Recognizing and Treating Tonsillitis

Release Date: May 1, 2013

Expiration Date: May 31, 2015

FACULTY:

Emily M. Ambizas, PharmD, CGP
Associate Clinical Professor
St. John’s University
College of Pharmacy & Allied Health
Professions
Queens, New York
Clinical Specialist
Rite Aid Pharmacy
Whitestone, New York

Alberto H. Ambizas, PharmD, CGP
Clinical Pharmacy Supervisor
Pharmacy Service
Department of Veterans Affairs
Northport, New York

FACULTY DISCLOSURE STATEMENTS:

Drs. Ambizas have no actual or potential conflicts of interest in relation to this activity.

Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.

ACCREDITATION STATEMENT:

Pharmacy acpe
Postgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
UAN: 0430-0000-13-010-H01-P
Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

FEE INFORMATION:

Payment of $6.50 required for exam to be graded.

TARGET AUDIENCE:

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

Exam processing and other inquiries to:
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DISCLAIMER:

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

GOAL:

To enhance the pharmacist's knowledge about the presentation, treatment, and complications associated with tonsillitis.

OBJECTIVES:

After completing this activity, the participant should be able to:

  1. Discuss the various etiologies of tonsillitis.
  2. Recognize signs and symptoms associated with viral and bacterial tonsillitis.
  3. Apply appropriate antibiotic therapy for the treatment of bacterial tonsillitis.
  4. Identify complications associated with tonsillitis.


ABSTRACT: Tonsillitis is a common childhood disorder. It is responsible for almost 6 million physician office visits annually. Tonsillitis has multiple etiologies, most commonly viruses and bacteria. Approximately 30% to 40% of tonsillitis cases in children can be attributed to a bacterial cause. Group A beta-hemolytic streptococcus is the most common bacterial pathogen causing tonsillitis and the only source warranting antibiotic treatment. Treatment is usually a 10-day course of penicillin; however, penicillin failure is a concern. Complications of tonsillitis can be classified as suppurative and nonsuppurative. Antibiotic treatment is important in preventing such complications from occurring.

The term tonsillitis typically refers to inflammation of the palatine tonsils. It is one of the most common problems encountered by otolaryngologists in the adult and pediatric populations; however, tonsillitis is primarily a childhood disease affecting children aged 5 to 15 years.1,2 This condition is responsible for more than 6 million physician office visits annually by children in this age group.3 Transmission is by person-to-person contact, most likely via droplets of saliva or nasal secretions.4 Tonsillitis can be defined as acute, recurrent, or chronic. Tonsillitis is considered to be recurrent when a patient experiences six to seven episodes of acute tonsillitis in 1 year, five episodes per year for 2 consecutive years, or three episodes per year for 3 consecutive years.5 Chronic tonsillitis is diagnosed when a sore throat is present for at least 3 months with tonsillar inflammation, halitosis, and persistent tender cervical adenopathy.5

The tonsils are simple lymphoid organs. They form a ring of lymphatic tissue around the entrance of the pharynx also known as Waldeyer's tonsillar ring. The tonsils are named according to their location. The palatine tonsils are located on the lateral walls of the oropharynx, the common entry of both the respiratory and the gastrointestinal tracts; the lingual tonsils are located at the base of the tongue; the pharyngeal tonsils (adenoids) are located in the posterior wall of the nasopharynx; and the tubal tonsils are situated at the pharyngeal opening of the eustachian tubes.5-7 The adenoids, along with the palatine and lingual tonsils, make up a major portion of Waldeyer's ring, while the tubal tonsils are a less prominent component.8

Palatine Tonsils

The palatine tonsils play an important role in initiating immune responses against various antigens that gain entry through the nasal and oral routes.6 The greatest immunologic activity of the palatine tonsils is found to occur between the ages of 3 and 10 years.6,9 The tonsils are mainly beta-cell organs with B lymphocytes constituting about 50% to 90% of all tonsillar lymphocytes, while T lymphocytes are relatively sparse.6,10,11 Each tonsil has 10 to 30 blind-ending, tubular, branched crypts that trap foreign material and transport it to the lymphoid follicles.6 There, dendritic cells and macrophages process the antigens and present them to helper T cells. The helper T cells stimulate proliferation of follicular B lymphocytes and their development into either antibody-expressing B memory cells or plasma cells that produce antibodies and release them into the lumen of the crypt.9 Although all five immunoglobulin (Ig) isotypes are produced in the palatine tonsils, IgA is perhaps the most important component of the tonsillar humoral immune system.6,9 Successful mucosal protection relies on the ability of secretory IgA to prevent adherence of both bacteria and viruses to the pharyngeal epithelium.7

