Microbial Flora and Antibiotic Resistance in Peritonsillar Abscesses in Upstate New York

The impact of social restrictions on the incidence and microbiology of peritonsillar abscess: a retrospective cohort study

OBJECTIVES

We aimed to explore the impact of social distancing on the incidence and microbiology of peritonsillar abscess (PTA).

METHODS

We performed a cross-sectional analysis of all patients with PTA and their microbiological findings in the 2 years preceding versus the 2 years following the COVID-19 lockdown in Denmark (11 March 2020), who were admitted to the Ear-Nose-Throat Department, Aarhus University Hospital. Age-stratified population data for the catchment area were obtained from Statistics Denmark.

RESULTS

The annual incidence rate was significantly higher in the 2-year period before (21.8 cases/100 000 inhabitants) compared with after (14.9 cases/100 000) the lockdown (p < 0.001). The number of cases with growth of Streptococcus pyogenes was significantly higher in the period before (n = 67) compared with after (n = 28) the lockdown (p < 0.001), whereas the number of cases positive for Fusobacterium necrophorum (n = 60 vs. n = 64) and streptococcus anginosus group (SAG) (n = 37 vs. n = 43) were stabile (p 0.79 and p 0.58, respectively). The relative prevalence of S. pyogenes was significantly higher in the period before (67/246 cultures, 27%) compared with after (28/179, 16%) the lockdown (p 0.007). On the contrary, the relative prevalence of F. necrophorum and SAG is significantly lower before (60/246, 24% and 37/246, 15%) compared with after (64/179, 36% and 43/179, 24%) the lockdown (p 0.013 and p 0.023).

DISCUSSION

Social distancing had a significant impact on the incidence and microbiology of PTA. Our findings suggest that S. pyogenes-positive PTA is highly related to direct social interaction, and represents a contagious pathogen. By contrast, PTA development caused by F. necrophorum and SAG is unrelated to direct social interaction and may be derived from flora imbalance.

Unveiling the etiology of peritonsillar abscess using next generation sequencing

BACKGROUND

Peritonsillar abscess (PTA) is a severe deep neck space infection with an insufficiently characterized bacterial etiology. We aimed to reveal the bacteria associated with PTA applying next generation sequencing (NGS). Tonsil biopsies and pus samples of 91 PTA patients were analysed applying NGS method.

RESULTS

Over 400 genera and 800 species belonging to 34 phyla were revealed. The most abundant species in both sample types were Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. When present, S. pyogenes was normally a predominant species, although it was recovered as a minor population in some samples dominated by F. nucleatum and occasionally F. necrophorum. S. pyogenes and F. necrophorum were the predominant species (> 10% in a community) in 28 (31%) pus samples, while F. nucleatum in 21 (23%) and S. anginosus in 8 (9%) pus samples. We observed no substantial differences between the microbial findings in pus and tonsil biopsies.

CONCLUSIONS

The most probable causative agents of PTA according to our NGS-study include Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. Some other streptococci (S. anginosus) and anaerobes (Prevotella, Porphyromonas) may contribute to the infection as well. Pus of the peritonsillar abscess is more representative specimen for microbiological examination than the tonsillar tissue. Our results are important in the context of optimizing the handling of the PTA patients.

Seasonal Variation of Peritonsillar Abscess Presentation to an Emergency Department in an Atlantic Canadian Climate: A Retrospective Review

OBJECTIVES

Patients with a peritonsillar abscess (PTA) often present to emergency departments as the first point of medical contact. Upper respiratory tract infections (URTIs) are more frequent in the winter. Therefore, we hypothesize that the incidence of PTAs will be more frequent in colder winter months as well. This is the first study assessing the seasonal variation and epidemiology of PTA presentations to an emergency department in Atlantic Canada, home to a unique maritime climate.

METHODS

A retrospective cohort study was conducted through a chart review of all patients who presented to the Saint John Regional Hospital Emergency Department from January 1, 2015, to December 31, 2020. Patient characteristics, treatment, and microbiology were reported. A chi-square goodness-of-fit test assessed the seasonal variation of PTA. Pearson correlations assessed PTA incidence per mean monthly temperature and humidity.

RESULTS

A total of 75 patients were included. 57.3% were male and 42.7% were female, with a mean age (±SD) of 35.9 ± 14.0. Most patients presented afebrile (82.7%, cutoff ≥ 38.0°C). Approximately half of all patients had an elevated WBC count (49.3%, cutoff ≥ 10.9 × 10⁹). The most common bacteria isolated were Streptococcus species followed by anaerobic bacteria (17.9%). No significant variation was found with respect to season (X²(3) = 1.0, P = .801), temperature (r(70) = 0.198, P = .096), or humidity, (r(70) = 0.063, P = .599).

CONCLUSION

This study did not find a seasonal variation of PTA in a maritime climate. These findings question the anecdotal hypothesis that PTA is associated with progression from acute URTIs and therefore would be more common in the winter months.

