Treatment Of Streptococcal Pharyngitis Research Articles

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) in a two-year-old

Streptococcal pharyngitis testing and treatment is not routinely recommended in children under the age of 3 because of the unlikely occurrence of infection and negligible risk of serious complications. However, streptococcal pharyngitis and its resulting complications are not uncommon in this age group and can have serious consequences. We report a case of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections in a 2-year-old with streptococcal pharyngitis. Testing and treatment for streptococcal pharyngitis should be strongly considered when there is evidence of infection and/or an immune-mediated streptococcal complication to prevent and/or decrease the severity of short- and longterm complications.

Acute tonsillopharyngitis - a review

Introduction and purpose: Acute pharyngitis and tonsillitis is the most common reason why people want to visit their primary care physician. Viruses are the most common cause of acute pharyngitis and acute tonsillitis in children and adults. The patient complains about pain with sudden onset and throat irritation, pain on swallowing, fever and headache, and in children also abdominal pain, nausea and vomiting.
 Brief description of the state of knowledge: Most acute tonsillopharyngitis is due to rhinoviruses (35%), influenza (30%), RSV and parainfluenza. Bacteria causes 30% of the infections and S. pyogenes is the most common cause. Viral infections are seasonal. S.pyogenes infection is most often in winter and early spring. Changes in the pharyngeal mucosa look similar in both bacterial and viral etiologies. Because of that, scales have been developed to assess the probability of a bacterial infection. The most used is Centor / McIsaac scale. The gold standard of diagnostics is throat swab culture. In the treatment of streptococcal pharyngitis and tonsillitis, penicillins are used as first-line treatment. Antibiotic treatment reduces infectivity, lowers the risk of rheumatic fever and made symptoms disappear two days earlier. Tonsillectomy does not reduce the number of recurrent pharyngitis and tonsillitis, therefore it cannot be recommended.
 Conclusion: Acute tonsillopharyngitis can result in many complications, the most serious of them is rheumatic fever. Therefore, it is very important to properly diagnose and use antibiotic therapy when necessary.

50 Years Ago in TheJournalofPediatrics: Treatment of Streptococcal Pharyngitis: Then and Now

50 Years Ago in TheJournalofPediatrics: Treatment of Streptococcal Pharyngitis: Then and Now

Impact of Clinical Decision Support on Antibiotic Prescribing for Acute Respiratory Infections: a Cluster Randomized Implementation Trial.

Clinical decision support (CDS) is a promising tool for reducing antibiotic prescribing for acute respiratory infections (ARIs). To assess the impact of previously effective CDS on antibiotic-prescribing rates for ARIs when adapted and implemented in diverse primary care settings. Cluster randomized clinical trial (RCT) implementing a CDS tool designed to guide evidence-based evaluation and treatment of streptococcal pharyngitis and pneumonia. Two large academic health system primary care networks with a mix of providers. All primary care practices within each health system were invited. All providers within participating clinic were considered a participant. Practices were randomized selection to a control or intervention group. Intervention practice providers had access to an integrated clinical prediction rule (iCPR) system designed to determine the risk of bacterial infection from reason for visit of sore throat, cough, or upper respiratory infection and guide evidence-based evaluation and treatment. Change in overall antibiotic prescription rates. Frequency, rates, and type of antibiotics prescribed in intervention and controls groups. 33 primary care practices participated with 541 providers and 100,573 patient visits. Intervention providers completed the tool in 6.9% of eligible visits. Antibiotics were prescribed in 35% and 36% of intervention and control visits, respectively, showing no statistically significant difference. There were also no differences in rates of orders for rapid streptococcal tests (RR, 0.94; P= 0.11) or chest X-rays (RR, 1.01; P= 0.999) between groups. The iCPR tool was not effective in reducing antibiotic prescription rates for upper respiratory infections in diverse primary care settings. This has implications for the generalizability of CDS tools as they are adapted to heterogeneous clinical contexts. Clinicaltrials.gov (NCT02534987). Registered August 26, 2015 at https://clinicaltrials.gov.

