What is the best course of action for a patient with a pus-filled tonsil (peritonsillar abscess) that is not responding to oral antibiotics?

Management of Peritonsillar Abscess Not Responding to Oral Antibiotics

For a pus-filled tonsil (peritonsillar abscess) failing oral antibiotics, you must immediately proceed to abscess drainage combined with intravenous antibiotics effective against Group A streptococcus and oral anaerobes, with clindamycin being the preferred agent. 1, 2

Immediate Management Steps

Drainage Procedure (Required)

• Drainage is mandatory and should not be delayed - peritonsillar abscess requires both drainage AND antibiotics, not antibiotics alone 1, 2
• Options include needle aspiration, incision and drainage, or immediate tonsillectomy (quinsy tonsillectomy) 2, 3
• Immediate tonsillectomy has the advantage of draining the abscess completely while eliminating potential for occult inferior pole or contralateral abscess 3

Antibiotic Selection After Oral Failure

Switch to intravenous clindamycin as the first-line agent for several critical reasons:

• Provides optimal coverage against both Group A streptococcus and oral anaerobes that cause peritonsillar abscess 1, 2, 4
• Superior to penicillin-based regimens in patients with recurrent or treatment-resistant infections 5
• Particularly important in patients with history of asthma due to increased risk of complications 1
• Dosing: 600 mg IV three times daily for adults; 20-30 mg/kg/day in 3 divided doses for children (max 300 mg/dose) 6

Alternative regimen if clindamycin unavailable or contraindicated:

• High-dose amoxicillin-clavulanate IV (provides broader coverage but less optimal anaerobic coverage than clindamycin) 1, 5
• Adult dosing: 4 g amoxicillin/250 mg clavulanate per day 6
• Pediatric dosing: 80 mg/kg/day amoxicillin component in three divided doses (max 3 g/day) 1

Duration and Route

• Continue IV antibiotics until clinical improvement is documented (typically 24-48 hours) 2
• Total antibiotic duration: 7-10 days, adjusting based on clinical response 1
• Transition to oral antibiotics once patient demonstrates improvement, can tolerate oral intake, and fever has resolved for 12-24 hours 6, 2

Bacteriology Considerations

The failure of oral antibiotics likely indicates:

• Staphylococcus aureus involvement - all S. aureus isolates in peritonsillar abscess are resistant to penicillin 4
• Polymicrobial infection with oral anaerobes requiring broader coverage 2, 4
• Streptococcus pyogenes remains sensitive to penicillin, but mixed infections are common 4

Surgical Decision-Making

Immediate Tonsillectomy Indications

Consider quinsy tonsillectomy (immediate tonsillectomy during acute infection) if:

• Patient has history of more than one peritonsillar abscess 1
• Severe presentation with airway compromise 2
• Inability to adequately drain abscess by needle aspiration 3
• Young children where cooperation with needle aspiration is limited 3

Critical point: If proceeding to immediate tonsillectomy, do NOT prescribe perioperative antibiotics - this is strongly recommended against by current guidelines 1

Interval Tonsillectomy

• Strongly consider tonsillectomy after resolution if patient has history of recurrent peritonsillar abscess, even if they don't meet standard Paradise criteria for recurrent tonsillitis 1
• This prevents future episodes and eliminates the need for repeated hospitalizations 3

Common Pitfalls to Avoid

• Never treat peritonsillar abscess with antibiotics alone - drainage is essential for treatment success 2, 3
• Don't continue oral antibiotics if patient is not improving after 48-72 hours - this indicates treatment failure requiring escalation 6, 2
• Don't use penicillin alone - it lacks coverage for S. aureus and many oral anaerobes commonly present in peritonsillar abscess 4
• Don't discharge patient until they demonstrate clinical improvement including decreased fever for 12-24 hours, ability to tolerate oral intake, and stable vital signs 6

Supportive Care

While managing the infection:

• Aggressive hydration (IV fluids if unable to tolerate oral intake) 2, 7
• Corticosteroids may reduce symptoms and speed recovery 2, 7
• Adequate pain control to allow oral intake 2, 7

Follow-Up Requirements

• Reassess within 24-48 hours after initiating IV antibiotics and drainage 2
• If no improvement or clinical deterioration occurs, consider imaging (CT scan) to evaluate for deep neck space extension or other complications 2
• Document barriers to care including ability to comply with therapy and availability for follow-up before any discharge 6