(KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A )87-94(

-87 ( ‫لثةرة‬
)1 ( 4 , 2006
)94 2706
A

Prophylactic Versus Therapeutic Antibiotic

Use for Tonsillectomy

Sherko Saeed F. Zmnako And Bakhawan Rafee Aziz

University of Sulaimani Sulaimani Teaching Hospital
College of Medicine Department of Ear, Nose and Throat

Kurdistan Region. Iraq.

Abstract
This is a prospective, comparative randomized study, implemented in Department of
Otorhinolaryngology, in Sulaimani Teaching Hospital, Sulaimani, Kurdistan region, Iraq, from 3 rd March
2003 to 2nd March 2004. The aim of the study is to assess and compare cost-effectiveness of
prophylactic antibiotic in elective tonsillectomy. The study was including patients of different age and
sex who under went elective tonsillectomy; they divided randomly in to two groups:
Group A, controlled group was receiving therapeutic antibiotic for 7 days postoperatively.
Group B, studied group, received just three doses of prophylactic antibiotic perioperatively.
We conclude that prophylactic antibiotic is less coasty and more effective than therapeutic one.

Keywords:- cost-effectiveness, prophylactic antibiotics, therapeutic antibiotics, elective

tonsillectomy.
prophylactic antibiotic is not the only
Introduction factor that determine the risk of
Tonsillectomy continues to be one of
the most common procedures performed
by Otolaryngologists in recent years [1, postoperative infection, other factors have
2], and it is one of the most frequent equal or even greater importance like
operations carried out in childhood [3, 4]. surgical technique, duration of surgery,
Since the wound in tonsillectomy is a and postoperative advices; include
clean contaminated wound and the bed frequent chewing, drinking and eating by
remains open postoperatively, with the patients [8 -10].
spillage of bacteria contaminated From economical point of view,
secretions from aero digestive tract and decision making in any subject will
possibility of infection [5], therefore the primarily depend on the principles of
usage of postoperative therapeutic Opportunity Cost, in which we will make
antibiotic became routine [6]. Several a comparison between the coast of a
studies shows that antibiotics given for 5- particular subject and the obtained
7 days post-tonsillectomy considered to be benefits of that projects, meanwhile we
beneficial [7], while there are studies that found the earned benefits of the subject in
not provide enough information to support the study is higher than the benefits
its usage as a routine. obtained from other studies with the same
Prophylactic antibiotic can be used in coasts, at that time, the decision making in
tonsillectomy, based on the type of its such a study is considered to be
surgical wound (clean-contaminated), as a acceptable and correct economically, but
measure to prevent postoperative the decision making will not be correct if
infection. Taking in consideration that

Email: sherko_zmnako@yahoo.com
87
(KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A
)1 ( 4 , 2006 2706
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there was higher obtained benefits with Figure (1): Distribution of therapeutic
less coast in other studies [11]. and prophylactic antibiotic in different
The aim of our study is to show whether ages
prophylactic use of antibiotic is superior The choice of antibiotic was made based
to the routine therapeutic use regarding on the pathogens mostly found in bacterial
the postoperative morbidity and mortality. flora of oropharynx and their sensitivities
to drugs.
Patients and Methods
The first group (73 patients) received
This study was including one hundred
therapeutic Amoxicillin postoperatively at
sixty three patients, admitted for elective
the doses according to their body weights
tonsillectomy with recurrent or chronic
(50-100 mg/kg/day) for 7 days (I.V.
tonsillitis, obstructive tonsillar
administration for first 24 hours then
hypertrophy or history of quinsy.
followed by oral for other 6 days).
Demographic data collected about: age,
The second group (70 patients) consisted
sex, occupation and preoperative
of patients who received prophylactic
assessment includes (temperature, pulse
antibiotic therapy in three consecutive
rate, blood pressure, hematological
intravenous doses according to their body
investigations such as Hb%, WBC,
weights. First dose was injected during the
bleeding time, clotting time and blood
induction of anaesthesia, the second doses
group).
during the operation and the third one
All were followed up over the ten
within 6 hours from the operation.
postoperative days, depending on different
All patients were anaesthetized and
parameters such as severity of pain, fever,
operated with the same technique
local hyperemia, local edema, fetor oris
(dissection and cauterization) and proper
and otalgia. W.B.C. counts in the 6th
postoperative advice; include frequent
postoperative day.
chewing, eating and drinking by the
Twenty patients were excluding from
patients, for both groups equally.
the study because they were not reported
Postoperative assessment and follow up
for follow up. The remaining (143
conducted according to the different
patients) initially divided randomly in to
parameters, which are present in the data
two groups; each group was dividing in to
sheet. We asked the patients to score the
two subgroups according to their ages,
symptoms from 0 to 3 scale, and zero was
from 2-10 years and 11-45 years. Figure
absence of symptoms, 1 was mild, 2 was
(1).
moderate and 3 was severe.
Distribution of therapeutic and prophylactic Lastly the average price of the
antibiotic in different ages medications used in this study during that
80 73 70
period obtained from the pharmacy
centers.
60 The results were analyzed by qui-square
37 40 Therapeutic
test, with significance of P value <0.05.
Number

