The effect of antibiotics on post-adenotonsillectomy morbidity in Tanzanian children: study protocol for a randomized, double-blind, placebo-controlled trial

Bacterial colonisation of surface and core of palatine tonsils among Tanzanian children with recurrent chronic tonsillitis and obstructive sleep apnoea who underwent (adeno)tonsillectomy

OBJECTIVE

Acute and chronic tonsillitis are frequently treated with antibiotics. This study aimed to understand the presence of pathogenic micro-organisms on the surface and core of chronically infected tonsils among Tanzanian children.

METHODS

The study enrolled children undergoing adenotonsillectomy. Surface and core tonsillar swabs were taken. Quantitative polymerase chain reaction was performed for Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Neisseria meningitidis and Pseudomonas aeruginosa.

RESULTS

Surface and core combined, isolated N meningitidis (86.1 per cent) was found the most, followed by H influenzae (74.9 per cent), S pneumoniae (42.6 per cent) and S aureus (28.7 per cent). M catarrhalis and P aeruginosa were only found in a few patients, 5.6 per cent and 0.8 per cent respectively.

CONCLUSION

Colonisation of the tonsillar surface and core has been found. Potentially pathogenic micro-organisms are likely to be missed based on a throat swab. Hence, the practice of surface tonsillar swabbing may be misleading or insufficient.

Usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy in northern Tanzania

Introduction

Antimicrobial Resistance (AMR) is a growing concern globally, mostly being contributed by a limited understanding of antibiotic utilization as a result of inappropriate acquisition and prescription. Parental awareness is essential in optimizing their usage and preserving the effectiveness of these crucial medications. The current study investigates the usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy ((A)TE) in Northern Tanzania.

Methods

a cross-sectional survey was conducted among parents/caregivers of children who underwent (A)TE in Northern Tanzania. A modified and well-structured questionnaire, which was adapted from a World Health Organization (WHO) questionnaire and used to assess the parents´ knowledge of antibiotics and antibiotic use.

Results

the study included 157 participants. About 54% of the children under the age of 5 years. As of 88% of children had already received antibiotics prior to surgery, 92% of the used antibiotics were prescribed by a clinician, and 5% of parents to used leftovers antibiotics for their children. While 88% of the parents reported adhering to prescriptions, 8% of reported buying the same antibiotic (as prescribed before) without consulting a clinician again when their children are sick.

Conclusion

the use of antibiotics, including broad-spectrum antibiotics, was found to be high in our study group. Parents demonstrate a relatively good understanding of antibiotic usage. It is plausible to speculate that a higher prevalence of non-insured, unemployed, and less educated parents may lead to an increased incidence of misuse and misinterpretation of antibiotics.

Effect of placebo versus prophylactic postoperative amoxicillin on post-(adeno) tonsillectomy morbidity in Tanzanian children: a two-centre, double-blind randomized controlled non-inferiority trial

INTRODUCTION

to date in Africa, there is limited evidence regarding the role of prophylactic antibiotics to prevent post (adeno) tonsillectomy ((A)TE) morbidity in children. As (A)TE is the most performed surgery in the pediatric population, the use of prophylactic antibiotics is likely a major factor in the development of AMR. In Tanzania, as in many other settings with limited resources antibiotics are misused and overprescribed. Potential reasons include limited stewardship and widespread use of postsurgical prophylactic antibiotics. Misuse of antibiotics might contribute significantly to the development of antimicrobial resistance (AMR).

METHODS

a two-centre, double-blinded randomized controlled non-inferiority trial. Subjects included children from 2-14 years of age with recurrent chronic tonsillitis and/or obstructive sleep apnoea due to adenotonsillar hypertrophy who were electively scheduled for (A)TE in two tertiary hospitals. Participants were randomly allocated to receive either placebo or amoxicillin for five days postoperatively. Primary outcome was non-inferiority of placebo compared with amoxicillin for postoperative haemorrhage (margin 5%; at 14 days) postoperative fever (margin 5%; at 7 days), and pain (margin 1 point; at 7 days). Secondary outcomes included the times required for resumption of normal diet and normal activities, and microbial recolonization of the tonsillar beds. Data were analysed according to intention-to-treat principle. Follow-up was 14 days.

RESULTS

between March 13, 2019 and September 20, 2019 270 children were enrolled. All children were randomly assigned to receive placebo (n = 136) or amoxicillin (n = 134). By 14^{t h}day post-operatively, total of 8 children were lost to follow-up in each arm. No major postoperative haemorrhage was registered. By 14^th day post-operatively, 22 (17.5%) children in the amoxicillin arm and 19 (14.8%) children in the placebo arm had reported minor haemorrhage (risk difference (RD) -2.6% (95%CI -10.2 - 5.0); p_{non-inferiority} = 0.045). By 7^th day post operatively, 8 (6.3%) children in amoxicillin arm and 4 (3.1%) children in placebo arm reported fever during the first week (RD -3.2% (95%CI -7.6 - 1.2); p_{non-inferiority} = 0.001). By 7^th day post operatively, mean pain score (mean (SD)) was 3.25 (1.53) in the amoxicillin arm and 3.56 (1.68) in the placebo arm (mean difference 0.31, (95% CI -0.02 - 0.65); p_{non-inferiority} < 0.001). No statistically significant differences between the two groups were found in any of the secondary outcomes. Findings shows, placebo is non-inferior to amoxicillin for post-operative morbidities in Tanzanian children undergoing (A)TE.

CONCLUSION

it is recommended that antibiotics should only be used when clinically necessary to treat a specific infection. Unnecessary use of antibiotics contributes to the development of antimicrobial resistance. Trial Registration: Pan African Clinical Trials Registry PACTR201905466349317. Retrospectively registered on 15 May 2019.