty patients were treated with

single intravenous antibiotic

regime, comprising of Augmentin,

Benzylpeni- cillin, 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.

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
sensi- tive to Metronidazole, half of
them had been treated with it. (Fig 4)

For the 41 patients on whom all

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

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
antibi- otics not been commenced
when they were, that they too may
have proceed- ed to develop a
peritonsillar abscess. We made no
attempt to identify what antibiotics
if any the patients had re- ceived
prior to admission. Other stud- ies
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
find- ings, 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).

in-patient stay of 3.1 days

compared with 2.0 days for those
managed with a single procedure.
Patients who re- ceived appropriate
antibiotic treat- ment 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)
The majority of our patients
under- went needle aspiration only,
and while this appears to be the
commonest pro- cedure of choice in
the United King- dom(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 tonsillec- tomy
due to a poor response to aspiration and antibiotics alone. A
study from Germany presented a
cohort of 76 patients who all
underwent a ton- sillectomy within
24 hours of admis- sion, 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

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,
equat- ing to 69 cases per year. This
is consid- erably 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
re- mainder being managed for
periton- sillitis alone. Patients were
seen and aspirated by different
doctors, and it
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 antibi- otics 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).

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
ef- fective, it does not compromise
patient care.

Although in practice the results of

microbial analysis of aspirates are
not available at the time of
commenc- ing therapy, they can
provide valu- able information to
accurately direct treatment in
resistant or complicated cases. Our
frequent finding of anaero- bic
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
rou- tine practice, in all patients
admitted to hospital with a

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 anaer- obe abscesses,
the blind use of Met- ronidazole
cannot be recommended from the
results of this study. There is no
significant difference in the length
of stay between overtreated,
under- treated 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
sta- tistical significance was not
reached even though the number of
admis- sions with peritonsillar
abscess were higher than the
national average. It was designed to
be observational and any bias
towards treatment modali- ties
cannot be excluded. A prospec- tive
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 aspi- ration out of
hours, rendering antibi- otics the
only treatment modality a patient
may have for up to 12 hours afperitonsillar abscess cannot be Anaerobes alone or as part of a group
recommended by this study as no account for 50% of all organisms found
significant difference in hospi- tal
in an aspirate
stay and clinical picture were ob- The use of Penicillin and Metroserved.
nidazole should cover almost all the
patients admitted with peritonsillar
Summary
abscess.
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

 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. Peritonsil- lar
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
ab- scess 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.

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: 52

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29%
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27%
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1,8

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2,4 (p=0.45).
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