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The Role of Anaerobic Bacteria in Recurrent Episodes of Sinusitis and Tonsillitis

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The Role of Anaerobic Bacteria in Recurrent Episodes of Sinusitis and Tonsillitis 1512 REVIEW ARTICLE The Role of Anaerobic Bacteria in Recurrent Episodes of Sinusitis and Tonsillitis Carl Erik Nord From the Department of Microbiology, Karolinska Institutet, Huddinge University Hospital, Huddinge, Sweden Chronic and recurrent upper respiratory tract infections represent a significant clinical chal- lenge. The causative organisms tend to be heterogeneous, involving both aerobes and gram-posi- Downloaded from https://academic.oup.com/cid/article/20/6/1512/477393 by guest on 27 September 2021 tive and gram-negative anaerobes. There is evidence that these mixed groups of bacteria interact synergistically, enhancing and prolonging the overall virulence of infection. The role of anaerobic bacteria, in particular their proposed ability to protect susceptible organisms by the production of ft-lactamases, has been the subject of intense speculation. The evidence of a significant role for anaerobic bacteria in recurrent episodes of tonsillitis and sinusitis is reviewed and the most appropriate antimicrobial strategies and possible future developments in diagnosis and therapy are discussed. The Lingering Threat of Sinusitis and Tonsillitis sinusitis and tonsillitis and clarifies appropriate future direc- tions for clinical management. There are a number of reasons why upper respiratory tract infections such as sinusitis and tonsillitis remain a serious health care problem. First, while chronic and recurrent up- The Shift in Microbial Flora Associated with Chronic per respiratory tract infections are generally not life-threaten- Tonsillitis and Sinusitis ing, they are common, are refractory to treatment, and ac- Normal Flora of the Upper Respiratory Tract count for a large proportion of physician visits and health care expenditures. Second, it has been suggested that chronic Tonsils. The tonsils are masses of lymphatic tissue that upper respiratory tract infections are associated with a shift play a role in protecting the body against infection. The ratio in microflora, which encourages the emergence of resistant of anaerobes to aerobes in the healthy human oropharynx is organisms, particularly in conjunction with misuse of antimi- 10:1 [3, 4]. The normal tonsil core harbors polymicrobial crobials. Third, chronic sinusitis and tonsillitis may poten- flora, including anaerobes such as Prevotella species and Por- tially act as sources for more serious secondary infections [ 1]. phyromonas species (formerly classified in the Bacteroides For example, chronic sinusitis is generally a mild disease, but group [5, 6]) and aerobes such as streptococci and staphylo- it can lead to infectious complications involving the CNS cocci [7]. Prevotella interinedia (formerly Bacteroides inter- such as brain abscesses and meningitis. In cases of tonsillitis, medius) has been found in high concentrations on the tonsil failure to eradicate streptococci can still occasionally lead to surface in healthy individuals, and Porphyromonas gingivalis the development of rheumatic fever and glomerulonephritis. (formerly Bacteroides gingivalis) has also been recovered [8, The association of sinusitis and tonsillitis with secondary in- 9]. The microflora in the entire oral cavity undergoes charac- fections became less significant following the introduction of teristic changes during the maturation of an individual from modern antimicrobials, resulting in more-effective elimina- infancy to adulthood [10]. tion of primary infection. However, with the increase in lev- Sinuses. The sinuses are air-filled cavities located within els of bacterial resistance [2], treatment failures may return the frontal, ethmoidal, maxillary, and paranasal bones of the to their former rate unless antimicrobial strategies are effec- skull. They open into the nasal cavity and are lined with tively adapted in response to changing resistance patterns. mucous membrane continuous with the nasal mucosa. Their This review outlines our current understanding of the an- function is to reduce the weight of the skull. Some investiga- aerobic microorganisms involved in recurrent episodes of tors have attempted to define the bacteriology of the healthy sinus [1 1]. For this study maximum effort was made to avoid contamination, and all 12 aspirates from the maxillary si- nuses of volunteers showed no bacterial growth; however, Received 29 August 1994: revised 7 December 1994. other studies have yielded conflicting results. In a study by Reprints or correspondence: Dr. Carl Erik Nord, Department of Microbi- Brook [12], bacteria were isolated from 12 of 12 healthy si- ology F88, Huddinge University Hospital, S-I4 I 86, Huddinge, Sweden. nuses examined (it should be noted