A us tralian Journal of Bas ic and A pplied Sciences , 3(3): 1948-1953, 2009 ISSN 1991-8178 © 2009, INSInet Publication

Chronic Tonsillitis Bacteriology in Egyptian Children Including Antimicrobial Susceptibility
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Mostafa Hammouda, 2Zeinab Abdel-Khalek, 3Seham Aw ad, 1Mosaad Abdel-Aziz and 3Manal Fathy Department of ENT, 2Department of Medical Microbiology and Immunology, Faculty of Medicine, Cairo University and 3Department of Pediatrics, Research Institute of Ophthalmology, Giza, Egypt.
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A bs tract: Objective: This s tudy was conducted to analyze the underlying bacterial pathogen s in tons illar dis eas e among Egyptian children, to inves tigate whether there is any difference bet ween tons illar s urface a n d d e e p tis s ue cultures in patients who underwent tons illectomy for recurrent tons illit is a n d a ls o to s tudy the incidence of beta lactamas e producing bacteria (âLPB) and Oxacillin res is tant s trains . M ethods : Specimens were c o lle c t e d over a period of three months from different tons illar s ites of 72 patients –their ages ranging from 5 to 12 y e ars - s uffering from recurrent tons illitis and undergoing tons illectomy. A erobic bacterial identification and antimicrobial s us ceptibility were carried out through s tandard procedures . Res ults : Sixty-five tons ils had pos itive aerobic is olates while the remaining s even cas es had normal flora (9.7%). The total number of pos itive is olates in both s urface and core cultures were 152. S. aureus was the mos t common aerobic organis m (56.9%) is olated from both s urface and core of excis ed to n s ils . M os t of S. aureus is olates (95%) had ßLactamas e activity, whereas only 11% was Oxacillin res is ta n t S . aureus (ORSA ). H. influenzae was is olated in (44.6%) of cas es , mos tly as core cultu re s with 58% of them s howing ß-Lactamas e activity. GA âHS had an incidence of 38.5%, mos tly as s urface cultu re s w ith 26% of them s howing ßLactamas e activity. Streptococcus pneumoniae were is olated in 20% of cas es , mos tly s urface is olates . Klebsiella pneumoniae were identified in the core of 5 cas es (7.7%). There was a noticeable difference between s urface and core cultures regard in g a ll t ypes of bacteria except S.aureus . Fifty percent dis crepancy between the two s ites was found. Co n c lus ion: S. aureus is the main offending pathogen res pons ible for chronic tons illitis nowadays . H. influenzae an d GA âHS had a near equal incidence. Due to the difference between the is olates from tons illar s urfac e a n d c o re , the practice of s urface tons illar s wab may be mis leading. Tons illar dis eas e may s tem from the bacteria w it h in t he s ubs tance of the tons ils rather than the bacteria identified on the s urface. Key words : Chronic tons illitis , Bacteriology, Surface s wab, Core culture, (âLPB), ORSA . INTRODUCTION Chronic tons illitis refers to t h e c o n d it ion in which there is enlargement of the tons ils accompanied by repeated attacks of infection. Tons illit is is o n e the mos t common ailments encountered at childhood. Its incidence is es pecially high among children in the age g ro u p b e t w e e n 5 to 10 years . The inflamed tons ils harbor numerous types of bacteria, alone or in combination (Brook and Gober, 2006). A ntimicrobial treatment often fails to eradicate the pathogens and prevent recurrences of the tons illar infection. Failure to eradicate pathogenic organis ms in the core either due to inappropriate antimicrobial therapy or from inadequate antibiotic penetration in the core paves way to either pers is tence of core infec t ion or reinoculation of t h e initially s terilized s urface. If the s urface culture is repres entative of the bacteriology of the core, then rational therapy could be directed at organis ms cultured by s urface s wab (Kumar et al., 2005). This s tudy was conducted to analyze the underlying bacterial pathogens in tons illar dis eas e, to inves tigate whether there is a n y d iffe re nce between tons illar s urface and deep tis s ue cultures in patients who underwent tons illectomy for recurrent tons illitis and als o to s t u d y t h e incidence of beta lactamas e producing bacteria (âLPB) and Oxacillin res is tant s trains .