Rheumatic Fever and Rheumatic Heart Disease in Children.

Acute rheumatic fever (ARF) and its sequelae, Rheumatic heart disease (RHD), contribute significantly to the cardiovascular morbidity and mortality in developing countries. Generally considered a disease of poverty and poor socio-economic conditions, RHD affects the population at the most productive phase of their life. The diagnostic criteria for ARF have been constantly updated to improve the sensitivity. The diagnosis of ARF was entirely clinical however, recently echocardiographic evidence has been added as a major criterion. The disease seems to be on the decline in India, but recent studies using echocardiography have shown high prevalence of RHD among school children. The focus of management has been on prompt recognition and treatment of streptococcal pharyngitis and preventing recurrences of ARF with long-term antibiotic prophylaxis. However, emphasis should be placed on the appropriate management of patients with established RHD, in order to limit the RHD related mortality.

Magnitude and associated factors of acute post streptococcal glomerulonepheritis among pediatric patients in aksum public hospitals, tigray, Ethiopia

Objective: Acute post streptococcus glomerulonephritis is reported from all over the world with higher rates among children than in adults. The objective of this study was to assess the magnitude and associate factors of acute post streptococcal glomerulonephritis among pediatric patients in Aksum city public hospitals, Tigray, Ethiopia. Methods: Institution based cross sectional study was conducted to retrieve data from 384 medical records of pediatric patients admitted to pediatric wards of Aksum city public hospitals between 2016 and 2018. The collected data were entered in to SPSS version 21 database for analysis. Finally, multivariate logistic regression was employed to identify determinants of adverse birth outcome at P value<0.05. Results: Acute post streptococcal glomerulonephritis was diagnosed in 31.51% of pediatrics patients. Nutritional status [AOR=2.37, 95%CI (1.28–4.41)], previous history of sore throat and skin infection [AOR=7.23; 95%CI (1.12–46.50)], duration of sore throat infection [AOR=0.35; 95%CI (0.18–0.66)], and season of infection [AOR=9.93; 95%CI (4.78–20.62)] were factors significantly associated with the development of acute post streptococcal glomerulonephritis among children. Conclusion: There is high burden of acute poststreptococcal glomerulonephritis among pediatric age group patients in Aksum public hospitals. Focus should be given to the early diagnosis and treatment of streptococcal pharyngitis.

Rheumatic fever: Down but not gone

Authors from the well-industrialized area of Abruzzo, in Central Italy document the population-based incidence of acute rheumatic fever and prevalence of rheumatic heart disease in children from 2000 through 2009. The observed rates are lower than those in developing countries but higher than those in most of the United States. Of the 88 cases identified, 75% were 5-14 years of age (with 14% younger than 5 years), 59% had arthritis, and 49% had carditis. The study reminds us that rheumatic fever is down but not gone. The Jones criteria for diagnosis still are relevant, with consideration of stand-alone echocardiographic criteria ongoing. Primary prophylaxis (eg, diagnosis and treatment of streptococcal pharyngitis) and secondary prophylaxis (continuous penicillin to prevent recurrent infection) are still our best weapons against this ongoing threat to children's lives and well being. Article page 832▶

Tratamiento de la amigdalitis estreptocócica con amoxicilina una vez al día: metaanálisis

