Angina (acute tonsillitis) - Treatment

Treatment of tonsillitis has several goals - elimination of inflammatory changes in the throat and other clinical manifestations of the disease, eradication of the pathogen, prevention of the development of general and local complications, as well as prevention of the spread of the disease among others.

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Non-drug treatment of angina

In the first days, a strict bed rest is prescribed, and then - home rest with limited physical activity, which is important to prevent complications. The patient must be given separate dishes, a towel, and contact with others, especially children, must be limited as much as possible. They recommend drinking plenty of fluids (fruit juices, tea with lemon, rosehip infusion, Borjomi, etc.), a gentle, non-irritating, predominantly dairy and plant-based diet, rich in vitamins.

Drug treatment of angina

In accordance with international recommendations, phenoxymethylpenicillin is prescribed as the drug of choice for streptococcal tonsillitis (0.5 g every 6 hours, taken orally one hour before meals). The course of treatment for tonsillitis is no less than 10 days. The basis for choosing this particular drug is the fact that phenoxymethylpenicillin has high activity against beta-hemolytic streptococcus and a narrow antimicrobial spectrum, due to which its "ecological pressure" on normal microflora is minimized.

Amoxicillin is widely used, characterized by high bioavailability (up to 93%), independent of food intake, and improved tolerability. It should be noted that domestic specialists consider amoxicillin as a first-line drug in the treatment of sore throat caused by beta-hemolytic streptococcus group A. Amoxicillin is excreted from the body more slowly, it is enough to prescribe 3, and in some cases 2 times a day. Its dosage form Flemoxin-Solutab is widely used, which is almost completely absorbed after oral administration. Flemoxin Solutab is prescribed in tablets to adults at 500 mg 2 times a day before or after meals. The drug can be used during pregnancy, since its negative impact on the fetus is minimal.

In severe cases of angina, as well as in case of recurrent disease, preference is given to inhibitor-protected penicillins (amoxicillin + and clavulanic acid 0.625-1.0 g every 8-12 hours, preferably during meals). After oral administration, the drug is quickly absorbed regardless of food intake; clavulanic acid, which is part of it, inhibits a significant number of beta-lactamases produced by aerobic and anaerobic bacteria.

In the presence of an allergy to penicillins, alternative antibiotics used to treat streptococcal tonsillitis include macrolides and oral cephalosporins of the first and second generations.

Azithromycin is used from the macrolide group, which is not destroyed in the stomach. A high concentration of the drug is quickly created in the tonsils, which, due to the long half-life in tissues, is maintained for up to 7 days after the end of the intake. This allows using azithromycin 500 mg 1 time per day for 3-5 days instead of the usual 10. The drug should be taken 1 hour before or 2 hours after meals. Good tolerability of the drug in children and adults is noted, side effects with its use are extremely rare. Other macrolides are also used to treat tonsillitis and exacerbation of chronic tonsillitis: spiramycin - 3 million ME 2 times a day; roxithromycin - 150 mg 2 times a day; midecamycin - 400 mg 3 times a day. These macrolides are used for 10 days.

Cephalosporin antibiotics are also used to treat angina. These drugs are third in terms of frequency of prescription. Cephalexin, which belongs to the first generation of cephalosporins, has a rapid and reliable effect on angina caused by gram-positive coccal flora; it is prescribed orally before meals at 500 mg 2-4 times a day. Cefuroxime can be prescribed initially parenterally at 1.5 g 2-3 times a day, and after the temperature has normalized, the pain in the throat has decreased and the ability to swallow normally has been restored, it can be switched to oral administration (150-500 mg 2 times a day).

Carbapenems have the broadest spectrum of antibacterial activity, so these antibiotics play the role of an empirical therapy for the most severe complications of inflammatory diseases of the pharynx. Imipenem, which has increased resistance to chromosomal and plasmid beta-lactamases, is used from this group. The drug is administered intravenously by drip or intramuscularly at a dose of up to 1.5-2 g per day (500 mg every 6-8-12 hours). Meropenem is characterized by high efficiency in severe infectious complications accompanied by a neutropenic reaction, as well as in the development of a nosocomial infection in a patient in the postoperative period, for example, after abscess tonsillectomyelectomy.

Neither fluoroquinolones nor tetracyclines are mentioned in current guidelines for the treatment of streptococcal sore throats because they do not have clinically significant activity against group A beta-hemolytic streptococci.

Sulfanilamides are significantly inferior in activity to modern antibiotics and at the same time are characterized by high toxicity. Most clinically significant pathogens are resistant to sulfanilamides. Therefore, sulfanilamides are currently practically not used in the treatment of angina. Co-trimoxazole should not be recommended for the treatment of angina, since in recent years the resistance of microorganisms to this drug has increased significantly; in addition, its potential toxicity should be taken into account.

Recent studies have shown that for complete sanitation of the tonsils and, consequently, full prevention of post-streptococcal diseases, a 10-day course of antibacterial therapy is necessary, which has proven itself to be effective for an adequately selected drug. The exception is azithromycin, which, due to its pharmacodynamics, can be used for 5 days.

Along with antibacterial therapy, it is advisable to prescribe antihistamine drugs (chloropyramine, clemastine, phenylephrine, loratadine, fexofenadine, etc.), vitamins, especially C and group B.

In some cases, when the beta-streptococcal nature of the disease is not confirmed, the use of local antibacterial agents is justified. The advantage of local action of the drug, when it gets directly on the mucous membrane of the tonsils and pharynx, is the absence or reduction to a minimum of its resorptive action, which is especially important, for example, in the treatment of tonsillitis in a pregnant woman or a nursing mother. For local action, the antibiotic fusafungin is widely used (available as an aerosol drug Bioparox for inhalation through the mouth every 4 hours), which has a wide spectrum of antimicrobial action and at the same time gives an anti-inflammatory effect. In case of catarrhal tonsillitis, treatment with fusangin inhalations may be sufficient, in severe forms of tonsillitis this drug is used as an auxiliary one, while the appointment of systemic antibiotic therapy is mandatory.