Etiology and Presentation

Tonsillitis occurs when trapped organisms multiply within and on the tonsils, exceeding the protective potency of activated lymphoid and immunoglobulin-producing cells.6,12 Many organisms can induce tonsillitis. These include bacteria, viruses, yeasts, and parasites (TABLE 1). Some of the infectious agents are part of the normal flora of the oropharynx and, because of this, most infections are polymicrobial. There appears to be a synergistic interaction between the various organisms, enhancing the virulence of the pathogens.13


table1

The most common pathogens causing tonsillitis include adenovirus, enterovirus, Epstein-Barr virus, group beta-hemolytic streptococcus (GABHS), Haemophilus influenzae, and Staphylococcus aureus.12-14 The risk of infection depends on environmental conditions such as exposure and season, and on individual variables such as age and immunity.13 Age appears to be the most helpful factor when trying to establish the causative agent as viral or bacterial; viral tonsillitis is more common in children younger than 3 years, and GABHS tonsillitis is more common in children 6 years or older.15

Approximately 30% to 40% of tonsillitis cases in children are bacterial.16 Group A streptococcus is an important bacterial cause of acute tonsillitis and the only common cause of sore throat warranting treatment with antibiotics.17,18

These bacteria are cultured in 15% to 36% of children with sore throat.17 Patients infected with GABHS usually present in the winter or early spring with fever, sudden onset of sore throat, halitosis, and dysphagia. Headache, nausea, vomiting, and abdominal pain may also be present.1,18 On physical examination, patients will have tonsillopharyngeal erythema, and tender, enlarged cervical lymph nodes.11 Other findings include a red, swollen uvula, petechiae on the palate, excorinated nares, and a scarlatiniform rash.11 Viral tonsillitis occurs in approximately 15% to 40% of children.16 Patients usually present with a triad of cough, coryza, and conjunctivitis; patients infected with the Epstein-Barr virus will present with anterior and posterior cervical lymphadenopathy, odynophagia, and a grayish tonsillar exudate.1

Diagnosis of GABHS Tonsillitis

Diagnosis of GABHS tonsillitis is important to prevent inappropriate administration of antibiotics to patients with nonstreptococcal tonsillitis. Inappropriate antibiotic use for upper respiratory infections has contributed to the rising incidence of antimicrobial resistance.19 Clinical features alone do not reliably differentiate between GABHS and viral tonsillitis, except when viral features such as rhinorrhea, cough, and/or hoarseness accompany a sore throat.18 Testing for GABHS is usually not recommended for children who present with symptoms of a viral etiology or for those who are <3 years because GABHS is uncommon in this age group.18 When GABHS is suspected, a throat swab by rapid antigen detection test (RADT) and/or culture should be confirmed.18 The culture of a throat swab on a sheep-blood agar plate is considered the gold standard for determining the presence of GABHS in the pharynx; if performed correctly, this method is 90% to 95% sensitive.18 A major disadvantage to the use of blood agar throat cultures is the delay in results. It can take at least 1 day before results are available. Because of this, RADTs were developed, allowing for a shorter turnaround time. Rapid identification and treatment of GABHS tonsillitis allows for earlier treatment with antibiotics, reducing the risk of spread and allowing children to return to school sooner.20 Compared to blood agar throat cultures, RADTs have a high specificity of approximately 95%, making false-positive test results highly unusual; however, the sensitivity of these tests ranges from 70% to 90%.18 Since most RADTs have a sensitivity of <90% and because the incidence of GABHS in children is high, a negative RADT should be confirmed with a blood agar throat culture.18

Pharmacologic Treatment

Antibiotic therapy is indicated in patients with acute tonsillitis if GABHS infection has been confirmed with either a throat culture or RADT.18 The most important goal of antibiotic therapy for GABHS is to prevent rheumatic fever.21 Other goals of antimicrobial treatment for the eradication of GABHS include reducing the severity and duration of symptoms; reducing the incidence of suppurative and other nonsuppurative complications; and reducing transmission.22 When selecting an antibiotic, it is important to consider efficacy, safety, dosing schedule, spectrum coverage, and cost. Several classes of antibiotics (TABLE 2) have been proven to be effective in the treatment of GABHS, but the American Academy of Pediatrics and the Infectious Diseases Society of America indicate penicillin as the agent of choice for first-line treatment.18,23 Amoxicillin is an appropriate alternative, especially in children, due to a more palatable suspension and comparable cost.24


