Group A Streptococcal Tonsillopharyngitis: Cost-Effective Diagnosis and Treatment☆,☆☆,★
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INTRODUCTION
A chief complaint of sore throat is frequently encountered by emergency physicians. It is the third most commonly seen infectious disease (preceded by viral upper respiratory infections and otitis media) and therefore the second most common reason (following otitis media) for which an antibiotic might be appropriately prescribed. The controversial issues in tonsillopharyngitis diagnosis and management are the focus of this review. Controversies to be addressed include (1) the relative
CAUSES OF TONSILLOPHARYNGITIS
The various causes of tonsillopharyngitis have epidemiologic differences in their clinical presentation. GAS tonsillopharyngitis tends to occur in temperate climates during the late fall through early spring. During that time of year, approximately 30% of children and 10% of adults presenting with sore throat will have GAS as the cause (Table 1).11, 12, 16, 19, 20, 21, 22, 23 Thus, strictly on a percentage basis, physicians who elect to treat all patients with sore throat as if they had GAS
CLINICAL DIAGNOSIS
GAS tonsillopharyngitis cannot be diagnosed solely on clinical grounds with accuracy in most patients.31, 32, 41, 42, 43, 44, 45, 46, 47 Even in the patient with fever, tonsillopharyngeal erythema and exudate, swollen and tender anterior cervical adenopathy, and an elevated WBC count, during midwinter to early spring and without rhinorrhea and cough (the classic clinical symptom constellation for GAS tonsillopharyngitis), the clinical likelihood that GAS is present does not exceed 70% in
THROAT CULTURE, RAPID DIAGNOSTIC TEST, OR EMPIRIC THERAPY?
GAS antigen detection tests can be performed quickly at a cost that is comparable to a 10-day supply of even the least expensive antimicrobial.10, 46, 47, 48, 49 To be most effectively used, the test should be performed in immediate proximity to where patients are seen. Such availability allows the integration of rapid GAS antigen detection testing into clinical decision making despite the busy flow of patients in emergency department or urgent care settings.50, 51, 52, 53, 54, 55 Performance
COST-EFFECTIVENESS ANALYSIS
Are throat cultures and rapid antigen detection tests for GAS cost-effective? This question is frequently asked and has been addressed in several separate studies.62, 63, 64, 65 From these reports, it appears that throat culture or rapid GAS antigen detection testing is cost-effective, particularly for selected clinical situations, when properly used. In 1977, Tompkins et al62 performed a cost-effectiveness analysis of tonsillopharyngitis management for the primary prevention of acute rheumatic
PENICILLIN TREATMENT
In 1951, Denny et al66 and Wannamaker et al67 published their studies on the efficacy of injectable penicillin therapy for the primary prevention of acute rheumatic fever. These studies were conducted at the Warren Air Force Base, a military setting where recruits living in close-quartered barracks volunteered to receive injections of penicillin G suspended in either sesame oil or peanut oil. These preparations were shown to maintain adequate therapeutic serum concentrations of penicillin for
ERYTHROMYCIN TREATMENT
An analysis of the bacterial pathogens putatively involved in tonsillopharyngitis might lead one to consider use of erythromycin or one of its derivatives for empiric treatment of sore throat. Rapid GAS antigen detection testing and throat cultures are targeted for identification or isolation of GAS exclusively. However, in some patients, group C, G, and F streptococci, A hemolyticum, M pneumoniae, and Chlamydia pneumoniae produce symptomatic tonsillopharyngitis. Erythromycin has a low serious
CEPHALOSPORIN TREATMENT
In 1986, Stillerman78 brought forward the suggestion that cephalosporins might outperform penicillin in the treatment of GAS tonsillopharyngitis. In 1991, a metaanalysis of trials in which cephalosporins were compared with penicillin for the treatment of acute GAS tonsillopharyngitis corroborated Stillerman's hypothesis.13 In this analysis of 19 studies covering the 20-year time span of 1970 to 1990, the overall bacteriologic failure rate for 1,169 penicillin-treated patients was 16% compared
OTHER ALTERNATIVE TREATMENTS
Amoxicillin/clavulanate has been evaluated for the treatment of GAS tonsillopharyngitis; it has been shown to be as efficacious85 or more efficacious86, 87 than penicillin V. Kaplan and Johnson86 evaluated amoxicillin/clavulanate for its potential role in treatment of penicillin failures. One hundred thirty-one patients were treated with oral penicillin V, and 50 failed therapy (38%). These 50 patients were asked to continue, and 45 agreed to do so. Twenty-four received a second course of oral
