Twice-daily penicillin in the treatment of streptococcal pharyngitis

Antibiotics for treatment of sore throat in children and adults

BACKGROUND

Sore throat is a common reason for people to present for medical care and to be prescribed antibiotics. Overuse of antibiotics in primary medicine is a concern, hence it is important to establish their efficacy in treating sore throat and preventing secondary complications.  OBJECTIVES: To assess the effects of antibiotics for reducing symptoms of sore throat for child and adult patients.

SEARCH METHODS

We searched CENTRAL 2021, Issue 2, MEDLINE (January 1966 to April week 1, 2021), Embase (January 1990 to April 2021), and two trial registries (searched 6 April 2021).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications amongst children and adults seeking medical care for sore throat symptoms.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. Two review authors independently screened studies for inclusion and extracted data, resolving any differences in opinion by discussion. We contacted the trial authors from three studies for additional information. We used GRADE to assess the certainty of the evidence for the efficacy of antibiotics on our primary outcomes (sore throat at day three and one week) and secondary outcomes (fever and headache symptoms and incidence of acute rheumatic fever, acute glomerulonephritis, acute otitis media, acute sinusitis, and quinsy).

MAIN RESULTS

We included 29 trials with 15,337 cases of sore throat. The majority of included studies were conducted in the 1950s, during which time the rates of serious complications (especially acute rheumatic fever) were much higher than today. Although clinical antibiotic trials for sore throat and respiratory symptoms are still being conducted, it is unusual for them to include placebo or 'no treatment' control arms, which is a requirement for inclusion in the review. The age of participants ranged from younger than one year to older than 50 years, but most participants across all studies were adults. Although all studies recruited patients presenting with symptoms of sore throat, few of them distinguished between bacterial and viral aetiology. Bias may have been introduced through non-clarity in treatment allocation procedures and lack of blinding in some studies. Harms from antibiotics were poorly or inconsistently reported, and were thus not quantified for this review. 1. Symptoms Throat soreness and headache at day three were reduced by using antibiotics, although 82% of participants in the placebo or no treatment group were symptom-free by one week. The reduction in sore throat symptoms at day three (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.60 to 0.80; 16 studies, 3730 participants; moderate-certainty evidence) was greater than at one week in absolute numbers (RR 0.50, 95% CI 0.34 to 0.75; 14 studies, 3083 participants; moderate-certainty evidence) due to many cases in both treatment groups having resolved by this time. The number needed to treat for an additional beneficial outcome (NNTB) to prevent one sore throat at day three was less than six; at week one it was 18. Compared with placebo or no treatment, antibiotics did not significantly reduce fever at day three (RR 0.75, 95% CI 0.53 to 1.07; 8 studies, 1443 participants; high-certainty evidence), but did reduce headache at day three (RR 0.49, 95% CI 0.34 to 0.70; 4 studies, 1020 participants; high-certainty evidence). 2. Suppurative complications Whilst the prevalence of suppurative complications was low, antibiotics reduced the incidence of acute otitis media within 14 days (Peto odds ratio (OR) 0.21, 95% CI 0.11 to 0.40; 10 studies, 3646 participants; high-certainty evidence) and quinsy within two months (Peto OR 0.16, 95% CI 0.07 to 0.35; 8 studies, 2433 participants; high-certainty evidence) compared to those receiving placebo or no treatment, but not acute sinusitis within 14 days (Peto OR 0.46, 95% CI 0.10 to 2.05; 8 studies, 2387 participants; high-certainty evidence). 3. Non-suppurative complications There were too few cases of acute glomerulonephritis to determine whether there was a protective effect of antibiotics compared with placebo against this complication (Peto OR 0.07, 95% CI 0.00 to 1.32; 10 studies, 5147 participants; low-certainty evidence). Antibiotics reduced acute rheumatic fever within two months when compared to the control group (Peto OR 0.36, 95% CI 0.26 to 0.50; 18 studies, 12,249 participants; moderate-certainty evidence). It should be noted that the overall prevalence of acute rheumatic fever was very low, particularly in the later studies.

