Bacteremia during tonsillectomy

Tonsil microbiome in pediatric patients with post tonsillectomy hemorrhage for tonsillar hypertrophy

OBJECTIVE

This study aimed to compare the tonsillar microbiota between post tonsillectomy patients with bleeding and without bleeding, and to investigate the potential role of tonsillar microbiota in the development of post-tonsillectomy hemorrhage (PTH).

METHODS

Nineteen tonsillar tissues from PTH patients and 21 tissues from control patients were collected. Metagenomic sequencing was used to compare the microbiota in PTH and control groups. Alpha diversity indices were used to compare the richness and evenness of the microbiota between the two groups. PCoA and NMDS analyses were used to evaluate beta diversity. LDA analysis was conducted to identify significantly abundant genera.

RESULTS

No significant difference in alpha diversity indices was found between PTH and control patients. The dominant bacteria in the tonsillar microbiota were Haemophilus, Streptococcus, and Fusobacterium. PCoA and NMDS analyses showed significant differences in beta diversity between PTH and control patients. PTH patients had a significantly higher relative abundance of Neisseria, Capnocytophaga, and Veillonella. Capnocytophaga was also identified as a significantly abundant genus by LDA analysis.

CONCLUSION

This study demonstrates that there is a difference in the tonsillar microbiota between PTH and control patients. The results suggest that Neisseria, Capnocytophaga, and Veillonella may be associated with the development of PTH. These findings provide new insights into the potential role of the tonsillar microbiota in the development of PTH, and may help to develop new strategies for preventing and treating this potentially life-threatening complication.

Antibiotic Prophylaxis for Infective Endocarditis: A Survey of Practice Among Pediatric Cardiology Providers

The 2007 American Heart Association (AHA) guidelines limited antibiotic prophylaxis (AP) for infective endocarditis (IE) to fewer patients with predisposing cardiac conditions (PCC). We surveyed the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery (AAP SOCCS) on their recommendations for AP for a number of PCC and procedures. We report on those 173 respondents who follow the 2007 AHA guidelines. AP rates for high-risk PCCs clearly meeting AHA criteria ranged from 70.5-89.8%. Conversely, for PCCs which did not meet AHA criteria, prescribing rates varied from <1% to 29.5%. PCC for which AP indication was unclear per guidelines, AP rates similarly varied from 9.9-39.8%. Similar variability is noted in AP for various procedures in setting of high-risk PCC. There is variability in AP prescribing practices among pediatric cardiologists based on both underlying PCC and noncardiac procedures in the setting of underlying cardiac disease.

Bacteriemia During Mastoidectomy and/or Tympanoplasty

OBJECTIVE: To investigate the risk of bacteriemia development during surgery in patients who underwent mastoidectomy and/or tympanoplasty for chronic otitis media.

PATIENTS AND METHODS: A total of 59 patients with chronic otitis media who were undergoing tympanoplasty operation with or without mastoidectomy were enrolled in this study. Smear cultures were obtained from outer ear canal and/or middle ears of all patients before the operation. Venous blood samples were obtained before and after the operation for bacteriologic analysis. Smear cultures were also obtained from the pressure dressing material that was applied during the operation for retrieval of the outer ear canal pressure.

RESULTS: There was a 13.5% difference between the outer ear canal and/or middle ear smear cultures and ear pressure dressing smear cultures of the same case. There was no growth in the blood cultures obtained before tympanoplasty in any of the involved cases, however, in 5 (8.4%) of the culture samples obtained immediately after the tympanoplasty operation, there was bacteriemia. In the pressure dressing smear cultures obtained after the operation, 11 patients had microbial growth.

CONCLUSION: Risk of bacteriemia should be considered in the preoperative period for the patients undergoing mastoidectomy especially in patients with cardiovascular diseases, this is of importance for the dramatic consequences that might arise after the operation. We also think that bacteriemia is also one of the factors that influences graft success rate.

Role of Laryngopharyngeal Reflux in Complications of Tonsillectomy in Pediatric Patients

Tonsillectomy and tonsillectomy with adenoidectomy are among the most common surgical procedures in otolaryngology practice. Gastroesophageal reflux was identified as a risk factor for complications in tonsillectomy. This prospective study was designed to assess the role of reflux in the development of complications following tonsillectomy in pediatric patients. Children (n = 60) who underwent tonsillectomy with adenoidectomy were divided into two groups, i.e., the laryngopharyngeal reflux (LPR) group and control group. Patients with LPR were identified by reflux symptom index and reflux finding score. Pain, hemorrhage, fever, nausea, vomiting, fever, dehydration, infection, and pulmonary problems were evaluated post operatively. The mean lengths of hospital stay were 2.11 days in the reflux group and 1.05 days in the control group. The difference was statistically significant. Visual analogue scores of both groups were similar on day 1 but it was significantly higher on day 7 and 14 in LPR group. Nausea and vomiting rates were 11.1 and 9.5 % for the patients in the LPR group and the controls, respectively. The difference between the two groups was not significant. The mean fever was 37.6 °C in the reflux group and 37.3 °C in the controls, which were not significantly different. 19 % of the controls and 22 % of the LPR group patients were readmitted. This difference was not statistically significant. There were two cases of bleeding in the reflux group, while no bleeding occurred in the control group. This difference was significant statistically. LPR is a risk factor for complications following tonsillectomy.

