Streptococccal sore throat

transcript

Streptococcal Sore Throat

Anas Bahnassi PhD

Pharmacotherapy of Infectious Diseases

Anas Bahnassi 2014

A Case-Based Approach

hGoals of Therapy

• Provide symptomatic relief.

• Prevent suppurative complications, e.g. mastoiditis, cervical lymphadentitis.

• Prevent nonsuppurative commplications, e.g. acute rheumatic fever.

• Prevent spread of group A streptococci to contacts.

Anas Bahnassi 2014

hInvestigations

• Culturing group A streptococci is needed in a child:

– > 3 year old.

– Acute sore throat.

– Lacks signs of viral URT infection.

– Has the sore throat symptoms.

Anas Bahnassi 2014

InvestigationsClinical Diagnosis of Streptococcal Throat

• Adenitis.• Positive throat cultures.

Although not diagnostic:• Signs: tender cervical adenopathy, erythematous

pharynx and tonsils, pharyngeal exudate, excoriated nares, scarlatiniform rash.

• Symptoms: sore throat, pain on swallowing, headache, abdominal pain, nausea, vomiting, and feer.

Anas Bahnassi 2014

hLaboratory Diagnosis

• Throat culture “Gold Standard” results in 24-48 hrs.

• Repeat cultures are not necessary in asymptomatic patients.

• Antigen screening of throat secretion is fast (7-70 mins) but sensetivity (<90%). Too low to rule out streptococcal infection in children and adolescents.

• If Antigen screening is negative or unavailable:– Hold antibiotics for 48hrs

– Perform throat culture.

– This procedure does not increase the chance of rheumatic fever but avoids the unnecessary use of antibiotics.

Anas Bahnassi 2014

hSelected Pathogens of Acute Pharyngitis:

• Viruses: (Adenoviruses, cytomegalovirus, Epistein=Barr, enteroviruses, influenza, herpes simplex virus, and parainfluenza virus)

• Group A β-hemolytic streptococci (children 15-30%, Adults 5-10%)

• Group C and G β-hemolytic streptococci.• Neisseria gonorrheae (consider child abuse).• Mycoplasma pneumoniae.• Chlamydia trachomatis.• Chlamydophila pneumoniae.• Corynebacterium diphtheriae.• Archanobacterium hemolyticum.

Anas Bahnassi 2014

hManagement of Acute Pharyngitis

Anas Bahnassi 2014

Acute Sore ThroatClinical Assessment

Signs and Symptoms of Group A Streptococcal Pharyngitis

Rapid Antigen Test Throat Culture Immediate investigation not essential, but

diagnosis of streptococcal pharyngitis not ruled out

+ve -ve +ve -ve

Antibiotic and Symptomatic Treatment

Symptomatic Treatment Only

Therapeutic ChoicesNonpharmacologic

• Strict handwashing to prevent spread of infection.

• Exclude from school or daycare for 24 hours after antimicrobial therapy is begun.

Anas Bahnassi 2014

Therapeutic ChoicesPharmacologic

• Analgesics:– APAP.

– Ibuprofen.

– Lozenges, gargles, etc…

• Antibiotics:– Antibiotic therapy for group A streptococcal pharyngitis can shorten

the course of acute illness and prevent both suppurativenonsuppurative complications if started early in the illness.

– Penicillin is the DRUG of CHOICE.

– Cephalosporins are effective but should not replace penicillin.

– Amoxicillin suspension is more palatable than penicillin for children.

– Erythromycin can be used for patients with penicillin allergies.

Anas Bahnassi 2014

Antibiotic Treatment Recommendations

Anas Bahnassi 2014

Class Drug Dose ADR Comments Cost

Cephalo-sporins

Cefadroxil Adults:1g/day as a single dose or BID X10d

Hyper-sensitivity

Use if treatment with Penicillin fails

Cefixime Adults and Children >12yrs400mg/d X10days

Children 6m-12yrs8mg/kg/d X10days

Hyper-sensitivity

Available in suspension.

Cephalexin Adults:250mg QID X10d

Children:25-50mg/kg/day divided QID X10d

Hyper-sensitivity

Anas Bahnassi 2014

Cephalo-sporins

Cefprozil Adults and Children>12yrs500mg/d X10days

Children 6m-12yrs15mg/kg/d divided

Hyper-sensitivity

Cefuroxime Adults and Children>12yrs250mg BID X10days

Children 3m-12yrs20mg/kg/d divided BIDX10days

Hyper-sensitivity

Add milk or juice prior to dose.

Anas Bahnassi 2014

Ketolides Telithromycin Adults 800mg/day once X5days

Diarrhea Use if treatment with β-lactam fails

Telithromycin: Atorvastatin,Lovastatin, Simvastatin, Itraconazole, Ketoconazole.

Digoxin levels.

Contraindicated with ergot, pimozide and disopyramide.

Anas Bahnassi 2014

Linco-semides

Clindamycin Adults 600mg/day BID-QID X10 days

Children20-30mg/kg/dayDivided TID X10 days

Diarrhea

C.Difficile

Alternative to Erythomycin

Maybe used in symptomatic patients with multiple pharyngitis

Anas Bahnassi 2014

Macro-lides

Azithromycin Adults 500mg on day 1then 250 on days 2-5

Children12mg/kg/dayX 5 days.

Lower GI effects than Eryth.

Available in susp.

Less likely to interact with other meds.

Clarithromycin Adults 250mg BID X10d days

Children15mg/kg/dayDivided Bid X 10 days.

Lower GI effects than Eryth.

Available in susp.

Clarithromycin: Atorvastatin,Lovastatin, Simvastatin, prednisone, theophylline.

Anas Bahnassi 2014

Macro-lides

Erythromycin Adults 1g/d divided BID-QID X10d1hr prior meals to prevent interactions.

Nausea, vomiting, epigastricdistress, diarrhea, elevated liver enzymes, cholestaticjaundice.

Alternative to penicillin.

Clarithromycin: Atorvastatin,Lovastatin, Simvastatin, prednisone, theophylline.

Anas Bahnassi 2014

Penicillin Amoxicillin 40mg/kg/d divided BID-TID X10days

Well tolerated

Available in chewable andsuspension

Penicillin Adults: 330mg TID or 600mg BID X 10 days.Children: 25-50mg/kg/d divided BID

AnaphylaxisGI distressDiarrhea.

DRUG of Choice $

Amox/Clav Adults: 500mg BID X10 daysChildren: 40mg/kg/d divided TID

GI distressDiarrhea.

Maybe used in symptomatic patients with multiple pharyngitis

hTherapeutic Tips

• Early institution of antibiotic therapy shortens the duration of fever, cervical adenitis, pharyngeal infections, and hastens the overall clinical improvement.

• Early treatment can hasten the return of children to school and reduce the number of days out of work.

• Since there is no efficient way to differentiate acutely infected child and carrier of group A streptococci, all systemic patients with positive culture should be treated.

• Unfortunately Penicillin (Drug of Choice of Acute pharangitis) often fails to eradicate pharyngeal streptococcal carriage, Some advocate the use of clindamycin (20mg/kg/d TID X10d max 600mg/d) or the addition of rifampin (20mg/kg/d TID X10d max 600mg/d) for the final 4 days of penicillin therapy.

Anas Bahnassi 2014

Pharmacotherapy:Infectious Diseases:

Anas Bahnassi PhD

abahnassi@gmail.com

http://www.twitter.com/abpharm

http://www.facebook.com/pharmaprof

http://www.linkedin.com/in/abahnassiAnas Bahnassi 2014

Streptococccal sore throat

Health & Medicine