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Streptococcal Pharyngitis
S Safvat
Iranian Journal of Pediatrics , 1997,
Abstract: Streptococcal pharyngitis is a very frequent infectious disease in children and adolescents. When untreated, it can cause serious complications such as rheumatic fever. It can hardly be distinguished from viral pharyngitis. Therefore, a throat culture is mandatory in sore throat. For the treatment, penicillin is still the drug of choice as no cases of streptococcal resistance to penicillin have been reported as yet. There is no need to repeat the throat culture after treatment as the carriers of this germ cause very little hazard to themselves and the society.
Microbiological diagnosis of streptococcal pharyngitis: Lacunae and their implications  [cached]
Brahmadathan K,Gladstone P
Indian Journal of Medical Microbiology , 2006,
Abstract: Post-streptococcal sequelae, especially acute rheumatic fever/rheumatic heart disease continue to occur in significant proportions in many parts of the world. Despite several attempts with various intervention strategies, little success has been achieved in the control of acute rheumatic fever/rheumatic heart disease in India. The success of the control programmes depends upon timely primary prophylaxis with benzathine penicillin for which a microbiological confirmation of group A streptococcal pharyngitis is essential. Isolation of beta hemolytic streptococci from throat cultures and their identification as GAS in the laboratory, clinches the microbiological diagnosis while demonstration of a ′significant rise′ in antibody titers such as Anti-streptolysin O and Anti-deoxyribonuclease B differentiates it from a group A streptococcal carrier state or pharyngitis of a viral etiology. Despite the easiness with which these can be achieved, many laboratories in India are not equipped to do so. Enhancing bacteriological and serological facilities in laboratories across the country will drastically improve the clinician′s ability to diagnose bonafide GAS pharyngitis and help to institute penicillin prophylaxis at the appropriate time. This will go a long way in enhancing the compliance to penicillin prophylaxis which is the cornerstone of any RF/RHD control program.
Streptococcal Pharyngitis: A Prospective Study of Compliance and Complications  [PDF]
E. Michael Sarrell,Shmuel M. Giveon
ISRN Pediatrics , 2012, DOI: 10.5402/2012/796389
Abstract: Background. Uncertainty exists concerning the necessity of 10-day antibiotic treatment of group A beta hemolytic streptococcus (GABHS) pharyngitis. Objective. To assess the incidence of GABHS recurrence and suppurative and nonsuppurative complications in relation to compliance. Methods. (Design). Prospective cohort observational study. (Subjects). 2,000 children aged 6 months to 18 years with sore throat and positive GABHS culture. (Main Outcome Measures). Recurrence of symptomatic culture positive GABHS pharyngitis, incidence of suppurative, and long-term, regional, nonsuppurative complications of GABHS pharyngitis, over a ten year period. Results. 213 (11%) of the children received no treatment. Most children received antibiotics for only 4–6 days (in correlation with the duration of fever, which in most cases lasted up to 3 days). Three hundred and six (15.3%) children had clinically diagnosed recurrent tonsillopharyngitis; 236 (12.3%) had positive GABHS findings within 10 to 14 days and thirty-four (1.7%) within 21–30 days after the index positive GABHS culture. The remaining 1.3% had no positive culture despite the clinical findings. Almost all recurrences [236 (11.6%)] occurred within 14 days and 156 (7.6%) in the fully treated group. The presence of fever during the first 3 days of the disease was the most significant predictor for recurrence. Other predictors were the age younger than 6 years and the presence of cervical lymphadenitis. No increase in the incidence of nonsuppurative or suppurative complications was noted during the 10-year follow-up period, compared to the past incidence of those complications in Israel. Conclusions. Our data suggests that the majority of children discontinue antibiotics for GABHS tonsillopharyngitis a day or two after the fever subsides. The incidence of complications in our study was not affected by this poor compliance. 1. Introduction Acute pharyngitis is one of the most common infections encountered in primary care clinics. Only 20–30% of patients with group A beta hemolytic streptococcus (GABHS) pharyngitis presents with classical symptoms of the disease [1]. Reliance on clinical judgment alone has a poor predictive value and results in 80% to 95% overestimation of disease [2, 3]. Diagnostic strategies for acute GABHS pharyngitis are thus based on epidemiological factors, signs, and symptoms, as well as the result of throat cultures (TCs) [4]. Several studies have shown that the use of throat culture leads to more judicious use of antibiotics [5–7]. Physicians prescribe antibiotics for acute pharyngitis as
Once-Daily Therapy for Streptococcal Pharyngitis with Amoxicillin vs, Intramuscular Benzathin Penicillin G  [PDF]
Saeideh Tarvijeslami,Hossein Nasirian
Iranian Journal of Pediatrics , 2007,