Posttonsillectomy bacteremia and comparison of tonsillar surface and deep culture

Objective. This study aimed to identify the microorganisms of surface and depth of tonsils and whether these microorganisms bring the menace of bacteremia during tonsillectomy in the children under surgery. Materials and Methods. The culture specimens were taken from surface and depth of tonsil from the patients suffering from chronic tonsillitis at the time of operation. Also, 10 mL venous blood samples were taken 5 minutes before and after the operation for microbiological study. Results. According to the results, 112 (76.1%) and 117 (79.6%) cultures from surface and depth of tonsils represented multiple microorganisms, respectively. Besides, staphylococci coagulase positive was the most common organism in both surface and depth of tonsils. None of the preoperation blood cultures were positive, while 3 postoperation blood cultures (2.1%) were positive. Staphylococci coagulase negative and alpha hemolytic streptococcus were detected in 2 cases (1.4%) and 1 case (0.7%), respectively. Conclusion. In the present study, the two cultured sites were almost similar regarding the types of isolated microorganisms. Our results suggested that bacteremia might occur after tonsillectomy. Therefore, to avoid the possible dramatic outcomes after tonsillectomy, pre- and postoperation attendances are essential.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Recovery of probiotic Lactobacillus rhamnosus GG in tonsil tissue after oral administration: randomised, placebo-controlled, double-blind clinical trial

The present randomised, double-blind, placebo-controlled study was conducted to determine whether consumption of probiotic Lactobacillus rhamnosus GG (GG) would lead to the recovery of GG in tonsil tissue. After 3 weeks’ daily consumption of GG as a single strain (n 20), GG as a part of a multispecies combination (n 17) or placebo (n 20), tonsil tissue samples were collected from fifty-seven young adults during tonsillectomy due to chronic or recurrent tonsillitis. Strain-specific real-time PCR was used to detect GG in the tonsil tissue. GG was recovered in the tonsil sample of 40% of the subjects in the GG group, 41% in the multispecies group and 30% in the placebo group (P value between groups 0.79). In all subjects with positive recovery of GG in the tonsil tissue, GG was also recovered in the faecal sample taken at the start of the intervention and at the time of the tissue sample collection, which indicates more persistent adherence of the probiotic. To conclude, GG can be recovered from tonsil tissue after oral administration as a singlestrain probiotic or as a part of a multispecies probiotic combination. The present results suggest that individual variation exists in the ability of GG to adhere to tonsil tissue. Persistence of GG appears to be high in tonsil tissue as well, in addition to persistence in faecal samples, which has been demonstrated previously. Further clinical trials are warranted to evaluate whether probiotic adherence in the tonsil tissue could have a role in respiratory symptom prevalence.

Bacteremia during quinsy and elective tonsillectomy: an evaluation of antibiotic prophylaxis recommendations for patients undergoing tonsillectomy

AIMS

Bacteremia during elective tonsillectomy is well recognized, whereas bacteremia during quinsy tonsillectomy has never been studied. The aim of the present study was to explore the incidence of bacteremia during elective and quinsy tonsillectomy in order to evaluate the antibiotic prophylaxis recommendations to patients at high risk of infective endocarditis who are undergoing tonsillectomy.

METHODS

A prospective study was conducted on 80 patients undergoing elective tonsillectomy and 36 patients undergoing acute tonsillectomy due to peritonsillar abscess. Blood cultures, tonsillar swabs, core tissue, and pus aspirates were analyzed by standard microbiological techniques.

RESULTS

Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy (P = .089, Fishers exact test). Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases (P < .001, Spearman rank correlation). In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid.

DISCUSSION

Our results challenge the distinction made by the European Society of Cardiology between elective and quinsy tonsillectomy, with regard to antibiotic prophylaxis recommendation only to patients undergoing procedures to treat an established infection. To provide full empiric coverage, including coverage for Staphylococcus aureus, we advocate the use of amoxicillin with clavulanic acid in patients at high risk of infective endocarditis.