It is also possible to recommend the antiseptic for local application stopangin. In addition to the antibacterial action, the drug has antifungal activity and exhibits an analgesic effect. Strepsils Plus is also used locally in the form of a spray, which includes two antiseptic components (dichlorobenzyl alcohol and amylmetacresol) and the application anesthetic lidocaine.

It is also prescribed to gargle the throat 5-6 times during the day with a warm solution of nitrofural diluted 1:5000, soda (1 teaspoon per glass of water), herbal decoctions (sage, chamomile, calendula, etc.), 0.01% solution of miramistin, hydrogen peroxide (2 tablespoons of 3% solution per glass of water), etc.

To increase local and general resistance of the body, immunomodulators are used, including a mixture of bacterial lysates. The drug contains lysates of the main pathogens of diseases of the oral cavity and pharynx. Take 1 tablet, dissolving in the mouth, 5 times a day for a week, then continue 1 tablet 3 times a day for another week).

The herbal preparation tonsilgon has an anti-inflammatory, immunostimulating effect, increases the phagocytic activity of macrophages and granulocytes, and increases the rate of destruction of phagocytized microorganisms. The drug is prescribed to adults at 25 drops 5 times a day, and to infants at 5 drops. After the acute manifestations of the disease have disappeared, the frequency of administration is reduced to 3 times a day; the course is up to 4-6 weeks. Local prescriptions also include a warming compress on the submandibular region, which should be changed every 4 hours.

In the treatment of Simanovsky-Plaut-Vincent angina, oral care, sanitation of carious teeth and perigingival pockets, which are often foci of fusospirillosis, are important. A non-irritating and vitamin-rich diet is prescribed. The ulcer is carefully cleaned of necrotic masses and treated with antiseptics every day. Rinsing is prescribed 5 times a day with a solution of hydrogen peroxide (1-2 tablespoons of a 3% solution per glass of water), potassium permanganate in a dilution of 1:2000, ethacridine in a dilution of 1:2000. The ulcer surface is treated with 5% iodine tincture, 1% alcohol solution of methylene blue, and is extinguished with a 10% solution of silver nitrate.

In case of fungal tonsillitis, it is necessary to cancel antibiotics, take measures to increase general and local resistance of the body. Intimate groups B, C and K are prescribed. It is recommended to dissolve tablets with dequalinium chloride in the mouth, 1-2 tablets every 3-5 hours. The affected areas of the mucous membrane are lubricated with solutions of natamycin, terbinafine, batrafen, 2% aqueous or alcohol solutions of aniline dyes - methylene blue and gentian violet, 5% solution of silver nitrate. For systemic antifungal therapy, fluconazole is used in capsules of 0.05-0.1 g once a day for 7-14 days, itraconazole in capsules of 0.1 g 1-2 times a day for 3 weeks.

Antibiotics are not indicated as initial therapy for viral tonsillitis, but may be prescribed if a bacterial infection develops. Irrigation of the throat with interferon and disinfectant rinses are recommended. Antiviral drugs are usually prescribed for herpetic lesions. Acyclovir is used at 0.2 g in tablets 3-5 times a day for 5 days, tilorone at 0.125 g in tablets 2 times a day for the first 2 days, then up to 1 tablet every 48 hours for a week. Symptomatic and general strengthening therapy is also indicated.

In case of infectious tonsillitis (diphtheria, measles, scarlet fever, etc.), the underlying disease is treated under the supervision of an infectious disease specialist; tonsillitis in a patient with a blood disease is treated by a hematologist.

After the local and general manifestations of the disease have been eliminated, you should wait 2-3 days before allowing you to return to work. In the following 3-4 weeks, it is recommended to follow a gentle regimen: limit physical activity, avoid hypothermia.

Depending on the form of tonsillitis and the characteristics of its clinical course, the nature and duration of treatment for tonsillitis vary.

Surgical treatment of angina

Surgical treatment of angina is carried out in case of diagnosis of phlegmonous angina (intratonsillar abscess). Treatment consists of wide opening of the abscess. In case of relapse, which is observed quite often, tonsillectomy is indicated.

Further management

For 3 weeks after clinical recovery, a patient who has had tonsillitis is recommended to take complex vitamin preparations (vitamins C, A, D, group B, etc.); in some cases, the use of topical immunomodulators (Imudon) is recommended.

If there was streptococcal tonsillitis, then it is necessary to perform an ECG, do a clinical blood and urine test. Consultations with a rheumatologist, therapist, and, if there are corresponding complaints, a nephrologist are indicated. Then an examination by an otolaryngologist is carried out to exclude chronic tonsillitis. It is necessary to take into account that earlier than after 3 weeks, it is difficult to differentiate residual effects of tonsillitis and local signs of chronic tonsillitis during mesopharyngoscopy.

It is important to remember that tonsillitis is an infectious disease and there is a high probability of spreading the infection among people with whom the patient communicates, up to the 10th-12th day of illness, but especially in the first days of illness. Therefore, it is necessary to limit his contacts with others, especially with children, to use individual dishes, and to ventilate the room in which the patient is more often. Even after clinical recovery, some people who have had tonsillitis remain carriers of the infection and can infect others. The carrier of the infection can be identified by bacteriological examination of material from the surface of the tonsils and the back wall of the pharynx.

Treatment of angina, consisting only of local means (rinsing, aerosols, antiseptics in pills or tablets for resorption in the mouth) in most cases is ineffective. It is necessary to conduct antibiotic therapy as prescribed by the doctor.