Recurrent acute tonsillitis: Therapeutic challenges

Abstract

Introduction: Acute tonsillopharyngitis is one of the most common infections of the upper respiratory tract, and in a number of patients a relapse of the infection may occur shortly after the termination of antibiotic treatment. It is more likely that recurrent acute tonsillopharyngitis (RATP) is primarily a result of therapeutic failure in pathogen eradication. Penicillin failure in the treatment of bacterial tonsillopharyngitis. The explanation for the penicillin failure in the treatment of bacterial tonsillopharyngitis should be sought in its inability to eradicate intracellular beta-hemolytic streptococci group A (GABHS), as well as its inability to achieve therapeutic concentration in the tonsillar surface fluid. Furthermore, betalactamase-producing bacteria (BLPB) act protectively against GABHS by inactivating penicillin. The synergistic effect with GABHS is frequently achieved with Moraxella catarrhalis, which in addition to the production of this enzyme, also enhances the adherence of GABHS to human epithelial cells. Normal bacterial flora with its various mechanisms influences on the colonization of pathogens and subsequent infection. It behaves competitively for nutrients and suppresses the growth of other strains with its products. This behavior is called bacterial interference and the best-known interfering bacterium is Alpha-hemolytic streptococcus. The presence of bacteria with interfering capacity was found in 30% of children with RATP, while in children without RATP it was found in as many as 85% of cases. Tonsillopharyngitis treatment: Current evidence suggests that the decrease in the number of acute tonsillopharyngitis episodes can be achieved with long-term prophylactic administration of cefpodoxime or 10-day course of clindamycin. Spontaneous resolution occurs in a number of patients, therefore the antibiotic treatment in the absence of an acute infection is not recommended. Penicillin should not be used in cases of confirmed presence of BLPB, when there is coaggregation of GABHS with Moraxella catarrhalis, in cases of absence of bacteria with interfering capacity, in patients that experienced failure of GABHS eradication with previous treatment, in recurrent GABHS tonsillopharyngitis, in the community with a high degree of unsuccessful treatment with penicillin (resistant bacterial strains) and in cases of allergic reaction to penicillin. The national guideline of good clinical practice for rational use of antibiotics does not recommend amoxicillin with clavulanate as the antibiotic of choice in the treatment of acute tonsillitis; also, according to other guidelines it is not the antibiotic of the first choice in recurrent tonsillitis. Macrolides were used as an effective alternative to penicillin, however, over time GABHS developed high resistance to macrolides and they should not be used routinely for the treatment of acute tonsillopharyngitis. Clindamycin has shown superiority in the tonsillar GABHS eradication of patients with RATP. Cephalosporins have been shown to be quite effective in patients with prior treatment failure or with RATP. High efficacy of cephalosporins is based on the ability to eradicate GABHS as well as concomitant BLPB and preserve interfering, protective bacterial strains. Conclusion: Tonsillectomy is recommended in patients with RATP. Antibiotic treatment may be offered to patients who do not meet criteria for tonsillectomy, in spite of their suffering from recurrent infections and to patients with contraindications or reluctance to tonsillectomy. Penicillin is not effective in eradicating GABHS and BLPB, as well as preventing future acute infections in patients with RATP, therefore it is preferable to use broad-spectrum antibiotics, such as cephalosporins. Prophylactic use of antibiotics in the treatment of RATP is not recommended.