The comparison of bacteremia and amount of bleeding during adenotonsillectomy

OBJECTIVE

Adenoidectomies and/or tonsillectomies are among the most frequently performed otolaryngological surgical procedures.The goals of this study were to investigate the relationship between the amount of bleeding and bacteremia during adenoidectomy and/or tonsillectomy procedures.

METHODS

Seventy-eight patients who underwent tonsillectomy with or without adenoidectomy and adenoidectomy with or without tube insertion were included in the study. Patients with severe chronic underlying diseases (including cardiovascular disorders, renal or hepatic disease, or immunodeficiency) were excluded from study, as were those who had suffered an acute episode of respiratory infection or had received antibiotics for any reason within three weeks prior to the operation. The amount of bleeding was measured and recorded for each patient during the surgery. Preoperative blood cultures immediately after the induction of anesthesia and postoperative blood cultures 20 min after the operation were collected.

RESULTS

While none of the blood cultures taken preoperatively was positive for any organisms, the cultures obtained postoperatively were positive in 16 (20.5%) of 78 patients who underwent tonsillectomy with or without adenoidectomy and adenoidectomy with or without tube insertion, and bacteremia was more frequent among those with greater amount of bleeding during the surgery.

CONCLUSION

The results of this study suggest that although bacteremia had no clinical consequences in patients, it should be kept in mind that patients with greater amount of bleeding are at higher risk for developing bacteremia and it may produce vital results in patients at risk.

Utility of prophylactic antibiotics in pediatric adenoidectomy

OBJECTIVE

To determine the utility of prophylactic antibiotics in non-risk pediatric patients undergoing adenoidectomy.

METHODS

We performed a prospective, controlled, randomized, and double-blind study on patients under 14 years of age, scheduled for adenoidectomy who accomplished the following criteria: absence of immunosuppressive and/or cardiovascular risk factors, no antimicrobial therapy for at least 15 days prior to operation, and no fever 1 week before surgery. Venous blood samples for culture were obtained at 30s and 20 min after the curettage of adenoidal tissue. Likewise, immediate and delayed complications were registered in all cases. The usefulness of prophylaxis was analyzed according to three major standpoints: bacteremia, immediate complications, and delayed complications.

RESULTS

One-hundred one patients fulfilled the inclusion criteria and were included in the study. Fifty-one children received prophylaxis and the remainder did not. In the non-prophylactic group incidence of bacteremia at 30s was significantly higher than in the prophylactic group (32.7% versus 4.0%) (p<0.001). Neither bacteremia at 20 min, nor immediate or delayed complications showed statistical differences between both treatment groups.

CONCLUSIONS

Preoperative antimicrobial prophylaxis in pediatric adenoidectomy did not offer advantages preventing complications in non-risk patients. Only bacteremia that occurs 30s after the curettage of adenoid tissue is reduced with the employment of prophylactic antibiotics.

The use of perioperative antibiotics in tonsillectomy: does it decrease morbidity?

OBJECTIVE

To assess the efficacy of perioperative antibiotics in decreasing post-operative morbidity among patients undergoing tonsillectomy or adenotonsillectomy.

DESIGN

Meta-analysis based on a structured search of the literature, using MEDLINE and the Cochrane database.

SUBJECTS

Only articles, which included both treatment and control groups, were included in the final analysis. Studies were limited to ones that involved human subjects, including both children and adults. Studies using steroids and topical antibiotics were excluded.

OUTCOMES

Articles were abstracted for patient factors, elements of study design, methods of patient assignment to treatment and control groups, and clinical outcomes. The primary outcome, time required for return to normal oral intake, was analyzed in the final meta-analysis.

METHODS

Four hundred and twenty-eight articles were initially identified. There were 23 potentially appropriate articles. Of these, 18 were able to be located in full text form and in English. Seven of these studies directly studied the efficacy of perioperative antibiotics (versus no antibiotics) in decreasing post-operative morbidity. Four studies had sufficient information to calculate effects estimates (xi) and standard deviations (Si) for the primary outcome. Three studies either did not report the outcome of interest or did not report a measure of stability (e.g. p-value or confidence interval). The data available from the first four studies were combined in a quantitative meta-analysis. Statistical analyses were performed using STATA for Windows software.

RESULTS

The pooled estimate indicated that the antibiotic group returned to normal oral intake, on average, 1 day sooner than the controls. This difference was found to be statistically significant with a 95% confidence interval of 0.5-1.6 days. An additional assessment of three qualitative reports also suggested the use of perioperative antibiotics for adenotonsillectomy was associated with less post-operative pain. However, studies varied in terms of study quality, sample size, outcome examined, measure used and antibiotic administered. Definitive conclusions regarding the effect of perioperative antibiotics on other outcomes including bleeding, halitosis, fever, activity level and nausea and vomiting could not be drawn due to the small numbers of studies.

