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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).

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.

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

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-

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Figure 1 Patients admitted with peritonsillar abscess

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) 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 2 Symptoms at presentation

Figure 3 Organisms grown from abscess (n=52)

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Figure 4 Comparison of antibiotic usage and sensitivities

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

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

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

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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-

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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.

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). : . . - : , , ,

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