Corresponding Author: M ostafa Hammouda, Department of ENT, Faculty of M edicine, Cairo University, Giza, Egypt. E-mail: hamouda_ent@yahoo.com 1948

biochemical reaction (oxidas e and ureas e pos itiv e ). Bas ings toke. S. catalas e tes t. Germa n y ). catalas e tes t. Haemophilus influenzae identification was carried out by s tandard procedures including colony & Gram s tain morphologies . For is ola t e s w it h a zo n e s ize of >19 mm after 18 to 19 h for the 30 µg cefoxitin dis k at 37°C. chocolate and M acConkey agar p la t e s (O xoid. United Kingdom).s uffering fro m re c u rre n t t ons illitis and undergoing tons illectomy. aureus identification was bas ed upon colony & Gram s tain morphologies and pos itive catalas e reaction.9%). Solna. H . aureus is olates were tes ted by dis k diffus ion us ing cefoxitin and Etes t (A B Biodis k.Aust.7%) were identified les s frequently (Fig. from crypta magna before tons illar removal) and deep tis s ue of the tons ils (after removal) us ing s terile s wabs . France). aureus was the mos t common aerobic organis ms encountered (56. Briefly. A s ingle colony of the is olate on the primary plate was s ubcultured onto Sheep blood a g a r (5% ) t o obtain a pure culture. aureus with a zone diameter of # 19mm were s cored as res is tant and thos e with a zone diame t e r o f $ 20mm were reported as s us ceptible. Klebsiella Pneumoniae was identified by colony & Gram s taining morphology and biochemical reactions us ing A PI 20E kit. Streptococcus pneumoniae (20%) and Klebsiella pneumoniae (7. and bac it ra c in s ens itivity (Oxoid. ß-Lactamas e activity was determined for is olates by us ing Cefinas e dis ks (Becton-Dickins on M icrobiology Sys tems .5 M cFarland turbidity.. 6-mm-diameter filter paper dis ks impregnated with nitro c e fin were mois tened with 0. Cefoxitin M ICs were read aft e r 18 to 19 h of incubation. re q u irement for X (hemin) and V (NA D) factors (Oxoid. Basic & Appl. Dis ks were examined for the appearance of a pink-red coloration for up to 60 min with is olates of S. Sweden) us ing cefoxitin an d o xacillin. Thirty-four cas es s howed a s ingle is olate in either s urface or core cultures (whether they w e re t he s ame or not). Becton Dickins on M icrobiology Sys tems ). S t r eptococcus pneumoniae is olates were identified by colony & Gram s tain morphologies . United Kingdom) us ing M ueller-Hinton BBL II agar (Becton Dickins on.aureus . Plates were incubated in ambient air at 37°C.85% NaCl. and up to 10 min with the other s pecies . plates were further incubated and read after 24 h as s pecified in M 100-S15.6%). Plates were incubated at 37 °C aerobically (M acConkey) and in 5% carbon dioxide (blood a n d c hocolate). United Kin g d o m). M arcy l’Etoile. In order to detect Oxacillin res is tant S.7%). S . Bas ingstoke. Cockeys ville. 3(3): 1948-1953.5 mL. 1949 . Is olates were identified to genus level by conventional methods (M urray et al. United Kingdom)(3). Bacteriological s t u d y : T h e s w a bs were inoculated (within 2 hours of collection) into Sheep blood (5 %). as mixed types of bacteria were is o lated in the s ame cas e. and rapid s lide latex agglutination tes ts (Slidex Staph Plus . 0. Ete s t oxacillin M IC tes ting was performed according to the manufacturer’s ins truct io n s us ing M ueller-Hinton BBL II agar s upplemented with 2% NaCl (wt/vol) and in c ubation at 37°C for a full 24 h. Etes t cefoxitin M IC tes ting was done us ing M ueller-Hinton BBL II a g a r w it hout NaCl s upplementation. Bas ings toke. Becton Dickins on M icrobiology Sys tems ) and Bile s olubility us ing Deoxycholate reagent (2%.. Sci. optochin-s us ceptibility (6 mm. s pecimens were taken as eptically from the s urfac e (es p. Sixty-five tons ils h a d p os itive aerobic is olates while the remaining s even cas es had normal flora (9. aureus (ORSA ). followed by GA âHS (38. Heidelberg. The age ranged between 5-12 years . Tube coagulas e tes t for the detection of free coagulas e activity on rabbit p la s ma (b io-M e´rieux. where as the remaining 31 cas es revealed mixed is olates . and s everal well-is olated colonies of tes t organis ms w e re t ra n s ferred to the dis k with a wire lo o p . Fore each patient. RES ULTS AND DIS CUS S ION Results: To t a l n u mb er of cas es was 72 (47 boys – 25 girls ). A nalyzing the data of the pres ent s tudy we obs erved that S. S. 1). The inoculum was s t a n d a rdized to 0. i n fluenzae was the s econd is olate (44.aureus . Ba s ings toke. J. 2009 MATERIAL AND METHODS Patients & s ampling: Specimens were collected over a p e riod of three months from different tons illar s ites of 72 patients –their ages ranging from 5 to 12 years . M d). A gar plates were incubated overnight (18 to 19 h) in ambient air at 37°C. bioM e´rieux) were performed for definitive identification of S. Dis k diffus ion was done with 10 µg and 30 µg dis ks (Oxoid. and examined at 24 and 48 h. The total number o f pos itive is olates in both s urface and core cultures were 152. In h ib ition zone diameters were read from the back of the agar plate us ing reflected light and calip e rs t o re ad to the neares t millimeter at the inner zone edge. 1995).5%). Group A â-haemolytic s treptococci (GA â H S ) were identified by colony & Gram s tain morphologies .