table2

Penicillin therapy when administered for 10 days has resulted in bacteriologic and clinical cure in approximately 90% of children infected with GABHS, but there has been growing concern about failure with penicillins to eradicate this organism from the inflamed tonsils.21,25,26 The reported failure rate varies from 6% to 23%; however, this failure does not appear to be due to penicillin resistance.27 This lack of resistance may result from the organism's lack of altered penicillin-binding proteins and/or inefficient gene transfer mechanisms for resistance.28,29 Failure of penicillin therapy can be attributed to noncompliance with the 10-day course of therapy, co-colonization by beta-lactamase-producing bacterial pathogens that can inactivate penicillins, rendering them ineffective against GABHS, and eradication of the normal oropharyngeal flora, particularly alpha-hemolytic streptococcus.22 Poor compliance is an important cause of penicillin failure. In one study evaluating amoxicillin and penicillin V therapy, almost half of patients completely finished their 10-day course, while almost one-third of patients missed one or two doses and the remaining patients missed three or more doses.30 In another study, it was noted that most parents stopped administering antibiotics to their children once symptoms subsided.31 There are many reasons why patients are nonadherent. Patients may stop taking the antibiotic once they start to feel better, children may reject the suspension due to poor palatability, side effects may prompt the patient to discontinue use, or the dosing regimen may be inconvenient.22 In patients where adherence may be a concern, use of a short-course antibiotic would be appropriate. Currently, the FDA has approved cefdinir, cefpodoxime, and azithromycin for a 5-day treatment course of GABHS tonsillitis.18

Cephalosporins are acceptable alternatives to penicillin, although they are not recommended as first-line therapy. Cephalosporins have demonstrated better microbiological and clinical cure rates when compared to penicillins.32 Cephalosporins may be more effective in eradicating GABHS from the oropharynx for three reasons: the presence of beta-lactamase-producing copathogens inactivates penicillin action but not cephalosporins; cephalosporins are not as active against alpha-hemolytic streptococcus; and cephalosporins achieve better bactericidal drug levels in the tonsillopharynx because of improved pharmacokinetic and pharmacodynamic profiles.32

Cephalosporins are recommended in patients who report a history of non-life-threatening penicillin allergy and in those with recurrent infections where copathogenicity is suspected in treatment failure.18,33 Recurrence of tonsillitis after antimicrobial therapy is common. Recurrence occurs within 30 days of therapy in 21.8% of penicillin-treated patients, in 16.8% of amoxicillin-treated patients, in 14% of macrolide-treated patients, and in 8.6% of cephalosporin-treated patients.34

Other alternatives utilized in penicillin allergic patients include clindamycin and oral macrolides. Clindamycin resistance is about 1% in the United States, so it is a reasonable alternative; however, potentially serious side effects such as pseudomembranous colitis limit its use.16,35 Oral macrolides include erythromycin, clarithromycin, and azithromycin. A 10-day course of therapy is required for all except azithromycin, which is given for 5 days. Erythromycin's use is limited owing to higher rates of gastrointestinal (GI) side effects. In the U.S., macrolide resistance has been noted to be around 5% to 8% in most areas.35,36 Even though the macrolides are an alternative choice to treat GABHS, their use should be limited or reserved for those who have a penicillin allergy. The increased use of macrolides in the treatment of various respiratory infections has been associated with increased GABHS resistance to them.

In general, patients should improve within 24 to 48 hours of initiating therapy. Even without treatment, fever and symptoms commonly resolve in a few days. If symptoms persist, it is indicative of the development of a suppurative complication or that the child may be a chronic carrier of GABHS with an intercurrent viral pharyngitis.18

There are certain antibiotics that should not be utilized in the treatment of GABHS tonsillitis.18 Tetracyclines should not be recommended because of high prevalence of resistant strains. Sulfonamides and sulfamethoxazole-trimethoprim have not shown efficacy in eradicating GABHS in patients with acute tonsillitis. Older fluoroquinolones should be avoided because they have limited activity against GABHS; newer fluoroquinolones (i.e., levofloxacin and moxifloxacin) have demonstrated in vitro activity against GABHS, but they are more expensive and have an unnecessarily broad spectrum of activity. In addition, fluoroquinolone use in younger patients has been controversial due to potential adverse drug reactions.

