Tonsillitis In Children Research Articles

Erratum to: Five-day spiramycin vs seven-day penicillin V in the treatment of streptococcal tonsillitis in children

Erratum to: Five-day spiramycin vs seven-day penicillin V in the treatment of streptococcal tonsillitis in children

Five-Day Spiramycin vs Seven-Day Penicillin V in the Treatment of Streptococcal Tonsillitis in Children.

Because of the frequency of penicillin allergies in children receiving β-lactam antibacterial agents, the macrolides are frequently chosen as alternatives in patients with group A β-haemolytic streptococcal (GABHS) infections. Spiramycin, amacrolide widely used in paediatrics, achieving remarkably high tonsillar tissue concentrations, was evaluated in this study in comparison with penicillin V (Phenoxymethylpenicillin). 298 children aged 1.5 to 14 years with acute tonsillitis and a positive rapid antigen test for GABHS were randomised to receive either a 5-day course of spiramycin 100 000 IU/kg twice daily or a 7-day course of penicillin V 25 000 IU/kg 3 times daily. Clinical and bacteriological assessments were recorded at inclusion (day 1), at the end of the treatment visit (days 8 to 12), and at the follow-up visit (days 25 to 35). GABHS isolated during the study were analysed by total DNA restriction fragment length polymorphism analysis. Of the 237 children with a positive GABHS culture at day 1,210 (88.6%) were evaluable for complete clinical and bacteriological efficacy at the end of treatment. Clinical efficacy was evident in 96.1% (98 of 102) for spiramycin and in 98.1% (106 of 108) for penicillin V. Bacteriological eradication was achieved in 79.4% (81 of 102) for spiramycin and in 89.8% (97 of 108) for penicillin V. Three failures occurred in the spiramycin group. In intent-to-treat analysis, the success rate (clinical cure and bacteriological eradication) for spiramycin was 77.9% (116 of 149) and that for penicillin V was 83.9% (125 of 149). At the follow-up visit, 182 children were evaluable for efficacy. Clinical cure with or without asymptomatic carriage of GABHS was observed in 97.7% (86 of 88) for spiramycin and in 89.4% (89 of 94) for penicillin V. Three relapses and 1 reinfection occurred in the penicillin V group. Adverse events, mainly gastrointestinal, occurred in 10.7% of spiramycin patients versus 12.8% of penicillin V patients. These results show that a 5-day treatment regimen with spiramycin twice daily is effective and well tolerated in GABHS tonsillitis, and is an alternative to penicillin V when necessary in children.

COMPARISON OF CLARITHROMYCIN SUSPENSION AND AMOXYCILLIN SYRUP FOR THE TREATMENT OF CHILDREN WITH PHARYNGITIS AND/OR TONSILLITIS

SUMMARYTwenty‐three general practices in the UK randomised 229 paediatric patients (aged 1‐12 years, body weight >8 kg) with clinical evidence suggestive of streptococcal tonsillitis and/or pharyngitis in this physician‐blind study. Patients received either clarithromycin suspension (7.5 mg/kg twice daily) or amoxycillin syrup (125 mg/kg three times daily body weight <25 kg, or 250 mg/kg three times daily body weight 25 kg) for 7 days and were followed up 3‐8 days post treatment and 21‐28 days later. Clinical and microbiological assessments were made at each visit. A total of 189 patients (98 on clarithromycin and 91 on amoxycillin) were clinically evaluable. At the post‐treatment visit, clinical success rates were high and comparable: 98% on clarithromycin and 97% on amoxycillin. Streptococcus pyogenes was eradicated in 88% of clarithromycin patients and 86% of amoxycillin patients. Both treatments were well tolerated. In conclusion, clarithromycin suspension was as safe and at least as effective as amoxycillin syrup for the treatment of pharyngitis and/or tonsillitis in children, and would be a suitable alternative therapy.

Early adenotonsillectomy for relief of acute upper airway obstruction due to acute tonsillitis in children

Early adenotonsillectomy (TA) for acute upper airway obstruction precipitated by acute tonsillitis was performed in 17 children admitted to the Royal Childrens Hospital over a 15 year period. The age ranged from 13 to 83 months (mean 37 months) and surgery was performed from 1 to 11 days (mean 5.8 days) following admission. One child who underwent surgery within 24 h of admission had an intraoperative blood loss of 250 ml requiring transfusion, but there were no cases of post operative hemorrhage. Airway obstruction was relieved by surgery in all cases and patients were discharged 1 to 6 days (mean 2.4 days) later. Early TA should be considered for relief of upper airway obstruction due to acute tonsillitis after an initial 24 h of intravenous antibiotic therapy.