The influences of α-hemolytic Streptococcus on class switching and complement activation of human tonsillar cells in IgA nephropathy

While β-hemolytic streptococcus (β-HS) infections are known to predispose patients to acute poststreptococcal glomerulonephritis, there is evidence that implicates α-hemolytic streptococcus (α-HS) in IgA nephropathy (IgAN). The alternative pathway of the complement system has also been implicated in IgAN. We aimed to explore the association between α-HS and complement activation in human tonsillar mononuclear cells (TMCs) in IgAN. In our study, α-HS induced higher IgA levels than IgG levels, while β-HS increased higher IgG levels than IgA levels with more activation-induced cytidine deaminase, in TMCs in the IgAN group. Aberrant IgA1 O-glycosylation levels were higher in IgAN patients with α-HS. C3 and C3b expression was decreased in IgAN patients, but in chronic tonsillitis control patients, the expression decreased only after stimulation with β-HS. Complement factor B and H (CFH) mRNA increased, but the CFH concentration in culture supernatants decreased with α-HS. The percentage of CD19 + CD35 + cells/complement receptor 1 (CR1) decreased with α-HS more than with β-HS, while CD19 + CD21 + cells/complement receptor 2 (CR2) increased more with β-HS than with α-HS. The component nephritis-associated plasmin receptor (NAPlr) of α-HS was not detected on tonsillar or kidney tissues in IgAN patients and was positive on cultured TMCs and mesangial cells. We concluded that α-HS induced the secretion of aberrantly O-glycosylated IgA while decreasing the levels of the inhibitory factor CFH in culture supernatants and CR1 + B cells. These findings provide testable mechanisms that relate α-HS infection to abnormal mucosal responses involving the alternative complement pathway in IgAN.

Current trend of antibiotic prescription and management for peritonsillar abscess: A cross-sectional study

OBJECTIVE

There are no consensus guidelines for managing peritonsillar abscess (PTA) despite its prevalence. In order to devise best practice guidelines, current practice patterns must first be established.

METHODS

This was a cross-sectional study, surveying Otolaryngology-Head & Neck Surgery trainees (residents and fellows) and consultant (academic and community). The primary outcome was the type and duration of outpatient antibiotic prescription. Secondary outcomes included differences in workup, management, prescription, and follow-up.

RESULTS

There were 57 respondents to the survey; 24 (42%) trainees (residents/fellows) and 33 (58%) consultants. On average, each respondent managed an average of 15.2 (SD 11.2) PTAs within the last year. All respondents prescribed oral antibiotics, with amoxicillin-clavulanic acid being the most common (61%). Trainees prescribed amoxicillin-clavulanic acid more often than consultants (n = 21, 88% vs n = 14, 42%, P = .0084), respectively. Duration of antibiotic therapy ranged from 5 to 14 days. Most commonly, a 10-day course of antibiotics was prescribed (n = 31, 54%). Regarding the management of PTAs, a majority of respondents requested blood work (n = 39, 68%), performed needle aspiration (n = 42, 72%) and performed incision and drainage (n = 52, 91%). Culture and sensitivity of the aspirate/drainage fluid was frequently performed (n = 41, 72%). Patients were often provided non-opioid analgesics (n = 46, 81%), but more than half still received prescription opioids (n = 36, 63%). The majority of clinicians arranged for follow-up (n = 42, 74%), most often with Otolaryngology - Head & Neck Surgery (n = 27, 64%), with an average follow-up of 12.5 (SD 8.2) days.

CONCLUSION

We found heterogeneity in the management of PTAs, with variability in the outpatient antibiotic prescription. This study highlighted the wide range of management strategies employed along with differences in workup, investigation, post-discharge analgesic prescription, and follow-up arrangements.

LEVEL OF EVIDENCE

5.

Calculated parenteral initial treatment of bacterial infections: Infections in the ear, nose, throat and mouth and jaw area

This is the sixth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the antibacterial treatment of more severe infections of the ear, the nose, the throat and the maxillofacial region, including odontogenic and salivary gland infections.

Infections of the Neck

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

Parapharyngeal Abscesses Caused by Group G Streptococcus

Deep neck abscess is a life-threatening infection that causes laryngeal edema and upper airway occlusion. The predominant bacterial species involved in this disorder is group A streptococcus. Group G streptococcus (GGS) constitutes the normal commensal flora of the human upper airway. Although rarely, it can cause pharyngitis, tonsillitis, and peritonsillar abscess. Here, we report a case of a woman with parapharyngeal abscess caused by GGS. A 56-year-old woman presented to the emergency department with complaints of sore throat and cervical swelling, and a diagnosis of parapharyngeal abscess was established. She had upper airway occlusion, requiring urgent tracheostomy. Endoscopic incision and drainage of the abscess using a specially designed, rigid curved laryngoscope was successfully performed. Since a rigid curved laryngoscope creates a wide viewing field and working space, it was useful for incision and drainage of the parapharyngeal abscess.

