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(KAJ) Kurdistan Academicians Journal, March 2006 , 4(1) part A ( بةشى1) ذ4 ,بةرط2006 ئازارى2706 نةوروزى كوردستان ئةكاديميانى ؤظارىط

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Prophylactic Versus Therapeutic AntibioticUse for Tonsillectomy

Sherko Saeed F. Zmnako And Bakhawan Rafee Aziz University of Sulaimani Sulaimani Teaching HospitalCollege 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.

Introduction Tonsillectomy continues to be one of the most common procedures performed by Otolaryngologists in recent years [1, 2], and it is one of the most frequent operations carried out in childhood [3, 4]. Since the wound in tonsillectomy is a clean contaminated wound and the bed remains open postoperatively, with spillage of bacteria contaminated secretions from aero digestive tract and possibility of infection [5], therefore the usage of postoperative therapeutic antibiotic became routine [6]. Several studies shows that antibiotics given for 5-7 days post-tonsillectomy considered to be beneficial [7], while there are studies that not provide enough information to support its usage as a routine.Prophylactic antibiotic can be used in tonsillectomy, based on the type of its surgical wound (clean-contaminated), as a measure to prevent postoperative infection. Taking in consideration that

prophylactic antibiotic is not the only factor that determine the risk of

postoperative infection, other factors have equal or even greater importance like surgical technique, duration of surgery, and postoperative advices; include frequent chewing, drinking and eating by the patients [8 -10]. From economical point of view, decision making in any subject will primarily depend on the principles of Opportunity Cost, in which we will make a comparison between the coast of a particular subject and the obtained benefits of that projects, meanwhile we found the earned benefits of the subject in the study is higher than the benefits obtained from other studies with the same coasts, at that time, the decision making in such a study is considered to be acceptable and correct economically, but the decision making will not be correct if

87Email: [email protected]

-87) الثةرة94)

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A there was higher obtained benefits with less coast in other studies [11]. The aim of our study is to show whether prophylactic use of antibiotic is superior to the routine therapeutic use regarding the postoperative morbidity and mortality.

Patients and Methods This study was including one hundred sixty three patients, admitted for elective tonsillectomy with recurrent or chronic tonsillitis, obstructive tonsillar hypertrophy or history of quinsy.Demographic data collected about: age, sex, occupation and preoperative assessment includes (temperature, pulse rate, blood pressure, hematological investigations such as Hb%, WBC, bleeding time, clotting time and blood group). All were followed up over the ten postoperative days, depending on different parameters such as severity of pain, fever, local hyperemia, local edema, fetor oris and otalgia. W.B.C. counts in the 6th

postoperative day. Twenty patients were excluding from the study because they were not reported for follow up. The remaining (143 patients) initially divided randomly in to two groups; each group was dividing in to two subgroups according to their ages, from 2-10 years and 11-45 years. Figure (1).

73 70

37 40 3630

0

20

40

60

80

Num

ber

Patints Age 2-10 Y Age 11-45Y

Distribution of therapeutic and prophylactic antibiotic in different ages

TherapeuticProphylactic

Figure (1): Distribution of therapeutic and prophylactic antibiotic in different ages The choice of antibiotic was made based on the pathogens mostly found in bacterial flora of oropharynx and their sensitivities to drugs. The first group (73 patients) received therapeutic Amoxicillin postoperatively at the doses according to their body weights (50-100 mg/kg/day) for 7 days (I.V. administration for first 24 hours then followed by oral for other 6 days). The second group (70 patients) consisted of patients who received prophylactic antibiotic therapy in three consecutive intravenous doses according to their body weights. First dose was injected during the induction of anaesthesia, the second doses during the operation and the third one within 6 hours from the operation. All patients were anaesthetized and operated with the same technique (dissection and cauterization) and proper postoperative advice; include frequent chewing, eating and drinking by the patients, for both groups equally. Postoperative assessment and follow up conducted according to the different parameters, which are present in the data sheet. We asked the patients to score the symptoms from 0 to 3 scale, and zero was absence of symptoms, 1 was mild, 2 was moderate and 3 was severe. Lastly the average price of the medications used in this study during that period obtained from the pharmacy centers. The results were analyzed by qui-square test, with significance of P value <0.05.

Results

The age varies between 2-45 years. (Figure 2). Shows the age distribution. Peak age is 2-10 years.