Abstract: Objective: Recent studies have shown that amoxicillin, taken once a day may be as effective as oral penicillin V, three or four times a day, as an effective choice for treatment of group A β-hemolytic streptococcal (GABHS) pharyngitis. The purpose of this study was to evaluate the effectiveness of once-daily amoxicillin vs intramuscular benzathine penicillin G in the treatment of streptococcal pharyngitis.Material & Methods: Children 6-15 years of age presenting to a private pediatric clinic with GABHS pharyngitis in the urban population of Mashhad, Iran. Prospective randomized controlled study in which patients were randomly assigned to receive orally amoxicillin (750 mg once daily) for 10 days versus a single shot of intramuscular benzathin penicillin G (600.000-1.200.000IU). They received orally amoxicillin by a health worker and compliance was monitored. After 48 hours if the first throat culture was positive, the patients were reevaluated by the same physician, and a second throat culture was obtained to evaluate bacteriologic response to treatment. Ninety-nine patients had throat swabs that yielded positive results on culture. In the latter group, 31 children were randomly assigned to receive intramuscularly penicillin, and 68 children were randomly assigned to receive once-daily amoxicillin. Outcomes were measured by impact on the clinical course and response, eradication of GABHS within 48 hours and compliance. Eleven of the amoxicillin-treated patients refused to take the drug, were noncompliant, or did not return for the follow-up visit. Three of this group, had residual positive culture 48 hours after treatment, and had bacteriologic failure with intramuscular penicillin. These were excluded as carriers, leaving 54 amoxicillin-treated patients. The children in the two treatment groups were comparable with respect to age and, gender.Findings: There were no significant differences in the clinical and bacteriological response, bacteriologic failure and residual positive cultures between the two groups after 48 hours. In the amoxicillin group, 18.9% failed to respond to treatment compared to 6.4% in the penicillin group. The difference was not statistically significant (P-value = 0.1).Conclusion: Our study was in line with two studies comparing oral forms of drugs. These data demonstrate that once-daily therapy with amoxicillin is as effective as intramuscular benzatine penicillin G for the treatment of GABHS pharyngitis.
Update on the management of acute pharyngitis in children
Marta Regoli, Elena Chiappini, Francesca Bonsignori, Luisa Galli, Maurizio de Martino
Italian Journal of Pediatrics , 2011, DOI: 10.1186/1824-7288-37-10
Abstract: Even the use of the Centor score, in order to evaluate the risk of streptococcal infection, is under debate and the interpretation of the test results may vary considerably. Penicillin is considered all over the world as first line treatment, but oral amoxicillin is also accepted and, due to its better palatability, can be a suitable option. Macrolides should be reserved to the rare cases of proved allergy to β-lactams. Cephalosporins can be used in patients allergic to penicillin (with the exception of type I hypersensibility) and have been also proposed to treat the relapses.Acute pharyngitis is defined as an infection of the pharynx and/or tonsils. It is a very common pathology among children and adolescents. Although viruses cause most acute pharyngitis episodes, group A Streptococcus (GABHS) causes 37% of cases of acute pharyngitis in children older than 5 years [1]. Other bacterial causes of pharyngitis are Group C Streptococcus (5% of total cases), C. pneumoniae (1%), M. pneumoniae (1%) and anaerobic species (1%). Between viruses Rhinovirus, Coronavirus and Adenovirus account for the 30% of the total cases, Epstein Barr virus for 1%, Influenza and Parainfluenza virus for about 4% [2].Streptococcal pharyngitis has a peak incidence in the early school years and it is uncommon before 3 years of age. Illness occurs most often in winter and spring [3]. The infection is transmitted via respiratory secretions and the incubation period is 2-5 days. Communicability of the infection is highest during acute phase and in untreated people gradually diminishes over a period of weeks; it ceases after 24 hours of antibiotic therapy [4].Clinical manifestations include sore throat and fever with sudden onset, red pharynx, enlarged tonsils covered with a yellow, blood-tinged exudate. There may be petechiae on the soft palate and posterior pharynx. The anterior cervical nodes are enlarged and swollen. Headache and gastrointestinal symptoms (vomiting and abdominal pain) are frequ
Manejo de la faringoamigdalitis estreptocóccica en pacientes adultos o adolescentes Management of streptococcal pharyngitis in adult or adolescent patients
Alberto Fica C
Revista chilena de infectología , 2002,
Abstract: Streptococcal pharyngitis is an important cause of morbidity and a common reason of antibiotic missuse. No more than 10 to 15% of adults that consult for acute sore throat and fever have a definite Group A streptococcal (GAS) pharyngitis. Inappropriate treatment exposes patients to allergic reactions, other adverse events and increased health care costs. Where rheumatic fever is declining and/or infrequent as observed in Chile, appropriate demonstration of GAS by rapid test or throat culture is the most logical approach. Rapid tests provide a good sensitivity (80-90%) and specificity (95-99%) to detect GAS pharyngitis. These tests can be applied at a reasonable cost and negative results can be further confirmed by culture. Several therapeutic options are now available to eradicate GAS from pharynx, a subsidiary marker of efficacy to protect patients from rheumatic fever. These alternatives do not significantly improve the efficacy obtained with oral penicillin V, have similar frequencies of adverse events and are characterized by an meaningful increase in acquisition costs. On the other hand, schemes based on oral amoxicillin or intramuscular penicillin G benzathine have similar costs than the standard treatment. Abbreviated courses of therapies using different compounds for 5 or 6 days, have similar efficacy to standard therapy but do not reduce the overall cost of treatment.
Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score
Jolien Aalbers, Kirsty K O'Brien, Wai-Sun Chan, Gavin A Falk, Conor Teljeur, Borislav D Dimitrov, Tom Fahey
BMC Medicine , 2011, DOI: 10.1186/1741-7015-9-67
Abstract: A systematic literature search was performed up to July 2010. Studies that assessed the diagnostic accuracy of signs and symptoms and/or validated the Centor score were included. For the analysis of the diagnostic accuracy of signs and symptoms and the Centor score, studies were combined using a bivariate random effects model, while for the calibration analysis of the Centor score, a random effects model was used.A total of 21 studies incorporating 4,839 patients were included in the meta-analysis on diagnostic accuracy of signs and symptoms. The results were heterogeneous and suggest that individual signs and symptoms generate only small shifts in post-test probability (range positive likelihood ratio (+LR) 1.45-2.33, -LR 0.54-0.72). As a decision rule for considering antibiotic prescribing (score ≥ 3), the Centor score has reasonable specificity (0.82, 95% CI 0.72 to 0.88) and a post-test probability of 12% to 40% based on a prior prevalence of 5% to 20%. Pooled calibration shows no significant difference between the numbers of patients predicted and observed to have GABHS pharyngitis across strata of Centor score (0-1 risk ratio (RR) 0.72, 95% CI 0.49 to 1.06; 2-3 RR 0.93, 95% CI 0.73 to 1.17; 4 RR 1.14, 95% CI 0.95 to 1.37).Individual signs and symptoms are not powerful enough to discriminate GABHS pharyngitis from other types of sore throat. The Centor score is a well calibrated CPR for estimating the probability of GABHS pharyngitis. The Centor score can enhance appropriate prescribing of antibiotics, but should be used with caution in low prevalence settings of GABHS pharyngitis such as primary care.Upper respiratory tract infections such as acute pharyngitis represent a substantial portion of the cases seen in primary care [1]. Although the cause of acute pharyngitis in the majority of patients is viral, approximately 5% to 17% is caused by a bacterial infection, often β-haemolytic streptococci [2]. A number of serotypes of β-haemolytic streptococci can caus
Rapidly progressing subperiosteal orbital abscess: an unexpected complication of a group-A streptococcal pharyngitis in a healthy young patient
Fulvia Costantinides, Roberto Luzzati, Daniele Tognetto, Gabriele Bazzocchi, Matteo Biasotto, Gian Tirelli
Head & Face Medicine , 2012, DOI: 10.1186/1746-160x-8-28
Abstract: We described a case of a 15-year-old patient with a history of acute pharyngodinia early followed by improvise fever and a progressive formation of a diffuse orbital edema, corneal hyperaemia, diplopia and severe decrease of visual acuity.The patient was surgically treated with functional endoscopic sinus surgery (FESS) after the response of a maxillofacial computed tomography scans that showed a pansinusitis complicated by a left orbital cellulites. Numerous colonies of Streptococcus pyogenes were found in the samples of pus and an antibiotic therapy with meropenem was initiated on the basis of the sensitivity test to antibiotics. The patient was finally discharged with diagnosis of left orbital cellulites with periorbital abscess, endophtalmitis and acute pansinusitis as a consequence of streptococcal pharyngitis.The case highlights the possible unusual complication of a group-A streptococcal pharyingitis in a immunocompetent child and the needing of a prompt surgical and medical approach toward the maxillofacial complications associated to the infection.Group A beta-haemolitic streptococcus (GAS) being the most common etiology of sore throats caused by bacteria. It has been estimated that GAS is responsible for around 15-30% of cases of acute pharyngitis in children [1]. Streptococcal pharyngitis is most common in children 5 to 12 and presents with a predominant sore throat and a temperature higher than 38.5°C. Symptoms include fever, chills, myalgias, headaches and nausea. Physical findings may include pharyngeal and tonsillar erithema and exudates and cervical adenopathy [2]. Sequelae associated to the GAS infection include non-suppurative (or post-streptococcal) complications as rheumatic fever and glomerulonephritis and suppurative complications as cervical lymphadenitis, peritonsillar or retropharyngeal abscess, sinusitis, mastoiditis, otitis media, meningitis, thrombosis of the intracranial venous sinuses, endocarditis, pneumonia, sepsis. In rare cases, nec
Seven-Year Surveillance of emm Types of Pediatric Group A Streptococcal Pharyngitis Isolates in Western Greece  [PDF]
