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 methods
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.
PICOs
Plain language summary
Antibiotics to reduce pain and improve recovery following tonsillectomy
Tonsillectomy is a commonly performed operation in children and adults. Following the operation nearly all patients experience significant pain, need regular painkillers and are unable to resume normal diet and activities for several hours. Rarer but more dangerous complications, such as bleeding from the operated area, also occur. Antibiotics are commonly prescribed to reduce some or all of these undesirable consequences of tonsillectomy.
The present review, however, suggests that antibiotics do not reduce pain, the need for painkillers or bleeding. They do, however, appear to reduce fever. This relatively minor benefit is more likely to be due to weaknesses in the studies themselves than any direct antibiotic effect. The risk of adverse events, such as skin rash and diarrhoea, is also slightly higher in patients who were prescribed antibiotics. Therefore, in the absence of clear‐cut and significant benefit and with the potential for harm, we advocate against prescribing antibiotics routinely for patients undergoing tonsillectomy.