S. Streptococcus pneumoniae were als o detected. J.aureus . the total number was 80 is olates . influenzae GAâHS Streptococcal pneumoniae Klebsiella pneumoniae Normal flora Number 26 14 22 10 0 21 In aerobic tons illa r c ore bacteriology. aureus was the mos t common is olate followed by GA âHS. H. there is a n o ticeable difference between the two s ites regarding all types of bacteria except S. 1: Relation of different is olates . influenzae whereas GA âHS came in the third order. No Klebsiella pneumoniae was detected (Table 1) Table 1: T ypes and number of isolates from the tonsillar surface. T ypes of isolates S.. S.influenzae GAâHS Streptococcal pneumoniae Klebsiella pneumoniae Normal flora Number 31 27 12 5 5 13 Correlation between types of is olates from tons illar s urface and core. 2009 Fig. the total number was 72 is olates .Aust. aureus was als o the mos t common is olate followed by H.aureus H. A s regards aerobic tons illar bacteriology via s urface s wab. aureus H. 3(3): 1948-1953. (Fig. influenzae and Streptococcus pneumonia e w e re les s frequently found on s urface cultures than others . Sci. 2) Fig. 2: Correlation between s urface and core is olates 1950 . Basic & Appl. Klebsiella pneumoniae was recovered from the core of 5 tons ils (Table 2) Table 2: T ypes and number of positive isolates from the tonsillar core T ypes S.

the is olate s fro m t h e s urface were the s ame as recovered from the core. Discussion: M uch has been written about bacteriology of recurrent tons illitis but it remains a controvers ial topic. Sci. aureus is olates (54 out of 57) had ß-Lactamas e activity. Fig. Twenty-s ix percent of them had ß-Lactamas e activity. H. GA âHS came in the third order of frequency in this s tudy. M ore than half of H. aureus were is olated. mos tly s urface is olates . Streptococcus pneumoniae was is olated in 20% of cas es . Table 3: Correlation between isolates from surface and core.Aust. Identical isolates from surface & core Similar isolates from surface & core Different isolates between surface & core 26 7 32 Half of total number of the cultured is olates (76 out of 152) had ß-Lactamas e a c t iv it y . whereas in the other half (33)..influenzae.. Table 4: Number of Beta lactamase producers. Fiftyeight percent of H. whereas quarter of GAâHS (7 out of 27) had this activity (Fig. aureus is olates (95%) had ß-Lactamas e activity. whereas only 11% was Oxac illin res is tant S. 3: Number of beta lactamas e producers per type of is olates . aureus (ORSA ). A lthough it was les s frequent in s urface cultures than GA âHS. Klebsiella p n e u m o n i a e were identified in the core of few cas es . t h e is olates cultured from the s urface differ from that of the core. Regarding Oxacillin res is tant S. 3(3): 1948-1953. 2006). Basic & Appl. (Table 4). and to a les s er extent GA âHS. Non producing Producing: S. 1951 . influenzae (15 out of 26) had ß-Lactamas e activity. while in 7 cas es there were additional types of ba c t e ria either in s urface or core (we termed thes e cas es as s imilar but not identical) Table (3). cons ens us s eems to be lacking as the main caus ative organis ms and the differences between children and adults (Loganthana et al. 2009 A bout half of cas es (32). J. M os t of S. aureus H. Twenty-s ix cas es out of the later were identical (means th a t t he is olates from the s urface were the s ame as the is olates from the core). influenzae GAâHS 76 76 54 15 7 M os t of S. Effective treat me n t d e pends on knowledge of the infecting organis ms . aureus was the mo s t c o mmo n aerobic organis m is olated from both s urface and core of excis ed tons ils . mos t of them were s urface is olates . aureus followed by H. aureus is th e ma in offending pathogen res pons ible for chronic to n s illitis nowadays . influenzae had ß-La c t a ma s e a c t ivity. aureus (ORSA ). only 6 (out of 57) S. it s p re v a le nce in core cultures was much more than GA âHS. This means that S. 3). influenzae was the s econd common is olate. The pres ent s tudy revealed that S. Des pite the fact that tons illitis is s o common. mos t of them were S.

