TREATING ACUTE BACTERIAL PHARYNGOTONSILLITIS IN PEDIATRIC AGE

Gallenga CE, Ferrulli T. Treating acute bacterial pharyngotonsillitis in pediatric age. International Journal of Infection. 2023;7(1):23-26.

C.E. Gallenga^1* and T. Ferrulli²

¹ Section of Ophthalmology, Department of Biomedical Sciences and Specialist Surgery, University of Ferrara, Ferrara, Italy;
² Unit of Clinical Pathology and Microbiology, Miulli General Hospital, Acquaviva delle Fonti, Italy.

*Correspondence to:
Carla Enrica Gallenga,
Section of Ophthalmology,
Department of Biomedical Sciences and Specialist Surgery,
University of Ferrara,
44121 Ferrara, Italy.
e-mail: gllcln@unife.it

ABSTRACT

Acute pharyngotonsillitis is a common pathology in pediatric age that is frequently caused by group A Streptococcus pyogenes. Viral etiology is the most common cause, but other pathogens such as group C and G Streptococcus, Mycoplasma pneumoniae, and Neisseria gonorrhoeae, can also cause acute pharyngotonsillitis. Acute tonsillitis due to bacterial infection should be treated as soon as possible with antibiotics to prevent both suppurative and non-suppurative complications. The diagnosis of this viral or bacterial disease is not simple to perform and is usually based on the clinical picture and international guidelines. Rapid tests have a lower sensitivity than culture tests but allow for a rapid diagnostic framework. Antibiotic therapy in pediatric age should be given as soon as possible and is reserved for children who have sore throat, the main symptom. Antibiotics can prevent complications of pyogenic infection, although streptococcal pharyngotonsillitis is likely to heal on its own after a few days. Guidelines recommend treatment with penicillin, but recently it has been shown that amoxicillin was more effective after 10 days of treatment. The choice of treatment depends on tolerability, duration of the therapy, the number of daily administrations, and the route of administration, amongst other factors. Some authors recommend treatment with Clarithromycin because it is more easily distributed to body tissues.

KEYWORDS: Acute bacterial pharyngotonsillitis, children, treatment, tonsilitis, Streptococcus pyogenes, antiobiotic therapy

INTRODUCTION

Acute pharyngotonsillitis predominantly affects children and is the third most common pathology in pediatric age, causing approximately 10% of annual outpatient visits (1). The causative agent of acute bacterial pharyngotonsillitis is primarily Group A Streptococcus pyogenes (2). Other possible pathogens are group C and G Streptococcus, Mycoplasma pneumoniae, Corynebacterium diphtheriae (less common), and Neisseria gonorrhoeae.

Acute bacterial pharyngotonsillitis is common in children, and it should be diagnosed and treated promptly to avoid potential complications. The most frequent aetiology of acute pharyngotonsillitis is due to viruses in approximately 70% of cases, whereas 37% of cases are due to bacterial infections and almost always caused by S. pyogenes (3). The goal of antibiotic treatment in pharyngotonsillitis is to prevent the onset of suppurative complications, including nasopharyngeal abscess or peritonsillitis, and non-suppurative complications, such as rheumatic fever and post-streptococcal glomerulonephritis, amongst others (4).

DISCUSSION

Pyogenes pharyngitis is not easily distinguished from viral pharyngitis when based only on clinical symptoms (5). Clinical scores are utilized to identify subjects at risk of pyogenes infection, of which the most widely used in pediatric age is the McIsaac score. After scores are used to identify potential infection, confirmatory diagnostic tests are performed, which can be rapid tests or culture examinations (6).

Twelve national guidelines for managing acute pharyngotonsillitis are available in the literature; six of these guidelines are European, five are American, and one is Canadian. Some of the guidelines consider the microbiological confirmation of S. pyogenes infections, which is a routine test to promptly identify subjects to be treated, and the others indicate microbiological tests to selected cases (7).

Antibiotic therapy in pediatric age should be reserved for children with “sore throat” in which the suspicion is supported by a suggestive clinical score (McIsaac score > 2) and a positive rapid test and/or a positive culture test. The advantages of the rapid test compared to the culture test are numerous, including rapid diagnostic assessment, reduction of inconvenience for the patient’s family, and saving of economic resources (8).

However, rapid tests have a slightly lower sensitivity than the culture test (95% versus 100%). The McIsaac score is calculated by evaluating the following signs in the child being examined: fever (T > 38^O C), absence of cough, swelling of the anterior cervical lymph nodes, hypertrophy or exudation of the tonsils, and age under 15 years. For a score less than 2, no laboratory test is recommended and therefore, no antibiotic treatment; for a score less than 2, it is always advisable to resort to diagnostic tests (rapid test or culture test) before starting antibiotic treatment. For a score greater than 4, the use of diagnostic tests is optional, and antibiotic treatment can be carried out as a first resort (9).

