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==Overview==
==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]].
The mainstay of therapy for tonsillitis includes analgesics and antimicrobial therapy. Antimicrobial therapy is recommended among patients with tonsillitis due to [[bacteria]] and the drug of choice is [[Penicillin]]. Viral tonsillitis is self-limited and usually resolves within one week.  Supportive therapy includes salt water gargles and lozenges.


==Medical Therapy==
==Medical Therapy==
===Bacterial Tonsillitis===
===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>
*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>
*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 used for people allergic to penicillin.
*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>  
*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>
**A [[macrolide]] such as [[erythromycin]] is indicated for patients allergic to [[penicillin]].
*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>
 
====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


====Antimicrobial Therapy====
====Challenges of Treatment====
:*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>
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>
:*Alternate regimen (1): [[Cephalosporins|2nd generation Cephalosporins]] PO for 4–6 days
*Over the past 50 years, the rate of penicillin failure has consistently increased from about 7% in 1950 to almost 40% in 2000.
:*Alternate regimen (2): [[Clindamycin]] or [[azithromycin]] for 5 days
*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>
:*Alternate regimen (3): [[Clarithromycin]] for 10 days
**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>
:*Alternate regimen (4): [[Erythromycin]] for 10 days. Extended-release [[amoxicillin]] is another (expensive) option
**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 tonsils, 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


===Symptomatic Treatment and Pain Management===
===Symptomatic Treatment and Pain Management===
*Treatments of tonsillitis consist of [[analgesics]] and [[lozenges]].<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. 
*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>
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 determine 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>
**[[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>
**[[Analgesics]] can help reduce [[edema]] and [[inflammation]] to allow the patient to resume swallowing liquids.<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>
*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>
*Topical anesthetics for temporary relief, such as viscous [[lidocaine]] solutions are often prescribed.<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>
*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>
*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>


===Complications in treatment===
==References==
Despite its excellence in vitro efficacy, the frequently reported inability of penicillin to eradicate [[GABHS]] from patients with acute and relapsing tonsillitis is a cause for concern.  Over the past 50 years, the rate of penicillin failure has consistently increased from about 7% in 1950 to almost 40% in 2000.<refname =>Pichichero ME, Casey JR.  The evidence base for cephalosporin superiority over penicillin in streptococcal pharyngitis.  Diagn Microbiol Infect Dis. 2007;57(Supplement):S39-S45.</ref>
{{Reflist|2}}
 
There are several explanations for the failure of penicillin to eradicate [[GABHS]] tonsillitis (Table 1).  One explanation is the poor penetration of penicillin into the tonsillar tissues as well as into 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> Other explanations relate to the bacterial interactions between [[GABHS]] and the other members of the pharyngo-tonsillar bacterial flora.  It is hypothesized that the enzyme [[beta-lactamase]] which is secreted by beta-lactamase-producing aerobic and anaerobic bacteria, that colonize the pharynx and tonsils, may “shield” [[GABHS]] from penicillins.<ref>Brook I.  Role of beta-lactamase–producing bacteria in the persistence of streptococcal tonsillar infection.  ''Rev Infect Dis''. 1984;6:601-607.</ref> These organisms include ''S. aureus'', ''Haemophillus influenzae'', and ''Prevotella'', Porphyromonas and ''Fusobacterium'' spp.<ref>[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC283957/pdf/aac00387-0172.pdf  Brook I, Calhoun L, Yocum PA Beta-lactamase-producing isolates of ''Bacteroides'' species from children. ''Antimicrob Agents Chemother''. 1980;18:164-6.]</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> Another possibility is the coaggregation between ''Moraxella catarrhalis'' and [[GABHS]], which can facilitate colonization by [[GABHS]].<ref name="jmm.sgmjournals.org">[http://jmm.sgmjournals.org/content/55/8/989.full.pdf+html Brook I, Gober AE. 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.'' 2006;55(Pt 8):989-92.]</ref> Normal bacterial flora can interfere with the growth of [[GABHS]],<ref name="ReferenceA">Grahn E, Holm SE. Bacterial interference in the throat flora during a streptococcal tonsillitis outbreak in an apartment house area.  Zbl Bakl Hyg A. 1983;256:72–79.</ref><ref name="ReferenceB">Brook I, Gober AE. 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.'' 1995;121:1405-9.</ref> and the absence of such competitive bacteria makes it easier for [[GABHS]] to colonize and invade the pharyngo-tonsillar area.<ref>[http://archotol.ama-assn.org/cgi/reprint/125/5/552  Brook I, Gober AE. Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis.''Arch Otolaryngol Head Neck Surg.'' 1999;125:552-4.]</ref> [[GABHS]] can also be reacquired from a contact or an object (i.e., toothbrush or dental braces)<ref>[http://archotol.ama-assn.org/cgi/reprint/124/9/993  Brook I, Gober AE. Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis.''Arch Otolaryngol Head Neck Surg''. 1998;124:993-5.]</ref>
 
*Causes of Antibiotics Failure in Therapy of [[GABHS]] Tonsillitis


:* The presence of beta-lactamase–producing organisms that “protect” [[GABHS]] from penicillins<ref>Brook I.  Role of beta-lactamase–producing bacteria in the persistence of streptococcal tonsillar infection.  Rev Infect Dis. 1984;6:601-607.</ref>
:* Coaggregation between [[GABHS]] and ''M. catarrhalis''<ref name="jmm.sgmjournals.org"/>
:* Absence of members of the oral bacterial flora capable of interfering with the growth of [[GABHS]] (through production of bacteriocins and/or competition on nutrients)<ref name="ReferenceA"/><ref name="ReferenceB"/>
:* 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 antibiotic used
:* Inappropriate dose, duration of therapy, or choice of antibiotic
:* Poor compliance
:* Reacquisition of [[GABHS]] from a contact or an object (i.e., toothbrush or dental braces)<ref>[http://archotol.ama-assn.org/cgi/reprint/124/9/993 Brook I, Gober AE. Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis.''Arch Otolaryngol Head Neck Surg''. 1998;124:993-5.]</ref>
:* Carrier state, not disease<ref>[http://jmm.sgmjournals.org/content/55/12/1741.full.pdf+html  Brook I, Gober AE. Recovery of interfering and beta-lactamase-producing bacteria from group A beta-haemolytic streptococci carriers and non-carriers.''J Med Microbiol''. 2006;55(Pt 12):1741-4.]</ref>


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


[[Category:Inflammations]]
[[Category:Infectious disease]]
[[Category:Disease]]
[[Category:Primary care]]


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Latest revision as of 06:44, 28 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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