CONCLUSIONS

In this meta-analysis, the use of perioperative antibiotics in patients who have had tonsillectomy or adenotonsillectomy appears to be associated with a 1-day reduction in the time required for return to normal oral intake. For other potentially important outcomes, such as post operative pain or bleeding, sufficient data were not available to make any definitive conclusions regarding the effect of perioperative antibiotics.

Bacteremia following pediatric adenoidectomy

OBJECTIVE

Adenoidectomy is frequently performed in children. The goals of this work were to determine the incidence of bacteremia during the adenoidectomy, to identify the microorganisms implicated, and to analyze the possible association of bacteremia with postoperative complications.

METHODS

One hundred pediatric patients operated of adenoidectomy without preoperative antibiotic prophylaxis were prospectively included in this study. They had no immunosuppressive and/or cardiovascular risk factors, no antimicrobial therapy for at least 15 days prior to operation, and no fever 1 week before surgery. Venous blood samples were obtained 30 s and 20 min after the curettage of adenoidal tissue.

RESULTS

The 33 and 14% of the samples were positive at 30 s and 20 min. The organism more commonly isolated was the streptococcus viridans. Bacteremia was only related to postoperative acute otitis media (p=0.012).

CONCLUSIONS

Bacteremia exists after pediatric adenoidectomy, although it seldom correlates with clinical signs or symptoms. Postoperative acute otitis media is the only complication related to postsurgical bacteremia.

Cold dissection versus bipolar cauterizing tonsillectomy for bacteriemia

OBJECTIVE

The purpose of this study is to compare transient bacteriemia ratios between cold dissection tonsillectomy and bipolar cauterizing tonsillectomy, and also to analyze the bacteria detected with superficial/central tonsillar cultures.

METHODS

A total of 86 patients that were grouped as 46 patients of cold dissection tonsillectomy and 40 patients of bipolar cauterizing tonsillectomy were included in this study. Preoperative surface swab cultures, intraoperative central swab cultures of tonsils, and preoperative and postoperative blood culture samples were obtained. Antibiotic sensitivity tests were determined. Fischer exact chi 2 test was performed to compare the results of postoperative bacteriemia of both techniques statistically.

RESULTS

Postoperative bacteriemia was detected in 6 (13%) patients of cold dissection tonsillectomy group. In 5 (83.3%) of the 6 postoperative bacteriemia patients of cold dissection tonsillectomy group, isolated microorganism was confirmed both in the blood cultures and in the central swab cultures of tonsils, and resistance to penicillin was established. No patient of bipolar cauterizing tonsillectomy group appeared with postoperative bacteriemia. There was a statistically significant difference (P=.028) for postoperative bacteriemia between cold dissection tonsillectomy group and bipolar cauterizing tonsillectomy group.

CONCLUSION

We recommend bipolar cauterizing tonsillectomy for high-risk patients.

[Sepsis, arthritis and acute renal failure following adenoidectomy and insertion of drainage tubes]

We present a six year-old patient suffering of adenoiditis and serous otitis. After surgical intervention, she developed septicemia with arthritis and acute renal failure. We discuss the need to carry out antibiotic prophylaxis in patients without previous risk factors.

Invasive group A streptococcal infection after tonsillectomy

Tonsillectomy is a very common procedure in childhood. Infectious complications after tonsillectomy are infrequently reported. We describe two children with severe group A beta-hemolytic streptococcal infection after tonsillectomy, and we review the literature about bacteremia and infectious complications after tonsillectomy.

Bacteremia during adenoidectomy

OBJECTIVE

Although adenoidectomy is one of the most commonly performed surgical procedures in children, there is no satisfactory information about the risk of bacteremia during adenoidectomy and necessity of antibiotic use. The aim of this study was to determine the incidence of bacteremia during adenoidectomy and identify the organisms leading to bacteremia.

METHODS

Thirty two patients who had undergone adenoidectomy at ENT Clinic of Sutcu Imam University were included in the study. They had received no antimicrobial therapy for at least 20 days before surgery. Adenoidal surface and deep tissue cultures were taken and venous blood samples were obtained for cultures before and immediately after adenoidectomy in which adenoid was removed with a curette.

RESULTS

While none of the blood cultures taken preoperatively was positive for any organisms, the cultures obtained postoperatively were positive in only two of 32 patients included in the study.

CONCLUSION

The results of this study suggest that there is an extremely low incidence of bacteremia during adenoidectomy. As a result, it may be concluded that the use of prophylactic antibiotics to prevent bacteremia or its complications is unnecessary unless the patient has a predisposing factor for cardiac infection like prosthetic valve replacement.