Immune response to Fusobacterium nucleatum, Prevotella intermedia and other anaerobes in children with acute tonsillitis.

The number of aerobic and anaerobic bacteria was determined in the saliva of 20 children with acute group A beta-haemolytic streptococcal (GABHS) pharyngo-tonsillitis, and 20 with acute non-GABHS tonsillitis. Antibody titres to four Gram-negative anaerobic bacilli that reside in the oropharynx (Fusobacterium nucleatum, Prevotella intermedia, Porphyromonas gingivalis, and Actinobacillus actinomycetemcomitans) were determined in these and 20 control patients. An average of 8.8 aerobic and anaerobic isolates per patient saliva specimens were found during the acute tonsillitis stage in both groups, and 6.9 (in GABHS tonsillitis) and 5.6 (in non-GABHS tonsillitis) 5-6 weeks later. There were 10- to 1000-fold more bacteria in the acute stages of the inflammation in both GABHS and non-GABHS groups. These bacteria were Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis, Peptostreptococcus spp., F. nucleatum, Prevotella spp. and Porphyromonas spp. Significantly higher antibodies levels to F. nucleatum and P. intermedia were found in the second serum sample of patients with non-GABHS pharyngo-tonsillitis (P < 0.001) and GABHS tonsillitis (P < 0.05), as compared with their first sample or the levels of antibodies in controls. The increase in the number of several aerobic and anaerobic bacteria during acute tonsillitis and the increase in antibody levels to F. nucleatum and P. intermedia, known oral pathogens, may suggest a possible pathogenic role for these organisms in acute non-GABHS and GABHS tonsillitis.

Microbiology of chronic maxillary sinusitis: comparison between specimens obtained by sinus endoscopy and by surgical drainage.

The aerobic and anaerobic microbiology of sinus aspirates obtained during surgery was compared with culture of samples obtained by endoscopy. Six patients with chronic maxillary sinusitis were evaluated. Polymicrobial flora was found in all specimens (two-to-five isolates/sample). A total of 24 isolates (18 anaerobic, five aerobic and one micro-aerophilic) was obtained from sinus aspirates, and 25 isolates (16 anaerobic and nine aerobic) were found in endoscopic specimens. The predominant organisms were Prevotella spp., Fusobacterium nucleatum, Peptostreptococcus spp. and Staphylococcus spp. Concordance in the type and concentration of organisms was found in all cases. Sixteen of the 18 anaerobes isolated from sinus aspirates were also found in the concomitant endoscopic sample. Five aerobic isolates were found in both sinus aspirates and endoscopic samples and their concentration was similar. However, four aerobic gram-positive bacteria (<10(4) cfu/sample) were found only in endoscopy samples. This pilot study demonstrates the usefulness of endoscopic aspiration in the isolation of bacteria from chronically infected maxillary sinuses.

Effect of penicillin or cefprozil therapy on tonsillar flora.

The effect on the tonsillar bacterial flora of antimicrobial therapy with penicillin or a second-generation cephalosporin (cefprozil) was studied. Sixty children scheduled for elective tonsillectomy because of recurrent group A beta-haemolytic streptococcal tonsillitis participated in a prospective randomized study that divided them into three groups. One group received no therapy, and the others were given either penicillin or cefprozil for 10 days prior to surgery. The core of the patients' tonsils was cultured for aerobic bacteria. Group A beta-haemolytic streptococci (GABHS) were isolated from 15/20 (75%) of untreated, 11/20 (55%) of penicillin, and 2/20 (10%) of the cefprozil group (P < 0.001). Thirty-two beta-lactamase-producing bacteria were recovered from 19/20 (95%) of untreated, 33 from 17/20 (85%) treated with penicillin and six from 4/20 (20%) treated with cefprozil (P < 0.01). Alpha-haemolytic streptococci (AHS) inhibiting GABHS were less often isolated from patients treated with penicillin. These data illustrate the ability of a second-generation cephalosporin to eradicate GABHs, as well as beta-lactamase-producing bacteria, while preserving AHS.

