Tonsil surface and core cultures in recurrent tonsillitis: prevalence of anaerobes and beta-lactamase producing organisms

Current bacteriological profile of tonsillar surface versus core tissue in patients undergoing tonsillectomy

PURPOSE

The current study explored the bacteriological profile in the tonsillar core in patients undergoing tonsillectomy and compared it with tonsillar surface organisms. The antibiotic sensitivity and resistance patterns were also studied.

MATERIALS AND METHODS

This prospective and observational study was conducted in the Department of Otorhinolaryngology, Head and Neck surgery in a tertiary care institute, on a total of sixty-one patients clinically diagnosed as chronic tonsillitis and undergoing tonsillectomy. Tonsillar surface culture swabs and core tissue specimen were sent in separate vials. The culture isolates and their antibiotic sensitivity were analysed and compared.

RESULTS

Bacterial growth was detected in 61% of the cases, in cultures from the surface or the core tissue or both. 50.8% specimens of core tissue versus 31.1% of tonsillar surface samples revealed bacterial growth. Of the 13 cases in which surface and core both had bacterial culture growth, the same pathogens were identified in 8 cases. Pseudomonas aeruginosa was the most commonly reported organism in both tonsillar core as well as surface swab cultures.

CONCLUSION

Our study shows that surface swab culture is not always a reliable indicator of organisms present in core of tonsils in cases of chronic infection. The surface swabs did not always match the pathogens in the core. The higher prevalence and the variability of pathogenic organisms in the core tissue as compared to the surface suggests that a targeted antibiotic treatment based on surface culture swabs is unlikely to eradicate them.

Tonsillar surface swab bacterial culture results differ from those of the tonsillar core in recurrent tonsillitis

OBJECTIVES/HYPOTHESIS

We aimed to determine whether there was a difference between core and surface bacteriology of Finnish adults with recurrent or chronic tonsillitis to understand whether a surface swab is worthwhile and which bacteria are involved.

STUDY DESIGN

Case series.

METHODS

Uninflamed tonsillar surface swabs and core biopsies were taken prior to and during surgery, respectively, in 103 patients aged 16 to 66 years undergoing tonsillectomy for recurrent or chronic tonsillitis. The McNemar test was used to determine differences between the surface and core in the most prevalent bacterial species.

RESULTS

Twenty-seven bacterial species were isolated in addition to normal flora and were more commonly found in the core (1.11 surface and 4.75 core bacteria isolated per patient). Viridans group streptococci were the most commonly detected bacteria, found in 88% of the patients, mainly in the core. The bacteria in general were mainly isolated from the core. Of the 10 most prevalent bacteria, only group C β-hemolytic streptococci showed no difference between detection from core and surface swabs. Other bacteria found mainly in the core include Prevotella melaninogenica, Staphylococcus aureus, and fusobacteria.

CONCLUSIONS

There is discord between the surface and core bacteria. A different population of bacteria exists in the core, especially anaerobic bacteria, suggesting that a core sample may be useful in evaluating recurrent and chronic tonsillitis.

LEVEL OF EVIDENCE

4 Laryngoscope, 2019.

Exploratory studies on the therapeutic effects of Kumarabharana Rasa in the management of chronic tonsillitis among children at a tertiary care hospital of Karnataka

The effect of an Ayurvedic poly-herbo-mineral formulation Kumarabharana Rasa (KR) in the management of chronic tonsillitis (Tundikeri) in children has been assessed in this study. This clinical study was a double-arm study with a pre- and post-test design at the outpatient level in a tertiary Ayurveda hospital attached to a teaching institute located in district headquarters in Southern India. Patients (n = 40) with chronic tonsillitis satisfying diagnostic criteria and aged between 5 and 10 years were selected from the outpatient Department of Kaumarbhritya, SDM College of Ayurveda and Hospital, Hassan. Among them, 20 patients were treated with Kumarabharana rasa (tablet form) at a dose of 500 mg once daily for 30 days (Group A). The other 20 patients were treated with Godhuma Vati (placebo) at a dose of 500 mg once daily for 30 days (Group B). In both groups, Madhu was the Anupana advised. After completion of 30 days of treatment, the patients were assessed on the following day and another investigation took place 15 days later. Statistically significant effects (p < 0.05) in the reduction of all signs and symptoms of chronic tonsillitis after KR treatment were observed. These results indicate that Kumarabharana Rasa has an ameliorative effect in reducing the signs and symptoms of chronic tonsillitis.

Tonsillitis and sore throat in children

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

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.

