File Name: diagnosis and treatment of streptococcal pharyngitis .zip
After a physical examination and patient history is completed, five types of diagnostic methods can be used to ascertain the presence of a GABHS infection: clinical scoring systems, rapid antigen detection tests, throat culture, nucleic acid amplification tests, and machine learning and artificial intelligence.
The Spanish Association of Pediatrics has as one of its main objectives the dissemination of rigorous and updated scientific information on the different areas of pediatrics.
Annals of Pediatrics is the Body of Scientific Expression of the Association and is the vehicle through which members communicate. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published. Read more. SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.
SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. An update of the Spanish consensus document on the diagnosis and treatment of acute tonsillopharyngitis in is presented. Clinical scores should not be used to prescribe antibiotics, unless microbiological tests are not available or there is a child at risk of rheumatic fever.
There is no score better than those set out in the previous consensus. Microbiological tests are recommended in proposed cases, regardless of the result of the scores. Penicillin is the treatment of choice, prescribed twice a day for 10 days. Amoxicillin is the first alternative, prescribed once or twice a day for the same time.
First-generation cephalosporins are the treatment of choice in children with non-immediate reaction to penicillin or amoxicillin. Josamycin and midecamycin are the best options for children with immediate penicillin allergic reactions, when non-beta-lactam antibiotics should be used.
In microbiological treatment failure, and in streptococcal carriers, the treatments proposed in the previous consensus are still applicable.. No existe ninguna escala que sea mejor que las expuestas en el consenso previo. As 9 years have passed since its publication, the Working Group considered that an update was advisable, subjecting 10 questions and answers on the most relevant aspects that may have changed in the past few years to a consensus process.
After performing a literature search and reviewing the selected articles, we present recommendations based on our findings. In addition, each recommendation was subjected to a vote by every member of the group, as has been done in the development of other consensus documents in Spain.
Clinical prediction rules have been developed for diagnosis of acute tonsillopharyngitis ATP to calculate the probability of a streptococcal aetiology.
The Centor criteria modified by McIsaac, recommended in the previous consensus, 1 offers a similar sensitivity. It includes consideration of tonsillar exudate and one item concerning the age of the patient, which is less relevant in the paediatric population, as use of clinical prediction rules is not recommended in children aged less than 3 years. The estimated probability of culture positive to group A beta-haemolytic streptococcus GABHS 8 is similar for all three scales, as can be seen in Table 2.
The group of experts considered that no new clinical prediction rules better than those that were already available and reviewed in the previous consensus. Clinical prediction rules should be used to make the decision whether to initiate empirical antibiotherapy only if diagnostic tests are not available or in patients at risk of developing rheumatic fever. In the best-case scenario, prescribing antibiotherapy based on these rules would lead to inappropriate treatment in 1 out of 3 children.
Therefore, nearly all paediatric guidelines in developed countries recommend against using clinical scoring systems to decide on the use of antibiotherapy. In conclusion, in children and adolescents, clinical prediction rules for identification of streptococcal ATP are not sensitive or specific enough to eliminate the need of microbiological testing and should not ever be the sole reason to initiate empirical antibiotherapy. The studies that support some of the most widely-used scales have methodological limitations that call their results into question.
Table 3 shows the cases in which the group of experts recommends ordering microbiological tests, supported by evidence of varying quality. Cases in which microbiological tests should be ordered in the opinion of the group of experts. As a counterbalance to all these advantages, we ought to mention two potential drawbacks. The first is the risk of overdiagnosis in patients that are only carriers, which ought to be minimised by careful selection of patients for testing, as is also the case for testing by means of a rapid antigen detection test RADT and throat swab culture.
Oral penicillin phenoxymethylpenicillin potassium and potassium phenoxymethylpenicillin-benzathine is the first-line antibiotic treatment for streptococcal ATP, and amoxicillin is the first alternative. These drugs are safe and effective and meet the current goals of treatment: to achieve rapid clinical improvement, shorten the contagious period and prevent already infrequent complications. Other advantages are their narrow spectrum, good bioavailability and low cost.