AUTHORS' CONCLUSIONS

Antibiotics probably reduce the number of people experiencing sore throat, and reduce the likelihood of headache, and some sore throat complications. As the effect on symptoms can be small, clinicians must judge on an individual basis whether it is clinically justifiable to use antibiotics to produce this effect, and whether the underlying cause of the sore throat is likely to be of bacterial origin. Furthermore, the balance between modest symptom reduction and the potential hazards of antimicrobial resistance must be recognised. Few trials have attempted to measure symptom severity. If antibiotics reduce the severity as well as the duration of symptoms, their benefit will have been underestimated in this meta-analysis. Additionally, more trials are needed in low-income countries, in socio-economically deprived sections of high-income countries, as well as in children.

Compliance with once-daily versus twice or thrice-daily administration of antibiotic regimens: a meta-analysis of randomized controlled trials

Objective

To investigate whether compliance of patients to antibiotic treatment is better when antibiotics are administered once than multiple times daily.

Methods

We performed a systematic search in PubMed and Scopus databases. Only randomized controlled trials were considered eligible for inclusion. Compliance to antibiotic treatment was the outcome of the meta-analysis.

Results

Twenty-six studies including 8246 patients with upper respiratory tract infections in the vast majority met the inclusion criteria. In total, higher compliance was found among patients treated with once-daily treatment than those receiving treatment twice, thrice or four times daily [5011 patients, RR=1.22 (95% CI, 1.11, 1.34]. Adults receiving an antibiotic once-daily were more compliant than those receiving the same antibiotic multiple times daily [380 patients, RR=1.09 (95% CI, 1.02, 1.16)]. Likewise, children that received an antibiotic twice-daily were more compliant than those receiving the same antibiotic thrice-daily [2118 patients, RR=1.10 (95% CI, 1.02, 1.19)]. Higher compliance was also found among patients receiving an antibiotic once compared to those receiving an antibiotic of different class thrice or four times daily [395 patients, RR=1.20 (95% CI, 1.12, 1.28)]. The finding of better compliance with lower frequency daily was consistent regardless of the study design, and treatment duration.

Conclusion

This meta-analysis showed that compliance to antibiotic treatment might be associated with higher when an antibiotic is administered once than multiple times daily for the treatment of specific infections and for specific classes of antibiotics.

Antibiotics for sore throat

BACKGROUND

Sore throat is a common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it.

OBJECTIVES

To assess the benefits of antibiotics for sore throat for patients in primary care settings.

SEARCH METHODS

We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to July week 1, 2013) and EMBASE (January 1990 to July 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. We contacted trial authors from three studies for additional information.

MAIN RESULTS

We included 27 trials with 12,835 cases of sore throat. We did not identify any new trials in this 2013 update. 1. Symptoms Throat soreness and fever were reduced by about half by using antibiotics. The greatest difference was seen at day three. The number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six; at week one it was 21. 2. Non-suppurative complications The trend was antibiotics protecting against acute glomerulonephritis but there were too few cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio (RR) 0.27; 95% confidence interval (CI) 0.12 to 0.60). 3. Suppurative complications Antibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo. 4. Subgroup analyses of symptom reduction Antibiotics were more effective against symptoms at day three (RR 0.58; 95% CI 0.48 to 0.71) if throat swabs were positive for Streptococcus, compared to RR 0.78; 95% CI 0.63 to 0.97 if negative. Similarly at week one the RR was 0.29 (95% CI 0.12 to 0.70) for positive and 0.73 (95% CI 0.50 to 1.07) for negative Streptococcus swabs.

AUTHORS' CONCLUSIONS

Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall.

Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

[Consensus document on the diagnosis and treatment of acute tonsillopharyngitis]

Acute tonsillopharyngitis is one of the most common childhood diseases. Viruses are the most frequent origin. Group A Streptococcus (Streptococcus pyogenes) is the main bacterial cause. A culture or a rapid antigen-detection test of a throat-swab specimen should only be done on the basis of clinical scores, in order to avoid over-diagnosis of bacterial origin and unnecessary antibiotic prescription. The objectives of treatment are: the reduction of symptoms, reduce the contagious period, and prevent local suppurative and systemic complications. Ideally, only confirmed cases should receive antibiotics. If there is no possibility to perform a rapid antigen-detection test, or in some cases if the result is negative, it is recommended to perform a culture and, if there is high suspicious index, to prescribe antibiotics. Penicillin is the treatment of choice, although amoxicillin is also accepted as the first option. Amoxicillin/clavulanate is not indicated in any case as empirical treatment. Macrolides are not a first choice antibiotic, and should be reserved for those patients with immediate penicillin allergy reaction or for the treatment of streptococcal carriers. It is of primordial importance to adapt the prescribing of antibiotics to the scientific evidence.

How do you improve compliance?

Compliance, or adherence, as it relates to health care is the extent to which a person's behavior coincides with medical or health advice. Medication compliance is critical for all aspects of pediatrics, specifically in successful treatment, disease prevention, and health promotion. Compliance depends on the patient's and physician's committing to the same objectives. It is unfortunate that numerous studies and physician accounts reveal difficulties in achieving compliance with pediatric medication therapy. Medication compliance in pediatric patients ranges from 11% to 93%. At least one third of all patients fail to complete relatively short-term treatment regimens. Poor compliance places children at risk for problems such as continued disease, complicates the physician-patient relationship, and prevents accurate assessment of the quality of care provided. This article presents the issue in the context of its incidence of and barriers to compliance and provides general principles to improve compliance in pediatrics by improving communication and characteristics of the practice setting. A one-on-one relationship between physician and patient is needed for communication and improved compliance.

Pattern of drug utilization in acute tonsillitis in a teaching hospital in Nepal

OBJECTIVE

A prospective study was undertaken to find out the baseline data on prescribing patten of drugs in acute tonsillitis.

METHODS

Prescriptions far acute tonsillitis were collected outside the ENT-OPD over a period of 6 months and were analyzed.

RESULTS

The average number of drugs per prescription was 3.24. Ninety five percent of the prescriptions contained antimicrobial agents (AMA with an average of 1.03 AMAs per prescription. AMA was the most commonly prescribed (31.81%) group of drugs followed by analgesics and antipyretics (20.70%). Amoxicillin (38.80%) and azithromycin (20.63%) were the most commonly prescribed AMAs. Erythromyein was prescribed in 11(6.73) patients while penicillin was not at all prescribed. Culture and sensitivity test was advised only in 14.75% of cases. Cough expectorants were the most commonly used fixed dose combination. Of the total drugs used, 96.9% were prescribed by brand names. The duration of therapy was not mentioned for 35.60% of the drugs prescribed. the iatyprtyriate and over use off antimicrobil agents make treatment east effective.

Diagnosis and treatment of group a streptococcal pharyngitis

Pharyngitis caused by the group A streptococcus requires accurate diagnosis and timely treatment to prevent acute rheumatic fever. Clinical signs and symptoms often do not distinguish pharyngitis caused by group A streptococci from pharyngitis caused by other microorganisms. Rapid antigen detection or throat culture are recommended for diagnosis except when viral signs and symptoms are prominent. Therapy with penicillin, the drug of choice, is associated with prevention of rheumatic fever, more rapid clinical improvement, and prompt loss of contagiousness. Bacteriologic treatment failure occurs despite universal sensitivity of group A streptococci to penicillin. The cause of treatment failure (and of chronic carriage) remain to be determined. Newer, more expensive antibiotics do not substantially enhance treatment success and need not be prescribed for most patients.

Adult and pediatric pharyngitis: a review

Acute pharyngitis is frequently encountered in the ambulatory care setting. Although usually of viral etiology, streptococcal disease is the focus of diagnostic efforts, in light of significant suppurative and nonsuppurative sequelae. The traditional symptoms of fever, adenopathy, and pharyngeal exudate are suggestive, but not diagnostic of streptococcal pharyngitis. Thus, the importance of diagnostic testing, including Group A beta hemolytic strep antigen screen and culture, is emphasized. Recent innovations in therapy include modification of antibiotic dosing regimens and use of cephalosporins to improve patient compliance.