A Randomized, Open, Comparative Study of Brodimoprim Versus Erythromycin in Patients with Acute Tonsillitis or Bronchitis

The objective of the study was the comparison of the efficacy and tolerability of brodimoprim to those of erythromycin in children with acute tonsillitis or bronchitis. 50 children aged 0.5 to 9.3 years were included in the study, 25 treated either with brodimoprim or with erythromycin. The evaluation of the therapeutic response was based exclusively on clinical criteria. In the brodimoprim group the therapy was successful in 24 patients (one failure), in the erythromycin group the therapy was also successful in 24 children (one failure). Side effects: three patients treated with brodimoprim reported adverse reactions (stomatitis, vomiting, skin rash), whereas only one patient in the erythromycin group developed a skin rash. both therapeutic regimens were equally effective against bronchitis and tonsillitis in children. The tolerability was good in both groups.

Spontaneous tonsillar bleeding; secondary to acute tonsillitis in children

Serious spontaneous tonsillar bleeding in three children was considered with respect to cause(s) and therapy. In two of the children the cause was related to streptococcal infection, and to hemophilus in the third child. A clinical and laboratory follow-up on our diagnosis indicated an infectious cause in each instance, inducing superficial vascular wall erosion. In our clinic the incidence of this relatively rare medical phenomenon in 254 cases of acute tonsillitis, has been only 1.2%. The children were successfully treated with conservative local treatment, such as cauterization and systemic antibiotics.

Interfering α-streptococci as a protection against recurrent streptococcal tonsillitis in children

Recurrent streptococcal tonsillitis/ pharyngitis is a great problem, especially in certain epidemiological situations. Patients treated with antibiotics often have a disturbed normal throat flora and may lack, e.g., a-streptococci known in vitro to have an interfering activity against group A streptococci. Thirty-one patients with recurrent streptococcal tonsillitis were given antibiotics for 10 days. At the end of this treatment they were sprayed in their mouths with four selected a-streptococcal strains known to have strong growth inhibiting activity in vitro against most /β-streptococci group A. The follow-up period after this colonization was 3 months. After α-streptococcal treatment, none of the patients attracted a new tonsillitis during the follow-up period while 8% of the controls had a second tonsillitis. Treatment of streptococcal tonsillitis/ pharyngitis with antibiotics followed by recolonization with α-streptococci seems to hinder further recurrences.

Double-Blind, Placebo-Controlled Multicentre Trial of the Efficacy and Tolerance of Morniflumate Suppositories in the Treatment of Tonsillitis in Children

The efficacy and tolerability of morniflumate suppositories used together with phenoxymethylpenicillin were studied in a placebo-controlled, double-blind trial in 101 children with acute tonsillitis. Patients received a suppository containing 400 mg morniflumate or placebo twice daily for 4 days; all patients also received 1,500,000 IU/day phenoxymethylpenicillin. Response to treatment was assessed by clinical examination before and after 2 and 4 days' treatment. Efficacy was evaluated by resolution of oropharyngeal pain, congestion, fever, size and sensitivity of adenopathies, quality of life and duration of sleep. Body temperature fell rapidly after the start of treatment. There was also resolution of pharyngeal pain, earache, dysphagia and adenopathy. Spontaneous pharyngeal pain was present after 4 days in significantly (P = 0.03) fewer patients receiving morniflumate than receiving placebo. It is suggested that morniflumate combined with antibiotic therapy is an effective and well-tolerated treatment for tonsillitis in children.

Microbial flora of surface versus core tonsillar cultures in recurrent tonsillitis in children

Surface and ‘core’ tonsillar specimens were collected from 60 children, between 2 and 14 years of age, suffering from recurrent tonsillitis, in order to establish the reliability of surface tonsillar swabbing technique and to define the most frequently involved aerobic and anaerobic microorganisms. From the qualitative point of view, the same mixed aerobic and anaerobic flora were obtained in both samples thus demonstrating the reliability of the surface swabbing technique. From the quantitative point of view, 187 microorganisms, 129 (69.2%) aerobes and 58 (30.8%) anaerobes were isolated from surface cultures while 184, 109 (59.2%) aerobes and 75 (40.8%) anaerobes from the core cultures, thus demonstrating a greater number of anaerobes in the core of the tonsil. The most common isolated aerobic microorganisms were the α- and β- hemolytic Streptococci, the Neisseriae and the Staphylococcus aureus; the predominant anaerobic ones were the Fusobacterium nucleatum, the Bacteroides sp. and the Veillonella parvula. The isolated staphylococcus aureus and the bacteroides sp. were all β-lactamase producers.

Beta-lactamase-producing bacteria in head and neck infection.