SHORTENED-COURSE ANTIMICROBIAL THERAPY
Although it has been amply shown that approximately 10-day therapy with oral penicillin V is necessary for optimal bacteriologic eradication of GAS70, 71, 72, new studies suggest that a shortened course of therapy with cephalosporins may be efficacious. Investigations from the United Kingdom92, France93, 94, Germany95, and the United States96 have compared 4 to 7 days of a cephalosporin with 10 days of penicillin for the treatment of GAS tonsillopharyngitis. The European investigations showed
EXPLANATIONS FOR ANTIMICROBIAL TREATMENT FAILURE
Lack of Compliance Patient compliance diminishes with more frequent dosing requirements per day.96, 97, 98 Thus, administration of an antimicrobial once or twice a day is preferred to three or four times a day. Twice-daily dosing with penicillin is adequate for GAS bacteriologic eradication99, 100; however, if patients fail to take one of their two doses of penicillin, this will be inadequate therapy.99, 101 Twice-daily administration of erythromycin for treatment of GAS tonsillopharyngitis is
ANTIBIOTIC SUPPRESSION OF IMMUNITY
With the advent of rapid GAS antigen detection testing and several convincing studies of more rapid clinical improvement of GAS tonsillopharyngitis from prompt antimicrobial treatment110, 111, 112, 113, many physicians prescribe antibiotics at the initial patient contact visit rather than waiting for throat culture confirmation of their clinical suspicion. Studies from decades ago had shown that prompt antimicrobial treatment of GAS tonsillopharyngitis suppresses the immune response to the
PENICILLIN TOLERANCE
All GAS remain exquisitely sensitive to penicillin in vitro; however, some strains have developed evidence of resistance to the bactericidal effects of this antimicrobial.124 Several clinical studies have associated penicillin tolerance with penicillin failure in the treatment of GAS tonsillopharyngitis.125, 126 This is probably a rare occurrence and may be related to uncommon clinical strains, but the possibility that such a phenomenon may occur within a given patient population must be kept
DISTURBANCE OF MICROBIAL ECOLOGY
α-Hemolytic streptococci (eg, Streptococcus sanguis and Streptococcus mitis) normally inhabit the tonsillopharynx, where they are not pathogenic. The presence of these microbes may represent an important element in host defense in preventing the establishment of GAS colonization and infection.127, 128, 129, 130, 131, 132, 133, 134 α-Hemolytic streptococci are believed to exert their protective effect against GAS infection through microbial interference, ie, through the elaboration of
GAS-CARRIER STATE
It has been well established that GAS can be carried as a nonpathogenic microbe for weeks to months in selected patients. The carrier condition predominates in the pediatric age group, in whom acute GAS tonsillopharyngitis is common (ie, 4- to 12-year-olds). Thus, in this patient population, the physician is continuously confronted with the possibility that a patient with acute sore throat may have a viral etiology while concomitantly carrying nonpathogenic GAS. It is easier to recognize the
CONCLUSION
Although the most common concern in the minds of patients and physicians regards the presence of GAS as a cause of tonsillopharyngitis, this microbe occurs in fewer than 10% of adult cases and fewer than 30% of pediatric cases. Other bacteria that cause pharyngitis do so infrequently, and are usually associated with other symptoms not typical for GAS infection, and symptomatic improvement with antimicrobial therapy for tonsillopharyngitis caused by these other organisms has not been proven. GAS
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2012, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :Acute pharyngotonsillitis is one of the most common infections encountered in the primary care setting [1]. Although the etiology to most cases are from viruses, up to 40% in pediatric patients and up to 10% in adult patients may have a bacterial origin [2]. When ineffectively treated, a collection of pus may form between the fibrous capsule of the tonsil and the pharyngeal constrictor muscles, otherwise referred to as a peritonsillar abscess (PTA) or quinsy [3].
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From the Departments of Pediatrics and Medicine, University of Rochester Medical Center, New York.
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No reprints available from the author.
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Reprint no. 47/1/62242