What is the treatment for a peritonsillar abscess caused by Streptococcus (Strep)?

From the Guidelines

A peritonsillar abscess caused by Streptococcus requires prompt treatment with antibiotics and drainage. The recommended approach is a combination of antibiotic therapy and surgical drainage. For antibiotics, start with penicillin G 2-4 million units IV every 4-6 hours, or if the patient has a penicillin allergy, clindamycin 600-900 mg IV every 8 hours 1. Once clinical improvement occurs, transition to oral antibiotics: amoxicillin-clavulanate 875/125 mg twice daily or clindamycin 300-450 mg four times daily for a total 10-14 day course.

Key Considerations

• Surgical drainage is essential and can be performed via needle aspiration or incision and drainage.
• The patient should be kept well-hydrated, given pain management with acetaminophen or NSAIDs, and monitored for airway compromise.
• If there are signs of airway obstruction, immediate otolaryngology consultation is necessary.
• This aggressive approach is needed because streptococcal peritonsillar abscesses can rapidly worsen, potentially causing airway obstruction, spread of infection to deep neck spaces, or sepsis 1.

Treatment Rationale

• Most patients improve within 24-48 hours of treatment initiation but should complete the full antibiotic course to prevent recurrence.
• The choice of antibiotic should be guided by the severity of the infection and the presence of any underlying medical conditions.
• The use of antibiotics in the treatment of peritonsillar abscesses is supported by the American College of Physicians and the Centers for Disease Control and Prevention 1.

From the FDA Drug Label

Clindamycin Injection, USP is indicated in the treatment of serious infections caused by susceptible strains of streptococci The FDA drug label does not answer the question.

From the Research

Strep Peritonsillar Abscess

• A peritonsillar abscess is a polymicrobial infection, but Group A streptococcus (Strep) is the predominant organism 2, 3.
• The condition occurs primarily in young adults, most often during November to December and April to May, coinciding with the highest incidence of streptococcal pharyngitis and exudative tonsillitis 2.
• Symptoms of peritonsillar abscess generally include fever, malaise, sore throat, dysphagia, and otalgia, as well as physical findings such as trismus and a muffled voice (also called "hot potato voice") 2, 3.

Bacteriology and Antibiotic Susceptibility

• Streptococcus pyogenes was isolated from 12 out of 18 positive culture samples in one study, and was found to be sensitive to penicillin 4.
• Staphylococcus aureus was also commonly isolated, but was resistant to penicillin, with cloxacillin being effective against it 4.
• Antibiotics effective against Group A streptococcus and oral anaerobes should be first-line therapy for peritonsillar abscess 2, 3.

Treatment and Management

• Drainage of the abscess, antibiotics, and supportive therapy for maintaining hydration and pain control are the foundation of treatment for peritonsillar abscess 2, 3.
• Corticosteroids may be helpful in reducing symptoms and speeding recovery 2, 3.
• Prompt recognition and initiation of therapy is important to avoid potential serious complications, such as airway obstruction, aspiration, or extension of infection into deep neck tissues 2, 3.