A systematic review of the role of penicillin vs penicillin plus
metronidazole in the management of peritonsillar abscess.
Abstract
Background Peritonsillar abscess is a common clinical problem.
Management involves drainage of the abscess and administration of
antibiotics. The choice of antibiotic is related to the polymicrobial
growth of aspirate cultures, leading to prescriptions of co-amoxiclav,
or metronidazole in addition to phenoxymethylpenicillin. However there
is little evidence to support this. Objectives The aim of this review
was to assess clinical effectiveness of phenoxymethylpenicillin vs
phenoxymethylpenicillin plus anaerobic cover in the management of
peritonsillar abscess. Design/Setting A systematic review of literature
and clinical trial databases in accordance with the PRISMA 2020
statement. Studies were screened for eligibility by two independent
reviewers. Main outcome measure Three studies were included, two
comparing oral penicillin to oral penicillin plus metronidazole, one
comparing IM/oral penicillin to IM/oral sulbactam-ampicillin. Clinical
outcomes were assessed in all, including recurrence rate, symptom
improvement and duration of pyrexia. Results There was no significant
difference in any clinical outcome across all studies between the two
groups. One study found a significant increase in diarrhoea and vomiting
as a side effect in the group receiving metronidazole plus penicillin
compared to penicillin alone (p=0.01). Conclusion On reviewing the
literature, no significant clinical benefit has been demonstrated in the
addition of either metronidazole or more broad-spectrum antibiotic cover
compared to oral penicillin monotherapy for peritonsillar abscess when
combined with incision and drainage protocols. Moreover, unnecessary
broad-spectrum antibiotics contribute to increased side effects, costs,
and antimicrobial resistance.