Introduction The objective of this systematic review is to determine if the treatment of streptococcal pharyngitis with a daily dose of amoxicillin is similar in effectiveness to other dosing schedules (every 6, 8 or 12 hours) of the same antibiotic or penicillin V. Material and methods Randomised clinical trials (RCT) comparing amoxicillin (one dose per day) compared to other dosages of amoxicillin (every 8-12 hours) or penicillin V (every 6, 8 or 12 hours). Search databases consulted: Medline, Central, EMBASE and Google Scholar. The results were combined using the risk difference (RD). We measured the effectiveness of each treatment with a negative throat culture on the 14-21th day, being previously positive to group A Streptococcus (under a non-inferiority hypothesis, where the upper limit of the 95% confidence interval [95% CI] of the DR does not exceed 10%) and clinical failure on days 10-21. The results were combined according to a fixed effects model or random depending on whether or not there was heterogeneity. Results Four RCT met the selection criteria with 1,314 participants (657 received amoxicillin once per day, and 657 received other antibiotics or dosages): a) any positive culture for Streptococcus (14-21st day, 4 RCTs): DR: –0.5% (95% CI: –5.1% to 4.2%; b) persistence of the same serotype (14-21st day, 3 RCT): DR: 0.32% (95% CI: –3.1% to 3.7%; c) clinical failure (2 RCT): DR: 1.7% (95% CI: –1.9% to 5.4%; d) adverse effects (4 RCT): DR: –0.39% (95% CI: –1.5% to 6.8%). There were no statistically significant differences in any comparisons. Conclusions Amoxicillin, administered once daily is not inferior to other dosages of the same antibiotic or penicillin V. These results are important because they may facilitate compliance.

Markers of susceptibility to acute rheumatic fever: the B-cell antigen D8/17 is not robust as a marker in South Africa

Acute rheumatic fever and its chronic sequelae, rheumatic cardiac disease, and neuropsychiatric movement disorders, remain major public health problems in South Africa. Early identification and treatment of streptococcal pharyngitis in susceptible individuals would prevent rheumatic cardiac disease. The B-cell antigen D8/17 is a marker of susceptibility to rheumatic fever in some populations. We assessed the significance of the D8/17 marker in a group of South Africans. Blood was collected from 107 individuals; 40 patients had previous confirmed rheumatic fever, 20 were first-degree relatives, and 47 were controls. The expression of D8/17 in each sample was analysed by flow cytometry. The mean proportion of B-cells that were D8/17 positive was 0.5% in the index cases, 0.47% in their relatives, and 0.27% in the controls. There was a significant difference between the index cases and the controls, p = 0.03, but the mean percentage positive in each group was very low. Patients with a history of rheumatic fever had statistically increased expression of the D8/17 marker. However, the actual percentages in this observational study were markedly lower than in other populations, ranging from 0.14%-1.53% compared to 11.6%-39.3%. The D8/17 marker would be an impractical screening tool in the South African population.

Prevention of Rheumatic Fever

Target Group: Primary care practitioners for adults and children; infectious diseases and cardiology specialists Sponsoring Organization: American Heart Association (AHA), with endorsement by the American Academy of Pediatrics Type: Scientific statement embodying assessment and classification of evidence by an expert committee and assignment of level using a categoric rating system Key Points: This document updates the AHA’s previous statement on prevention of rheumatic fever (RF), published in 1995. It focuses on timely diagnosis and treatment of streptococcal pharyngitis (primary prevention) and on prevention of streptococcal pharyngitis in individuals with a …

Once-a-day Amoxicillin Therapy of Streptococcal Pharyngitis: Good, Better and, Future, Best?

