Faringoamigdalitis por Streptococo grupo A.docx

8/10/2019 Faringoamigdalitis por Streptococo grupo A.docx

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Faringoamigdalitis por Streptococo grupo A

- Inicio abrupto- Odinofagia- Exudado amigdaliano

- Adenopata cervical sensible- Fiebre- Resolucin espontnea en 2-5 das.- Si odinofagia dura ms de 1 semana, en general no es.

- 15-30% de faringitis en nios de 5-15 aos.

- En general en invierno e inicios de primavera.

- Tambin puede acompaarse de cefalea, nuseas y vmitos, dolor

abdominal, disminucin de ingesta oral, petequias palatinas, vula

inflamada, rash escarlatiniforme.

Metas teraputicas para erradicacin del estrepto grupo a de la faringe :

- Reducir la duracin y severidad del cuadro, incluyendo complicacionessupurativas

- Reducir incidencia de complicaciones no-supurativas: ej: fiebrereumtica aguda.

- Reducir transmisin a contactos cercanos al reducir infectividad.

Consideraciones de tratamiento: facilitar administracin Ab y gasto limitado con los

menos efectos adversos posibles.

- Ab es lo ms beneficioso para apurar la resolucin de los sntomas si se daen los 1 2 das de enfermedad.

- Tambin es beneficiosa para reducir las complicaciones supurativas comoabsceso periamigdaliano, linfadenitis cervical y mastoiditis.

- Reduccin complic no-supurativas: principalmente reduce incidencia defiebre reumtica aguda. Rol de Ab en disminuir glomerulonefritis y trastornoneuropsiquitrico peditrico asociado con SGA (PANDAS) no est claro.

- Fiebre reumtica aguda(FRA): aunque los sntomas de faringitis por SGA

se resuelven con Ab, persisten los organismos en el tracto respiratoriosuperior produciendo respuesta inmune que puede conllevar el riesgo defiebre reumtica aguda si la cepa es reumatognica y el husped estgenticamente predispuesto. En alguna poblacin, el S. grupo B y Ctambin podran jugar un rol en patognesis de FRA.

- Prevencin primaria de FRA con penicilina (G). es til si se inicia hasta 9das luego de iniciados los sntomas.


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- Glomerulonefritis: Nios menores de 7 aos parecen tener el mayor riesgode GNPS. El rol del Ab para prevenirla no es claro.

- Transmisin a contactos cercanos es aprox 35%. Ab tiene rol en prevenirlo.luego de 24hrs de tto con penicilina aprox 80% cultivos (-)

Tto:

- Confirmar SGA en faringe por cultivo o test rpido de deteccin antignica(RADT)

- Iniciarlo empricamente, y si los resultados son negativos, suspender.- Tb debe darse en SG-C y G, pero no por 10 das, sino por 5, ya que no se

complican con FRA.

- No hay beneficio para otras bacterias, excepto las raras por:corynebacterium diphteriae y n. gonorrhoeae.

- Historia natural: perodo incubacin 2-4 das, fiebre y sntomasconstitucionales mejoran en 3-4 das. Se observa mejora clnica 48hrsantes en pacientes con PNC vs. placebo en los 1s 2 das de enfermedad.

- Hay preocupacin sobre si la terapia temprana puede reducir la respuestainmune del husped, incrementando el riesgo de faringitis recurrente. Noest indicado retrasar el tratamiento, pero podra ser til en casos deinfeccin recurrente, moderada. Retrasar el tratamiento hasta 9 dastodava el til para prevenir la aparicin de FRA, aunque tal vez menos paralas complicaciones supurativas.

However, this approach should not be considered if

the patient is severely ill or if highly virulent or

rheumatogenic strains are actively circulating within acommunity. Patients are considered no longer

contagious after 24 hours of antibiotic therapy [15].
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ResistanceAntimicrobial resistance has not been

a significant issue in the treatment of GAS. No clinical

isolate of GAS has demonstrated penicillin

resistance, likely due to the organism's lack of altered

penicillin-binding proteins and/or inefficient gene

transfer mechanisms for resistance [22,23]. However,

streptococcal strains tolerant to penicillin (eg, strains

inhibited but not killed by penicillin in vitro, with ratio

of minimum bactericidal concentration to minimuminhibitory concentration [MIC] of 32) have been

described [24-27]. The clinical significance of such

strains is not clear; they have been isolated in the

setting of outbreaks in which penicillin treatment

failure was observed, but there was no difference in

failure rates among tolerant and susceptible strains.

(See "Antibiotic failure in the treatment of

streptococcal tonsillopharyngitis".)

