Eur Arch Otorhinolaryngol (2015) 272:15251528
DOI 10.1007/s00405-014-3434-3
MISCELLANEOUS
Effect of antibiotic use on bacterial flora of tonsil core in patients
with recurrent tonsillitis
Uzeyir Yildizoglu Bahtiyar Polat
Ramazan Gumral Abdullah Kilic
Fuat Tosun Mustafa Gerek
Received: 15 October 2014 / Accepted: 4 December 2014 / Published online: 16 December 2014
Springer-Verlag Berlin Heidelberg 2014
Abstract The aim of this study was to investigate the
effects of commonly used antibiotics on bacterial flora of
the tonsil core. Patients who underwent tonsillectomy for
recurrent chronic tonsillitis were included in the study.
Three groups were formed: group 1 was treated for 10 days
preoperatively with amoxicillin/clavulanic acid; group 2
was treated for 10 days preoperatively with clarithromycin;
and group 3 included patients who underwent tonsillec-
tomy without preoperative antibiotic use. The removed
palatine tonsils were sent to our microbiology department
in sterile tubes for bacteriological analysis. Seventy-three
patients (group 1 = 19, group 2 = 20, group 3 = 34
patients) aged 318 years (mean 7 years) were included in
the study. At least one bacterium was isolated from all
tonsils, except for two cases in group 1; the difference in
single bacterial growth among groups was not significant
(p = 0.06). On the other hand, the numbers of patients with
pathogenic bacterial growth was significantly lower in
group 2 (n = 2) compared with group 1 (n = 10) and
U. Yildizoglu (&)
Department of Otorhinolaryngology Head and Neck Surgery,
Beytepe Military Hospital, Cankaya 06800, Ankara, Turkey
e-mail: dr.uzeyr@gmail.com
B. Polat
Department of Otorhinolaryngology Head and Neck Surgery,
Gelibolu Military Hospital, Gelibolu 17500, Ankara, Turkey
R. Gumral
A. Kilic
Department of Microbiology, Gulhane Military Medical
Academy, Etlik 06018, Ankara, Turkey
F. Tosun
M. Gerek
Department of Otorhinolaryngology Head and Neck Surgery,
Gulhane Military Medical Academy, Etlik 06018, Ankara,
Turkey
group 3 (n = 27) (p \ 0.001). The bacterium isolated most
frequently from the tonsils was Streptococcus viridans.
Pseudomonas aeruginosa was the only pathogenic bacte-
rium that grew in all three groups. Clarithromycin was
more effective than amoxicillin/clavulanic acid in eradi-
cating pathogenic bacteria in the tonsil core. Pseudomonas
aeruginosa might be responsible for resistant or recurrent
tonsil infections. To prevent endocarditis, antibiotic pro-
phylaxis toward S. viridians, which is the most prevalent
bacterium in the tonsil core, should be kept in mind for
patients with heart valve damage.
Keywords Chronic tonsillitis
Tonsillectomy
Tonsil
core
Bacterial flora
Antibiotic usage
Introduction
Tonsillitis is one of the most common infections of the
upper respiratory tract. The most frequent cause is viruses,
and the second most frequent cause is bacteria, such as
group A b-hemolytic streptococci, Staphylococcus aureus,
Haemophilus influenzae, Streptococcus pneumoniae,
Escherichia coli, and Pseudomonas aeruginosa [1, 2].
Persistence of bacteria in the tonsil core results in recurrent
chronic tonsillitis, which in turn causes frequent attacks of
sore throat, malaise, joint pain, cervical adenopathy, and
halitosis. Recurrent tonsil infections cause parenchymal
hyperplasia and tonsillar hypertrophy, which is an impor-
tant etiologic factor of snoring and obstructive sleep apnea,
particularly in children. Other serious complications of
recurrent tonsillitis include rheumatic fever, which mainly
affects the heart and nervous system (Sydenhams chorea),
glomerulonephritis, peritonsillar abscess, middle ear
infections, and septicemia (Lemierres syndrome).
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Recurrent tonsillitis also causes a significant loss of school
and work attendance.
The main goal is eradication of bacteria in the tonsil
parenchyma, either by antibiotic use or tonsillectomy.
