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JOURNAL READING

THE EPIDEMIOLOGY, ANTIBIOTIC


RESISTANCE AND
POST-DISCHARGE COURSE OF
PERITONSILLAR ABSCESSES IN
LONDON, ONTARIO
Tutors:
dr. Agus Sudarwi, Sp.
THT-KL
h
a
Idi sari
dr. Afif Zjauhari, Sp.
p
THT-KL
Ha iki
K tin
us
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A

Journal Identity
Title : The epidemiology, antibiotic
resistance and post-discharge course of
peritonsillar abscesses in London,
Ontario
Author :Leigh J Sowerby1, Zafar
Hussain2 and Murad Husein
Publisher : Sowerby et al. Journal of
Otolaryngology - Head and Neck Surgery
2013, 42:5

Abstract
Background:
To examine increasing
antimicrobal resistance
patterns
and
examine the post discharge
course of treated patients in
Canada.

Abstract
Methods:
A prospective observational study. To the Emergency
Department in London, Ontario over one year.
A follow-up telephone survey was conducted 23 weeks
after abscess drainage.
Results:
60 patients were diagnosed with an abscess, giving an
incidence of 12/100,000.
Streptococcus pyogenes and Streptococcus anginosus were
present in 56% of isolates and 7/23 (32%) of specimens
demonstrated resistance to clindamycin.
51% of patients reported a return to solid food within 2
days, and 75% reported no pain by 5 days.
Resolution of trismus took a week or longer for 51%.

Abstract
Interpretation:
Clindamycin resistance was identified in a
third of Streptococcus isolates
Routine culture unnecessary as patients
recover quickly from outpatient drainage
and empiric therapy,
Keywords:
Epidemiology, Peritonsillar abscess, Antibiotic resistance, Microbiology,
Pain, Post-operative follow-up

INTRODUCTION
Peritonsillar abscess is a collection of
infected material in the area around
the tonsils.
This infection begins as a superficial
infection and progresses into tonsillar
cellulitis. A peritonsillar abscess forms
at the most advanced stage.

Epidemiology
Peritonsillar abscess is most common in
persons 20 to 40 years of age. Young children
are seldom affected unless they are immunocompromised, but the infection can cause
significant airway obstruction in children. This
infection affects males and females equally.
Evidence shows that chronic tonsillitis or
multiple trials of oral antibiotics for acute
tonsillitis may predispose persons to the
development of a peritonsillar abscess.

ANATOMY
The normal anatomy of the palatine tonsils and their surrounding
tissues is depicted in the picture. The two tonsillar pillars define
the palatine tonsils
anteriorly and posteriorly. The glossopalatine and the
pharyngopalatine
muscles are the major muscles of the anterior and posterior
pillars,
respectively. The tonsil lays in the depression between the
palatoglossal and the
palatopharyngeal arches

Peritonsillar infection
untreated or treated
inappropriately

Abscesses in
parapharyngeal
space
Sepsis
Airway obstruction
Carotid
pseudoaneurysm
Death

PURPOSE

To classify flora bacterial, epidemiology and


antimicrobial resistance patterns of bacteria
local peritonsillar abscess.
To patients post-discharge detailing course
with peritonsillar abscess drainage has been
done, with regard to pain, oral intake, trismus
and the need for pain-killers, with the ultimate
goal of optimizing outpatient management.

METHODS
After obtaining
research ethics board
approval,

A prospective
observational study was conducted in all
four
(three adult and one pediatric) Emergency
Departments
(ED) in London, Ontario, Canada

All patients
seen in
consultation for
a possible
peritonsillar
abscess

Sheets history / physical


examination completed
by the treating
physician to record
demographic and
findings of the
investigation and

If pus
was
obtaine
d

1. a specimen
was sent for
aerobic
culture/sensitivi
ty
2. the
patient was
asked to
participate in
the study.
Patient
approve
d

Post-discharge course
Follow-up for the
patient was dictated
by the treating
physician.

the patient was


contacted 2 to 3
weeks postdrainage
Survey
by
phone
The survey questionnaire asked:
1. the number of days to solid
food,
2. days to full pain
Resolution
3. days requiring any pain
medication, 4. days to
resolution of trismus.

If any signs of persistent disease


were evident on questioning,
Follow-up was arranged for
the patient.
If bacteria with antibiotic
resistance were
cultured
The patient was informed, so as
to help guide
any future antibiotic therapy.

Event capture
To ascertain the
true
participation rate

after
complet
ion
of the
study

SPSSW version 13.0


was used. Chisquared tests
of independence
were used for
categorical
variables,
students t-test was
used for continuous
variables and
ANOVA was used in
the setting of
multiple variables.
All tests were twotailed and p 0.05
was set as the
threshold for

the ED patient
database was
retrospectively
reviewed using the
International
Classification of
Diseases,
Ninth Revision (ICD9-CM) code for
peritonsillar abscess
to identify
peritonsillar abscess
as either a primary
or secondary
diagnosis
Statisti
cal
analysi
s

RESULT
46 subject
25 (54%)
21 (46%)

Figure 2.
Age Distribution
Of Patients With
Peritonsillar
Abscesses.

Duration of symptoms an
average of 6 days, with only
3 patients (6.7%) had onset
of symptoms two days.
Only 15% of patients
admitted to smoking,
And half of the patients had
been taking antibiotics for
pharyngitis during the
previous month.

Only 15 patients (24%) had a temperature higher


than 38 C at presentation but the number of
white blood cells (higher than 11.0 109 / L)
seen in 82% of patients, and 91% had high
neutrophil count (higher of 7.5 109 / L). Only
two patients (4.5%) had a positive heterophile
antibody test.
On physical examination, the classic symptoms

RESULT
Pus in the drainage volume is 5 mL or
less of the 32 patients (71%) with an
overall average of 4 mL (+/- 1.1);
There was no statistically significant
relationship between the amount of pus
drained by fever, white blood cell count,
duration of symptoms or neutrophils.

MICROBIOLOGY

In patients prescribed clindamycin (31 patients, 69%)


Figure 4.
All 5 patients had been treated initially with
clindamycin, and were switched to a different broadspectrum antibiotic after re-drainage.
Sensitivity for two of the five patients F. necrophorum
Resistance (erythromycin
and clindamycin) S. pyogenes

Figure 5. Number of days to resolution of


symptoms

The result after post-discharge course, half of


patient (51%) were able to eat solid food with in 2
days.
Resolution of any pain by 5 days.
Pain medication after 3 days.
Trismus at 7 days until 2 weeks.

CONCLUSION

In epidemiologic findings did not show an


increase of a factor of smoking.
The majority of drainedabscesses grew a
Streptococcus species and 32 % rate of
resistance to clindamycin.
abscess experience healing despite using
advanced antibiotics, although resistance
but can still be treated with advanced
therapy