Immune response to anaerobic bacteria in patients with peritonsillar cellulitis and abscess.

The role of four oral organisms (Fusobacterium nucleatum. Prevotella intermedia, Porphyromonas gingivalis, and Actinobacillus actinomycetemcomitans) was investigated in 19 children with peritonsillar abscess, and 17 with peritonsillar cellulitis. Antibody titers to these organisms were measured by enzyme- linked immunosorbent assay in the patient, as well as in 32 control patients. Serum levels in the patients were determined at day 1 and 42-56 days later. Significantly higher antibody levels to F. nucleatum and P. intermedia were found in the second serum sample of patients with peritonsillar cellulitis or abscess, as compared to their first sample or the levels of antibodies in controls. A total of 136 bacterial isolates, 100 anaerobic and 36 aerobic were isolated from the 19 peritonsillar abscesses. Anaerobic bacteria were found in all abscesses, and they were mixed with aerobic bacteria in 5 (26%). F. nucleatum was recovered in 14 (74%) abscesses and P. intermedia was isolated in 13 (68%). The elevated antibody levels to F. nucleatum and P. intermedia, known oral pathogens, suggest a pathogenic role for these organisms in peritonsillar infections.

Microbiology of the transition from acute to chronic maxillary sinusitis.

Repeated aspirations of sinus secretions by endoscopy was performed in five patients over a period of 34-50 days and, ultimately, surgical drainage was done in three who presented with acute maxillary sinusitis that did not respond to antimicrobial therapy and became chronic. The aspirates were cultured for aerobic and anaerobic bacteria. Most of the bacteria isolated from the first culture were aerobic or facultative bacteria: Streptococcus pneumoniae (three isolates), Haemophilus influenzae non-type-b (two) and Moraxella catarrhalis (one). Three of these cultures yielded bacteria that were resistant to the antimicrobial agents prescribed for treatment. Failure to respond to therapy was associated with the emergence of resistant aerobic and anaerobic bacteria in subsequent aspirates. These organisms included Fusobacterium nucleatum, pigmented Prevotella and Porphyromonas spp. and Peptostreptococcus spp. Eradication of the infection was achieved in all instances following the administration of antimicrobial agents effective against these bacteria, and in three instances by surgical drainage. This study illustrates the microbial dynamics of maxillary sinusitis that did not respond to antimicrobial therapy.

Changes in the core tonsillar bacteriology of recurrent tonsillitis: 1977-1993.

Microbiological studies of the core of tonsils removed from children with recurrent tonsillitis due to group A beta-hemolytic streptococci were conducted during three periods, with 50 patients in each period: 1977-1978 (period 1), 1984-1985 (period 2), and 1992-1993 (period 3). Mixed flora were present in all tonsils, with 8.1 organisms per tonsil (3.8 aerobes and 4.3 anaerobes). The predominant isolates in each period were Staphylococcus aureus, Moraxella catarrhalis, Peptostreptococcus species, pigmented Prevotella species, Porphyromonas species, and Fusobacterium species. The rate of recovery of Haemophilus influenzae type b increased from 24% in period 1 to 76% in period 2 (P < .001); a decline to 12% in period 3 correlated with a concomitant increase in the frequency of recovery of non-type b strains of H. influenzae from 4% and 10% in periods 1 and 2, respectively, to 64% in period 3 (P < .001). Both the rate of recovery of beta-lactamase-producing bacteria and the number of these organisms per tonsil increased over time. Specifically, beta-lactamase-producing strains were detected in 37 tonsils (74%) during period 1, in 46 tonsils (92%) during period 2, and in 47 tonsils (94%) during period 3, and the number of such strains per tonsil increased from 1.1 in period 1 to 2.9 and 3.3 in periods 2 and 3, respectively.

Immune response to Prevotella intermedia in patients with recurrent nonstreptococcal tonsillitis.