We have summarized our experience in recovery of beta-lactamase-producing bacteria (BLPB) in head and neck infection (HNI). These HNI include conjunctivitis, serous and chronic otitis media, cholesteatoma, chronic mastoiditis, chronic sinusitis, adenoiditis, recurrent tonsillitis in children and adults, peritonsillar abscess, and retropharyngeal abscess. Beta-lactamase-producing bacteria were found in 262 (51%) of 513 patients with HNI; 72% had aerobic BLPB and 57% had anaerobic BLPB. The infections, where these organisms were most frequently recovered, were adenoiditis (85% of patients), tonsillitis in adults (82%) and children (74%), retropharyngeal abscess (71%), and chronic otitis media (57%). The predominant BLPB were Staphylococcus aureus (49% of patients with BLPB), the Bacteroides-melaninogenicus group (28%), the Bacteroides fragilis group (20%), Pseudomonas aeruginosa (13%), Hemophilus influenzae (5%), and Branhamella catarrhalis (3%). The high incidence of recovery of BLPB in head and neck infections may have important implications on the antimicrobial management of these infections.

Febrile Exudative Tonsillitis: Viral or Streptococcal?

A prospective 1-year study of acute febrile exudative tonsillitis in 110 children was carried out. Viral infection was associated with 42% of the cases, beta-hemolytic streptococci with 31% (12% group A), Mycoplasma pneumoniae with 5%, and unknown cause with 35%. More than one agent was implicated in 14% of the cases. Adenovirus was the viral agent most frequently (19%) recorded. Other viruses involved were Epstein-Barr virus, parainfluenza, influenza A, herpes simplex, and respiratory syncytial viruses. The responsible agent was found by rapid viral antigen detection in 20% of all cases and by rapid test for group A streptococcal antigen detection in 10%. Age was the most important factor in predicting the causative agent. Viral tonsillitis was most common in children younger than 3 years of age and group A beta-hemolytic streptococci tonsillitis in children 6 years of age or more. Clinical analysis of the illness, WBC count, and ESR did not reveal differences that could help in differentiating bacterial from viral tonsillitis. All patients were treated with a regimen of oral penicillin. Fever associated with group A beta-hemolytic streptococci tonsillitis responded to penicillin therapy significantly more rapidly than fever associated with viral infections. These observations demonstrate the prominent role of viruses in the etiology of febrile exudative tonsillitis, especially in young children, and reinforce the benefit of rapid tests before antibiotic therapy is started.

The relevance of physical signs in recurrent tonsillitis in children (a prospective study).

Tonsillar physical signs plus cervical lymphadenopathy are irrelevant factors in the assessment of children with recurrent tonsillitis. Tonsillar protrusion, but not size, is related to snoring.

C-reactive protein in the differentiation of adenoviral, Epstein-Barr viral and streptococcal tonsillitis in children.

Sixty-two children with febrile exudative tonsillitis were studied to explore whether quantitative measurements of serum C-reactive protein (CRP) are useful in differentiating viral from streptococcal tonsillitis. There were 23 cases of adenoviral tonsillitis, 21 of EB viral tonsillitis and 18 of streptococcal tonsillitis. Measurements of CRP, WBC counts and erythrocyte sedimentation rates (ESR) were not useful in distinguishing viral from streptococcal tonsillitis. Seventy-four percent of patients with adenoviral tonsillitis were under the age of 3 years and 71% of the patients with Epstein-Barr (EB) viral tonsillitis were under the age of 6 years whereas 72% of the patients with streptococcal tonsillitis were over the age of 6 years. Age was clearly the most important factor in distinguishing between viral and bacterial tonsillitis in children.

Long-Term Investigation of Habitual Tonsillitis in Children

The authors were in close contact with children who had indications for tonsillectomy and investigated them in both acute tonsillitis and intermittent periods of tonsil inflammation. The results obtained were as follows: Repeated attacks of acute tonsillitis clearly decreased in number. No secondary diseases due to tonsillitis were observed. When repeated attacks of acute tonsillitis occurred, the symptoms were not as serious as previously.

The diagnostic value of symptoms and signs in acute tonsillitis in children over the age of 10 and in adults.

267 outpatients with acute tonsillitis were studied with regard to clinical signs and symptoms and presence of beta-hemolytic streptococci. Beta-hemolytic streptococci were found in 169 patients (63%), compared to 6/64 healthy controls (9%). Of the tonsillitis patients with beta-hemolytic streptococci, 80% harboured group A and 20% groups C and G. Five out of 6 controls had group C and G streptococci. Eight clinical signs and symptoms of acute tonsillitis were rated on a 10-point scale. A correlation was found between redness in the oropharynx and on the tonsils and positive culture for beta-hemolytic streptococci group A. The total WBC count, polymorphonuclear leucocytes and ratio of polymorphonuclear to mononuclear leucocytes were strongly correlated to a positive culture for streptococci group A. Groups C and G did not show these correlations. The study stresses the importance of quantitative culture technique and the value of this for diagnosis in the acute ill patient with tonsillitis.

