New Guideline Curbs Overuse of Antibiotics for Tonsillectomies

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Antimicrobial resistance is spreading around the world, hampering physicians’ capacity for treating bacterial infections swiftly and reliably. Partly to blame is clinical overuse of antibiotics, so researchers are examining ways that clinicians can change or improve their antibiotic stewardship practices.

For example, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published a guideline in 2011 recommending that “clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.”

“This is a big deal because tonsillectomy is the second most common surgical procedure in kids — each year, more than 500,000 children undergo the procedure in the U.S.,” said Jeffrey S. Gerber, MD, PhD, MSCE, an attending physician in Infectious Diseases at The Children’s Hospital of Philadelphia. “Just at CHOP and our satellite ambulatory surgical centers, we perform about 3,000 tonsillectomies per year.”

Tonsillectomy is usually an outpatient procedure in which a surgeon removes a child’s tonsils. In many cases, the reason for a child having a tonsillectomy is a history of recurrent throat infections or obstructive sleep apnea.

Prior to implementing the AAO-HNS guideline, patients undergoing tonsillectomy at CHOP received antibiotics in the operating room and then were sent home with a prescription for three to five days of outpatient oral antibiotics. Do some quick math, and that equals about 12,000 additional patient-days of antibiotic use. Reducing children’s exposure to antibiotics not only would help combat antimicrobial resistance, but it also would avoid antibiotics’ adverse side effects and reduce drug costs.

Dr. Gerber and colleagues designed a study to see what happened at CHOP after this guideline was published. If clinicians followed the guideline, did this change in practice have any effect on patients’ health? In order to assess these trends, they conducted a time series analysis, which basically is a before-and-after study that takes into account trends over time. They used data from CHOP’s shared electronic health record and narrowed it down to 5,359 routine tonsillectomy cases performed from January 2009 through August 2012.

The results showed “a dramatic decrease in perioperative antibiotic use in concordance with the guideline’s recommendation,” wrote the study’s lead author, Edmund A. Milder, MD, of the Naval Medical Center in San Diego, in JAMA Otolaryngology-Head & Neck Surgery.

The findings suggest that CHOP’s group of 10 ear, nose, and throat surgeons quickly adapted their practices to meet the new guidelines, essentially stopping cold turkey from prescribing perioperative antibiotics for tonsillectomies. The researchers reported a 91 percent decrease in perioperative antibiotic use.

“That is pretty impressive,” Dr. Gerber said. “They perform operations at three different sites, and they were all doing things in a standardized, guideline-adherent way, which was terrific.”

The potential rub of the study, however, is that the researchers uncovered a small but statistically significant increase in the rate of post-tonsillectomy bleeding in the month following guideline publication. Other clinical complications were uncommon, and there was no increase in the rate of surgery office visits, emergency department visits, or hospital admissions.

The researchers found the increased rate of bleeding surprising, Dr. Gerber said, because there is not a plausible biological mechanism to explain to why antibiotics would prevent bleeding or, on the other hand, why it would be an unintentional consequence of the practice change to decrease antibiotic use. The study team plans to investigate this unexpected outcome further in a larger, multicenter study that is underway.

“We are looking at a database of 48 children’s hospitals across the country,” said Dr. Gerber, who also is associate director for Inpatient Research Activities for CHOP’s Center for Pediatric Clinical Effectiveness and director of CHOP’s Antimicrobial Stewardship Program. “We’ll see if other hospitals, in addition to CHOP, changed their practice according to the guideline, and if so, is there a relationship between antibiotic use and post-tonsillectomy bleeding?”

The study team’s goal is to have some preliminary data ready to present at ID Week, an international infectious disease meeting set to be held in San Diego this October.

Mark Rizzi, MD, a CHOP otorhinolaryngologist and assistant professor of Clinical Otorhinolaryngology in the department of Head and Neck Surgery at the Perelman School of Medicine of the University of Pennsylvania; Knashawn Morales ScD, assistant professor of Biostatistics and Epidemiology at UPenn; Rachael Ross, MPH, of CHOP’s division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness; and Ebbing Lautenbach, MD, MPH, MSCE, chief of the division of Infectious Diseases and associate director of the Clinical Epidemiology Unit at the Center for Clinical Epidemiology and Biostatistics at UPenn, contributed to the JAMA Otolaryngology-Head & Neck Surgery article.

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