Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment

Microbial factors leading to recurrent upper respiratory tract infections

The treatment or prophylaxis of upper respiratory tract infections such as otitis media, sinusitis and tonsillitis with penicillins can generate bacterial resistance caused by production of beta-lactamase or changes in the penicillin-binding proteins. This resistance can spread in the community even to untreated individuals. The prevalence of resistant organisms tends to increase in the winter months. Beta-lactamase-producing bacteria may interfere with the eradication of penicillin-susceptible organisms and may account for substantial numbers of therapeutic failures among cases of otitis media, sinusitis and tonsillitis. The presence of normal flora that possess interfering capabilities against potential pathogens is beneficial to the host. Such flora may enhance recovery and prevent infections of the tonsils by group A beta-hemolytic streptococci. Therapeutic use of antimicrobial agents that preserve the normal flora but overcome penicillin-susceptible or -resistant pathogens may enhance recovery from upper respiratory tract infections.

Upper respiratory tract infections in family practice

The causative pathogens in the majority of mild to moderate upper respiratory tract infections are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Bacterial infections of the respiratory tract are often treated empirically; however, the recent increase in serious infections caused by S. pneumoniae and rising antimicrobial resistance rates have prompted experts to reevaluate the therapeutic approaches to treatment of these infections. Although amoxicillin continues to be considered a first line therapy, some situations warrant alternative therapies. Antimicrobial therapy must provide effective coverage of the potential pathogens, yet issues of compliance must also be addressed to ensure clinical success. Ease of administration, taste and the potential for adverse events are important considerations for the pediatric population. Clinical trials support the use of alternative therapies in the treatment of patients with upper respiratory tract infections.

Anthroposophic perspectives in primary care

Anthroposophically Extended Medicine (AEM) is a truly integrative healing system. AEM represents an expansion, not an alternative to conventional medicine. Its unique understanding of the interplay among physiological, soul and spiritual processes in healing and illness serves to bridge allopathy with naturopathy, homeopathy, functional/nutritional medicine and other healing systems.

Bedside diagnostic testing of body fluids

Numerous bedside diagnostic modalities are appropriate for the practice of emergency medicine. The proliferation of sophisticated technology is likely to increase both the availability and accuracy of commercial testing products. If health care reform in the United States results in a relaxation of the CLIA regulations, there will be a rapid expansion of research and development aimed at the biotechnology market. How much this would pertain to hospital-based emergency practice remains to be seen. Cost containment pressures may act in both directions on the utilization of available bedside technology. Although these tests are often less expensive than centralized laboratory determinations, the ready availability of near-patient testing may result in an increase in use that negates the lower cost. As with other diagnostic modalities, a thoughtful, considered approach based on scientific evidence will be necessary to formulate the appropriate use of bedside testing in individual emergency practice settings.

Eye, ear, nose, and throat

Patients present to the emergency department with a number of eye, ear, nose, and throat (ENT) problems. This article updates some very common problems; identifies a few pearls on nasal foreign body removal, ophthalmologic medication, and epistaxis; and reviews a few pitfalls in identifying malignancies and sore throats.

Sore throat after sore throat after sore throat. Are you asking the critical questions?

In this discussion of recurrent group A streptococcal tonsillopharyngitis, the author notes that even at the peak of the streptococcal infection season, not more than 30% to 40% of children with sore throats actually have group A streptococci as the cause. Thus, it is vital to confirm clinical diagnosis of group A streptococcal tonsillopharyngitis with laboratory tests. When patients have recurrent infections with group A streptococci, possible causes include noncompliance, bacterial resistance, repeated exposure, alteration of the throat's microbial ecology, suppression of antibody response due to previous antibiotic therapy, and treatment failure. When noncompliance is an issue, an injection of penicillin G benzathine may be appropriate. In other circumstances, pharmacologic options for treatment of recurrent group A streptococcal tonsillopharyngitis include macrolides, clindamycin hydrochloride, rifampin (in combination with a second agent), and oral cephalosporins. If a patient has six or seven recurrences over 1 or 2 years despite antibiotic treatment, tonsillectomy should be considered.

Streptococcal pharyngitis in a paediatric emergency department

OBJECTIVE

To determine the prevalence and clinical features of beta-haemolytic streptococcal infection in children with acute pharyngitis and thereby to define those requiring antibiotic therapy.

DESIGN

Prospective 2:1 case--control study.

SETTING

Emergency Medicine Department of the Royal Children's Hospital, Melbourne, between May 1994 and May 1995.

PARTICIPANTS

Cases (n = 271) were the first 10 self-referred children in each week with pharyngitis and no antibiotic use in the previous week. Controls (n = 135) were age-matched children without infection.

MAIN OUTCOME MEASURES

Presence of groups A, C or G beta-haemolytic streptococci in oropharyngeal cultures; demographic and clinical characteristics.

RESULTS

Group A beta-haemolytic streptococci (GABHS) were isolated from significantly more case than control children (cases, 57/271 [21%]; controls, 9/135 [7%]; odds ratio [OR], 3.7; P < 0.001). Groups C and G beta-haemolytic streptococci were isolated from 10 (4%) and 5 (2%) case children, respectively, but not from controls. Age > or = 4 years, tender cervical lymph nodes, pharyngotonsillitis, absent coryza and scarlatiniform rash were significantly associated with GABHS (P < 0.02). GABHS was uncommon in children aged < 4 years (4%), but was present in 12 of 14 children > or = 4 years with a rash (86%). However, most cases lacked a rash, and for children > or = 4 years likelihood of GABHS varied from 10%-65%, depending on other clinical features.

CONCLUSIONS

In children aged < 4 years, GABHS is an unlikely cause of acute pharyngitis and symptomatic treatment alone should be considered. In children > or = 4 years, the likelihood of GABHS being the cause of acute pharyngitis increases with presence of scarlatiniform rash, pharyngotonsillitis and tender cervical nodes.

Azithromycin. A review of its pharmacological properties and use as 3-day therapy in respiratory tract infections

The azalide antibacterial agent azithromycin is a semisynthetic acid-stable erythromycin derivative with an expanded spectrum of activity and improved tissue pharmacokinetic characteristics relative to erythromycin. The drug is noted for its activity against some Gram-negative organisms associated with respiratory tract infections, particularly Haemophilus influenzae. Azithromycin has similar activity to other macrolides against Streptococcus pneumoniae and Moraxella catarrhalis, and is active against atypical pathogens such as Legionella pneumophila, Chlamydia pneumoniae and Mycoplasma pneumoniae. Once-daily administration of azithromycin is made possible by the long elimination half-life of the drug from tissue. Azithromycin is rapidly and highly concentrated in a number of cell types after absorption, including leucocytes, monocytes and macrophages. It undergoes extensive distribution into tissue, from where it is subsequently eliminated slowly. A 3-day oral regimen of once-daily azithromycin has been shown to be as effective as 5- to 10-day courses of other more frequently administered antibacterial agents [such as erythromycin, amoxicillin-clavulanic acid and phenoxymethylpenicillin (penicillin V)] in patients with acute exacerbations of chronic bronchitis, pneumonia, sinusitis, pharyngitis, tonsillitis and otitis media. Adverse effects of azithromycin are mainly gastrointestinal in nature and occur less frequently than with erythromycin. Azithromycin is likely to prove most useful as a 3-day regimen in the empirical management of respiratory tract infections in the community. Its ease of administration and 3-day duration of therapy, together with its good gastrointestinal tolerability, should optimise patient compliance (the highest level of which is achieved with once-daily regimens). Azithromycin is also likely to be useful in the hospital setting, particularly for outpatients and for those unable to tolerate erythromycin.