40 36
30 Prophylactic
Results
20
The age varies between 2-45 years.
0 (Figure 2). Shows the age distribution.
Patints Age 2-10 Y Age 11-45Y
Peak age is 2-10 years.

88
 (KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A
)1 ( 4 , 2006 2706
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Age distribution
Postoperative assessment of subjective
parameters (pain, fetor oris, hyperemia
50
and edema), which were conducted in the
45 6th postoperative day, shows that there was
40 slight increase in the incidence of these
35
parameters in the patients treated by
30
therapeutic antibiotic, which is not
Age/years

25 Age

20
significant statistically. (Table 2).
15 We observed 11 cases (15.06%) in the
10 patients were treated with therapeutic
5
antibiotic and 9 cases (12.8%) in the
0
0 50 100 150 200 patients were treated with prophylactic
Figure (2): the Age distribution.
Number
antibiotic, (Table 3), they have had
infection in the analysis conducted in the
Table (1): Sex distribution in different 6th postoperative day according to the
groups. (Male: female ratio was 74:69) subjective parameters with infected
slough, fever (of 38 C or more) and
Groups Patients Male Female leukocytes count (more than 11000),
(Table 4). So there was slight increase in
Therapeutic 73 35 38 the incidence of infection in the patients
were treated by therapeutic antibiotic,
Prophylactic 70 39 31 which is not significant statistically.
Total 143 74 69

Table 2: Comparison between both groups according to the presence of pain, fetor
oris, hyperemia and edema, with P values.

P
Groups Patient Pain Fetor oris Hyperemia Edema
value
Therapeutic (2-10 Y) 37 11(29.7%) 7(18.9%) 4(10.8%) 5(13.5%)
0.3662
Prophylactic (2-10 Y) 40 9(22.5%) 1(2.5%) 3(7.5%) 5(12.5%)
23(63.8%
Therapeutic (11-45 Y) 36 ) 10(27.7%) 8(22.2%) 6(16.6%) 0.1971
Prophylactic (11-45 Y) 30 15(50%) 1(3.3%) 5(16.6%) 6(20%)

Table 3: Numbers of cases with infection and/or secondary bleeding in different groups

Incidence
Patie Total rate of
Groups Infection rate of P value
nts infection
bleeding
Prophylactic (2-10 Y) 40 5 (12.5%)
9 (12.85%) 3
Prophylactic (11-45 Y) 30 4 (13.3%)
Therapeutic (2-10 Y) 37 5 (13.5%) 0.71
11 (15.06%) 5
Therapeutic (11-45 Y) 36 6 (16.6%)
Total 143 20 13.98% 8 (5.59%)

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)1 ( 4 , 2006 2706
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Table 4: Numbers of patients with fever and/or leukocytosis in cases with
infection in different groups.

Groups Patients Cases with Fever

Leukocytes
infection (Of 38 C
(>11000)
or more)
Therapeutic (2-10 Y) 37 5 4 3
Prophylactic (2-10 Y) 40 5 4 3
Therapeutic (11-45 Y) 36 6 5 3
Prophylactic (11-45 Y) 30 4 3 2

Table 5: Numbers of cases those properly cooperate with postoperative

advices.