The role of three oral flora organisms (Prevotella intermedia, Porphyromonas gingivalis, and Actinobacillus actinomycetemcomitans) was investigated in 31 children with recurrent nonstreptococcal tonsillitis. Antibody titers to the three organisms were measured by enzyme-linked immunosorbent assay in the 31 patients, as well as in 32 control patients who had not suffered from recurrent tonsillitis. None of the individuals in either group suffered from periodontal or dental illness. Significantly higher antibody levels to P intermedia were found in the study group as compared to controls (median 91.0 versus 72.5; p = .02). In contrast, the antibody titers to the other two organisms were generally low (less than 0.30), and no difference was found among the two study groups. The elevated antibody levels to P intermedia, a known oral pathogen that is also isolated from most recurrently inflamed tonsils, suggest a pathogenic role for this organism in recurrent tonsillitis.

Microbiology of "normal" tonsils.

Core tonsillar cultures for aerobic and anaerobic bacteria were performed on four normal tonsils removed from four children because of velopharyngeal insufficiency and on four tonsils removed from four children because of recurrent tonsillitis. The data illustrate the presence of polymicrobial flora in the cores of normal noninflamed tonsils and the increase in their number and encapsulation during the inflammatory process.

Penicillin and clindamycin therapy in recurrent tonsillitis. Effect of microbial flora.

Fifty patients, scheduled for an elective tonsillectomy because of recurrent group A beta-hemolytic streptococcal tonsillitis, participated in a prospective randomized study that compared the efficacy of presurgical treatment with either phenoxymethyl penicillin or clindamycin hydrochloride in eradicating group A beta-hemolytic streptococci and beta-lactamase-producing bacteria (BLPB) from the tonsillar core. They were randomized into three groups as follows: 11 received penicillin, 22 received clindamycin, and 17 received no therapy. Group A beta-hemolytic streptococci were isolated from 8 (40%) of 17 untreated patients, 4 (36%) of 11 patients treated with penicillin, and none of 22 patients treated with clindamycin. Twenty-one BLPB were isolated from 16 (94%) of 17 untreated patients, 11 BLPB from 9 (82%) of 11 patients treated with penicillin, and 7 BLPB from 7 (32%) of 22 patients treated with clindamycin compared with penicillin or no therapy. Of the 22 patients treated with clindamycin, 10 were younger than 12 years of age. The BLPB were eradicated in nine patients (90%). However, BLPB were eradicated only in 6 (50%) of the 12 patients who were aged 13 years and older. These data illustrate the efficacy of clindamycin therapy in eradicating group A beta-hemolytic streptococci, as well as BLPB, in recurrent inflamed tonsils, especially in persons aged 12 years old and younger.

Comparison of the microbiology of recurrent tonsillitis between children and adults.

The microbial flora of recurrently inflamed tonsils removed from 25 children with recurrent episodes of tonsillar pharyngitis were compared to flora of tonsils removed from 23 adults suffering from similar illness. More bacterial isolates per tonsil were recovered in adults (10.2 per tonsil) than in children (8.4 per tonsil). The difference between these groups was due to a higher recovery rate in adults of Bacteroides melaninogenicus group (1.6 isolates per adult, 0.8 per child) and Bacteroides fragilis group (0.4 per adult, 0.2 per child). Conversely, Group A beta-hemolytic streptococci were isolated in seven (28%) children as compared to their isolation in one (4%) adult. More isolates of beta-lactamase-producing organisms (BLPO) per tonsil were recovered in adults. Forty-three BLPO were detected in 21 (91%) of the 23 tonsils removed from adults (1.9 isolates per patient) as compared to 31 isolates in 16 (64%) of the 25 tonsils removed from children (1.2 isolates per patient) (P = 0.04). These findings suggest that the etiology of recurrent tonsillitis in adults may differ from that in children. The differences in the tonsillar flora may be due to the effect of many more courses of antimicrobials given over the years to adults and the changes in tonsillar tissue that occur in this age group.