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Postoperative assessment of subjective parameters (pain, fetor oris, hyperemia and edema), which were conducted in the 6th postoperative day, shows that there was slight increase in the incidence of these parameters in the patients treated by therapeutic antibiotic, which is not significant statistically. (Table 2).We observed 11 cases (15.06%) in the patients were treated with therapeutic antibiotic and 9 cases (12.8%) in the patients were treated with prophylactic antibiotic, (Table 3), they have had infection in the analysis conducted in the 6th postoperative day according to the subjective parameters with infected slough, fever (of 38 C or more) and leukocytes count (more than 11000), (Table 4). So there was slight increase in the incidence of infection in the patients were treated by therapeutic antibiotic, which is not significant statistically.

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

Groups Patient Pain Fetor oris Hyperemia EdemaP 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%)Therapeutic (11-45 Y) 36 23(63.8%) 10(27.7%) 8(22.2%) 6(16.6%)

0.1971Prophylactic (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

Table 4: Numbers of patients with fever and/or leukocytosis in cases with

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Figure (2): the Age distribution.

GroupsPatients

Infection rateTotal rate of infection

Incidence of bleeding

P value

Prophylactic (2-10 Y) 40 5 (12.5%)9 (12.85%) 3

0.71Prophylactic (11-45 Y) 30 4 (13.3%)Therapeutic (2-10 Y) 37 5 (13.5%)

11 (15.06%) 5Therapeutic (11-45 Y) 36 6 (16.6%)Total 143 20 13.98% 8 (5.59%)

Table (1): Sex distribution in different groups. (Male: female ratio was 74:69)

Groups Patients Male Female

Therapeutic 73 35 38

Prophylactic 70 39 31

Total 143 74 69


A infection in different groups.

Groups Patients Cases with infection

Fever (Of 38 C or more)

Leukocytes(>11000)

Therapeutic (2-10 Y) 37 5 4 3Prophylactic (2-10 Y) 40 5 4 3Therapeutic (11-45 Y) 36 6 5 3Prophylactic (11-45 Y) 30 4 3 2

Table 5: Numbers of cases those properly cooperate with postoperative

advices.

No. Of cases

GroupsCooperative Non cooperative Total P value

Therapeutic 30 43 73

0.005

Prophylactic 45 25 70

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

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

Figure 3: Incidence of secondary bleeding in relation with age

The incidence of bleeding is more common in males than females, were 6/74 cases males and 2/69 cases females. (Figure 4).

Total costs ($) of post-tonsillectomy antibiotic for individual patient are shown in tables [7,8].

Table7: Total cost ($) of post- tonsillectomy antibiotic for individual patient in therapeutic groups.

Table 8: Total cost ($) of post- tonsillectomy antibiotic for individual patient in prophylactic group.

Total cost ($) of post-tonsillectomy antibiotics for patients in both groups are shown in (table 9)

Type of drug

Cost ($)

Type of

drug

Coast ($)

Total

cost ($)

3 vials of Amoxicillin

1.5 Nil Nil 1.5

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Figure 4: Incidence of secondary bleeding in relation with sex

Type of

drug

Cost

($)

Type of drug

Cost

($)

Total

cost

($)

4 vials of Amoxicillin

230

capsules of

1.5 3.5

($)= (US. Dollars)

0 5

10 15 20 25 30 35

1 2 3 4 5 6 7 8 Patients


A Table 9: Total cost ($) of post-tonsillectomy antibiotics for patients in both groups,

P value was less than 0.05 (0.000), which

is significant. Average: 180.25

S. D. (standard deviation): 10

Discussion Regarding the incidence of infection according to postoperative assessment of subjective parameters (Pain, fetor oris, hyperemia and edema of the bed of the tonsil), (Table 2), the study revealed that there is no significant difference between the both prophylactic and therapeutic group in the same range of age, however, the infection rate was slightly less in the group treated by prophylactic antibiotics than those with therapeutic one, (Table 3), and this is due to the affectivity of prophylactic antibiotic which enters the blood and tissue before the incision and manipulation [9]. It is well known that 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, 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.

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Groups

No. of

patients

Total

Price

($)

P

value

Therapeutic

73 255.5

0.0000Prophyla

ctic70 105


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.

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http://ipro.tempdomainname.com/documents/hcqip/impact-reports/impact-prophylactic-antibiotic-011997.pdf

http://ipro.tempdomainname.com/documents/hcqip/impact-reports/impact-prophylactic-antibiotic-011997.pdf

http://www.land/aeknir.is/uploads/files/SIGN45.pdf

http://www.emedicine.com/ent/topic/8.htm

http://www.ampath.Co.Za/AntibiotGuide/chapter6.htm

http://www.utmb.edu/otoret/Grnds/Indect-0003.htm


A 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.