A recent Cochrane review 23 did not find evidence of differences in symptom resolution when comparing penicillin and amoxicillin with cephalosporins and macrolides. The superiority of cephalosporins with a broader spectrum and higher cost in achieving a cure and reducing the incidence of recurrence was not statistically significant and required a high number needed to treat to benefit NNTB, the number of patients that need to be treated to observe any additional benefit.
Azithromycin allows shorter courses of treatment, but there is variability in the rate of antimicrobial resistance and its use could induce the development of antimicrobial resistances in other colonising bacteria, such as Streptococcus pneumoniae. In young children, some paediatricians prefer to use amoxicillin rather than phenoxymethylpenicillin because it does not require fasting and it is available as a suspension with a pleasant taste.
Intramuscular injection of a single dose of penicillin is painful and thus reserved for cases in which oral administration is not possible or there is concern regarding adherence to treatment. Since then, most studies have aimed to improve adherence to treatment. The 2-dose per day schedule for penicillin was first proposed in , when the statement of the AHA was updated. A review and meta-analysis conducted in concluded that a 2-dose per day schedule was as effective as schedules with more frequent doses.
However, the schedule consisting of a single daily dose of oral penicillin has exhibited a lower efficacy. The greater palatability of oral amoxicillin in suspension has led to a greater use of this drug compared to penicillin in clinical practice in some countries. Due to its longer half life, studies have been conducted to assess its effectiveness when administered a single daily dose. The first randomised trials in the s found a similar effectiveness on comparing a single daily dose of amoxicillin with administration of 3—4 doses a day of penicillin.
The recommended duration of oral penicillin and oral amoxicillin courses is 10 days. The residual strains are strains lacking protein M, which are more likely to colonise the mucosa than damage adjacent tissues. The recommended length of treatment with first-generation cephalosporins is also 10 days, although 5-day courses have been proven to be equally efficacious in resolving symptoms and eradicating the pathogen.
This could be an alternative in patients with poor adherence. Oral first-generation cephalosporins are the drug of choice for children with non-severe delayed hypersensitivity reactions to penicillin or amoxicillin. In case of immediate Ig-E-mediated hypersensitivity reactions and severe delayed reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis , patients should be given non-beta-lactam antibiotics.
In such cases, the treatment must always be guided by the results of antimicrobial susceptibility testing. At present, there is still agreement that failure to eradicate the bacterial pathogen and carrier status entail a minimal risk of complication or contagion. In the rare cases that require treatment, the evidence is still insufficient to support a specific regimen.
These forms of disease are referred to as strep throat , streptococcal fever or streptococcal pharyngitis. In case of streptococcal infection, the yield of rapid tests and culture is lower, so if these tests are indicated, we recommend obtaining both nasal and throat samples. In case of a scarlatiniform rash or known presence of streptococcal pharyngitis in the environment of the child, a RADT in a tonsillar exudate sample alone is useful.
The incidence of complications of invasive disease is low, but higher in early childhood. In case antibiotherapy is initiated, we recommend the same selection of antibiotic agents, dosage and duration as in older children. Recommendation 1. There is no new clinical prediction rule to determine eligibility for a rapid test for detection of GABHS that performs better than those previously known and discussed in the previous consensus document. Quality of evidence: III. Strength of recommendation supporting use: C.
Vote: 23 agreed, 0 abstained, 0 disagreed. Recommendation 2. Clinical prediction rules should not be used to make the decision to initiate empirical antibiotherapy unless microbiological testing is not available or there is risk of rheumatic fever. Quality of evidence: I. Strength of recommendation against use: A. Recommendation 3. The group of experts proposes situations in which microbiological tests should be performed regardless of clinical prediction scores. Varying quality of evidence.
