Which, if any, antibiotics to use for “strep throat”?
Penicillin is three times more likely than cephalosporins to fail in the treatment of “strep throat” in children, according to US researchers (Pediatrics 2004;113:866).
They carried out a meta-analysis of 35 randomised controlled studies
on the topic carried out since 1969, involving more than 7,000 children
aged under 18 years. Patients had to have had bacteriological confirmation
of group A beta-haemolytic streptococcal (GABHS) tonsillopharyngitis
and have had oral treatment with either a cephalosporin or penicillin
for 10 days.
The overall odds ratio of bacteriological cure rate was 3.02 for cephalosporins
compared with penicillin. The individual cephalosporins — cefalexin,
cefadroxil, cefuroxime, cefpodoxime, cefprozil, cefixime, ceftibuten,
and cefdinir — showed significantly lower bacteriological failure
rates. The odds ratio for clinical cure was 2.34 for cephalosporins compared
with penicillins.
These findings contradict some guidelines including those from the World
Health Organization and the American Academy of Pediatrics. Penicillin
is considered the gold standard for treating “strep throat”.
Sharon Conroy, lecturer in paediatric clinical pharmacy, University of
Nottingham, said the meta-analysis appeared well-conducted and convincing,
though results would be influenced by local patterns of microbial resistance.
She drew The Journal’s attention
to UK advice in Medicines for Children 2003, advising penicillin V first
line for this condition. She also pointed out 1999 recommendations from
the Scottish Intercollegiate Guidelines Network. These say that a 10-day
course of antibiotic may reduce the number and frequency of attacks of
recurrent sore throat associated with GABH streptococcus. It acknowledges
that cefuroxime may be superior to penicillin V where sore throat recurs
in antibiotic-treated
patients. It does not recommend antibiotic treatment of acute sore throat
or the taking of throat swabs to identify GABHS, as it deems these tests
unreliable.
Pharyngitis guidelines Another trial published this week assessed
US guidelines to treat group A streptococcus pharyngitis. There
are various US recommendations for treatments, with children generally
requiring throat cultures. Adults, on the other hand, may be treated
empirically, according to some guidelines, or only on positive
cultures,
according to others. The trial found that
empirical treatment, according to clinical prediction, is associated with a
high rate of unnecessary antibiotic use. Although UK guidance from SIGN does
not recommend
testing for this infection, the US researchers say that throat culture had
high sensitivity and specificity (JAMA 2004;291:1587).
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