George A. Syrogiannopoulos, Ioanna N. Grivea, Adnan Al-Lahham, Maria Panagiotou, Alexandra G. Tsantouli, Aspasia N. Michoula Ralf René Reinert, Mark van der Linden
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0071558
Abstract: Background An experimental 26-valent M protein Group A streptococcal (GAS) vaccine has entered clinical studies. Pharyngeal GAS emm type surveillances in different areas and time-periods enhance the understanding of the epidemiology of GAS pharyngitis. Moreover, these surveillances, combined with the data on GAS invasive disease, can play a significant role in the formulation of multivalent type-specific vaccines. Methods During a 7-year period (1999–2005), 2408 GAS isolates were recovered from consecutive children with pharyngitis in Western Greece. The overall macrolide resistance rate was 22.8%. Along the study period we noted a tendency towards significantly decreased rates of resistance, with the lowest rates occurring in 2002 (15.3%), 2003 (15%) and 2004 (16.7%). A random sample of isolates from each year, 338 (61.7%) of the 548 macrolide-resistant and 205 (11%) of the macrolide-susceptible, underwent molecular analysis, including emm typing. Results The 543 typed isolates had 28 different emm types. A statistically significant association was found between macrolide resistance and emm4, emm22 and emm77, whereas emm1, emm3, emm6, emm12, emm87 and emm89 were associated with macrolide susceptibility. A significant yearly fluctuation was observed in emm4, emm28 and emm77. The most common macrolide-resistant GAS were emm77 isolates harboring erm(A), either alone or in combination with mef(A), emm4 carrying mef(A), emm28 possessing erm(B), emm75 carrying mef(A), emm12 harboring mef(A) and emm22 carrying erm(A). We estimated that 82.8% of the isolates belonged to emm types included in the novel 26-valent M protein vaccine. The vaccine coverage rate was determined mainly by the increased frequency of nonvaccine emm4 isolates. Conclusions A limited number of emm types dominated among macrolide-susceptible and macrolide-resistant GAS isolates. We observed seasonal fluctuations, which were significant for emm4, emm28 and emm77. This type of data can serve as baseline information if the novel 26-valent M protein GAS vaccine is introduced into practice.
Impact of rapid antigen detection testing on antibiotic prescription in acute pharyngitis in adults. FARINGOCAT STUDY: a multicentric randomized controlled trial
Jordi Madurell, Montse Balagué, Mónica Gómez, Josep M Cots, Carl Llor
BMC Family Practice , 2010, DOI: 10.1186/1471-2296-11-25
Abstract: Multicentric randomized controlled trial in which antibiotic prescription between two groups of patients with acute pharyngitis will be compared. The trial will include two arms, a control and an intervention group in which RADT will be performed. The primary outcome measure will be the proportion of inappropriate antibiotic prescription in each group. Two hundred seventy-six patients are required to detect a reduction in antibiotic prescription from 85% in the control group to 75% in the intervention group with a power of 90% and a level of significance of 5%. Secondary outcome measures will be specific antibiotic treatment, antibiotic resistance rates, secondary effects, days without working, medical visits during the first month and patient satisfaction.The implementation of RADT would allow a more rational use of antibiotics and would prevent adverse effects of antibiotics, emergence of antibiotic resistance and the growth of inefficient health expenses.ISRCTN23587778Acute pharyngitis is frequently seen in primary care for which uncertain etiology may result in inappropriate management. Acute pharyngitis includes rhinitis, the most common cause of visit in primary care in Spain [1]. Most pharyngotonsillitis are viral in origin while group A β-hemolytic Streptococcus (GABHS) is the most common bacterial cause of acute pharyngitis, accounting for approximately 15% to 30% of the cases in children and 5% to 15% of cases in adults [2]. GABHS is the only commonly occurring form of acute pharyngitis for which antibiotic therapy is indicated [3]. Nonetheless, a total of 78-98% of adults with acute pharingytis is treated with antibiotics, especially if sore throat is present [4,5]. Pharyngeal infection is also a frequent cause of absenteeism, with an estimated average of 6.5 days of sick leave per episode [2,6]. In streptococcal pharyngitis, antibiotic treatment shortens the transmission and dissemination of GABHS in the community, reduces the symptomatology compared to
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