Immediate Treatment for Peritonsillar Abscess
The immediate treatment for peritonsillar abscess requires drainage (needle aspiration or incision and drainage) combined with empiric antibiotics effective against group A streptococcus and oral anaerobes, along with hydration and pain control. 1
Initial Stabilization and Assessment
- Provide adequate hydration immediately, as volume depletion is common from fever, poor oral intake, and tachypnea 1
- Assess for severe systemic symptoms, inability to maintain hydration, or signs of sepsis to determine if hospital admission is needed 1
- Most patients can be managed as outpatients with appropriate drainage, antibiotics, steroids, and pain control 1
Source Control: Drainage is Essential
Drainage is essential for treatment success—antibiotics alone without drainage should not be relied upon. 1
The drainage options include:
- Needle aspiration
- Incision and drainage
- Immediate tonsillectomy (in select cases) 2
The choice depends on clinical presentation, practitioner experience, and patient factors, but source control must be achieved promptly 1
Empiric Antibiotic Therapy
Initiate empiric antibiotics immediately once peritonsillar abscess is diagnosed, targeting group A streptococcus and oral anaerobes 1, 3
Recommended antibiotic regimens:
- Penicillin plus metronidazole provides coverage for both streptococci and anaerobes (Bacteroides and Fusobacterium species) 4
- Amoxicillin-clavulanic acid is an effective single-agent alternative that covers the polymicrobial nature of these infections 5
- The most frequently isolated organisms are gram-positive bacteria (Streptococcus pyogenes and other streptococci) and anaerobes (mainly Bacteroides spp. and Fusobacterium nucleatum) 2, 4
Pain Control and Supportive Care
- Use ibuprofen, acetaminophen, or both for adequate pain control, which is essential for maintaining oral intake and hydration 1
- Adequate analgesia prevents dehydration and allows patients to tolerate oral intake 6, 3
Corticosteroids
- Corticosteroids may be helpful in reducing symptoms and speeding recovery 3
- Consider adding corticosteroids to the treatment regimen for symptomatic relief 6
Admission Criteria
Admit patients with:
- Severe systemic symptoms
- Inability to maintain hydration
- Signs of sepsis
- Airway compromise concerns 1, 3
Most patients without these features can be safely managed as outpatients with close follow-up 1, 6
Common Pitfalls to Avoid
- Do not rely on antibiotics alone without drainage—this is a key treatment failure 1
- Do not use potentially nephrotoxic antibiotics like aminoglycosides 7
- Ensure anaerobic coverage is included, as these infections are polymicrobial 4, 3
- If unilateral tonsillectomy is performed, be aware that 14% may develop contralateral streptococcal tonsillitis and 7% may develop contralateral peritonsillar complications 2