Antibiotic treatment is postponed until microbiological testing is confirmed for important reasons. In order to prevent complications of pyogenic infection, it is sufficient to start antibiotic therapy within 9 days of the onset of symptoms. Streptococcal pharyngotonsillitis usually heals on its own in three to four days from the onset, and antibiotic therapy has relatively small benefits for acute symptoms, shortening the duration of symptoms by only 16 hours (10).

Although all guidelines agree in recommending penicillin V as the first-line treatment for streptococcal pharyngitis, recent randomized clinical trials have confirmed the higher efficacy of amoxicillin, both in terms of clinical and bacteriological cure (11). Treatment of streptococcal pharyngitis must last at least 10 days to eradicate the bacterium. If we compare the classic 10-day therapeutic regimen with penicillin V with a short therapeutic regimen of 6 days with amoxicillin, we can see an equivalence in terms of percentage eradication of relapses and side effects in the two treatments (12). Furthermore, the short treatment has a higher percentage of adherence to therapy. Compliance with antibiotic treatment depends on several factors, including tolerability, duration of treatment, number of daily administrations, and route of administration (13).

Despite the data reported on the increase in therapeutic failures with penicillins, they remain the treatment of choice in streptococcal pharyngitis. A percentage of therapeutic failures is probably attributable to the failure to identify patients allergic to penicillins, in which case, the use of macrolides is recommended (14). According to some authors, the macrolide Clarithromycin should used in the treatment of streptococcal pharyngitis because it is more easily distributed to body tissues and to the tonsils thanks to a better pharmacokinetic profile (15).

In Europe, the resistance of S. pyogenes to macrolides is approximately 38% (16). However, since the therapeutic alternatives in penicillin-allergic subjects are limited, the use of macrolides is still recommended, if sparing and associated with surveillance for erythromycin-resistance. It may be useful in this regard to determine in vitro the phenotypes of erythromycin-resistant S. pyogenes, especially in areas where macrolides are more frequently prescribed (17).

Cephalosporins should be reserved for cases in which the macrolide is not tolerated, however erythromycin can induce gastrointestinal side effects in pediatric age (18). The use of cephalosporins in cases of allergy to penicillins may be questionable as a cross-reaction to cephalosporins is possible. Third-generation cephalosporins are more effective than amoxicillin and clavulanic acid in the treatment of pharyngitis caused by S. pyogenes (19).

Furthermore, compliance with treatment with third-generation cephalosporins is greater than with amoxicillin and clavulanic acid, as these have better palatability and tolerability and are administered for a shorter period (5-6 days versus ten days of amoxicillin and clavulanic acid). However, no guideline recommends cephalosporins as first-line therapy for S. pyogenes pharyngitis, given their higher cost compared to amoxicillin and penicillin, and the risk of spreading resistant strains (12). Their use should therefore be limited not only to cases of allergy to penicillins (in which they represent a valid alternative to macrolides), but also to cases of recurrent pharyngitis. The efficacy of cephalosporins in terms of eradication is in fact higher than that of amoxicillin and amoxicillin clavulanate (20).

Among cephalosporins, only the first-generation ones are to be preferred (cefalexin or cefadroxil in two daily administrations). These antimicrobial agents have a narrower spectrum and are less expensive than second- and third-generation cephalosporins (21).

CONCLUSIONS

Acute bacterial pharyngotonsillitis is an infectious disease that mostly affects children and is mainly caused by S. pyogenes. It should be treated early to prevent complications and alleviate symptoms.

Conflict of interest

The authors declare that they have no conflict of interest.