Since the 1950s, 10 days of penicillin has been the treat-
ment of choice for bacterial eradication in tonsillopharyn-
gitis. Until the early 1970s, treatment failure of group A b-
hemolytic streptococci tonsillopharyngitis ranged from 2 to
10 %, but it exceeded 20 % thereafter [3]. Poor patient
compliance and co-pathogenic colonization with S. aureus,
H. influenzae, and Moraxella catarrhalis, anaerobes that
inactivate penicillin with b-lactamase, can cause clinical
treatment failure [3]. Biofilm-producing bacteria such as S.
aureus might also be responsible for recurrent tonsillitis
[4]. Biofilm might serve as infection reservoirs, as the
bacteria in biofilm are more resistant to antibiotics than
similar free bacteria in the body. The presence of mixed
bacteria in biofilm might be a further cause of bacterial
resistance to antibiotic therapy.
Tonsillectomy is a commonly performed surgery for
radical treatment of recurrent tonsillitis and tonsillar
hypertrophy. Repeated antibiotic use always precedes
tonsillectomy. However, its effectiveness on bacterial
eradication is controversial due to antibiotic resistance. The
aim of this study was to investigate the effects of frequently
used antibiotics on bacterial flora of the tonsil core.
Materials and methods
Patients
This prospective study was approved by the ethics com-
mittee of our institute (1574/July 2011) and was conducted
in our department between January 2012 and October
2014. Children with recurrent tonsillitis (having at least
seven attacks of sore throat due to documented tonsillitis in
the preceding year, five similar attacks in the preceding
2 years, or fewer than three episodes per year in the pre-
ceding 3 years) were enrolled in the study [5]. The patients
were included in the study after a signed consent form was
obtained. Three groups were formed. In group 1, the
patients were given amoxicillin/clavulanic acid for 10 days
just before tonsillectomy; in group 2, the patients were
given clarithromycin for 10 days before tonsillectomy; and
in group 3, the patients underwent tonsillectomy without
preoperative antibiotic use. The amoxicillin/clavulanic acid
doses were 875/125 mg (1,000 mg) tablet every 12 h in
children older than 12 years and 25/3.6 mg/kg every 12 h
in children younger than 12 years. Clarithromycin was
prescribed as a 500 mg tablet every 12 h in children older
than 12 years and 7.5 mg/kg twice a day in children
younger than 12 years. All of the patients underwent
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Eur Arch Otorhinolaryngol (2015) 272:15251528
tonsillectomy under general anesthesia. The palatine tonsils
were removed en bloc with their capsules and sent to the
microbiology department in sterile tubes for bacteriologic
analysis. Patients who underwent tonsillectomy for reasons
other than recurrent tonsillitis, such as excisional biopsy for
malignancy, hypertrophic tonsillitis that caused obstructive
sleep apnea or snoring, and specific diseases such as
tuberculosis, were excluded from the study.
Bacteriological analysis
The bacteriological culture was performed according to the
method described by Kasenomm et al. [6]. After excision,
each patients two tonsils were placed into a sterile 50 mL
conical tube containing sterile physiological saline solution
and submitted immediately to the microbiology laboratory.
The surface of the tonsil tissue specimen was rinsed three
times with sterile physiological saline in a falcon tube and
placed in a sterile Petri dish, after which the outer surface
of the tonsil was gently removed with a sterile scalpel.
Approximately 0.2 g of tissue was aseptically excised for a
tonsil core culture and homogenized in a sterile Petri dish
with a sterile scalpel. The specimen was transferred into a
sterile tube containing 1 mL of thioglycollate broth; then,
100 lL of this broth were inoculated on 5 % sheep blood
agar, chocolate agar, and eosin/methylene blue agar plates
and incubated for 2448 h at 37 C. The chocolate agar
was incubated in an incubator with an atmosphere enriched
with 10 % CO2. The culture plates were examined for
growth, and colonies growing on the plates were gram
stained and subjected to microscopy. Then, the microor-
ganisms were identified, mostly at the genus and species
levels, using conventional methods [7]; the BD Phoenix
System was used for identification if necessary. Antimi-
crobial susceptibility tests were performed using the BD
Phoenix System and conventional methods according to
the standards of the Clinical and Laboratory Standards
Institute.
