Tonsillectomy Revisited: New guidelines represent a clinical shift for some otolaryngologists

Changes in Antibiotic Use

“The most surprising finding is that the current literature does not support the routine use of antibiotics after tonsillectomy,” said Ron B. Mitchell, MD, professor and chief of otolaryngology-head and neck surgery within the division of pediatric otolaryngology at Cardinal Glennon Children’s Hospital and Saint Louis University School of Medicine, St. Louis, Mo., another author of the guidelines.

Under statement 8, the guidelines strongly recommend against the routine use of perioperative antibiotics, based on the fact that the aggregate data show no support or benefit in the perioperative period (defined as the 24 hours prior to and after surgery). This statement, according to Dr. Rosenfeld, will clash with the clinical practice of up to 80 percent of otolaryngologists, who currently give antibiotics on a routine basis for seven to 10 days after tonsillectomy, with the perceived benefit of speeding recovery.

He emphasized, however, that aggregate data from randomized clinical trials over the last decade or two do not show this benefit. “Looking at all the research, it looks like giving antibiotics versus placebo after tonsillectomy really doesn’t change, in a meaningful way, how a child recovers,” he said.

Because of this finding, Drs. Rosenfeld and Mitchell have already changed their practice and no longer routinely use antibiotics in this setting.

For Nancy Bauman, MD, a pediatric otolaryngologist at Children’s National Medical Center in Washington, D.C., such a switch is not yet likely, however. Although she applauds the authors for their diligent review of the literature and developing guidelines that represent an outstanding review of the data, she nonetheless is hesitant to change her clinical practice and accept the particular recommendation regarding antibiotic use until she can review the topic further.

“I know that personal and anecdotal experience should not guide my judgement in the face of evidence based guidelines,” she said, “However, I am not certain that enough data is available to judge the effect of antibiotics for pain control in the pediatric patient population.”

In support of this statement, Dr. Bauman pointed to evidence used to generate the recommendation, specifically evidence from a Cochrane Review published in 2010 (Otolaryngol Head Neck Surg. (7): (CD005607). Only one of the five series reviewed analyzed the effect of post-op antibiotics for seven days in pediatric patients and it showed a significant reduction in the mean number of days with continuous subjective pain compared to placebo.