aureus was the mos t common pathogen in core cultures of tons ils and adenoids . gamma-hemolytic s treptococci. while in 42% was identical.2%).9% of S. GA âHS and S.aureus . M ahakit et al.aureus . Correlations were 100% s pecificity fo r GA âHS. influenzae and 81. M eanwhile others proved that there was a high correlation in cultures obtained from tons illar crypt and tons illar core. and Loganathan et al. W hat followed S. influenzae were ßLPB.. aureus in the percentages of (25. mos tly s urface is olates .2%. Streptococcus pneumoniae and then H. influenzae was les s frequently predicted by s urface cultures than others . 88.9%) and (24%) were is olated from the crypts of 61 removed tons ils . 66. influ e n z a e a n d M oraxella catarrhalis ..aureus . Basic & Appl. yet.4%) came in a near equal incidence. The difference in is olated technique may account for the higher correlation when compared to previous s tudies (M ahakit et al. influenzae in a decreas ing order. aureus (ORSA ). and 62. In a s tudy done by Brook and Foote (2006). In our s tudy. aureus (23. influenzae and GA âHS (23%) we re more prevalent in children. H. H. aureus were bet al actamas e-producing bacteria. i n fl u e n z ae and GA âHS had a near equal incidence. K u mar et al. aureus w as the mos t common pathogenic bacteria (40. H. whereas in 25 patients . 2003. A fter S.4%. Sci. (2007). H. (2006) s tated that S. different types of bacteria were recovered from the s urface and deep tis s ue cultures .9%) cultured both in adult and children. Streptococcus pneumoniae and Klebsiella pneumoniae were more prevalent in adults . aureus is the main offending pathogen res pons ible for chronic tons illitis in Egyptian children nowadays . M any recent reports declared that S. 2006). influenzae (15.2% for H. Streptococcal pneumoniae.6%. 38. (2005) arranged GA âHS. whereas in the other h a lf (33). Kocaturk and his c o lla g u e s (2003) conclud e d t hat S. Klebsiella pneumoniae were identified in 1952 .Aust. its prevalence in core cultures was much more than GA âHS. 1991).3%). The es timated prob a b ilities of tons illar bacteriology via s urface s wabs for H.. aureus was differently reported among workers .5% for S.4%) and Streptococcal Viridian (11.aureus . aureus was as s ociated with betalactamas e production in 88%.3% was is olated fo rm t h e tons illar core) in recurrent tons illitis . Sixteen percent of cas es of the s tudy group s howed normal flora. while 29. influenzae had ß-Lactamas e activity. aureus was the mos t common is olates in chronic tons illitis (Kocaturk et a l . S. aureus. Seven is olates of M ERSA were recovered from the cores and two were is olated from the s urface (16%). H. So the authors thought that the s wab cultures taken from the tons illar s urface might not always reveal the real pathogen of the tons ils . This is correlated with our res ults where we found that 29% and 18% Normal Flora were is olated from the s urface and core of tons ils res pectively. i n fl u e n z a e and S. 3(3): 1948-1953. influenzae was les s frequent in s urface cultu re s t h a n GA âHS. S. t h e is olates from the s urface were the s ame a s re c o v e re d from the core. S. aureus was the mos t common pathogen (30. Gu l et al. F ifty-two percent ßLPB were recovered from tons illar s urface and 75% from core. Kumar et al. Pathogen is olated from the s urface culture may be colonizing the tons il and not infecting it. In a d d it ion.2% of H.. This means a 50% dis crepancy between s urface and core res ults . Conclusion: S. whereas only 11% was Oxacillin res is tant S. H .. Regarding ß-Lac t a mas e production. The predominant ßLPB were S. t here is a noticeable difference between the two s ites regarding all types of bacteria except S.influenzae. the es timated probability of tons illar bacteriology by s urface s wabs varies with the type of the pathogen. regarding correlation between types of is olates from tons illar s urface and core . 