Streptococccal sore throat

Pharnacologic and nonpharmacologic therapeutic choices to treat streptococcal sore throat.

1. 3 Streptococcal Sore Throat Anas Bahnassi PhD Pharmacotherapy of Infectious Diseases Anas Bahnassi 2014 A Case-Based Approach

2. Goals 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

3. Investigations 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

4. Investigations Clinical 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

5. Laboratory 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

6. Selected Pathogens of Acute Pharyngitis : Viruses: (Adenoviruses, cytomegalovirus, Epistein =Barr, enteroviruses , influenza, herpes s implex 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

7. Management of Acute Pharyngitis Anas Bahnassi 2014 Acute Sore Throat Clinical 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

8. Therapeutic Choices Nonpharmacologic Strict handwashing to prevent spread of infection. Exclude from school or daycare for 24 hours after antimicrobial therapy is begun. Anas Bahnassi 2014

9. Therapeutic Choices P harmacologic Analgesics: APAP. Ibuprofen. Lozenges, gargles, etc… Antibiotics: Antibiotic therapy for group A streptococcal pharyngitis can shorten the course of acute illness and prevent both suppurative nonsuppurative 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

10. 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 $$$ Cefixime Adults and Children >12yrs 400mg/d X10days Children 6m-12yrs 8mg/kg/d X10days Hyper-sensitivity Use if treatment with Penicillin fails Available in suspension. $$$$ Cephalexin Adults: 250mg QID X10d Children: 25-50mg/kg/day divided QID X10d Hyper-sensitivity Use if treatment with Penicillin fails Available in suspension. $

11. Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Cephalo-sporins Cefprozil Adults and Children >12yrs 500mg/d X10days Children 6m-12yrs 15mg/kg/d divided BID Hyper-sensitivity Use if treatment with Penicillin fails Available in suspension. $$$$ Cefuroxime Adults and Children >12yrs 250mg BID X10days Children 3m-12yrs 20mg/kg/d divided BIDX10days Hyper-sensitivity Use if treatment with Penicillin fails Available in suspension. Add milk or juice prior to dose. $$

12. Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost 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 . $$$$

13. Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Linco-semides Clindamycin Adults 600mg/day BID-QID X10 days Children 20-30mg/kg/day Divided TID X10 days Diarrhea C.Difficile Alternative to Erythomycin Maybe used in symptomatic patients with multiple pharyngitis Available in suspension. $$$$

14. Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Macro- lides Azithromycin Adults 500mg on day 1 then 250 on days 2-5 Children 12mg/kg/day X 5 days. Lower GI effects than Eryth . Available in susp . Less likely to interact with other meds. $$ Clarithromycin Adults 250mg BID X10d days Children 15mg/kg/day Divided Bid X 10 days. Lower GI effects than Eryth . Available in susp .  Clarithromycin : Atorvastatin , Lovastatin , Simvastatin , prednisone, theophylline . $$

15. Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Macro- lides Erythromycin Adults 1g/d divided BID-QID X10d 1hr prior meals to prevent interactions. Nausea, vomiting, epigastric distress, diarrhea, elevated liver enzymes, cholestatic jaundice. Alternative to penicillin.  Clarithromycin : Atorvastatin , Lovastatin , Simvastatin , prednisone, theophylline . $$

16. Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Penicillin Amoxicillin 40mg/kg/d divided BID-TID X10days Well tolerated Available in chewable and suspension $$ Penicillin Adults: 330mg TID or 600mg BID X 10 days. Children: 25-50mg/kg/d divided BID Anaphylaxis GI distress Diarrhea. DRUG of Choice $ Amox / Clav Adults: 500mg BID X10 days Children: 40mg/kg/d divided TID GI distress Diarrhea. Maybe used in symptomatic patients with multiple pharyngitis Available in suspension. $$

17. Therapeutic 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

18. Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD [email protected] http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi 2014