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
References
[1]
P. S. Little and I. Williamson, “Are antibiotics appropriate for sore throats? Costs outweigh the benefits,” British Medical Journal, vol. 309, no. 6960, pp. 1010–1011, 1994.
[2]
M. E. Pichichero, “Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment,” Annals of Emergency Medicine, vol. 25, no. 3, pp. 390–403, 1995.
[3]
M. H. Lin, W. K. Fong, P. F. Chang, C. W. Yen, K. L. Hung, and S. J. Lin, “Predictive value of clinical features in differentiating group A βhemolytic streptococcal pharyngitis in children,” Journal of Microbiology, Immunology and Infection, vol. 36, no. 1, pp. 21–25, 2003.
[4]
K. L. O'Brien, B. Schwartz, R. Facklam, et al., “Population based active surveillance for invasive group A Streptococcus,” in Program and Abstract of the 37th International Conference on Antimicrobial Agents and Chemotherapeutics, p. 356, American Society for Microbiology, Toronto, Canada, September 1997.
[5]
M. E. Pichichero, “Group A beta-hemolytic streptococcal infections,” American Academy of Pediatrics, vol. 19, no. 9, pp. 291–302, 1998.
[6]
K. A. Robertson, J. A. Volmink, and B. M. Mayosi, “Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis,” BMC Cardiovascular Disorders, vol. 5, article 11, 2005.
[7]
C. B. Del Mar, P. P. Glasziou, and A. B. Spinks, “Antibiotics for sore throat,” Cochrane Database of Systematic Reviews, no. 4, Article ID CD000023, 2006.
[8]
C. B. Del Mar, P. P. Glasziou, A. B. Spinks, W. R. Saliba, and R. Mader, “Antibiotics for sore throat,” Israel Medical Association Journal, vol. 2, no. 6, pp. 433–437, 2000.
[9]
K. L. O'Brien, B. Schwartz, R. Facklam, et al., “Population based active surveillance for invasive group A Streptococcus,” in Proceedings of the 37th International Conference on Antimicrobial Agents and Chemotherapeutics, Program and Abstract, Toronto, Canada, September 1997, in Cochrane Database of Systematic Reviews, vol, 2, article CD000023, 2000.
[10]
C. Olivier, “Rheumatic fever—is it still a problem?” Journal of Antimicrobial Chemotherapy, vol. 45, no. 1, pp. 13–21, 2000.
[11]
G. S. Habib, Rheumatic Fever in the Nazareth Area During the Last Decade, American Society for Microbiology, Washington, DC, USA, 1997.
[12]
P. Bidet, C. Plainvert, C. Doit et al., “Streptococcus pyogenes or groupA streptococcal infections in child: french national reference center data,” Archives de Pediatrie, vol. 17, no. 2, pp. 201–208, 2010.
[13]
U. B. Schaad, “Acute streptococcal tonsillopharyngitis: a review of clinical efficacy and bacteriological eradication,” Journal of International Medical Research, vol. 32, no. 1, pp. 1–13, 2004.
[14]
A. L. Bisano, M. A. Gerber, J. M. Gwalenty Jr., E. L. Kaplan, and R. H. Schwartz, “Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Disease Society of America,” Clinical Infectious Diseases, vol. 35, pp. 113–125, 2002.
[15]
M. R. Jacobs, “Antimicrobial-resistant Streptococcus pneumoniae: trends and management,” Expert Review of Anti-Infective Therapy, vol. 6, no. 5, pp. 619–635, 2008.
[16]
C. Llor, N. Sierra, S. Hernández et al., “Compliance rate of antibiotic therapy in patients with acute pharyngitis is very low, mainly when thrice-daily antibiotics are given,” Revista Espanola de Quimioterapia, vol. 22, no. 1, pp. 20–24, 2009 (Spanish).
[17]
M. W. Attia, T. Zaoutis, J. D. Klein, and F. A. Meier, “Performance of a predictive model for streptococcal pharyngitis in children,” Archives of Pediatrics and Adolescent Medicine, vol. 155, no. 6, pp. 687–691, 2001.
[18]
B. B. Breese, “A simple scorecard for the tentative diagnosis of streptococcal pharyngitis,” American Journal of Diseases of Children, vol. 131, no. 5, pp. 514–517, 1977.
[19]
S. Nandi, R. Kumar, P. Ray, H. Vohra, and N. K. Ganguly, “Clinical score card for diagnosis of group A streptococcal sore throat,” Indian Journal of Pediatrics, vol. 69, no. 6, pp. 471–475, 2002.
[20]
C. Hofer, H. J. Binns, and R. R. Tanz, “Strategies for managing group A streptococcal pharyngitis: a survey of board-certified pediatricians,” Archives of Pediatrics and Adolescent Medicine, vol. 151, no. 8, pp. 824–829, 1997.
[21]
R. A. Rennie, “Prospective study of antibiotic prescribed for children,” Canadian Family Physician, vol. 44, pp. 1850–1856, 1998.
[22]
R. M. Centor, “Expand the pharyngitis paradigm for adolescents and young adults,” Annals of Internal Medicine, vol. 151, no. 11, pp. 812–815, 2009.
[23]
S. Vinker, E. Zohar, R. Hoffman, and A. Elhayany, “Incidence and clinical manifestations of rheumatic fever: a 6 year community-Based survey,” Israel Medical Association Journal, vol. 12, no. 2, pp. 78–81, 2010.
[24]
M. E. Pichichero, J. R. Casey, T. Mayes et al., “Penicillin failure in streptococcal tonsillopharyngitis: causes and remedies,” Pediatric Infectious Disease Journal, vol. 19, no. 9, pp. 917–923, 2000.
[25]
D. A. Kafetzis, G. Liapi, M. Tsolia et al., “Failure to eradicate Group A β-haemolytic streptococci (GABHS) from the upper respiratory tract after antibiotic treatment,” International Journal of Antimicrobial Agents, vol. 23, no. 1, pp. 67–71, 2004.
[26]
M. E. Pichichero, J. L. Green, A. B. Francis et al., “Recurrent group A streptococcal tonsillopharyngitis,” Pediatric Infectious Disease Journal, vol. 17, no. 9, pp. 809–815, 1998.
[27]
M. A. Gerber, R. R. Tanz, W. Kabat et al., “Potential mechanisms for failure to eradicate group A streptococci from the pharynx,” Pediatrics, vol. 104, no. 4 I, pp. 911–917, 1999.
[28]
J. Li？ares, C. Ardanuy, R. Pallares, and A. Fenoll, “Changes in antimicrobial resistance, serotypes and genotypes in Streptococcus pneumoniae over a 30-year period,” Clinical Microbiology and Infection, vol. 16, no. 5, pp. 402–410, 2010.
[29]
L. F. McCaig, R. E. Besser, and J. M. Hughes, “Trends in antimicrobial prescribing rates for children and adolescents,” Journal of the American Medical Association, vol. 287, no. 23, pp. 3096–3102, 2002.
[30]
D. Adam, H. Scholz, and M. Helmerking, “Short-course antibiotic treatment of 4782 culture-proven cases of group A streptococcal tonsillopharyngitis and incidence of poststreptococcal sequelae,” Journal of Infectious Diseases, vol. 182, no. 2, pp. 509–516, 2000.
[31]
T. Koga, T. Rikimaru, N. Tokunaga et al., “Evaluation of short-term clinical efficacy of 3-day therapy with azithromycin in comparison with 5-day cefcapene-pivoxyl for acute streptococcal tonsillopharyngitis in primary care,” Journal of Infection and Chemotherapy, vol. 17, no. 4, pp. 499–503, 2011.