Tonsillectomy

The surgical removal of tonsils in children has become very controversial is recent years; however, is has remained one of the most commonly performed ambulatory surgical procedures in the U.S.37 A tonsillectomy can be considered in patients whose symptomatic episodes do not diminish over time and for whom no alternative explanation for recurrent GABHS tonsillitis is evident.18 A practitioner may recommend a tonsillectomy for patients who suffer from recurrent tonsillitis episodes with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3C, cervical adenopathy, tonsillar exudate, or positive GAHBS test.9 When considering surgery, it is important to remember that most tonsil-related problems in children will diminish naturally with increasing age. Decisions should be individualized according to potential benefits and risks in comparison to alternate strategies, taking into consideration the values and preferences of the family and child.9 Although a tonsillectomy will always prevent tonsillitis, the impact on sore throats due to pharyngitis is much less predictable.38

Complications of Tonsillitis

Complications of tonsillitis can be categorized into suppurative and nonsuppurative complications. Suppurative complications include peritonsillar, parapharyngeal, and retropharyngeal abscesses; otitis media; and sinusitis. These complications are rare, but some are very serious. Otitis media is one of the two most common suppurative complications of GABHS tonsillitis. It occurs because of direct extension of the bacteria to the ear via the eustachian tube. Although it is one of the most common suppurative complications, GABHS accounts for less than 5% of all acute otitis media cases; in the winter months, incidence increases to 10%.39 Sinusitis is another common complication. The use of antibiotics has been shown to decrease the incidence of acute otitis media by two-thirds and acute sinusitis by a half.40

Peritonsillar abscesses most commonly occur in patients with recurrent or chronic tonsillitis who have not been adequately treated.11 These infections typically occur in young adults, but can cause significant airway obstruction in children.41 The infection is usually polymicrobial, formed by a combination of aerobic and anaerobic bacteria.41 Patients will usually present with unilateral pain that causes odynophagia; this pain can be severe enough that patients are unable to swallow and dehydration may result.42

Peritonsillar abscesses and tonsillitis may result in parapharyngeal abscesses. These abscesses can occur at any age, but rarely before 8 years.43 The most common symptoms are fever, sore throat, dysphagia, swelling, and trismus.43,44 As with peritonsillar abscesses, this infection is polymicrobial.

A retropharyngeal abscess may also result from peritonsillar abscess. These are more common in children younger than 3 years. Patients with this abscess will usually present as irritable and have fever, dysphagia, airway obstruction, unilateral pain, and torticollis.42 Unlike the previous two abscesses discussed, retropharyngeal abscesses are more likely to have pathogenic aerobic isolates (group A and B streptococcus, S aureus), alone or mixed.43

Nonsuppurative complications of tonsillitis include scarlet fever, acute rheumatic fevers, and poststreptococcal glomerulonephritis. Scarlet fever is a diffuse erythematous eruption that generally occurs with GABHS pharyngitis.45 The skin appears sunburned and roughened. The rash is most intense in the axillae and groin and on the abdomen and trunk.45 Other clinical signs include fever, severe lymphadenopathy, tachycardia, and a yellow exudate overlying the tonsils.11 Scarlet fever with pharyngitis/tonsillitis can predispose a patient to acute rheumatic fever.

Acute rheumatic fever (ARF) has become a relatively rare complication of GABHS tonsillitis in Western countries, but this disease still causes 25% to 40% of all cardiovascular disease in the world.46 It is an inflammatory disease of the heart, joints, central nervous system, and subcutaneious tissues. ARF precedes GABHS throat infections, such as tonsillitis, by 1 to 4 weeks. Patients will usually experience fever, malaise, anorexia, migrating arthritis, and dyspnea.46 In addition, ARF is characterized by cardiac manifestations including pericarditis, myocarditis, and endocarditis.42

Poststreptococcal glomerulonephritis may develop 1 to 2 weeks after GABHS infection of the pharynx or skin. It can occur in patients of any age, but it is more common in children aged 6 to 10 years. The clinical presentation of poststreptococcal glomerulonephritis can range from no symptoms to the presence of hematuria accompanied by varying degrees of increase in serum creatinine, edema, and hypertension. The urine may be red to brown in color. Edema may be present due to sodium and water retention resulting from alteration in glomerular function. Fever is uncommon and headache may be present in cases accompanied with hypertension. Severe glomerular injury may be accompanied by massive proteinuria, anasarca, ascites, and severe compromise of renal function.47

Conclusion

The tonsils are constantly exposed to airborne pathogens presenting to the digestive and respiratory tracts. Because of this, it is inevitable that tonsillitis would be a common condition, especially in childhood. Although multiple organisms cause tonsillitis, it is important to accurately diagnose and treat GABHS tonsillitis to prevent complications; the incidence of complications due to tonsillitis has markedly decreased with the widespread use of antibiotics. Antimicrobial therapy for tonsillitis caused by other agents has not been proven to be effective. Penicillin is considered the gold standard of therapy, but failure does occur. Many failures are the result of poor adherence. It is essential that pharmacists educate patients about the importance of finishing a full course of antibiotic therapy even though symptoms usually resolve within 1 to 3 days.

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