No. Of cases Cooperative Non cooperative Total P value

Groups
Therapeutic 30 43 73
0.005
Prophylactic 45 25 70

The proper postoperative advice post tonsillectomy bleeding over all the
cooperation was significantly more in study, (Table 6).
those with prophylactic antibiotic as a There was an increase in the incidence of
comparison with therapeutic group, (Table bleeding with age, (Figure 3), which was
5) more common in the patients aged above
There were 8 (5.59%) cases of secondary 18 years.

Table 6: Numbers of cases presented with secondary post tonsillectomy Bleeding

35

30

25

20

15

10

90 0
1 2 3 4 5 6 7 8

Patients
 (KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A
)1 ( 4 , 2006 2706
A
T
Type Co
Type of Cost otal
of ast
drug ($) cost
drug ($)
($)
3 vials of
1.5 Nil Nil 1.5
Amoxicillin
Total cost ($) of post-tonsillectomy
antibiotics for patients in both groups are
shown in (table 9)
Figure 3: Incidence of secondary bleeding
in relation with age Table 9: Total cost ($) of post-
tonsillectomy antibiotics for patients in
The incidence of bleeding is more both groups,
common in males than females, were 6/74
cases males and 2/69 cases females.
No. Total
(Figure 4). P
of
Groups Price
pati value
ents ($)
Therapeu
73 255.5
tic
0.0000
Prophyla
70 105
ctic

Figure 4: Incidence of secondary

bleeding in relation with sex P value was less than 0.05 (0.000), which
Total costs ($) of post-tonsillectomy is significant. Average: 180.25
antibiotic for individual patient are shown
in tables [7,8]. S. D. (standard deviation): 10

Table7: Total cost ($) of post- Discussion

tonsillectomy antibiotic for individual Regarding the incidence of infection
patient in therapeutic groups. according to postoperative assessment of
subjective parameters (Pain, fetor oris,
T hyperemia and edema of the bed of the
Co Co otal
Type of Type of tonsil), (Table 2), the study revealed that
st st cos
drug drug there is no significant difference between
($) ($) t the both prophylactic and therapeutic
($)
group in the same range of age, however,
4 vials of 30 the infection rate was slightly less in the
Amoxicil 2 capsules 1.5 3.5 group treated by prophylactic antibiotics
lin of than those with therapeutic one, (Table 3),
Table
($)= 8: Total
(US. Dollars) cost ($) of post- and this is due to the affectivity of
tonsillectomy antibiotic for individual prophylactic antibiotic which enters the
patient in prophylactic group. blood and tissue before the incision and
manipulation [9]. It is well known that

