In a 68‑year‑old man with a left peritonsillar fluid collection (≈1.3 × 1 × 1.3 cm) that has not been drained, fever and leukocytosis, how many weeks of oral amoxicillin‑clavulanate (Augmentin) therapy are indicated?

Augmentin Duration for Peritonsillar Fluid Collection Without Drainage

For this 68-year-old man with a small peritonsillar fluid collection (1.3 cm) that is not being drained, treat with oral amoxicillin-clavulanate (Augmentin) for 10-14 days.

Rationale for Treatment Duration

The standard duration for peritonsillar infections treated with antibiotics alone (without drainage) is 10-14 days 1, 2. This extended course is necessary because:

• Peritonsillar abscesses and fluid collections are polymicrobial deep space infections involving both aerobic bacteria (primarily Streptococcus pyogenes) and anaerobic organisms 1, 2
• Without surgical drainage, antibiotics must penetrate the collection and surrounding inflamed tissue to achieve adequate bacterial eradication 1
• The patient's persistent leukocytosis (WBC 14.7) indicates ongoing infection requiring complete antibiotic course 3

Specific Dosing Recommendation

• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 10-14 days 3
• This dosing provides adequate coverage against both Streptococcus pyogenes and beta-lactamase producing Staphylococcus aureus, the two most common pathogens in peritonsillar infections 4

Critical Reassessment Timepoints

• 48-72 hours: Patient should demonstrate clinical improvement with reduced fever, decreased throat pain, and improved ability to swallow 5, 3
• If no improvement or worsening at 72 hours: This constitutes treatment failure requiring either drainage procedure or switch to alternative antibiotics (such as clindamycin or a respiratory fluoroquinolone) 5, 3
• The mean hospital stay for similar cases is 3 days, suggesting most patients show sufficient improvement by this timepoint to transition to outpatient oral therapy 3

Why 10-14 Days (Not Shorter)

• Studies of peritonsillar infections treated with needle aspiration plus antibiotics used 10-14 day courses with 5% recurrence rates 3
• The 1.3 cm collection size, while small, still represents a deep space infection requiring complete eradication to prevent complications such as extension into deep neck tissues or airway compromise 2
• Shorter courses (5-7 days) are validated only for uncomplicated acute bacterial sinusitis, not for deep space head and neck infections 6

Adjunctive Measures to Enhance Recovery

• Single dose of corticosteroids (such as dexamethasone 10 mg IV) may reduce symptoms and speed recovery 3
• Adequate hydration and pain control with NSAIDs or acetaminophen 1, 2
• Warm saline gargles to promote drainage and reduce inflammation 2

Common Pitfalls to Avoid

• Do not use a 5-7 day course: This duration is appropriate for sinusitis but inadequate for peritonsillar infections 6, 3
• Do not discharge without clear follow-up instructions: Patient must return immediately if develops worsening dysphagia, drooling, respiratory distress, or inability to tolerate oral intake 2
• Do not assume clinical improvement means infection is eradicated: Complete the full 10-14 day course even after symptoms resolve to prevent recurrence 3, 7

When to Escalate Care

• Worsening symptoms at any time during treatment warrants immediate ENT re-evaluation for possible drainage 5, 2
• Persistent fever or leukocytosis beyond 72 hours suggests treatment failure requiring drainage or antibiotic change 5, 3
• Development of trismus, drooling, or respiratory symptoms indicates potential airway compromise requiring urgent intervention 2