Bacteriological evaluation of tonsillar microbial flora according to age and tonsillar size in recurrent tonsillitis

Although numerous studies based on the bacteriology of the tonsil have been carried out, none of them analyzed the variation of tonsillar flora with respect to both age and tonsillar size. The purpose of this study was to isolate the facultative and obligate anaerobes both from the surface and the core of tonsils in recurrent tonsillitis as well as to analyze the variation of isolated bacterial strains according to age and tonsillar size. A prospective study was performed on 111 patients who underwent tonsillectomy. We analyzed the differences between the bacterial pathogens in recurrent tonsillitis and semi-growth estimates with regard to age and tonsillar grade. Among 111 cases, 604 bacterial strains of 21 different from the tonsil superficial and core were isolated. The most common facultative anaerobic species isolated from the surface and core were Coagulase-negative staphylococci, Alpha-hemolytic streptococci and Diphtheroid bacilli in all subgroups except patients below 8 years old. The most commonly obligate anaerobic species isolated from the core were Propionibacterium acnes, Prevotella melaninogenica and Peptostreptococcus anaerobius. We found no significant difference in the cultured bacteria with respect to age and tonsillar size. The study subgroups did not differ in the occurrence of semiquantitative growth estimates of 3-4+. Our study demonstrates that there is polymicrobial aerobic and anaerobic flora in tonsils with regardless of patient's age and tonsillar size. This polymicrobial spectrum of bacteria may contribute to recurrence and to the failure of conservative treatment of these cases and therefore leads to surgical therapy.

Comparison of the surface and core bacteria in tonsillar and adenoid tissue with Beta-lactamase production

Adenoidectomy and tonsillectomy, indicated for children with recurrent or persistent symptoms of infection or hypertrophy, are among the most frequent operations performed in children. This study was carried out for investigating the microbial flora of the tonsils and adenoids regarding to core and surface microorganisms and also pathogen microrganisms' beta-lactamase production rate. Cultures were taken from the core and surface of tonsils and adenoids of the 91 patients at the time of the surgery for tonsillectomy and adenoidectomy. Aerobic and anaerobic cultures were inoculated and identified. Beta-lactamase production was detected also. The most frequently isolated aerobic microorganisms were Streptococcus viridans and Neisseria spp. The number of the microorganisms isolated from the tonsil core compared to the surface of the tonsils was found statistically insignificant (P > 0.05). The number of the adenoid surface aerobic microorganisms was found higher from the adenoid core (P < 0.05). The amount of adenoid and tonsil core anaerobic microorganisms were alike. The patients' preoperative antibiotherapy whether using beta-lactam or beta-lactamase resistant were compared for beta-lactamase producing bacteria production and the number of beta-lactamase producing bacteria were found statistically insignificant (P > 0.05). The togetherness of Staphylococcus aureus and other beta-lactamase producing bacteria was found statistically significant (P < 0.05). This study demonstrates that there is polymicrobial aerobic-anaerobic flora in both adenoids and tonsils. There was a close relationship between the bacteriology of the tonsil and adenoid flora. Staphylococcus aureus and and other beta-lactamase producing bacteria may be responsible for treatment failures in patients with tonsillitis.

Intracellular persisting Staphylococcus aureus is the major pathogen in recurrent tonsillitis

Background

The two major indications for tonsillectomy are recurrent tonsillitis (RT) and peritonsillar abscess (PTA). Unlike PTAs, which are primarily treated surgically, RT is often cured by tonsillectomy only after a series of failed drug therapy attempts. Although the bacteriological background of RT has been studied, the reason for the lack of success of conservative therapeutic approaches is not well understood.

Methods

In a prospective study, tonsil specimens from 130 RT patients and 124 PTA patients were examined for the presence of extra- and intracellular bacteria using antibiotic protection assays. Staphylococcus aureus isolates from RT patients were characterized by pulsed-field gel electrophoresis (PFGE), spa-typing and MSCRAMM-gene-PCR. Their ability for biofilm formation was tested and their cell invasiveness was confirmed by a flow cytometric invasion assay (FACS), fluorescent in situ hybridization (FISH) and immunohistochemistry.

Findings

S. aureus was the predominant species (57.7%) in RT patients, whereas Streptococcus pyogenes was most prevalent (20.2%) in PTA patients. Three different assays (FACS, FISH, antibiotic protection assay) showed that nearly all RT-associated S. aureus strains were located inside tonsillar cells. Correspondingly, the results of the MSCRAMM-gene-PCRs confirmed that 87% of these S. aureus isolates were invasive strains and not mere colonizers. Based upon PFGE analyses of genomic DNA and on spa-gene typing the vast majority of the S. aureus isolates belonged to different clonal lineages.

Conclusions

Our results demonstrate that intracellular residing S. aureus is the most common cause of RT and indicate that S. aureus uses this location to survive the effects of antibiotics and the host immune response. A German translation of the Abstract is provided as supplementary material (Abstract S1).