Source: Clegg HW, Ryan AG, Dallas SD, et al. Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin. Pediatr Infect Dis J. 2006;25:761–767; doi:10.1097/01.inf.0000235678.46805.92Investigators from several Charlotte, NC institutions and the University of Minnesota, Minneapolis conducted a prospective, randomized, blinded, non-inferiority trial comparing once-daily (1xd) with twice-daily (2xd) amoxicillin for the treatment of group A ß-hemolytic streptococcal (GABHS) pharyngitis. Patients with a positive rapid GABHS test were stratified by weight and then randomly assigned to receive either 1xd amoxicillin (750 mg if <40 kg, 1000mg if ≥40 mg) or 2xd amoxicillin (375 mg 2xd if <40 kg, 500 mg 2xd if ≥40 mg) for 10 days. Of 652 patients enrolled and randomized, 590 (90%) were evaluable: 294 in the 1xd and 296 in the 2xd group. Of the 62 patients not evaluated, 45 were excluded because they did not follow up, 11 for negative cultures following a positive rapid streptococcal test, 3 because they did not take medication, and 3 who were enrolled twice and only had their first enrollment included.At visit 2 (14 to 21 days post-therapy), bacteriologic failure rates were similar between the 1xd treatment group (20.1%) and the 2xd group (15.5%, difference non-significant). The clinical recurrence rate was also comparable for the 2 treatment groups at visit 2 (9.2% 1xd vs 7.1% 2xd). At visit 3 (28 to 35 days post-therapy) the bacteriologic failure rate was significantly higher in the 2xd group (7.1% vs 2.8%). There were no significant differences in adverse events between the 2 treatment groups (gastrointestinal symptoms being most common). This study, along with previous studies,1,2 shows that 1xd amoxicillin is not inferior to 2xd amoxicillin for the treatment of GABHS pharyngitis despite the failure rate observed.Dr. Rathore has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of a commercial product/device. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The purpose of antimicrobial therapy for GABHS pharyngitis is both for the treatment of the acute illness and for prevention of non-suppurative post-streptococcal complications.3 Dependable rapid diagnosis has made immediate treatment of GABHS pharyngitis easier, but adherence to the antibiotic regimen may be problematic. Treatment with injectable depot penicillin is the best option to assure adherence and the only one shown to decrease non-suppurative complications of GABHS pharyngitis.4 However, the intramuscular route is frequently not acceptable to patients, parents, or physicians. Oral treatment regimens for GABHS pharyngitis have improved with time. Over the years we have decreased the frequency of daily antibiotic administration from 4 times a day to twice a day for treatment of GABHS pharyngitis.5Our ability to generalize the results of this study is limited because the patients were overwhelmingly white. Despite this limitation, the findings of this preliminary study will be welcome news for many pediatricians and parents. The next steps will be to replicate the study in other population groups and then go on to test the dogma that 10 days of antibiotic therapy are necessary for treatment of GABHS. Previous investigations have shown that the pharynx is sterile within 24 hours of antibiotic treatment for GABHS pharyngitis.6 It may be that a 5- or 7-day treatment course, or perhaps an even shorter one, would be just as effective as a 10-day course. While 1xd amoxicillin should increase adherence to treatment, a shorter course of therapy, if effective, would improve adherence even more, and a single oral dose would be best of all.

Compliance of Resident and Staff Physicians With IDSA Guidelines for the Diagnosis and Treatment of Streptococcal Pharyngitis

We evaluated physician's compliance with the Infectious Disease Society of America guidelines for diagnosis and management of group A streptococcal (GAS) pharyngitis in the emergency room. Of the 1423 episodes of acute pharyngitis evaluated, 38% received care by supervised resident physicians. Physicians prescribed antibiotics for 75% of the episodes. Diagnostic tests were obtained in only 519 episodes (36%). Among patients tested, 38% had positive results for GAS. Among patients with negative rapid antigen detection test and/or throat culture, 25% were inappropriately treated with antibiotics. Eighty-nine percent of patients who were not tested with rapid antigen detection test or culture were prescribed an antibiotic. As the number of clinical criteria increased, the likelihood for diagnostic testing for GAS decreased, whereas the likelihood for antibiotic treatment increased. There was no difference in disease management by resident or staff physicians. We conclude that both resident and staff physicians in this emergency room setting exhibited limited compliance with the Infectious Disease Society of America guidelines for GAS pharyngitis.

Bacteriological and clinical efficacy of various antibiotics used in the treatment of streptococcal pharyngitis in Italy. An epidemiological study

