Cochrane Review: Antibiotics to reduce post‐tonsillectomy morbidity
Authors: Dhiwakar M , Clement WA , Supriya M , McKerrow WS 
Published: December 2008

Background

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 strategy

Cochrane ENT Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2007), MEDLINE (1950 to 2007) and EMBASE (1974 to 2007) were searched. The date of the last search was March 2007.

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 if any documented haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, summary measures were generated using random‐effects models.

Main results

Nine trials met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were 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 0.92, 95% CI 0.45 to 1.87, P = 0.81). 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 review suggests that there is little or no evidence that antibiotics reduce the main morbid outcomes following tonsillectomy (i.e. pain, the need for analgesia or secondary haemorrhage rates). They do however appear to reduce fever. Some important methodological shortcomings exist in the included trials which are likely to have produced bias favouring antibiotics. We therefore advocate caution when prescribing antibiotics routinely to all 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.

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 however more likely due to weaknesses in the studies themselves rather than any direct antibiotic effect. The risk of adverse events such as skin rash and diarrhoea are also slightly higher in patients who were prescribed antibiotics. Therefore in the absence of clear‐cut and significant benefit and with potential for harm, we advocate caution while prescribing antibiotics routinely for all patients undergoing tonsillectomy.