Selected bacterial recovery in Trinidadian children with chronic tonsillar disease

Pharyngotonsillitis in children is widely treated with antibiotics. Aim: To examine tonsil surface and core microflora following elective adenotonsillectomy in children. Methods: Tonsils of 102 Trinidadian children were prospectively examined for surface and core bacteriological culture and identification between 2005-2006. Results: Tonsils (360) yielded 800 isolates of Streptococcus spp. (51.3%), Staphylococcus spp. (42.3%) and Gram-negative genera (6.4%). Surface and core recovery of staphylococci and streptococci were similar (p>0.05). More (p<0.001) surfaces (82.2%) than cores (63.3%) grew Streptococcus spp.; α-haemolytic Streptococcus prevalence was higher (p<0.001) than ß-haemolytic Streptococcus on surfaces (74.4% vs. 18.6%) than cores (58.9% vs. 13.7%). Surfaces and cores were not concordant for streptococci (p<0.0004) and α-haemolytic Streptococcus (p<0.007). Surface and core ß-haemolytic Streptococcus yield was higher (p<0.05) in 6-16 than 1-5 year olds (31% and 23.8% vs 12.5% and 8%). S. pyogenes surface and core prevalence was (84.6% vs 70%) and (50.0% vs 25.0%) in older and younger children respectively. Klebsiella spp. (6.6 %, 2.2%), Proteus (4.4%, 4.4%) and Pseudomonas (4.4 %, 1.1%) grew on surfaces and cores respectively.

Oropharyngeal flora changes after tonsillectomy

Objective: We aimed to investigate the effect of tonsillectomy on oropharyngeal flora in children who underwent tonsillectomy for chronic recurrent tonsillitis.

Study Design and Setting: A prospective study was performed comprising patients with chronic recurrent tonsillitis who underwent tonsillectomy at the Department of Otolaryngology, Cerrahpasa Medical School. Incisional core biopsies of excised tonsils were also performed. Swabs and core biopsy specimens were transferred and maintained in Stuart's medium and sent to the Department of Microbiology and Clinical Microbiology at Cerrahpasa Medical School for microbiologic evaluation.

Subjects and Methods: Oropharyngeal swabs and tonsillar core biopsy specimens from 31 patients operated on for recurrent tonsillitis were cultured. Follow-up oropharyngeal swabs were cultured one month after tonsillectomy.

Results: There was no significant difference between the preoperative and postoperative isolation rate of the potentially pathogenic bacteria. Normal aerobic flora did not change significantly. However, the isolation rate of the Neisseria species dropped ( P = 0.097) but did not reach statistical significance. Among anaerobes, Bacteroides fragilis, one of the major anaerobic bacteria, dropped significantly ( P = 0.007). The Propionibacterium acnes isolation rate increased significantly ( P = 0.009).

Conclusion: Oropharyngeal anaerobic bacterial flora decreases after tonsillectomy in recurrent tonsillitis patients. The isolation rate for bacteria of the normal flora and potentially pathogenic bacteria does not change. Tonsils with recurrent infections may become a nidus for anaerobic bacteria. In patients with chronic recurrent tonsillitis, tonsillectomy may help change anaerobic bacterial oropharyngeal flora to the normal flora found in healthy individuals.

Bacteriologic Comparison of Tonsil Core in Recurrent Tonsillitis and Tonsillar Hypertrophy

OBJECTIVES

Although many bacteriology studies on tonsillar diseases have been completed, all have been confined to children and were characterized by a paucity of cases. The purpose of this study was to analyze the underlying bacterial pathogens in tonsillar disease.

METHODS

A retrospective study was performed on 824 patients who underwent elective tonsillectomy with or without adenoidectomy. We analyzed the differences between the bacterial pathogens in recurrent tonsillitis and tonsillar hypertrophy with regard to age, season, and antibiotic sensitivity.

RESULTS

Among 824 cases, 966 bacterial strains from the tonsil core were isolated. In recurrent tonsillitis, Staphylococcus aureus was the most common pathogen (30.3%), followed by Haemophilus influenzae (15.5%) and group A beta-hemolytic Streptococcus (Streptococcus pyogenes, 14.4%). In patients over 14 years of age, quite differently from other age groups, Klebsiella pneumoniae was isolated at a significantly higher percentage. In tonsillar hypertrophy, H. influenzae was isolated most commonly (31.4%) regardless of age, followed by S. pyogenes (24.2%), S. aureus (22.9%), and Streptococcus pneumoniae (12.6%). Furthermore, mixed infection was common because of its high resistance to penicillin. In both groups, S. pneumoniae was more common in younger patients, whereas K. pneumoniae was relatively common in adults. We found no differences in the detection rate by season; however, H. influenzae was frequently isolated in the tonsillar hypertrophy group regardless of seasonal variations. We also found no difference in the antibiotic sensitivity between the two groups; however, strains resistant to penicillin were relatively prevalent and showed a high sensitivity to third-generation cephalosporin.

CONCLUSIONS

We observed some differences in the types of bacteria in the tonsillar core between the recurrent tonsillitis and tonsillar hypertrophy groups. Our study indicates that essential bacteria have been changing and, thus, we need to change our choice of antibiotics.