A total of 123 community paediatricians and 23 microbiology laboratories studied the clinical and bacteriological efficacy of treatment of group A streptococcal pharyngitis in Italy. Of 1065 patients, from whom Streptococcus pyogenes was isolated, 723 returned to follow up and of these 138 (19%) still had a positive throat culture. The erythromycin resistance (ER) rate was 23.7% with resistance phenotype distribution of: 31.7% constitutive (CR), 26.6% inducible (IR) and 41.7% efflux pump (M) resistance phenotype. All strains were susceptible to the β-lactam agents tested. CR strains were highly resistant to all 14, 15 and 16 membered macrolides with the exception of rokitamycin which showed activity against 37.8% of isolates. All phenotype M and some IR isolates were susceptible to clindamycin, rokitamycin, josamycin and spiramycin; clarithromycin was active against a small percentage of strains belonging to the IR and M phenotype. Bacterial eradication was found in 85.5, 78.7 and 75.8% of the penicillin, macrolide and cephalosporin treated groups. Genotyping of strains showed that 8.7% of the 19% of cases classified as ‘failed bacterial eradication’ were due to recolonization with a different isolate, observed exclusively among β-lactams treated patients. Clinical cure was achieved in a high percentage of cases, irrespective of the antibiotic prescribed, with the best clinical efficacy being found following therapy with amoxycillin and clarithromycin (90.9%).

Does Strep Throat Mandate Penicillin? Maybe.

The recommended treatment for streptococcal pharyngitis remains 10 days of oral penicillin, despite results of small studies suggesting that shorter

Twice-daily oral penicillin for treatment of streptococcal pharyngitis: less is best.

Penicillin has been the drug of choice for treatment of streptococcal pharyngitis since it became available for general use in the late 1940s. Because of its efficacy, safety, narrow spectrum, and low cost, it remains standard therapy for this indication. In controlled clinical trials, penicillin is the only antibiotic that has been shown to prevent rheumatic fever when used to treat streptococcal pharyngitis.1 Penicillin is the drug to which other antibiotics approved for treatment of streptococcal pharyngitis have been compared. All strains of group A β-hemolytic streptococci remain exquisitely sensitive to penicillin and there has been no indication of emerging resistance. Over the past half century numerous studies have been reported that have helped to determine the optimal preparation, route of administration, dosage, dose interval, and duration of treatment. A major concern in using oral penicillin (the preferred treatment over the past 3 decades) has been that of compliance by the patient of taking the drug as prescribed. Most patients with streptococcal pharyngitis are well within 2 to 3 days after treatment is initiated. Without specific counseling that the drug must be taken in the proper dosage and duration to eradicate the infecting organism, avoid relapse, and prevent rheumatic fever, treatment is too often discontinued after symptoms abate.2 When this counseling is provided, treatment results may be …

New cefalosporin shows promise against respiratory infections

Cefditoren pivoxil [cefditoren; ‘Spectracef’], a new investigational oral cefalosporin with broad spectrum activity against both Gram-positive and Gram-negative bacteria, appears to be effective and well tolerated in the treatment of streptococcal pharyngitis and acute bacterial exacerbations of chronic bronchitis (AECB). Data from 2 phase III clinical trials and in vitro antimicrobial activity studies demonstrating these findings were presented at the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy [ San Francisco, US; September 1999 ]. *

Infectious mononucleosis.

EBV-induced IM is a generally self-limited infection characterized by fever, pharyngitis, and adenopathy. Management consists of basic supportive measures and treatment of streptococcal pharyngitis when present. Corticosteroids may be considered for individuals who exhibit evidence of significant upper airway obstruction. To date there is little evidence to support the use of antiviral agents in immunocompetent patients. Complications of IM may arise, which can be life-threatening, but these are relatively rare.

Azithromycin. A review of its use in paediatric infectious diseases.

