Tonsillectomy for recurrent tonsillitis: the NATTINA trial
Authors: Christopher R Jones, Rebecca L Guy, Mariyam Mirfenderesky, Colin S Brown, Theresa Lamagni
Journal: The Lancet (2024)

The surge in scarlet fever and invasive group A streptococcal infection in England during winter, 2022–23,1Guy R Henderson KL Coelho J et al.Increase in invasive group A streptococcal infection notifications, England, 2022.Euro Surveill. 2023; 282200942 Crossref PubMed Scopus (41) Google Scholar has stimulated the consideration of optimal sore throat management, as point-of-care tests for diagnosis are not routinely used. Clinical prediction scores can identify patients who are most likely to benefit from antibiotics; however, balance is required between optimising clinical outcome, antimicrobial stewardship, cost-effectiveness, and reducing transmission.2McGuire E Li A Collin SM et al.Time to negative throat culture following initiation of antibiotics for pharyngeal group A Streptococcus: a systematic review and meta-analysis up to October 2021 to inform public health control measures.Euro Surveill. 2023; 282200573 Crossref Scopus (6) Google Scholar, 3Watts V Balasegaram S Brown CS et al.Increased risk for invasive group A Streptococcus disease for household contacts of scarlet fever cases, England, 2011–16.Emerg Infect Dis. 2019; 25: 529-537Crossref PubMed Scopus (0) Google Scholar Ideally, interventions should be appraised on these wider public health merits. The NATTINA study by Janet A Wilson and colleagues4Wilson JA O'Hara J Fouweather T et al.Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial.Lancet. 2023; 401: 2051-2059Summary Full Text Full Text PDF PubMed Google Scholar provides evidence of clinical benefit and cost-effectiveness of tonsillectomy to treat recurrent tonsillitis in adults. However, the effect on antimicrobial usage, development of antimicrobial resistance, and the wider public health implications were not considered. An association between tonsillectomy rates, tonsillitis admissions, and invasive group A streptococcal incidence has been suggested in children previously but requires further study.5Banigo A Moinie A Bleach N Chand M Chalker V Lamagni T Have reducing tonsillectomy rates in England led to increasing incidence of invasive group A Streptococcus infections in children?.Clin Otolaryngol. 2018; 43: 912-919Crossref PubMed Scopus (9) Google Scholar Interventions to reduce the impact of infectious disease—whether diagnostics, clinical prediction scores, treatment, or preventive measures—require careful evaluation at both an individual and population level to support infection management, prevention, and control. Transmission impact evaluation is challenging but necessary to understand the wider public health impact of infectious disease interventions and is an ongoing priority for group A streptococcal infection. Experimental research studies provide an ideal opportunity to perform such evaluations, given challenges with observational studies. We declare no competing interests. Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trialCompared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. Full-Text PDF Open AccessTonsillectomy for recurrent tonsillitis: the NATTINA trial – Authors' replyWe welcome the enthusiasm of fellow researchers to explore other aspects of recurrent tonsil disease in adults and comment on our Article.1 Christopher R Jones and colleagues highlight the putative association between tonsillectomy rates, tonsillitis admission, and invasive group A streptococcus incidence in children.2 It is impossible for us to suggest how improved and timely access to tonsillectomy could affect societal levels of invasive group A streptococcus but the trends in tonsillectomy rates are clear. Full-Text PDF