Comparison of Helicobacter Pylori Colonization on the Tonsillar Surface versus Tonsillar Core Tissue as determined by the CLO test

We conducted a prospective study to determine the correlation between the presence or absence of Helicobacter pylori on the tonsillar surface and in the tonsillar core as determined by the Campylobacter- like organism (CLO) rapid urease enzyme test. Our study population was made up of 55 patients who underwent adenoidectomy, tonsillectomy, or both from December 2002 through April 2003 at Khalili Hospital in Shiraz, Iran. Of these 55 patients, 45 (82%) were positive and 10 (18%) were negative for H pylori colonization as determined by CLO testing. Analysis of samples obtained from individual patients revealed differences in H pylori colonization between tonsillar surface samples and the core tissue samples. Of 106 tonsils obtained from 53 patients who underwent adenotonsillectomy or tonsillectomy, H pylori was found on 56 tonsillar surface samples (53%) and 24 tonsillar core samples (23%); only 13 tonsils (12%) contained H pylori both on the surface and in the core. We conclude that a surface swab is neither specific nor sensitive as an indicator of the presence or absence of H pylori colonization in tonsillar core tissue.

Isolation of methicillin resistant Staphylococcus aureus from the surface and core of tonsils in children

BACKGROUND

The rate of recovery methicillin resistant Staphylococcus aureus (MRSA) in tonsils that were removed because of recurrent Group A-beta-hemolytic streptococci (GABHS) tonsillitis was not previously reported. MRSA may serve as a potential source for the spread of these organisms to other body sites as well to other individuals. This study investigated the rate of recovery of MRSA as well as other aerobic organisms from tonsils that were removed because of recurrent GABHS infection.

PATIENTS AND METHODS

Core and surface tonsillar cultures for aerobic bacteria were obtained from 44 children who had tonsillectomy because of recurrent GABHS tonsillitis.

RESULTS

A total of 167 aerobic isolates were recovered from the core of the tonsils (3.8/specimen) and 151 (3.4/specimen) were isolated from the surface. The predominant isolates were alpha-hemolytic streptococci, GABHS, S. aureus, gamma-hemolytic streptococci, Haemophilus influenzae and Moraxella catarrhalis. Concordance in the recovery of all organisms was noted in 117 instances. Certain organisms (i.e. GABHS, S. aureus) were recovered more often from the tonsillar cores, where other (i.e. alpha-hemolytic streptococci, gamma-hemolytic streptococci) were recovered more often from the tonsillar surface. Forty-four beta-lactamase-producing bacteria (BLPB) were recovered from 32 (75%) of the tonsillar cores, and 28 were isolated from 23 (52%) of the tonsillar surfaces. The predominant BLPB were S. aureus, H. influenzae and M. catarrhalis. Seven isolates of MRSA were recovered from the cores and two were isolated from the surface. Five of the core isolates and the two surface isolates were also BLPB. All of the MRSA isolates were resistant to oxacillin, penicillin and erythromycin and were susceptible to clindamycin, trimethoprim-sulfamethoxazole and vancomycin.

CONCLUSIONS

These data demonstrated that in recurrently GABHS infected tonsils, BLPB was recovered from over 75% of the tonsillar cores, core tonsillar cultures yielded more GABHS and S. aureus, and MRSA was isolated from 16% of the tonsils.

Oral clindamycin 300 mg BID compared with oral amoxicillin/clavulanic acid 1 g BID in the outpatient treatment of acute recurrent pharyngotonsillitis caused by group a β-hemolytic streptococci: An international, multicenter, randomized, investigator-blinded, prospective trial in patients between the ages of 12 and 60 years

BACKGROUND

The increasing rate of treatment failure with penicillin and other beta-lactam antibiotics in pharyngotonsillitis caused by group A beta-hemolytic streptococci (GABHS) has prompted the search for alternative antimicrobials. Both clindamycin and amoxicillin/clavulanic acid have excellent clinical activity in pharyngotonsillitis.

OBJECTIVE

This study compared the clinical and bacteriologic efficacy and tolerability of oral clindamycin with those of oral amoxicillin/clavulanic acid in the outpatient treatment of acute recurrent GABHS pharyngotonsillitis.

METHODS

This was an international, multicenter, randomized, investigator-blinded, prospective study in patients with acute recurrent pharyngotonsillitis. Recurrence was defined as > or =2 episodes of documented pharyngeal and/or tonsillar infection within the 12 months before the study. A rapid diagnostic test for GABHS was performed before initiating therapy, and positive results were confirmed by pharyngotonsillar culture. Patients were randomly assigned to receive oral clindamycin 300 mg BID or oral amoxicillin/clavulanic acid 1 g BID for 10 days. Culture was repeated on day 12. The primary study end points were clinical and bacteriologic efficacy assessed on day 12, and clinical and bacteriologic recurrence rates assessed at a visit taking place up to 3 months after the completion of treatment. Tolerability was the secondary end point.

