Is Augmentin (amoxicillin-clavulanate) a good choice for treating a Peritonsillar abscess?

Augmentin for Peritonsillar Abscess: Treatment Recommendations

Augmentin (amoxicillin-clavulanate) is an appropriate first-line antibiotic choice for treating peritonsillar abscess due to its coverage of both aerobic and anaerobic bacteria commonly involved in these infections.

Rationale for Using Augmentin

Peritonsillar abscess is the most common deep infection of the head and neck in adults and requires both drainage of the abscess and appropriate antibiotic therapy. The microbiology of peritonsillar abscesses is typically polymicrobial, involving both aerobic and anaerobic bacteria:

• Common pathogens include Streptococcus pyogenes (Group A Streptococcus), Staphylococcus aureus, and oral anaerobes 1, 2
• A study of peritonsillar abscess bacteriology found that while Streptococcus pyogenes was sensitive to penicillin, Staphylococcus aureus was resistant to it 3

Augmentin provides coverage against both these common pathogens due to:

• Amoxicillin component: Effective against susceptible strains of Streptococcus
• Clavulanic acid component: Beta-lactamase inhibitor that extends coverage to beta-lactamase-producing organisms including many Staphylococcus aureus strains

Treatment Algorithm

1. Initial management:

   • Drainage of the abscess (needle aspiration, incision and drainage, or quinsy tonsillectomy) 2, 4
   • Antibiotic therapy with Augmentin
   • Pain control and hydration

2. Antibiotic dosing:

   • Adults: Augmentin 875/125 mg twice daily
   • Children: Augmentin 90 mg/6.4 mg per kg per day divided into two doses 5

3. Duration of therapy:

   • 10-14 days of antibiotic treatment is typically recommended

4. Alternative antibiotics (if penicillin allergy):

   • Non-type I hypersensitivity: Cephalosporins (cefdinir, cefpodoxime, or cefuroxime) 6
   • Type I hypersensitivity: Clindamycin (provides good coverage against streptococci, staphylococci, and anaerobes) 5
   • For severe cases: Consider respiratory fluoroquinolones (in adults only) 5

Important Clinical Considerations

1. Drainage is essential:

   • Surgical drainage (needle aspiration, incision and drainage) is the cornerstone of treatment and should be performed before antibiotic administration 2
   • Antibiotics alone are insufficient for treatment

2. Adjunctive therapy:

   • Corticosteroids may help reduce symptoms and speed recovery 4
   • Adequate pain control with acetaminophen or ibuprofen
   • Maintain hydration

3. Monitoring and follow-up:

   • Reassess within 48-72 hours if not improving 6
   • Consider changing antibiotics if symptoms persist despite drainage and initial antibiotic therapy

4. Warning signs requiring urgent attention:

   • Airway compromise
   • Extension of infection into deep neck spaces
   • Systemic toxicity

Evidence Comparison

While one older study suggested that intravenous penicillin alone was as effective as broader-spectrum antibiotics after drainage 7, more recent evidence supports using antibiotics with broader coverage due to the polymicrobial nature of these infections and increasing antibiotic resistance patterns 3.

The choice of Augmentin is supported by:

1. Its coverage of both streptococci and beta-lactamase producing staphylococci
2. Its activity against oral anaerobes
3. Its established safety profile and availability

Conclusion

Augmentin represents an excellent empiric choice for peritonsillar abscess treatment, providing appropriate coverage for the polymicrobial nature of these infections while maintaining a relatively narrow spectrum compared to alternatives like respiratory fluoroquinolones, which should be reserved for more severe cases or when first-line agents fail.