2009 This work matches with that of Jeong et a l . H. 86. M ore than half of H. (2007) found that 52 out 77 patients . Kumar et al. aureus were recovered more often from the core. Core o rg a n is ms are res pons ible for pathological changes in the t o n s ils (Gaffney et al. the s ame types of bacteria were is olated from both s urface and deep tis s ue cultures . M os t of S. Loganathan et al. Core cultures revealed H. GA âHS. J. w h e re a lpha-hemolytic s treptococci and gammahemolytic s treptococci were recovered from s urface. they cultured a total of 151 aerobic bacteria fro m t he s urface o f 44 removed tons ils and 167 aerobic is olates from the core. (2005) reported that H . whereas about quarter o f GA â HS had this activity. They found that S. A bout half of cas es (32). aureus is olates (95%) had ß-Lactamas e activity. influenzae (25. 2005). The predominant is olates were alpha -h e mo ly t ic s treptococci. Streptococcus pneum o n i a e were is olated in 20% of cas es . The frequency of ßLPB a mo n g is o la ted bacteria from tons illar core was 44%.5% res pectively. 2005. the is olates cultured from the s urface differ from that of the core. The s urface of the tons il is cons tantly expos ed to oral s ecretions with their attendant flora and as s uch s urface c u lture is likely to grow thes e organis ms . and GA âHS were 27.. S. M ixed infection was common becaus e of its high res is tance to penicillin.5%) and GA âHS (14.aurues . (2005) reported that o v erall s urface culture was in variance as the pres ence or abs ence of core pathogens in 58% cas es . influenzae and M oraxella catarrhalis .

2006. R. Erkam.. R. 5th Ed. Cafferkey. 70(12): 2099-102.. M . Nov. E. M . D... Gupta. 55: 989-992.W . A . Lee. M urra y P. Bacteriologic comparis on of tons il core in recurrent tons illitis and tons il core hypertrophy.S. A .A . 47(4): 271-5. Gupta Vais hali. Comparative s tudy of bacteriology in re c u rrent tons illitis among children and adults . A ral. Kandirali. Demiray. M ed. J. W as hington. Laryngos cope. S. A kif Kilic.A . Gul. T. M anual of Clinical M icrobiology.. The practice of s urface tons illar s wab may be mis leading. 3(3): 1948-1953. 1953 . A rumainathan. Comparis on of adenoid and tons il core cultures in chronic adenotons ilitis . Chantratchada. 2005. P.C. 2009 the core of few c a s e s . The comparis on of tons illar s urface and core cultures in recurrent tons illitis . K. T h e re was a noticeable difference between the is olates from tons illar s urface and core regarding all types of bacteria exce p t S . The correlation of micro-organis ms between tons illar crypt culture and tons illar culture in chronic Tons illitis . E. M ert.. Basic & Appl. F. Raman. Ciragil. J.H. Lee. Inces ulu. Ryu. 57(2): 118-20. Clinico bacteriological evaluation of s urface and core microflora in chronic tons illitis microflora.J. Yolken. Otolaryngol. Is olation of methicillin res is tant s taphylococcus aureus from the s u rface and core of tons ils in children. M . 88 Supp l3: 582-810. Tae. M . Kulak Burun Bogaz ihtis Derg.H. 1991. Gober A lan. E.. Y. Yild irim. 2007. Tons illar dis eas e may s tem from the bacteria within the s u b s tance of the tons ils rather than the bacteria identified on the s urface. Foote P e rry . Singapore M edical Journal. U. G. 2006. a u r e u s.J. A .J. Pfaller. Indian J o u rnal of Otolaryngology and Head and Neck. A . J.Aust. M . 2005. J. M edical A s s ociation Thia. A m. M ahakit. Jeong. Differences in tons il core b a c t e riology in adults and children: a pros pective s tudy of 262 patients . Kumar.A . D. Freeman. Gaffney R. Sci.. 10(3): 105-9. M oungthong. Okur.H. 2003. 2006.D. J. I. U. 117(12): 2146-56 K o c a t u rk. Chandra Kamies h. Increas ed recovery of M oraxe lla c a t a rrhalis and Haemophilus influenzae in as s ociation with group A â-haemolytic s treptococci in healthy children and thos e with pharyngotons illitis . Loganthana. Brook Itzhak and E. Lee. T. K a n g . Journal of M edical M icrobiology. Baron.. Tenover and R. International journal of pediatric otorhinolaryngology. 28(3): 173-6. S. Sombulna and S. DC: A merican Society for M icrobiology. REFERENCES Brook itzhak. P.. Vars hney Saurabh. 1995. W als h and M . A bhay. P. Res pir.O .. 85(5): 383. 2007.T.

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