RESULTS

Seven hundred seventy-four patients with acute, recurrent GABHS pharyngotonsillitis were enrolled in the study (mean age, 28 years; age range, 12-60 years). Five hundred forty-two patients (272 clindamycin, 270 amoxicillin/clavulanic acid) were clinically evaluable at day 12. Four hundred ninety-four patients were bacteriologically evaluable, and the safety population included 772 patients. There were no significant differences between groups at baseline. In terms of clinical efficacy at day 12, 252/272 (92.6%) patients in the clindamycin group and 230/270 (85.2%) patients in the amoxicillin/clavulanic acid group were considered cured (P < 0.003). At day 12, bacteriologic eradication was achieved in 237/242 (97.9%) and 238/252 (94.4%) patients in the respective treatment groups (P = NS). No clinical response was observed in the absence of bacteriologic eradication. At 3-month follow-up, clinical cure was achieved in 267/280 (95.4%) patients in the clindamycin group and 267/280 (95.7%) patients in the amoxicillin/clavulanic acid group (P = NS); bacteriologic eradication was observed in 235 (99.2%) and 237 (99.6%) of the respective treatment groups (P = NS). Both treatments were well tolerated. Adverse events were reported in 53/384 (13.8%) patients in the clindamycin group and 41/390 (10.5%) patients in the amoxicillin/clavulanic acid group. The most commonly reported adverse events involved the digestive system (mainly diarrhea), occurring in 33 (8.6%) and 22 (5.6%) patients in the respective treatment groups.

CONCLUSIONS

In this study in patients with acute recurrent GABHS pharyngotonsillitis, oral clindamycin 300 mg BID and oral amoxicillin/clavulanic acid 1 g BID achieved comparable rates of bacteriologic eradication at 12 days and 3 months and comparable clinical cure rates at 3 months. Patients who received clindamycin had significantly greater clinical cure rates at 12 days. Both regimens were well tolerated.

Situación actual de las resistencias a antibióticos en infecciones amigdalares

OBJECTIVE

To obtain the main responsible organisms, its sensitivity and resistances to antibiotics in tonsillitis.

MATERIAL AND METHODS

We have studied the post-surgical tonsils, carrying out a microbiologic study, its culture and sensitivity.

RESULTS

The most frequent isolated organisms were Staphylococcus aureus (29.3%), followed by Streptococcus pyogenes (23.4%), and Haemophilus influenzae (12.1%). The highest resistances were for the S. aureus (penicillin 91%, erythromycin 18% and 5% to the rest of the beta-lactams), followed by H. influenzae (50% clarithromycin, 30% amoxyciIlin and 2% cephalosporins) and S. pyogenes (28% erytromycin, 10% clindamycin and 3% penicillin).

CONCLUSIONS

We noticed the minimal resistance found to cephalosporins, and for this reason they appear to be the safest option, except in children under five years old, in which amoxicillin is still the first line treatment, because the causative agent is S. pyogenes, sensitive to that antibiotic.

Selection of indicators for tonsillectomy in adults with recurrent tonsillitis

BACKGROUND

We aimed to find some new indicators for tonsillectomy (TE) in adults with recurrent tonsillitis (RT) by exploring whether the frequency of tonsillitis episodes and the length of morbidity period are associated with the macroscopic signs of sclerotic process in tonsils and microbiological data assessed by culture, molecular (PCR) and transmission electron microscopy (EM) methods.

METHODS

The study involved 62 RT patients admitted for TE (age range 15-35, median 22 years) and 54 healthy volunteers (age range 18-24, median 20 years). The index of tonsillitis (IT) was calculated by multiplying the number of tonsillitis episodes per year by the morbidity period in years. On oropharyngeal examination the presence or absence of three sclerotic signs was evaluated: tonsillar sclerosis, obstruction of tonsillar crypts and scar tissue on the tonsils. The occurrence of Streptococcus pyogenes was assessed by culture and PCR methods in 24 tonsillar core specimens. The samples for EM investigation of crypt epithelium were taken from 10 removed tonsils.

RESULTS

The IT values were in positive correlation with the number of sclerotic signs on oropharyngeal examination (r = 0.325, P = 0.010). Based on the IT values and the presence or absence of tonsillar sclerosis and obstruction of tonsillar crypts the receiver-operating curve (ROC) was constructed. It revealed that an IT score of 36 is an optimal cut-off value for prediction of sclerotic type tonsils. S. pyogenes was never found by culture, but its presence by PCR in nearly one third (29%) of diseased tonsillar tissue specimens was tightly associated with longer morbidity. EM revealed coccoid forms of intracellular bacteria in the crypt epithelium, which was accompanied with the damage of tight junctions between epithelial cells.

CONCLUSION

The index of tonsillitis > or = 36, being a combination between the frequency of tonsillitis and the length of morbidity period, predicts the sclerotic process in recurrently inflamed tonsils. Therefore, the high IT values could serve as an indicator for TE in adults. The correlation between the longer morbidity period and the presence of S. pyogenes by PCR suggests that persistent infection may have a role in maintenance of recurrent inflammation in tonsils.

