Comparing Healthcare Utilization Between Adenotonsillectomy Patients With and Without Postoperative Antibiotic Use

The objective for this trial is to provide evidence that not prescribing postoperative
antibiotics increases the number of phone calls to the physician, increases the number of
emergency department/urgent care/clinic visits in the postoperative period, and increases
medical diagnostic costs (ie: labwork, cultures, x-rays). Additionally, the investigators
aim to provide evidence that a higher percentage of patients not given a prescription for
antibiotics will ultimately obtain a prescription from another provider.

One of the most common surgical procedures performed in the pediatric population is
tonsillectomy. The term "tonsillectomy" refers to the surgical excision of the entire tonsil
tissue and may or may not include excision of the adenoid tissue as well. Typical symptoms
following surgery are pain, malaise, and fever among others. Otolaryngologists for many
years have prescribed antibiotics postoperatively based on early randomized controlled
trials that suggested a benefit in improved recovery. A recent poll showed that 79% of
otolaryngologists routinely prescribe antibiotics to reduce postoperative morbidity and not
for antibiotic prophylaxis. The American Academy of Otolaryngology-Head and Neck Surgery
(AAOHNSF) recently published an evidenced-based Clinical Practice Guideline for
tonsillectomy in children in which the routine use of postoperative antibiotics was
evaluated. Evaluation of more recent literature showed that routine use of post-operative
antibiotics does not show benefit in improving the main measures of perioperative morbidity
. Multiple individual trials showed that antibiotic use had no impact on pain, amount of
analgesic use, recovery time, or time required to return to a normal diet. However, routine
antibiotic use for prevention of postoperative fever remains in controversy and has shown
benefit in two trials and while showing no benefit in two different trials. Considering the
lack of supporting evidence of benefit in reducing postoperative morbidity, the AAOHNSF has
issued a strong recommendation against the routine administration of postoperative
antibiotics for tonsillectomy.

The investigators experience as a very busy pediatric surgical service is that in the 1-2
weeks following tonsillectomy, physicians and clinics commonly receive phone calls from
concerned parents regarding local and referred pain, bad breath, and fever. Despite patient
education at several steps during the process, parental phone calls regarding postoperative
fever remain common. While post-operative fever is known to occur following tonsillectomy,
management of this issue on the phone, sometimes over the weekend, can be challenging.
Children are often in pain, more tired than usual, and not eating well. Even though these
are all anticipated symptoms, when they occur with fever, it is difficult to provide
adequate reassurance to a concerned parent. Often parents think their child has an infection
and are expecting that their provider will start an antibiotic. From the clinician
perspective, it can be difficult to discern whether or not there is a concurrent illness
that should be evaluated. As a result, parents often bring their children to an urgent care
clinic, emergency department, or physician clinic for evaluation and may eventually obtain
an antibiotic prescription for their complaints to cover a possible infection.

While routine use of antibiotics does not show benefit in improving many of the main
elements of morbidity, controversy remains regarding reduction of postoperative fever. When
a fever occurs in a child who is not taking an antibiotic, parents often become concerned
about an infection and desire an antibiotic and further evaluation. The concern of the
parent in some cases leads to unnecessary visits to emergency departments, urgent care
clinics, and physician clinics for evaluation. The workup performed in the evaluation of
these patients may include complete blood count, chest x-ray, urinalysis, and urine
cultures. Ultimately, the patient may be given an empiric antibiotic prescription. To date
there has been no literature documenting healthcare utilization compared between patients
who were given antibiotics and those who were not given antibiotics. The goal of this study
is to evaluate healthcare utilization and patient/caregiver burden between these groups. If
increased healthcare utilization and patient/caregiver burden is found in the "no
antibiotic" group, then analysis of the type of utilization and outcome will direct future
efforts to improve patient education regarding postoperative morbidity or possibly to
continue routinely administering post operative empiric antibiotics. This will benefit in
the effort to improve patient satisfaction with surgery, reduce unnecessary healthcare
costs, and reduce unnecessary antibiotic use.

Inclusion Criteria:

- Patients who are candidates for Adenotonsillectomy or Tonsillectomy only (AT/T).

- Patient age 18 years or younger(if patient not 18 years, then parent/guardian will be
the participant and must also meet inclusion criteria #3).

- English as the primary language.

Exclusion Criteria:

- Patients not having English as their primary language

- Patients <18 years of age without a parent/guardian present.

- Patients with periodic fever syndrome, immunocompromise, hemophilia, cerebral palsy,
down syndrome, sickle cell disease, or with known preoperative aspiration.