Azithromycin is an azalide antimicrobial agent active in vitro against major pathogens responsible for infections of the respiratory tract, skin and soft tissues in children. Pathogens that are generally susceptible to azithromycin include Haemophilus influenzae (including ampicillin-resistant strains), Moraxella catarrhalis, Chlamydia pneumoniae, Chlamydia trachomatis, Mycoplasma pneumoniae, Legionella spp., Streptococcus pyogenes and Streptococcus agalactiae. Azithromycin is also generally active against erythromycin- and penicillin-susceptible Streptococcus pneumoniae and methicillin-susceptible Staphylococcus aureus. Azithromycin is administered once daily, achieves clinically relevant concentrations at sites of infection, is slowly eliminated from the body and has few drug interactions. In children, azithromycin is usually given as either a 3-day course of 10 mg/kg/day or a 5-day course with 10 mg/kg on the first day, followed by 5 mg/kg/day for a further 4 days. These standard regimens were as effective as amoxicillin/clavulanic acid, clarithromycin, cefaclor and amoxicillin in the treatment of children with otitis media. Azithromycin was also as effective as either phenoxymethylpenicillin (penicillin V), erythromycin, clarithromycin or cefaclor against streptococcal pharyngitis or tonsillitis in children, but appears to result in more recurrence of infection than phenoxymethylpenicillin in this indication, necessitating a dosage of 12 mg/kg/day for 5 days. Community-acquired pneumonia, bronchitis and other respiratory tract infections in children responded as well to azithromycin as to amoxicillin/clavulanic acid, cefaclor, erythromycin or josamycin. Azithromycin was similar or superior to ceftibuten in mixed general practice populations of patients. However, symptoms of lower respiratory tract infections resolved more rapidly with azithromycin than with erythromycin, josamycin or cefaclor. Skin and soft tissue infections responded as well to azithromycin as to cefaclor, dicloxacillin or flucloxacillin, and oral azithromycin was as effective as ocular tetracycline in treating trachoma. Although not as well tolerated as phenoxymethylpenicillin in the treatment of streptococcal pharyngitis, azithromycin is at least as well tolerated as most other agents used to treat respiratory tract and other infections in children and was better tolerated than amoxicillin/clavulanic acid. Adverse events that do occur are mostly gastrointestinal and tend to be mild to moderate in severity. Azithromycin is an effective and well tolerated alternative to first-line agents in the treatment of respiratory tract, skin and soft tissue infections in children, offerring the convenience of a short, once-daily regimen.

Randomized evaluation of benzathine penicillin V twice daily versus potassium penicillin V three times daily in the treatment of group A streptococcal pharyngitis

In a randomized, prospective, multicenter study the clinical and bacteriological efficacies of three dosage schedules with two different salts of oral penicillin V suspensions (regimen 1: potassium salt of penicillin V, 50,000 U/kg of body weight per day in three divided doses; regimen 2: benzathine salt of penicillin V, 50,000 U/kg of body weight per day in two divided doses; and regimen 3: benzathine salt of penicillin V, 100,000 U/kg of body weight in two divided doses) for the treatment of streptococcal pharyngitis were evaluated. Children with clinical signs of acute pharyngitis and a positive throat culture for group A beta-hemolytic streptococci (GABHS) were eligible. There was no difference between the treatment groups with respect to the overall clinical success rate. Eradication of the original serotype of GABHS from throat cultures was achieved in 87.1% (regimen 1), 85.5% (regimen 2) and 87.7% (regimen 3) of patients. The incidence of potential drug-related adverse events was significantly higher in patients treated with regimen 3. The results of this and earlier studies strongly suggest that oral penicillin given twice daily should be the recommended treatment for the initial treatment of pharyngitis due to GABHS. Doubling the total daily dose is not beneficial in the usual clinical setting. Because of its favorable pharmacokinetics, the benzathine salt of penicillin V appears to be well suited for a twice-a-day dosage schedule.

Penicillin V Twice Daily vs. Four Times Daily in the Treatment of Streptococcal Pharyngitis

Treatment failure of streptococcal pharyngitis with oral penicillin might be due to patient noncompliance. We performed a randomized controlled study of 104 patients with group A β-hemolytic streptococcal pharyngitis; 51 patients received penicillin V 1 g twice daily and 53 patients, 500 mg four times a day for 10 days. At day 9-10 of treatment, the number of patients free of symptoms was significantly greater in the twice-daily than in the four-times-daily group (92% vs. 77%); similarly, the number of patients with sterile throat cultures was significantly greater in the twice-daily group (90% vs. 73%). Differences in clinical and bacteriologic responses were still significant 28 days posttherapy. Compliance was 90% in the twice-daily group vs. 58%. Penicillin V given twice daily is more effective than a four-times-daily regimen in the treatment of streptococcal pharyngitis, probably because patient compliance is improved.