Streptococcal pharyngitis: a review of pathophysiology, diagnosis, and management

Infectious indications for tonsillectomy

Tonsillectomy is the most common major surgery performed on children in the United States. Recurrent throat infections of either bacterial or viral etiology can cause significant morbidity and decreased quality of life, and potentially lead to life-threatening complications. When performed in the proper patient, tonsillectomy can be a highly effective procedure. Recent clinical trials have sought to better define the appropriate infectious indications for surgery. Despite the improved understanding gained from these studies, the decision to operate always must be made on an individual basis with the primary care physician, surgeon, patient, and family all involved in the decision-making process.

Efficacy of single-dose dexamethasone as adjuvant therapy for acute pharyngitis

HYPOTHESIS

Pharyngeal inflammatory pain is reduced by a single dose of dexamethasone.

STUDY DESIGN

Prospective, randomized, double-blinded, placebo-controlled study.

METHODS

From August 1998 to July 2000, a total of 118 patients were enrolled. We compared placebo (n = 37), a 10-mg single dose of intramuscular injection of dexamethasone (n = 39), and a 10-mg single dose of oral dexamethasone (n = 42). All patients were given oral antibiotics and had bacterial throat cultures.

RESULTS

Complete telephone follow-up 12 hours after treatment was available in 111 patients, and 24-hour follow-up data were available in 116. The change in pain visual analogue scale scores (pretreatment score minus 12-h follow-up score) reported by patients who were given either intramuscular (median score, 4; mean score +/- SD, 4.2 +/- 2.3) or oral dexamethasone (median score, 3; mean score +/- SD, 3.8 +/- 2.3) was significantly greater than that of the patients who were given placebo (median score, 2; mean score +/- SD, 2.1 +/- 2.0) (P <.001 and P =.002, respectively). This difference in improvement was also evident when the percentage of change was compared in the three treatment arms at 12-hour and 24-hour follow-up. Patients who were given dexamethasone had the onset of pain relief a median of 4 hours earlier than those who were given oral and intramuscular placebo (P =.029). Statistically significant differences among the three treatment arms were confirmed when a bacterial pathogen was identified (n = 47) but not in a subset that did not have a pathogen identified.

CONCLUSIONS

Single-dose dexamethasone appears to be a safe, effective, and inexpensive adjunctive treatment for acute pharyngitis in patients 15 years of age and older. Patients treated with intramuscular or oral dexamethasone had significant relief of pain (relative to baseline) compared with patients who were given placebo. Identification of a bacterial pathogen had a significant impact on the response to dexamethasone.

The impact of dosing frequency on the efficacy of 10-day penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: A meta-analysis

OBJECTIVE

The recommended dosing frequency of oral penicillin for the treatment of acute streptococcal tonsillopharyngitis has long been 3 to 4 times daily. In 1994, treatment guidelines included twice-daily (BID) dosing for the first time, a recommendation that could significantly increase the ease of compliance. This meta-analysis was performed to determine whether overall cure rates differed between BID or once-daily (QD) versus more frequent dosing schedules in the treatment of streptococcal tonsillopharyngitis.

DATA SOURCES

Candidate studies for this meta-analysis included all clinical trials of therapy for streptococcal tonsillopharyngitis published through August 1998 and identified using Medline, Dissertation Abstracts, conference proceedings, and bibliographies of all retrieved articles.

STUDY SELECTION

A study was eligible for inclusion if it was a randomized clinical trial that compared the efficacies of different dosing frequencies of 10-day penicillin or amoxicillin in the treatment of streptococcal tonsillopharyngitis. Of the 30 articles initially identified, 6 studies met eligibility criteria.

OUTCOME MEASURE

The measure of interest was the difference in proportion cured between the BID or QD dosing group and the comparison group with more frequent dosing.

RESULTS

The results of this analysis suggest that BID dosing of 10-day penicillin is as efficacious as more frequent dosing regimens in the treatment of streptococcal tonsillopharyngitis. This result also holds true in a subgroup analysis confined to pediatric cases and does not vary with total daily dose of the regimen. QD dosing of penicillin is associated with a cure rate that is 12 percentage points lower than more frequent dosing (95% confidence interval: 3-21). In contrast, this decreased efficacy is not found with QD dosing of amoxicillin.

CONCLUSIONS

This meta-analysis supports current recommendations for BID dosing of penicillin in treating streptococcal tonsillopharyngitis. QD penicillin is associated with decreased efficacy and should not be used. Simplified regimens of amoxicillin of shorter duration or of less frequent dosing should be further investigated.

Use of the clinical microbiology laboratory for the diagnosis and management of infectious diseases related to the oral cavity

Our knowledge regarding the pathogenesis of infections relative to the oral cavity is rapidly expanding, similar to our overall understanding of how infectious diseases impact our daily lives. The complexity of the flora within the oral cavity is quite unique and often makes diagnosis difficult; however, it is becoming more apparent that accurate diagnostic testing is important from the standpoint of focusing appropriate therapy on pathogens within this crucial body site, and avoiding overuse of antimicrobial agents in settings of infection where they have no demonstrated benefit. New diagnostic methods are being developed to detect pathogens and rapidly delineate resistance patterns. Many will be based on new genetic assays, but they must be cost effective, sensitive, and specific. Another growing challenge is to provide adequate lab support to outpatient offices and clinics, without compromising the specimen culture or turnaround times. So many patients are being seen away from hospital laboratories that we need ways to diagnose sinusitis, pharyngitis, abscess, and other infections of the oral cavity without killing the anaerobes and other significant facultative bacteria, and without ruining the direct stains by overgrowth or inflammatory cell degradation during specimen transport. These results need to be available quickly enough to give useful information for office diagnosis in order to effect therapy. To optimize both diagnosis and treatment, a key to the future will be better communication between the clinical practitioner and laboratory, with an increasing emphasis on training expertise in medical microbiology and infectious diseases.

Case management by physician assistants and primary care physicians vs emergency physicians

OBJECTIVES

To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs).

METHODS

An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed.

RESULTS

The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows: [table: see text]

CONCLUSION

The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.

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.

Antibiotic use in the emergency department. IV: Single-dose therapy and parenteral-loading dose therapy

There are a number of infectious diseases that can be treated efficaciously with a single dose of an antimicrobial agent. Other infections that can be treated with oral antibiotics on an outpatient basis may resolve more quickly if a parenteral loading dose is given in the emergency department (ED) prior to discharge. This article reviews the supporting literature and indications for single-dose and parenteral first-dose-loading antimicrobial therapy in the ED. This approach may be appropriate for such diverse infections as streptococcal pharyngotonsillitis, otitis media, urinary tract infections, chlamydial genital infections, vaginitis due to yeast, bacteria, or trichomoniasis, pneumonia, gonorrhea and pelvic inflammatory disease, and pediatric fever without a source.

Streptococcal pharyngitis: is penicillin still the drug of choice?

With the advent of cephalosporins, penicillin appears to have lost some ground for treatment of Acute Group A Beta Hemolytic Streptococcal Pharyngitis. It has been argued for some time now whether penicillin should remain the drug of choice for the management of this infection. Evidence has been presented both in favour and against using penicillin for Group A beta hemolytic streptococcal (GABHS) pharyngotonsillitis. In this commentary, we review the available data in the current literature and conclude that penicillin should still remain the drug of first consideration for GABHS pharyngitis. If penicillin treatments were less effective now, the clinical and bacteriologic failure rates should be on the rise compared to the previous years.