The role of anaerobic bacteria in tonsillitis

This review summarizes the information that supports the potential importance of anaerobic bacteria in tonsillitis. Some anaerobic bacteria possess interfering capability with Group A beta-hemolytic streptococci (GABHS) and other pathogens. The possible role of anaerobes in the acute inflammatory process in the tonsils is supported by several observations: anaerobes have been isolated from the cores of tonsils of patients with recurrent GABHS and non-GABHS tonsillitis (NST); the recovery of anaerobes as predominant pathogens in abscesses of tonsils, in many cases without any aerobic bacteria; their recovery as pathogens in well-established anaerobic infections of the tonsils (Vincent's angina); the increased recovery rate of encapsulated pigmented Prevotella and Porphyromonas spp. in acutely inflamed tonsils; their isolation from the cores of recurrently inflamed NST; and the response to antibiotics in patients with NST. Furthermore, immune response against Prevotella intermedia is present in patients with recurrent NST, and an immune response can also be detected against P. intermedia and Fusobacterium nucleatum in patients who recovered from peritonsillar cellulitis or abscesses, infectious mononucleosis and acute non-streptococcal and GABHS tonsillitis. Although more studies are needed, these findings support the possible pathogenicity of Gram-negative anaerobic bacilli in tonsillitis.

Macroscopic oropharyngeal signs indicating impaired defensive function of palatine tonsils in adults suffering from recurrent tonsillitis

The present study explored in adults suffering from recurrent tonsillitis the association between macroscopic oropharyngeal signs of recurrent inflammation, immunomorphology of palatine tonsils (counts of neutrophils by CD4 and macrophages by CD68 monoclonal antibodies in tonsillar microcompartments) and the occurrence of post-tonsillectomy bacteremia. The study involved 50 adults (31 females and 19 males) with recurrent tonsillitis. According to predominance of either inflammatory changes or evidence of sclerotic process in palatine tonsils and surrounding tissue macroscopic at oropharyngeal examination, the patients were divided into groups with 'inflammatory-type' and 'sclerotic-type' tonsils. Biochemically detected mean collagen content was significantly higher in 'sclerotic-type' tonsils than in 'inflammatory-type' tonsils (p=0.001). Post-tonsillectomy bacteremia was found in 22 patients (44%). A noteworthy finding was the higher recovery of anaerobes from blood cultures than in previous studies. A logistic regression analysis revealed that the post-tonsillectomy bacteremia was strongly associated with 'sclerotic-type' tonsils (p=0.0015) and with low counts of neutrophils in tonsillar tissue (p=0.047). We conclude that macroscopic oropharyngeal signs of sclerotic process in palatine tonsils indicate impaired tonsillar defense, in terms of lowered counts of neutrophils, increasing the risk of post-tonsillectomy bacteremia.

Fine-needle aspiration as a diagnostic tool for recurrent tonsillitis

Acute tonsillitis is a common childhood disease, but repeated antibiotic treatment may fail, leading to tonsillectomy. Superficial swab cultures do not sufficiently represent the core bacteria present, but fine-needle aspiration may be a promising diagnostic method. We evaluated 58 patients undergoing tonsillectomy, and took superficial and core swabs, and fine-needle aspirations. Staphylococcus aureus was the most common bacterial pathogen identified, present in 26 out of 50 (52%) positive core cultures, followed by Haemophilus influenza in 13 positive core cultures (26%), and group A beta-haemolytic streptococci in 10 positive core cultures (20%). Fine-needle aspiration detected 33 out of 50 positive core cultures (66%), whereas superficial swab culture detected 18 of 50 (36%); the difference being statistically significant. All pathogens detected by superficial swabs and fine-needle aspiration were detected in core cultures. The sensitivity and specificity of fine-needle aspiration were 66% and 100%, respectively, compared with 36% and 100% for superficial swabs. Fine-needle aspiration is therefore a promising method for detecting core bacteria in patients with recurrent tonsillitis.

Neutrophils are hyperactive in recurrent tonsillitis

The pathogenesis of recurrent tonsillitis has not been fully explored. Most studies in this field have focused on pathogenic bacteria whereas less research has been done concerning the host defense. In earlier studies it was shown that there is an active cellular defense in the tonsillar surface secretion, consisting of phagocytes, and therefore in this study the possibility that this defense is altered in patients with recurrent tonsillitis was explored. Neutrophils were obtained from tonsillar surface secretions in eight patients with recurrent tonsillitis and eight healthy volunteers and the capacity of the neutrophils to respond to chemotactic stimuli was examined in an in vitro system. A significantly higher fraction of the neutrophils obtained from the patients with recurrent tonsillitis responded to chemotactic stimuli compared to those obtained from the healthy volunteers. It is concluded that there is a hyperactive cellular defense in the tonsillar surface secretion in patients with recurrent tonsillitis. This finding and its significance in the pathogenesis of recurrent tonsillitis are discussed.