REFERENCES

1. Pallon J, Sundqvist M, Hedin K. A 2-year follow-up study of patients with pharyngotonsillitis. BMC Infectious Diseases. 2018;18(1). doi:https://doi.org/10.1186/s12879-017-2917-4
2. Brook I, Dohar JE. Management of group A beta-hemolytic streptococcal pharyngotonsillitis in children. PubMed. 2006;55(12):S1-11; quiz S12.
3. Fernández González N, Herrero-Morín JD, Solís Sánchez G, et al. Variabilidad e idoneidad en el tratamiento antimicrobiano de las faringoamigdalitis agudas pediátricas en Asturias, España [Variability of antibiotic treatment in paediatric acute pharyngotonsillitis in Asturias, Spain]. Archivos argentinos de pediatría. 2012;110(3):207-213. doi:10.5546/aap.2012.207
4. Lundberg C, Nord CE. Streptococcal throat infections: still a complex clinical problem. Scandinavian journal of infectious diseases. Supplement. 1988;57:7-11.
5. Di Pierro F, Colombo M, Zanvit A, Risso P, Rottoli A. Use of Streptococcus salivarius K12 in the prevention of streptococcal and viral pharyngotonsillitis in children. Drug, Healthcare and Patient Safety. 2014;6:15-20. doi:https://doi.org/10.2147/dhps.s59665
6. Ba-Saddik IA, Munibari AA, Alhilali AM, et al. Prevalence of Group A beta-haemolytic Streptococcus isolated from children with acute pharyngotonsillitis in Aden, Yemen. Tropical medicine & international health. 2014;19(4):431-439. doi:https://doi.org/10.1111/tmi.12264
7. Tyrstrup M, André M, Brorsson A, Gröndal H, Strandberg EL, Hedin K. A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis. Scandinavian Journal of Primary Health Care. 2020;38(1):83-91. doi:https://doi.org/10.1080/02813432.2020.1717073
8. Safizadeh Shabestari SA, Malik ZA, Al-Najjar FYA. Diagnostic accuracy of QuickVue® Dipstick Strep A test and its effect on antibiotic prescribing in children in the United Arab Emirates. BMC Pediatrics. 2019;19(1). doi:https://doi.org/10.1186/s12887-019-1761-7
9. Muzio FD, Barucco M, Guerriero F. Diagnosis and treatment of acute pharyngitis/tonsillitis: a preliminary observational study in General Medicine. PubMed. 2016;20(23):4950-4954.
10. Mantia IL, Gelardi M, Drago L, et al. Probiotics in the add-on treatment of pharyngotonsillitis: a clinical experience. Journal of biological regulators and homeostatic agents. 2020;34(6 Suppl. 1):11-18.
11. Chiappini E, Regoli M, Bonsignori F, et al. Analysis of Different Recommendations From International Guidelines for the Management of Acute Pharyngitis in Adults and Children. Clinical Therapeutics. 2011;33(1):48-58. doi:https://doi.org/10.1016/j.clinthera.2011.02.001
12. Brook I. Antibacterial Therapy for Acute Group A Streptococcal Pharyngotonsillitis. Pediatric Drugs. 2002;4(11):747-754. doi:https://doi.org/10.2165/00128072-200204110-00006
13. Balfour JA, Benfield P. Cefpodoxime Proxetil. PharmacoEconomics. 1996;10(2):164-178. doi:https://doi.org/10.2165/00019053-199610020-00008
14. Salinas Salvador B, Moreno Sánchez A, Carmen Marcén G, Molina Herranz D, Arana Navarro T, García Vera C. Retrospective study on the effectiveness and safety of the shortened 5- to 7-day antibiotic regimen for acute streptococcal pharyngotonsillitis compared to the classic 10-day regimen. Anales de Pediatría (English Edition). 2022;97(6):398-404. doi:https://doi.org/10.1016/j.anpede.2022.07.005
15. Portier H. Five day clarithromycin modified release versus 10 day penicillin V for group A streptococcal pharyngitis: a multi-centre, open-label, randomized study. Journal of Antimicrobial Chemotherapy. 2002;49(2):337-344. doi:https://doi.org/10.1093/jac/49.2.337
16. Cattoir V. Mechanisms of Antibiotic Resistance. In: Ferretti JJ, Stevens DL, Fischetti VA, eds. Streptococcus pyogenes: Basic Biology to Clinical Manifestations. Oklahoma City (OK): University of Oklahoma Health Sciences Center; February 10, 2016.
17. Varaldo PE, Ripa S, Nicoletti G, et al. In vitro Activity of Sulbactam/Ampicillin against Ampicillin-Resistant, β-Lactamase-Producing Bacteria Isolated in Italian Hospitals. Chemotherapy. 1990;36(2):141-146. doi:https://doi.org/10.1159/000238760
18. Esposito S, Novelli A, Noviello S, D’Errico G. Trattamento della faringotonsillite acuta batterica in età pediatrica: una metanalisi [Treatment of acute bacterial tonsillopharyngitis in pediatrics: a meta-analysis]. Le infezioni in medicina. 2005;13(4):241-250.
19. Brook I, Gober AE. Rate of eradication of group A beta-hemolytic streptococci in children with pharyngo-tonsillitis by amoxicillin and cefdinir. International Journal of Pediatric Otorhinolaryngology. 2009;73(5):757-759. doi:https://doi.org/10.1016/j.ijporl.2009.02.004
20. Munck H, Jørgensen AW, Klug TE. Antibiotics for recurrent acute pharyngo-tonsillitis: systematic review. European Journal of Clinical Microbiology & Infectious Diseases: Official Publication of the European Society of Clinical Microbiology. 2018;37(7):1221-1230. doi:https://doi.org/10.1007/s10096-018-3245-3
21. de Jongh E, Opstelten W; Werkgroep NHG-Standaard Acute keelpijn. Herziening van de NHG-standaard ‘Acute keelpijn’ [Revision of the Dutch College of General Practitioners practice guideline ‘Acute sore throat’]. Ned Tijdschr Geneeskd. 2015;159:A9456.