Statistical analyses
Statistical analyses were performed using SPSS software
version 15. The Chi-square test was used to compare dif-
ferences among the three groups. A p value of less than
0.05 was considered statistically significant.
Results
Seventy-three patients (group 1 = 19, group 2 = 20, group
3 = 34 patients) aged 318 years (mean 7 years) were
included in the study. A total of 99 bacteria were isolated
from specimens (23 bacteria in group 1, 26 bacteria in
Eur Arch Otorhinolaryngol (2015) 272:15251528 1527

group 2, and 50 bacteria in group 3). The distribution of positive pathogenic bacterium was isolated from group 2;
bacteria isolated from the core tonsils is presented in however, 11 gram-positive pathogenic bacteria grew in
Table 1. At least one bacterium grew in every tonsil group 1 and 27 gram-positive pathogenic bacteria grew in
specimen in the three groups, except two cases in group 1; group 3. The difference in gram-positive pathogenic bac-
the differences among groups were not significant terial growth was significant among the groups (p \ 0.001).
(p = 0.06) in terms of bacterial growth and no bacterial
growth. More than one bacterium were seen in four, eight,
and 16 tonsils in the group 1, group 2, and group 3, Discussion
respectively; the differences in single and multiple bacte-
rial growth among groups were not significant (p = 0.08). Normal oropharyngeal flora contains different aerobic and
The number of patients with pathogenic bacterial anaerobic bacteria, including a hemolytic and non-hemo-
growth, including S. aureus, S. pneumoniae, b-hemolytic lytic streptococci, coagulase negative staphylococci, Neis-
streptococci, H. influenzae, P. aeruginosa, and E. coli, was seria, Corynebacterium, Actinomyces, Leptotrichiae, and
significantly lower (p \ 0.001) in group 2 (n = 2) than in Fusobacterium species [1]. The bacteria group A b-
group 2 (n = 10) and group 3 (n = 27). hemolytic streptococci, S. aureus, H. influenzae, S. pneu-
Streptococcus viridans was the most frequently isolated moniae, Corynebacterium diphtheriae, and Neisseria gon-
bacterium (n = 33) from the tonsil core, and S. aureus was orrhoeae are the main causes of bacterial tonsillitis [1].
the most frequently isolated pathogenic bacterium Staphylococcus aureus is the most frequently isolated
(n = 21). Pseudomonas aeruginosa was the only patho- pathogenic bacterium in patients with recurrent tonsillitis;
genic bacterium that grew in all three groups. No gram- b-hemolytic Streptococcus is another common pathogen
that causes recurrent tonsillitis [2, 8]. These group A b-
Table 1 Distribution of bacteria isolated from tonsils of patients hemolytic streptococci are most prevalent in children [2],
treated with amoxicillin/clavulanic acid, patients treated with clari- and S. pneumoniae may frequently cause recurrent tonsil-
thromycin, and patients not treated with antibiotics litis in younger patients [8]. Large colonies of group C and
Microorganisms Number of isolates G streptococci were isolated from 3 % of swabs of 2,085
children with acute tonsillitis; they were considered unu-
AMC CLR NT Total
sual throat pathogens [9]. Haemophilus influenzae is a
Gram-positive cocci common tonsil pathogen regardless of seasonal variations
Staphylococcus aureus 6 15 21 [8]. Pseudomonas aeruginosa, a pathogenic growth seldom
Coagulase negative staphylococcus 1 2 3 seen (3.8 %) in the tonsils [2], can cause tonsil infections
Streptococcus viridans 6 16 11 33 resistant to antibiotics, and tonsillectomy may be needed
Streptococcus pneumoniae 2 4 6 for eradication [10]. Klebsiella pneumoniae, E. coli, and
Streptococcus salivarius 3 1 4 Enterobacter species may also be isolated in patients with
Group A b-hemolytic streptococci 2 2 4 recurrent tonsillitis [2]. At the present study, the most
Group C b-hemolytic streptococci 2 2 frequently isolated pathogenic bacterium was S. aureus and
Group G b-hemolytic streptococci 1 1 2 the only pathogenic bacterium that grew in all three groups
Group F b-hemolytic streptococci 1 1 was P. aeruginosa.