Helicobacter pylori and tonsillectomy

Tonsillar tissue is a component of mucosa-associated lymphoid tissue (MALT), which has evolved to protect vulnerable mucosal surfaces. Helicobacter pylori, implicated as an aetiological factor in duodenal ulcers and gastritis, induces the appearance of lymphoid aggregates (MALT) in the stomach. This organism is cytotoxic via a nitric oxide synthase cascade. The possibility that tonsillar tissue processes Helicobacter pylori or that Helicobacter pylori can colonize the palatine tonsils is explored. The study design was that of a prospective study. We determined if Helicobacter pylori (i) forms part of the normal microenvironment of the tonsil, (ii) plays a role in the pathogenesis of tonsillitis and (iii) is associated with increased expression of inducible nitric oxide synthase (iNOS) in macrophages of the tonsil. Serology for Helicobacter pylori was performed on 50 patients undergoing tonsillectomy. Tonsillar specimens were monitored for urease activity by CLO test (a sealed plastic slide holding an agar gel, which contains urea and detects the urease enzyme of Helicobacter pylori), and immunocytochemically probed for Helicobacter pylori and iNOS expression. The mean age of this patient group was 17.2 years (3-36 years). Fourteen (28%) were sero-positive for Helicobacter pylori but no evidence of this pathogen was found in any tonsillar specimen. The number of macrophages staining for iNOS, per field, under a magnification of x40, was increased in sero-positive patients (13.3 +/- 1.3 versus 9.9 +/- 0.7; P = 0.01). Helicobacter pylori does not appear to colonize the tonsil. We believe that Helicobacter pylori primes the tonsils by inducing macrophage iNOS expression. The higher expression in sero-positive patients is a reflection of a pro-inflammatory reaction to Helicobacter pylori that is both local and systemic.

Bacteriology of the tonsil core in recurrent tonsillitis and tonsillar hyperplasia--a short review

In recurrent tonsillitis, the tonsil core harbours numerous bacteria, some of which are pathogenic and may occur in great numbers. The most frequent bacteria are Haemophilus influenzae, followed by Staphylococcus aureus and Streptococcus pyogenes. A high tissue concentration of these bacteria correlates with clinical parameters of infection and hyperplasia of the tonsils. The role of Streptococcus pyogenes, while undisputed in acute and epidemic tonsillitis, should perhaps be re-evaluated in recurrent and/or hyperplastic tonsillitis.

Antibiotic resistance in oral/respiratory bacteria

In the last 20 years, changes in world technology have occurred which have allowed for the rapid transport of people, food, and goods. Unfortunately, antibiotic residues and antibiotic-resistant bacteria have been transported as well. Over the past 20 years, the rise in antibiotic-resistant gene carriage in virtually every species of bacteria, not just oral/respiratory bacteria, has been documented. In this review, the main mechanisms of resistance to the important antibiotics used for treatment of disease caused by oral/respiratory bacteria--including beta-lactams, tetracycline, and metronidazole--are discussed in detail. Mechanisms of resistance for macrolides, lincosamides, streptogramins, trimethoprim, sulfonamides, aminoglycosides, and chloramphenicol are also discussed, along with the possible role that mercury resistance may play in the bacterial ecology.

Clinico microbiological evaluation of surface and core microflora in chronic tonsillitis

A total of 100 patients with chronic tonsillitis were selected for this study. Specimens collected immediately before surgery and the operated specimen of tonsils were subjected to appropriate microbiological techniques. The commonest isolate on the surface was Streptococcus pneumoniae and in the core group a streptococcus. The largest group was the one in which surface and core pathogens were the same. At the same time it is interesting to note that surface culture was misleading as to the presence or absence of core pathogens in 32% of the study group. The core only was pathogenic in 12% and the group which isolated a different pathogen on the surface and core was 20%. It is evident that in a significant group of patients surface cultures were not useful in predicting core pathogens.

Acute pharyngotonsillitis is an infection restricted to the crypt and surface secretion

A commonly accepted hypothesis is that acute pharyngotonsillitis is caused by bacteria which first adhere to the epithelial surface and then invade the tonsillar parenchyma; however, evidence directly supporting this hypothesis is not available. In previous studies on acute pharyngotonsillitis, we found that the secretion in crypts and at the surface was infected in acute pharyngotonsillitis while no bacteria were detected in the parenchyma. Based on these results, we have proposed a new hypothesis stating that the infection is restricted to the crypt and surface secretions in acute pharyngotonsillitis. To evaluate this hypothesis further, in the present study we examined tonsillar tissue and secretion from patients with acute pharyngotonsillitis, recurrent pharyngotonsillitis and healthy tonsils. Surface secretion was studied after sampling by an imprint technique followed by routine histological preparation. Tonsillar tissue was examined by fluorescence microscopy after staining with acridine orange and by transmission electron microscopy. There were high numbers of bacteria and moderate or extensive ongoing phagocytosis in the crypt and surface secretion from patients with acute pharyngotonsillitis. Bacteria, leucocytes and phagocytosis were also present, but to less extent in the secretion from patients with recurrent pharyngotonsillitis and to even less extent in the healthy controls. In none of all the investigated tonsils were bacteria present in the parenchyma. Bacterial adherence to the epithelial surface was only very rarely observed. This study supports the hypothesis that acute pharyngotonsillitis is an infection restricted to the crypt and surface secretion and that bacterial adherence is not of significant importance in the pathogenesis of acute pharyngotonsillitis.