See Table 3. Recommendation 4. Molecular tests can be used for diagnosis of streptococcal pharyngitis, but we do not recommend their routine use at this time. Quality of evidence: II. Recommendation 5. We recommend a daily dose of penicillin for 10 days for first-line treatment of streptococcal pharyngitis.
Amoxicillin, given in 1 or 2 doses a day for the same duration, is the first alternative. Quality of evidence: II Strength of recommendation supporting use: A. Vote: 22 agreed, 1 abstained RPP , 0 disagreed. Some authors consider that both penicillin and amoxicillin should be considered for first-line treatment. There are also authors that propose shorter courses in specific situations.
Recommendation 6. First-generation cephalosporins are the drugs of choice in children that exhibit non-severe, delayed hypersensitivity reactions to penicillin or amoxicillin. In case of immediate hypersensitivity reaction, a non-beta-lactam antibiotic agent should be used, and the best options are josamycin and diacetyl-midecamycin. Quality of evidence: II Strength of recommendation supporting use: B.
Recommendation 7. In case of failure of first-line treatment or carrier status, the therapeutic alternatives proposed in the previous consensus documents still hold.
Recommendation 8. In children aged less than 3 years, given the low incidence of streptococcal infection, microbiological testing for GABHS is not recommended, save in select cases. In case streptococcal infection is suspected, we recommend collection of 2 samples for the RADT: a nasal swab and a throat swab.
Strength of recommendation supporting use: B. Vote: 22 agreed, 1 abstained MCO , 0 disagreed. Tables 5 and 6 detail the updated antibiotic doses and schedules recommended for treatment of patients with streptococcal ATP and carriers.
The Spanish Association of Pediatrics has as one of its main objectives the dissemination of rigorous and updated scientific information on the different areas of pediatrics. Annals of Pediatrics is the Body of Scientific Expression of the Association and is the vehicle through which members communicate. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published. Read more.
While respiratory viruses are responsible for the majority of cases, group A streptococcus GAS is the most common bacterial cause of what is generally referred to as strep throat. The Infectious Diseases Society of America recently released updated clinical practice guidelines for the diagnosis and management of GAS pharyngitis. First-line treatment for GAS pharyngitis is penicillin or amoxicillin, and alternative agents include a first-generation cephalosporin, clindamycin, clarithromycin, and azithromycin.
Overtreatment of acute pharyngitis is a major cause of inappropriate antibiotic use that can be avoided through appropriate evaluation and treatment. Currently, based on the same evidence, there are conflicting recommendations regarding treatment for GAS. The ESCMID guideline recommends that antibiotics should not be used in patients with less severe presentation of sore throat, e. In reviewing primary literature on treatment of GAS, the work group found several limitations. Many of the studies are on patients with sore throats and suspected but not confirmed GAS.
Metrics details. This study evaluated the overall diagnosis and treatment of acute pharyngitis in the United States, including predictors of test type and antibiotic prescription. Multivariate models were used to identify significant predictors of NAAT use and antibiotic prescription. A total of
The clinical diagnosis is difficult to determine and laboratory tests have limitations; hence, the condition is generally overdiagnosed and overtreated. Several clinical pediatric-specific predictive models have been published but none have been prospectively studied. Forty-nine percent were boys.
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Alan L. Bisno, Michael A. Gerber, Jack M. Gwaltney, Jr, Edward L. Kaplan, Richard H. The objective of this practice guideline is to provide recommendations for the accurate diagnosis and optimal treatment of group A streptococcal pharyngitis in children and adults.
A more recent article on streptococcal pharyngitis is available.Burrell D. T. 18.05.2021 at 16:08
Although current guidelines recommend Use of clinical decision rules for diagnosing GABHS pharyngitis improves quality of care while.Raina A. 22.05.2021 at 04:55
Increased group A beta-hemolytic streptococcus (GABHS) treatment failure with penicillin has been reported. Although current guidelines.Cleopatra M. 22.05.2021 at 17:10
Controversy remains about the need for antibiotic therapy of group A streptococcal GAS pharyngitis in high-resource settings.