Is a short-course antibiotic treatment effective for streptococcal tonsillopharyngitis in children?

[How to reduce the antibacterial load in the treatment of acute tonsillitis and pharyngitis? Possible tactics and practical approaches]

Acute tonsillopharyngitis is one of the most frequent reasons for visiting a doctor and prescribing inappropriate antibiotic therapy (ABT). There are several reasons for this - from the difficulties of etiological diagnosis and the development of relapses and possible severe complications to the personal attitude of doctors and patients to the choice of treatment. At the same time, the issue of antibiotic resistance and other aspects associated with the prescription of ABT is one of the most important problems of modern healthcare worldwide. The purpose of this review is to demonstrate the best practical approaches to the choice of treatment tactics for acute tonsillitis (AT) in the treatment of children and adults, with an emphasis on reducing the load of ABT. The review examines the indications and disadvantages of clinical and laboratory diagnosis of AT. There are no highly sensitive clinical and laboratory instruments that differentiate viral and bacterial AT. Exudativeis AT in children is not an underlying symptom of streptococcal etiology. Despite the limitations, the modified Centor/McIsaac score ≥3 (taking into account age and the presence of respiratory symptoms) should be used as an indication for ABT in conjunction with a rapid streptotest and subsequent bacteriological culture for S. pyogenes if the screening test is negative. Additional examinations (determination of leukocytosis, CRP and procalcitonin test) are not required for most patients. ABT should not be given to low-risk patients for the treatment and prevention of rheumatic fever and acute glomerulonephritis. Prevention of purulent complications (paratonsillitis and retropharyngeal abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis) is not a specific indication for ABT in AT and is not required in most patients. The strategy of «delayed antibiotic prescriptions» with monitoring the patient's condition for 2-3 days is appropriate and highly effective in doubtful cases. The drugs of choice for treatment of AT are amoxicillin and oral forms of I and II generation cephalosporins. Macrolides are not indicated as first-line treatment for AT. The course of ABT for streptococcal AT is 10 days, which reduces the risk of recurrent episode. Topical drugs can be the only means of etiopathogenetic treatment with viral AT, or additional for bacterial AT. Their use not only relieves sore throat, but also shortens the duration of the disease, and also improves the patients prognosis. Benzalkonium chloride + tyrothricin + benzocaine (Dorithyrcin) may be a rational drug of choice for topical therapy due to the available clinical evidence. There is a significant reserve for reducing the load of ABT during AT. Further clinical trials are needed to assess the efficacy of short courses of ABT in the treatment of AT in high-income countries and provide a basis for strong recommendations for topical drug use. This can reduce the frequency of ABT prescribing and increase the level of interaction between specialists and patients.

Short- vs. Long-Course Antibiotic Treatment for Acute Streptococcal Pharyngitis: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

To evaluate the effectiveness of short courses of antibiotic therapy for patients with acute streptococcal pharyngitis.

METHODS

Randomized controlled trials comparing short-course antibiotic therapy (≤5 days) with long-course antibiotic therapy (≥7 days) for patients with streptococcal pharyngitis were included. Two primary outcomes: early clinical cure and early bacterial eradication.

RESULTS

Fifty randomized clinical trials were included. Overall, short-course antibiotic treatment was as effective as long-course antibiotic treatment for early clinical cure (odds ratio (OR) 0.85; 95% confidence interval (CI) 0.79 to 1.15). Subgroup analysis showed that short-course penicillin was less effective for early clinical cure (OR 0.43; 95% CI, 0.23 to 0.82) and bacteriological eradication (OR 0.34; 95% CI, 0.19 to 0.61) in comparison to long-course penicillin. Short-course macrolides were equally effective, compared to long-course penicillin. Finally, short-course cephalosporin was more effective for early clinical cure (OR 1.48; 95% CI, 1.11 to 1.96) and early microbiological cure (OR 1.60; 95% CI, 1.13 to 2.27) in comparison to long-course penicillin. In total, 1211 (17.7%) participants assigned to short-course antibiotic therapy, and 893 (12.3%) cases assigned to long-course, developed adverse events (OR 1.35; 95% CI, 1.08 to 1.68).

CONCLUSIONS

Macrolides and cephalosporins belong to the list of "Highest Priority Critically Important Antimicrobials"; hence, long-course penicillin V should remain as the first line antibiotic for the management of patients with streptococcal pharyngitis as far as the benefits of using these two types of antibiotics do not outweigh the harms of their unnecessary use.