The surface epithelium of recurrent infected palatine tonsils is rich in gammadelta T cells

Using a large panel of MoAbs in quantitative morphometric analysis of immunohistochemically stained tissue sections, we compared the frequency and distribution of immune cells in palatine tonsils from patients with recurrent tonsillitis (RT) and patients with idiopathic tonsillar hypertrophy (ITH). We found that differences between the two patient groups in leucocyte populations were limited to the surface epithelium, whereas the cellular composition of interfollicular and follicular areas was similar. Most intraepithelial lymphocytes were CD8+ T cells in both groups. However, the number of intraepithelial T cells was significantly higher in RT compared with ITH. This was due to a selective increase in the number of intraepithelial CD8+ gammadelta T cells utilizing Vdelta1 and Vgamma9. In both patient groups the majority of the intraepithelial gammadelta T cells expressed Vdelta1 and Vgamma9. Subepithelially, gammadelta T cells utilizing Vgamma9 dominated over cells utilizing Vgamma8, while equal proportions expressed Vdelta1 and Vdelta2. These results suggest that cells utilizing the otherwise rare combination Vdelta1/Vgamma9 in their T cell receptors (TCR) may constitute a major gammadelta T cell population in palatine tonsils and are probably reactive to antigens specific to the tonsillar milieu. Furthermore, they indicate that preferentially this gammadelta T cell subpopulation is involved in immune reactions within the surface epithelium in RT. We speculate that gammadelta T cells are involved in clearing infectious bacteria at the tonsillar surface and in limiting inflammatory responses in the tonsils. Both local expansion and infiltration of blood cells probably contribute to the high numbers of gammadelta T cells in RT patients.

Gram-positive anaerobic cocci

Gram-positive anaerobic cocci (GPAC) are a heterogeneous group of organisms defined by their morphological appearance and their inability to grow in the presence of oxygen; most clinical isolates are identified to species in the genus Peptostreptococcus. GPAC are part of the normal flora of all mucocutaneous surfaces and are often isolated from infections such as deep organ abscesses, obstetric and gynecological sepsis, and intraoral infections. They have been little studied for several reasons, which include an inadequate classification, difficulties with laboratory identification, and the mixed nature of the infections from which they are usually isolated. Nucleic acid studies indicate that the classification is in need of radical revision at the genus level. Several species of Peptostreptococcus have recently been described, but others still await formal recognition. Identification has been based on carbohydrate fermentation tests, but most GPAC are asaccharolytic and use the products of protein degradation for their metabolism; the introduction of commercially available preformed enzyme kits affords a physiologically more appropriate method of identification, which is simple and relatively rapid and can be used in routine diagnostic laboratories. Recent reports have documented the isolation in pure culture of several species, notably Peptostreptococcus magnus, from serious infections. Studies of P. magnus have elucidated several virulence factors which correlate with the site of infection, and reveal some similarities to Staphylococcus aureus. P. micros is a strongly proteolytic species; it is increasingly recognized as an important pathogen in intraoral infections, particularly periodontitis, and mixed anaerobic deep-organ abscesses. Comparison of antibiotic susceptibility patterns reveals major differences between species. Penicillins are the antibiotics of choice, although some strains of P. anaerobius show broad-spectrum beta-lactam resistance.

Microbiological features and pathogenesis of peritonsillar abscesses

Samples of pus aspirated from 53 peritonsillar abscesses were examined in detail for aerobic and anaerobic bacteria, and the microbiological results correlated with clinical data in 44 cases. In 45 samples (85%) cultures were positive: 7 yielded organisms consistent with an aerobic infection, mainly Lancefield group A beta-haemolytic streptococci (5/7), and 38 yielded organisms consistent with an anaerobic infection. The anaerobic infections were usually mixed, but in two cases Fusobacterium necrophorum was isolated in pure culture. Peptostreptococcus micros and Streptococcus milleri were the predominant isolates in this group. Direct Gram stain smear and gas-liquid chromatography were useful indicators of the type of infection present. Samples from ten patients (18.9%) grew one or more beta-lactamase-producing isolates. Of the 25 patients prescribed antibiotics by their general practitioners prior to admission, 18 received one or more beta-lactam antibiotics. Most cases of peritonsillar abscess were due to mixed anaerobic infections, Lancefield group A beta-haemolytic streptococci playing a central role in only a minority of cases. In light of these findings and the possibility of infection with beta-lactamase-producing isolates, it is suggested that the first-line antibiotic therapy in this group of patients should include a chemotherapeutic agent directed against anaerobic bacteria.