بةرامبةر ثاراستن بةشَي وةى دذةتةنَينةوة ةكارهَي نانىب بةكارهَي نانى

البردنى نةشتةرطةرى لة ضارةسةر بةشَي وةى ئالووةكان

سليمانى زانكؤى ثزيشكى، ؤليجىك ،زمناكؤ الله فتح سةعَيد َي ركؤش .5ركارى، ةخؤشخانةىن ،عةزيز رافع اخةوانب وطوآ ولووت قورط بةشى في .

5ميه 5راق ةري كوردستان/ عي

وختةث ل??ة وط??وى ول??ووت ق??ورط بةش??ى ل??ة ك??ة هةرةمةكىي??ة ةراووردىب?? ايين??دةبينىئ ليكؤلينةوةي??ةكى ةم??ةئ

دراوة. ئةنجام فيركارى نةخؤشخانةى.2004 ئازارى بؤ2003 ئازارى لة/ عيراق/ كوردستان هةريمى/ ليمانىس ثاراس??تن ستىةبةمةب دذةتةنينةوةية بةكارهينانى نرخاندنى كاريطةرىو بةراووردى ليكؤلينةوةية ئةم امانجىئ

ئالووةكان. البردنى نةشتةرطةرى ثاش لةهةوكردن لةوان??ةى رةطةزةك??ة ه??ةردوو ل??ة و تةم??ةنيك لةه??ةموو طرت??ةوة نةخؤش??ى ذمارةي??ةك يكؤلينةوةك??ةل

دوو ب??ة ك??ران داب??ةش هةرةم??ةكى ش??يوةيةكى ب??ة , ك??ة كراب??وو ب??ؤ ئالووةكاني??ان الب??ردنى نةش??تةرطةرىكؤمةلةوة:

نةشتةرطةرى. دواى رؤذ ( حةوت7) ماوةى تا وةرطرتبوو دذةتةنينةوةيان كة, يةكةم: كؤنترؤل ؤمةلةىك وةرطرتب??وو دذةتةنين??ةوةيان ذةم ( س?آ3, ) ب?وون ليكؤلين??ةوةدا لةذير كة كؤمةلةيةى ةوئ دووةم: ؤمةلةىك

نةشتةرطةرى(. , ثاش نةشتةرطةرى , كاتى نةشتةرطةرى )ثيش وكاريطةرترة تىئةضيت كةمترى ثاراستن بةشيوةى دذةتةنينةوة بةكارهينانى كة دةركةوت بؤمان ةمةوةل

ضارةسةر. بةشيوةى لةبةكارهينانى

إستعماله مقابل الوقائي الحَيوى المضاد إستعمالالعالجي

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اللوزتَين إستئصال عملَية في

زمناكو الله فتح سعَيد السلَيمانَية شَيركو جامعة الطب، كلَية ، .عزيز، رافع واألذن باخوان األنف قسم التعلَيمي، السلَيمانَية مستشفى

.والحنجرةعراقال / كوردستاناقلَيم

الخالصه

والحنجرة واألذن األنف قسم في اجري وعشوائَية مقارنة مستقبلَية دراسة البحث هذاالتعلَيمي السلَيمانَية مستشفى .في

آذار \ \ \ من العراق كردستان أقلَيم آذار 2003السلَيمانَية 2004إلىالوقائَية الحَيوية المضادات إستعمال وكلفة فعالَية ومقارنة تقَيَيم هو البحث هذا من الهدف

اللوزتَين إستئصال عملَية .بعدعملَية لهم أجريت الذين من الجنسَين ومن األعمار مختلف من مرضى تضمنت الدراسة

مجموعتَين , إلى Zعشوائَيا وقسموا اللوزتَين :إستئصال , : أيام سبعة لمدة الحَيوية المضادات إعطائها تم بها المتحكم المجموعة األولى المجموعة

العملَية .بعد , : ثالث على الحَيوية المضادات إعطائها تم الدراسة تحت المجموعة الثانَية المجموعة

( , العملَية ( بعد و أثناء قبل .جرعاتالحَيوي المضاد من فعالَية وأكثر كلفة أقل هو الوقائي الحَيوي المضاد أن إستنتجنا لقد

.العالجي

95

.Received on 2/11/2004 .24/7/2005 لة ثةسندكرا و2/11/2004 لة وةركيراAccepted 24/7/2005 .

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