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Antibiotics to reduce post-tonsillectomy morbidity.

Abstract

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008.Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics.

OBJECTIVES

To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy.

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to 2009) and EMBASE (1974 to 2009). The date of the last search was 30 October 2009.

SELECTION CRITERIA

All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total (any documented) haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, we generated summary measures using random-effects models.

MAIN RESULTS

Ten trials, comprising a pooled total of 1035 participants, met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were mostly not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (relative risk (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.90, 95% CI 0.56 to 1.44, P = 0.66). With regard to secondary outcomes, antibiotics reduced the proportion of subjects with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002).

AUTHORS' CONCLUSIONS

The present systematic review, including meta-analyses for select outcomes, suggests that although individual studies vary in their findings, there is no evidence to support a consistent, clinically important impact of antibiotics in reducing the main morbid outcomes following tonsillectomy (i.e. pain, need for analgesia and secondary haemorrhage rates). Limited benefit apparent with antibiotics may be a result of positive bias introduced by several important methodological shortcomings in the included trials. Based on existing evidence therefore, we would advocate against the routine prescription of antibiotics to patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials.

Authors+Show Affiliations

Department of Otolaryngology - Head & Neck Surgery, University of Edinburgh Hospitals, Edinburgh, UK.No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

20614441

Citation

Dhiwakar, Muthuswamy, et al. "Antibiotics to Reduce Post-tonsillectomy Morbidity." The Cochrane Database of Systematic Reviews, 2010, p. CD005607.
Dhiwakar M, Clement WA, Supriya M, et al. Antibiotics to reduce post-tonsillectomy morbidity. Cochrane Database Syst Rev. 2010.
Dhiwakar, M., Clement, W. A., Supriya, M., & McKerrow, W. (2010). Antibiotics to reduce post-tonsillectomy morbidity. The Cochrane Database of Systematic Reviews, (7), CD005607. https://doi.org/10.1002/14651858.CD005607.pub3
Dhiwakar M, et al. Antibiotics to Reduce Post-tonsillectomy Morbidity. Cochrane Database Syst Rev. 2010 Jul 7;(7)CD005607. PubMed PMID: 20614441.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Antibiotics to reduce post-tonsillectomy morbidity. AU - Dhiwakar,Muthuswamy, AU - Clement,W A, AU - Supriya,Mrinal, AU - McKerrow,William, Y1 - 2010/07/07/ PY - 2010/7/9/entrez PY - 2010/7/9/pubmed PY - 2010/8/12/medline SP - CD005607 EP - CD005607 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev IS - 7 N2 - BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008.Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics. OBJECTIVES: To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy. SEARCH STRATEGY: We searched the Cochrane ENT Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to 2009) and EMBASE (1974 to 2009). The date of the last search was 30 October 2009. SELECTION CRITERIA: All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults. DATA COLLECTION AND ANALYSIS: Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total (any documented) haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, we generated summary measures using random-effects models. MAIN RESULTS: Ten trials, comprising a pooled total of 1035 participants, met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were mostly not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (relative risk (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.90, 95% CI 0.56 to 1.44, P = 0.66). With regard to secondary outcomes, antibiotics reduced the proportion of subjects with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002). AUTHORS' CONCLUSIONS: The present systematic review, including meta-analyses for select outcomes, suggests that although individual studies vary in their findings, there is no evidence to support a consistent, clinically important impact of antibiotics in reducing the main morbid outcomes following tonsillectomy (i.e. pain, need for analgesia and secondary haemorrhage rates). Limited benefit apparent with antibiotics may be a result of positive bias introduced by several important methodological shortcomings in the included trials. Based on existing evidence therefore, we would advocate against the routine prescription of antibiotics to patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/20614441/Antibiotics_to_reduce_post_tonsillectomy_morbidity_ L2 - https://doi.org/10.1002/14651858.CD005607.pub3 DB - PRIME DP - Unbound Medicine ER -