Rothia mucilaginosa 1 1 The use of antibiotics always precedes tonsillectomy.
Arcanobacterium haemolyticum 1 1 However, repeated use of antibiotics may not eradicate
Gemella morbillorum 1 1
pathogenic bacteria from the tonsils. Penicillin was initially
Gram-negative cocci
the treatment of choice for tonsillitis, but the failure rate
increased to 20 % after the 1970s [3]. Various theories
Haemophilus species 3 3
have been suggested to explain the antibiotic resistance.
Neisseria species 4 1 5
One theory is that b-lactamase-producing bacteria protect
Gram-negative rods
group A b-hemolytic streptococci from penicillin. The
Pseudomonas aeruginosa 1 2 2 5
second theory is that unusual bacteria are out of the peni-
Pseudomonas fluorescens 1 1
cillin activity spectrum, such as P. aeruginosa, which grew
Escherichia coli 2 2
in all three groups in our study. Other explanations include
Burkholderia gladioli 1 1
poor patient compliance during the ten-day course of
Morganella morganii 1 1
therapy, asymptomatic bacterial carriage, and reinfection
Ralstonia species 2 2
[11]. Fibrosis, which develops as a result of recurrent
Total 23 26 50 99
tonsillitis, can also hamper penetration of the antibiotic into
AMC amoxicillin/clavulanic acid, CLR clarithromycin, NT not treated the tonsil tissue. Averono et al. [12] found a median level

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of amoxicillin concentration in tonsil tissue (1.1 lg/g) that
was significantly lower than the plasma level (4.7 lg/mL)
in pediatric patients who underwent tonsillectomy for
recurrent tonsillitis. Staphylococcus aureus and group A b-
hemolytic streptococci grew in the tonsil tissues of the
patients treated with amoxicillin/clavulanic before tonsil-
lectomy in our study. The last explanation is the presence
of bacterial biofilm around the tonsil tissue. In a study by
Woo et al. [13] tonsillar biofilms were significantly pre-
valent and of a higher grade in the recurrent tonsillitis
group than in the control group.
Tonsillectomy is the radical treatment for recurrent
tonsillitis, and adenotonsillectomy drastically reduces
median use of respiratory medication [5]. In a retrospective
study including 11,000 children, median antibiotic use
dropped from four boxes in the year before surgery to one
box in the first year after adenotonsillectomy [14]. In the
same study, the median number of doctor visits dropped
from seven before the surgery to four after the surgery.
Tonsillectomy decreases the numbers of sore throat epi-
sodes and upper airway infections, prevents airway
obstruction, and increases sleep quality and Insulin-like
growth factor binding protein-3 (IGFBP-3) concentrations
[15]. However, adenotonsillectomy is a surgical procedure,
and indications should be judged meticulously before
operating.
Streptococcus viridans was the most frequently isolated
bacterium in the infected and non-infected tonsils in a
prospective study by Bista et al. [16]. While S. viridians
can be isolated in the normal oropharyngeal flora, it is also
an important etiological factor of bacterial endocarditis. It
accumulates around the teeth, and dental manipulation or
dental diseases cause bacteremia, which is a common cause
of bacterial endocarditis. Streptococcus viridans was the
bacterium isolated most frequently from the tonsils in our
study. Therefore, if a patient has previous heart valve
damage, a preoperative antibiotic prophylaxis should be
prescribed before the tonsillectomy.
In conclusion, amoxicillin/clavulanic acid is not effec-
tive for eradicating frequently isolated gram-positive
pathogen bacteria in the tonsil core; clarithromycin is more
effective for this purpose. However, these two commonly
used antibiotics cannot eradicate gram-negative bacteria
such as Pseudomonas aeruginosa. In patients with heart
valve damage, endocarditis prophylaxis should be kept in
mind for S. viridians, which is the most prevalent bacte-
rium in the tonsil core.
Conflict of interest The authors declare that they have no conflict
of interest.
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Eur Arch Otorhinolaryngol (2015) 272:15251528
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