Bacteriology of peritonsillar abscess: the changing trend and predisposing factors

Introduction

Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors.

Objective

To identify the major causative pathogen of peritonsillar abscess and investigate the relationship between the causative pathogen, host clinical factors, and hospitalization duration.

Methods

This retrospective study included 415 hospitalized patients diagnosed with peritonsillar abscess who were admitted to a tertiary medical center from June 1990 to June 2013. We collected data by chart review and analyzed variables such as demographic characteristics, underlying systemic disease, smoking, alcoholism, betel nut chewing, bacteriology, and hospitalization duration.

Results

A total of 168 patients had positive results for pathogen isolation. Streptococcus viridans (28.57%) and Klebsiella pneumoniae (23.21%) were the most common microorganisms identified through pus culturing. The isolation rate of anaerobes increased to 49.35% in the recent 6 years (p = 0.048). Common anaerobes were Prevotella and Fusobacterium spp. The identification of K. pneumoniae increased among elderly patients (age > 65 years) with an odds ratio (OR) of 2.76 (p = 0.03), and decreased in the hot season (mean temperature > 26 °C) (OR = 0.49, p = 0.04). No specific microorganism was associated with prolonged hospital stay.

Conclusion

The most common pathogen identified through pus culturing was S. viridans, followed by K. pneumoniae. The identification of anaerobes was shown to increase in recent years. The antibiotics initially selected should be effective against both aerobes and anaerobes. Bacterial identification may be associated with host clinical factors and environmental factors.

Peritonsillar abscess (PTA): clinical characteristics, microbiology, drug exposures and outcomes of a large multicenter cohort survey of 412 patients hospitalized in 13 French university hospitals

The aim of this study was to describe the epidemiology of hospitalized patients with peritonsillar abscess (PTA). We conducted a multicenter survey in 13 French university hospitals in 2009-2012 describing 412 patients. Median age was 29 year (range, 2-84) and current smoking habit was reported by 177 (43 %) patients. Most of the patients (92 %) had consulted a physician for sore throat within 10 days before admission for PTA diagnosis. Additional symptoms such as visible tonsil abnormalities (83 %), tender cervical adenopathy (57 %) and fever ≥ 38.5 °C (53 %) were also reported. A total of 65 % patients (269/412) reported recent systemic anti-inflammatory agents (AIAs) exposure by medical prescription (70 %), self-medication (22 %), or both (8 %); 61 % and 27 % reported recent exposure to antibiotic and topical treatments for sore throat, respectively. Non-steroidal AIAs were used most often (45 %), particularly arylpropionic derivatives. A rapid diagnosis antigen test (RDT) for Streptococcus pyogenes was performed in 70 (17 %) patients and was positive in 17 (24 %), of whom 9 (53 %) were exposed to AIAs and 14 (82 %) to antibiotics. To treat PTA, antibiotic therapy was given to 392 (95 %) patients. Of 333 antibiotic prescriptions, amoxicillin-clavulanic acid and metronidazole were the most prescribed antibiotics (42 and 17 %, respectively). Surgical drainage of the abscess was performed in 119 (29 %) cases and tonsillectomy in 75 (18 %) cases. The clinical outcome was favorable during the hospital stay in 404 (98 %) patients. In conclusion, patients with sore throat are often exposed to AIAs before PTA diagnosis, and antibiotic prescription was not often based on the RDT positivity.

The role of bacteriological studies in the management of peritonsillar abscess

OBJECTIVE

Since most patients with peritonsillar abscess (PTA) can be successfully treated with surgical drainage and empirical antibiotic therapy, routine bacteriologic studies for all patients with PTA may be unnecessary. This study tried to evaluate which patients with PTA should certainly undergo bacteriologic studies.

METHODS

Hundred consecutive patients with PTA were treated and underwent culture tests of purulent contents obtained by surgical drainage between April 2008 and December 2013.

RESULTS

In 62 of the 100 patients, 71 pathogenic bacteria were identified; 61 (86%) were Gram-positive cocci (GPC), 8 (11%) were Gram-negative rods (GNR), and 6 (8%) were anaerobes. Normal flora were isolated in 27 patients, and culture results were negative in 11 patients. Although not significant, primary (without prior antibiotic therapy) case (odds ratio (OR)=2.19; 95% CI, 0.95-5.05) and laryngeal edema (OR=2.04; 95% CI, 0.82-5.03) showed a tendency of associations with detection of pathogenic bacteria. After taking into account interactions between smoking habit and laryngeal edema, the covariate-adjusted OR for non-smokers with laryngeal edema was significant and showed a strong relationship (OR=7.43; 95% confidence interval, 1.05-52.73) compared to non-smokers without laryngeal edema.

CONCLUSION

Although empirical antibiotic therapy was effective for most of the PTA patients, bacteriologic studies might be indispensable for the patients with laryngeal edema considering the failure of the first treatments. Particularly, the culture tests may be useful for non-smokers with laryngeal edema.