Acute Tonsillopharyngitis

Topics: Penicillin, Antibiotic resistance, Bacteria Pages: 11 (3856 words) Published: February 17, 2013


Michael E Pichichero, MD
Section Editors
Daniel J Sexton, MD
Morven S Edwards, MD
Deputy Editor
Elinor L Baron, MD, DTMH
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Dec 2012. | This topic last updated: Oct 17, 2012. INTRODUCTION — Group A streptococcal (GAS) tonsillopharyngitis presents with abrupt onset of sore throat, tonsillar exudate, tender cervical adenopathy, and fever, followed by spontaneous resolution within two to five days. Patients with sore throat lasting longer than one week usually do not have GAS tonsillopharyngitis. Issues related to treatment and prevention of group A streptococcal tonsillopharyngitis will be reviewed here [1]. A general approach to patients with pharyngitis and the factors responsible for antibiotic failure are discussed separately. GOALS OF THERAPY — Goals of antimicrobial therapy for eradication of GAS from the pharynx in the setting of acute streptococcal pharyngitis include: * Reducing duration and severity of clinical signs and symptoms, including suppurative complications * Reducing incidence of nonsuppurative complications (eg, acute rheumatic fever) * Reducing transmission to close contacts by reducing infectivity Considerations of treatment include ease of antibiotic administration and limited expense with as few adverse effects as possible [2-4]. Reducing clinical symptoms — Antibiotic therapy is most beneficial for hastening resolution of symptoms if instituted within the first two days of illness [5-9]. Antibiotic therapy is also beneficial for reducing suppurative complications such as peritonsillar abscess, cervical lymphadenitis, and mastoiditis. Additional issues related to antibiotic therapy for reducing clinical symptoms are discussed further below. Reducing nonsuppurative complications — Antibiotic therapy is primarily helpful for reducing the incidence of acute rheumatic fever as a nonsuppurative complication of GAS pharyngitis. The role of antibiotic therapy in decreasing the nonsuppurative complications of glomerulonephritis and PANDAS syndrome is not clear [10]. Acute rheumatic fever — Although symptoms of GAS pharyngitis resolve without antibiotic therapy, persistence of the organism in the upper respiratory tract elicits an immune response that can set the stage for subsequent risk of acute rheumatic fever (ARF) if the strain is rheumatogenic and the host is genetically predisposed. In some populations, group G and group C streptococci may also play a role in ARF pathogenesis [11,12]. The efficacy of penicillin for primary prevention of ARF was established in the early 1950s, when military recruits with GAS tonsillopharyngitis received injectable penicillin G mixed in peanut oil or sesame oil with 2 percent aluminum monostearate [13,14]. GAS eradication and ARF primary prevention were optimized with injection schedules that provided at least 9 to 11 days of penicillin. Subsequently, evaluation of GAS tonsillopharyngitis therapies has been based upon GAS eradication from the upper respiratory tract; it is assumed that such eradication is an adequate surrogate marker for efficacy in primary prevention of rheumatic fever. Antibiotic therapy can be helpful for prevention of rheumatic fever if initiated up to nine days following onset of symptoms [13]. Glomerulonephritis — Children younger than seven years of age appear to be at greatest risk of poststreptococcal glomerulonephritis. Although antibiotic therapy has efficacy for primary prevention of acute rheumatic fever, the role of antibiotics in the setting of GAS tonsillopharyngitis for prevention of poststreptococcal glomerulonephritis is not certain. PANDAS syndrome — Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS) is discussed...
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