The Diagnostic Value of Symptoms and Signs in Acute Tonsillitis in Children over the Age of 10 and in Adults

The Diagnostic Value of Symptoms and Signs in Acute Tonsillitis in Children over the Age of 10 and in Adults

Treatment failure in acute streptococcal tonsillitis in children over the age of 10 and in adults.

13/169 outpatients (8%) with streptococcal tonsillitis developed a new tonsillitis with the same strain within 2 weeks of completion of therapy (clinical treatment failures) and 24 (14%) remained carriers (bacterial treatment failures) after treatment with phenoxymethylpenicillin (penicillin V) 12.5 mg/kg body weight twice daily for 10 days. The mean serum concentration 60 min after penicillin V administration was 7.84 micrograms/ml. Very large individual differences in serum concentration were found but these differences could not be correlated to treatment failure. About 60% of the patients showed salivary concentrations around 0.03 micrograms/ml. Three strains of streptococci (groups C and G) from patients with bacterial treatment failure had MIC values of 0.06 and 0.12 micrograms/ml. A majority of the patients with clinical treatment failures had contact with individuals with high carrier rates of beta-hemolytic streptococci. It therefore seems likely that some so-called treatment failures in reality are new infections. In clinical treatment failures group A streptococci were twice as common as groups C + G. In bacteriological treatment failures the ratio between A and C + G was 1:1. Patients with nonstreptococcal tonsillitis as well as carriers of groups C and G may appear among bacterial treatment failures.

Acute tonsillitis in children: microbial pathogens in relation to age

Tonsil swabs were collected from 248 children (1 through 10 yr) who presented with acute tonsillitis. A beta-hemolytic streptococcus was grown from 129 (53%) of 244 cases and as the sole pathogen from 83 (47%) of 178 cases. Beta-Hemolytic streptococci were especially common over the age of 6 yr (68% of children) relatively uncommon under the age of 4 yr (18%); most (90%) streptococci belonged to group A; 18 streptococcal T types were represented amongst 88 group A strains; the potentially nephritogenic serotypes 4 and 12 were prominent and accounted for 42 (47%) of typable isolates. Eight (8%) of 96 unmatched children (1 through 10 yr) who served as controls were found to be carrying beta-hemolytic streptococci, 5 of which belonged to group A. A virus was grown from 52 (29%) of 182 children and as the sole pathogen from 40 (22%) of 178 children. Only echoviruses (8 serotypes) and adenoviruses (5 serotypes) were common; younger children showed a higher isolation rate of viruses. The clinical picture in children yielding a virus was indistinguishable from that of cases who yielded a beta-hemolytic streptococcus.

In vitro protection of group A beta-hemolytic streptococci from penicillin and cephalothin by Bacteroides fragilis.

beta-Lactamase produced by Bacteroides fragilis could protect from antibiotics group A beta-hemolytic streptococci (GABHS), penicillin-susceptible pathogens frequently isolated from acute tonsillitis in children. To test this hypothesis we determined the minimal bactericidal concentration (MBC) to penicillin and cephalothin of GABHS alone and in mixed culture with eleven beta-lactamase-producing strains of B. fragilis. B. fragilis strains with MBC values less than or equal to 32 micrograms/ml to penicillin and less than or equal to 64 micrograms/ml to cephalothin did not provide any protection for GABHS. However, strains with MBC greater than or equal to 128 micrograms/ml to penicillin and greater than or equal to 256 micrograms/ml to cephalothin provided protection by increasing the MBC of GABHS at least 8,534 times for penicillin and 2,048 times for cephalothin. This phenomenon was most marked in 5% CO2. B. fragilis provided no protection against clindamycin. These results may explain the inability of penicillin therapy to completely eradicate GABHS from cases of recurrently infected tonsils.

Gangrenous tonsillitis in children

Gangrene of the tonsil is one of the most fatal conditions of the throat occurring in children especially in those with lowered resistance. To recognise and distinguish this condition from the other ulcero-membranous conditions of the throat is extremely important not only to pronounce the probable prognoses, but to chalk out the correct line of treatment. A case of gangrene of the right tonsil with uneventful recovery has been presented. The combination of Broadspectrum antibiotics with anabolic therapy appears to be mainly responsible for the recovery of the child.