that the sinuses aspirated Clinical Infectious Diseases 1995;20:1512-24 (1) 1995 by The University of Chicago. All rights reserved. were those of patients with facial anomalies requiring correc- 1058-4838/95/2006-0008802.00 tive surgery); the bacteria that were recovered included both CID 1995;20 (June) Recurrent Sinusitis and Tonsillitis 1513 aerobes (Staphylococcus aureus, Streptococcus pneumoniae, pharynx and interfere with breathing and swallowing. Since and Haemophilus parainfluenzae) and anaerobes (Bacter- the mucous membranes of the pharynx, eustachian tubes, oides species, Prevotella species, anaerobic cocci, and Fuso- and middle ear are continuous, an infection may travel from bacterium species) [12]. the throat into the middle ear. The specific location of the different sinuses affects their A major difference between the microbial flora in episodes microenvironmental conditions, which will determine the of acute and chronic tonsillitis is the increased numbers of nature of their normal flora. For example, the atmosphere of anaerobes isolated from patients with the chronic disease the ethmoidal sinus is relatively aerobic as a result of in- (i.e., in terms of cfu per gram [7]), and this variation is re- creased exposure to inspired oxygen [13]. lated to microenvironmental and structural changes in the chronically infected tissue. Tables 1 and 2 indicate the per- centages of aerobes vs. anaerobes isolated from children and Downloaded from https://academic.oup.com/cid/article/20/6/1512/477393 by guest on 27 September 2021 Microbial Flora Associated with Acute Sinusitis and Tonsillitis adults with chronic tonsillitis. The most frequently isolated Tonsillitis. Tonsils are common sites of infection, and anaerobes were Bacteroides species, Fusobacterium species, inflammation of the tonsils is termed tonsillitis. Acute tonsil- Prevotella species, and anaerobic cocci. litis is usually a self-limited disease. It is common, particu- The proportion of anaerobes isolated from patients with larly in children and young adults, and constitutes 60% of chronic tonsillitis is highly variable (33%-88% of organisms upper respiratory tract infections. The majority of cases of detected in different studies were anaerobes). It is important tonsillitis are of viral origin. Of those cases due to bacteria, to make a distinction between variations that represent tech- most are caused by group A 13-hemolytic streptococci; how- nical artifacts and those that are clinically significant. Dis- ever, other bacteria have also been implicated including S. crepancies between sampling techniques and culture meth- aureus, S. pneumoniae, Haemophilus influenzae, and anaer- ods may give rise to artifactual variations in the obes [1, 14]. It has also been suggested in some reports that aerobe-to-anaerobe ratio. A number of investigators, includ- Mycoplasma and Chlantydia are pathogens of the upper respi- ing Bieluch et al. [27] and Gaffney et al. [29], used direct ratory tract. For instance, Chlamydia trachomatis and Myco- plating rather than the fluid enrichment technique favored plasma pneumoniae have been identified in adults with phar- by Brook et al. [32]. Furthermore, the former two groups yngitis, both by positive culture and by serological tests [15, incubated their plates for only 48 hours in an attempt to 16]. However, the reports of isolation of these organisms identify those anaerobes present in clinically significant num- vary widely, which is probably a result of the technical diffi- bers; in contrast, Brook et al. incubated their plates for 96 culties in their identification. It has been found that C. tra- hours. chomatis may be difficult to recover from the oropharynx: Technical variations also arise when the tonsils are excised passage is required for isolation in over one-half of the cul- prior to sampling. In some studies a heated scalpel was used tures [15]. False-positive reactions can occur in serological to cauterize the tonsil surface prior to incision, thereby tests [16]. Thus, further studies on the potential role of Chia- avoiding surface contamination [29]; other investigators inydia and Mycoplasma in upper respiratory tract infections, have deemed this surface-sterilization procedure unneces- including chronic tonsillitis, are required. sary [19]. In addition, the sterilization method has varied Sinusitis. Sinusitis accounts for 10% of upper respiratory within the same study [29]: some of the tonsils were soaked tract infections and occurs when drainage of mucous secre- in alcohol-iodine solution for 5 minutes and rinsed in sterile tions from a sinus is blocked by swollen membranes, usually saline, while others were not. The method of homogeniza- resulting from a nasal infection (generally viral) or allergic tion of tonsil tissue also varied: in one study the tissue was reaction [ I]. Accumulation of fluid in the sinuses
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