91
(KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A
)1 ( 4 , 2006 2706
A
antibiotic is not the only factor that
determines the risk of postoperative
infection, other factors have equal or even
greater importance like postoperative
advices inform of frequent chewing,
drinking and eating by the patients [8],
neglecting of this fact by the therapeutic
group in which they depend on
postoperative antibiotic in contrast with
that of prophylactic group in which they
depend more on postoperative advice,
(Table 5), is also another cause for this
incidence of infection in therapeutic
group.
Our study showed that incidence of
infection was 12.8% in patients with
prophylactic antibiotic, (Table 3); this
result is slightly more than the other
studies in which the rate of infection is
less than 10% [9], which is due to the fact
that operative facilities are deficient in our
locality.
Conclusions
Since there is no statistically significant
difference between the two groups,
92
regarding the postoperative outcome, it is
revealed from this comparative study that
prophylactic way for treatment in
comparison with the therapeutic one is:
1. Less coasty.
2. Less causing infection and
complications.
3. More easy and comfortable for the
patient.
As well as the study did not provide
enough information to support the routine
use of post-tonsillectomy therapeutic
antibiotic.
Recommendation
The regime of routine use of post-
tonsillectomy therapeutic antibiotic needs
revision.
Acknowledgement
I would like to thank all medical,
paramedical staffs and my colleagues in
the ENT department / Sulaimani Teaching
Hospital for their great help.
(KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A
)1 ( 4 , 2006 2706
A
References
1.Timms M.S., Tiempl RH.: Oblation tonsillectomy: a double blind randomized
2.controlled study. The journal of Laryngology & Otology. 2002, 116, pp.450-452.
3. Homer J.J, Swallow J, Semple P, An audit of post-operative analgesia in children
4. following tonsillectomy. The journal of Laryngology & Otology.2002, 116,
367- 370.
5.Hung T, Moore - Gillon V., Hern J., Hinton A., Ratel N.: Topical bubivacaine in
pediatric day-case tonsillectomy. The journal of Laryngology & Otology. 2002, l. 116,
33-36.
6.Panarese A.., Clarke R.W., Yardle M.P.: Early post-operative morbidity following
tonsillectomy. The journal of Laryngology & Otology. 1999, 113, 1089-1091.
7.Francis B. Quinn, Jr. Elizabeth J. Rosen,: Microbiology, Infection and Antibiotic
therapy. http://www.utmb.edu/otoret/Grnds/Indect-0003.htm.
8.Cecil C. Ramos, Maria E. R. Goncalves, Priscila Bogar Rapport; Porphylactic
Antibiotic Therapy after Tonsillectomy.
http://www.ampath.Co.Za/AntibiotGuide/chapter6.htm.
9.Francis B. Quinn, Ronald W. Deskin, Karen L. Stierman, Antibiotics in Head and
Neck Surgery. http://www.emedicine.com/ent/topic/8.htm.
10.Dr. Dilip Nathwani, Tayside University Teaching Hospital. Professor Peter Davey.
Antibiotic Prophylaxis in Surgery, 2000.
http://www.land/aeknir.is/uploads/files/SIGN45.pdf.
11.Charles V. Mann, Russel M.S. Norman S. Williams: Bailey & Love’s, Short Practice
of Surgery. 22nd edition P. 71-72.
12.Alan Silver, Clinical Coordinator - Project Leader. Maryanne Daley, Senior PRA:
Trends in Post-operative Use of Prophylactic Antibiotic,
1999.http://ipro.tempdomainname.com/documents/hcqip/impact-reports/impact-
prophylactic-antibiotic-011997.pdf
13.Locke Anderson W. H., Ann Putalluz and William G. Shepherd; ECONOMICS. New
Delhi-110001.
14.Alan G kerr, Royal Victoria Hospital, Belfast and Belfast City Hospital: Scott-
Brown's Otolaryngology. Sixth edition 1997. Peadiatric Otolaryngology, 6/18/11.
15.Alan G kerr, Royal Victoria Hospital, Belfast and Belfast City Hospital: Scott-
Brown's Otolaryngology. Sixth edition. Laryngology and Head and Neck Surgery1997,
5/4/21-22.

93
‫‪(KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A‬‬
‫( ‪)1‬‬ ‫‪4‬‬ ‫‪, 2006‬‬ ‫‪2706‬‬
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‫بةكارهيَنانى دذةتةنينةوة بةشيَوةى ثاراستن بةرامبةر‬

‫بةكارهيَنانى‬
‫بةشيَوةى ضارةسةر لة نةشتةرطةرى لبردنى‬
‫ئالووةكان‬
‫‪.‬شيَركؤ سةعيد فتح الله زمناكؤ‪ ،‬كؤليجى ثزيشكى‪ ،‬زانكؤى سليمانى‬
‫‪.‬باخةوان رافع عةزيز‪ ،‬نةخؤشخانةى فيَركارى‪ ،‬بةشى قورط ولووت وطوآ‬
‫هةريَمي كوردستان‪ /‬عيَراق‬
‫ثوختة‬
‫ئةمشششة ليكؤلينةوةيةكشششى ئاييندةبينشششى بةراووردى هةرةمةكىيشششة كشششة لة بةششششى قورط ولووت وطوى لة‬
‫نةخؤشخانةى فيركارى ئةنجام دراوة‪.‬‬
‫سليمانى ‪ /‬هةريمى كوردستان ‪ /‬عيراق‪ /‬لة ئازارى ‪ 2003‬بؤ ئازارى ‪.2004‬‬
‫ئامانجششى ئةم ليكؤلينةوةيششة بةراووردى كاريطةرىو نرخاندنششى بةكارهينانششى دذةتةنينةوةيششة بةمةبةسششتى‬
‫ثاراستن لةهةوكردن ثاش نةشتةرطةرى لبردنى ئالووةكان‪.‬‬
‫ليكؤلينةوةكشششششة ذمارةيةك نةخؤششششششى طرتةوة لةهةموو تةمةنيشششششك و لة هةردوو رةطةزةكشششششة لةوانةى‬
‫نةشتةرطةرى لبردنششى ئالووةكانيان بششؤ كرابوو ‪ ,‬كششة بششة شيوةيةكششى هةرةمةكششى دابةش كران بششة دوو‬
‫كؤمةلةوة‪:‬‬
‫كؤمةلةى يةكةم‪ :‬كؤنترؤل ‪ ,‬كة دذةتةنينةوةيان وةرطرتبوو تا ماوةى (‪ )7‬حةوت رؤذ دواى نةشتةرطةرى‪.‬‬
‫كؤمةلةى دووةم‪ :‬ئةو كؤمةلةيةى كششة لةذيششر ليكؤلينةوةدا بوون ‪ )3( ,‬سششآ ذةم دذةتةنينةوةيان وةرطرتبوو‬
‫(ثيش نةشتةرطةرى ‪ ,‬كاتى نةشتةرطةرى ‪ ,‬ثاش نةشتةرطةرى)‪.‬‬
‫لةمةوة بؤمان دةركةوت كة بةكارهينانى دذةتةنينةوة بةشيوةى ثاراستن كةمترى تىئةضيت وكاريطةرترة‬
‫لةبةكارهينانى بةشيوةى ضارةسةر‪.‬‬

‫إستعمال المضاد الحيوى الوقائي مقابل إستعماله العلجي‬

‫في عملية إستئصال اللوزتين‬
‫‪.‬شيركو سعيد فتح ال زمناكو‪ ،‬كلية الطب‪ ،‬جامعة السليمانية‬
‫‪.‬باخوان رافع عزيز‪ ،‬مستشفى السليمانية التعليمي‪ ،‬قسم النف والذن والحنجرة‬
‫اقليم كوردستان ‪ /‬العراق‬

‫الخلصه‬

‫‪.‬هذا البحث دراسة مستقبلية مقارنة وعشوائية اجري في قسم النف والذن والحنجرة في مستشفى السليمانية التعليمي‬
‫السليمانية \ أقليم كردستان \ العراق \من آذار ‪ 2003‬إلى آذار ‪2004‬‬
‫‪.‬الهدف من هذا البحث هو تقييم ومقارنة فعالية وكلفة إستعمال المضادات الحيوية الوقائية بعد عملية إستئصال اللوزتين‬
‫الدراسة تضمنت مرضى من مختلف العمار ومن الجنسين من الذين أجريت لهم عملية إستئصال اللوزتين ‪ ,‬وقسموا عشوائياً إلى‬
‫‪:‬مجموعتين‬
‫‪.‬المجموعة الولى‪ :‬المجموعة المتحكم بها ‪ ,‬تم إعطائها المضادات الحيوية لمدة سبعة أيام بعد العملية‬
‫‪.‬المجموعة الثانية‪ :‬المجموعة تحت الدراسة‪ ,‬تم إعطائها المضادات الحيوية على ثلث جرعات )قبل‪ ,‬أثناء و بعد( العملية‬
‫‪.‬لقد إستنتجنا أن المضاد الحيوي الوقائي هو أقل كلفة وأكثر فعالية من المضاد الحيوي العلجي‬

‫‪Received on 2/11/2004. Accepted‬‬ ‫وةركيرا لة ‪ 2/11/2004‬و ثةسندكرا لة ‪.24/7/2005‬‬

‫‪.24/7/2005‬‬

‫‪94‬‬