There have been reports of relatively high levels of

resistance to macrolide antibiotics in some regions;

given the increasing use of macrolides for treatment

of upper and lower respiratory tract infections,

clinicians should be cognizant of local patterns of

antimicrobial resistance [28-37].
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SelectionOralpenicillin Vis the agent of choice

for treatment of GAS pharyngitis given its proven

efficacy, safety, narrow spectrum, and low cost [2,38-

42]. The appropriate duration is 10 days of therapy;

dosing is outlined in the Table (table 1). This

approach is extrapolated from studies performed in

the 1950s demonstrating that treatment of

streptococcal pharyngitis with intramuscular penicillin

prevents acute rheumatic fever [14,20].(See "Treatment and prevention of acute rheumatic

fever".)

Amoxicillinis often used in place of oral penicillin in

children, since the taste of the amoxicillin suspension

is more palatable than that of penicillin. Some datasuggest that oral amoxicillin may be marginally

superior to penicillin, most likely due to better

gastrointestinal (GI) absorption [43,44]. In addition,

amoxicillin has activity against the common

pathogens that cause otitis media (which presents

concurrently with GAS tonsillopharyngitis in up to 15

percent of children, particularly those under four

years of age). Dosing is outlined in the Table (table
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1). (See"Acute otitis media in children: Treatment",

section on 'Initial antimicrobial therapy'.)

Intramuscular penicillin G benzathine(single dose)

may be administered to patients who cannot

complete a 10-day course of oral therapy or to

patients at enhanced risk for rheumatic fever (eg,

those with history of previous rheumatic heart

disease and/or living in crowded conditions).

Injections of benzathine penicillin provide bactericidal

levels against GAS for 21 to 28 days. The addition of

procaine penicillin alleviates some of the discomfort

associated with benzathine injections and may

favorably influence the initial clinical response. The

preferred product in children is the combination of900,000 units of benzathine penicillin G plus 300,000

units of procaine penicillin (Bicillin C-

R 900/300). (SeePenicillin G benzathine-penicillin G

procaine:Drug information). Dosing is outlined in the

Table (table 1).

Cephalosporins are acceptable alternatives in

patients with recurrent GAS infection but are not

recommended as first-line therapy [45-52].
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Cephalosporins have demonstrated better

microbiologic and clinical cure rates than penicillin;

these differences appear to be greater among

children than adults, and some favor use of first-

generation cephalosporins as first-line therapy in this

group [53-55]. However, second- and third-generation

cephalosporins are more expensive than penicillin

and may facilitate development of antibiotic

resistance [46,47]. (See'Recurrent infection'below.)

Antibiotic therapy directed against beta-lactamase

producing upper respiratory tract flora (such

asamoxicillin-clavulanate) remains controversial and

is not indicated in patients with acute pharyngitis

[2,56,57].

For patients with beta-lactam hypersensitivity,

cephalosporins (cefuroxime,cefpodoxime,cefdinir,

andceftriaxone) may be used [38,44-50], in the

absence of history of life-threatening allergic reaction;

cross reactivity with penicillin is less likely for later-generation cephalosporins than first-generation

cephalosporins [45,58-60]. Macrolides

(clarithromycin,azithromycin, or erythromycin) are an
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acceptable alternative for penicillin allergic patients,

depending on local resistance patterns [28,31-36].

For the rare patient with an erythromycin-resistant

strain of GAS who is unable to tolerate beta-lactam

agents,clindamycinis an appropriate choice [61].

DurationIn general, the conventional duration of

oral antibiotic therapy to achieve maximal pharyngeal

GAS eradication rates is 10 days, even though

patients usually improve clinically within the first few

days of treatment [62,63]. If penicillin is discontinued

after three days of therapy, the probability of relapse

is higher than if penicillin is discontinued after seven

days of treatment (50 versus 34 percent, respectively)

[14,16,20].

Five days of therapy withcefpodoxime,cefdinir,

orazithromycinis an acceptable alternative

approach, with rates of bacteriologic and clinical cure

of streptococcal pharyngitis comparable with that of

the conventional 10-day course of penicillin [33-36,41,64-76].

Attempts to treat GAS pharyngitis with a single daily

dose of penicillin have been unsuccessful. Although
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some data suggest that once-dailyamoxicillinmay be

sufficient for treatment of GAS pharyngitis, others

have shown that this approach is not adequate for

effective eradication; further investigation is needed

[77-80]. Among the alternative

agents,azithromycinand some cephalosporins

(including cefixime,cefpodoxime,cefadroxil,

andcefdinir) are effective for eradication of

pharyngeal streptococci with once-daily dosing[69,81-84].

Antibiotics for other organismsThe differential

diagnosis of acute pharyngitis is outlined separately

(table 2). (See"Evaluation of acute pharyngitis in

adults".)

The approach to treatment of infection due to

Streptococcus other than group A, influenza,

infectious mononucleosis, primary HIV infection,

Neisseria gonorrhoeae, Mycoplasma pneumoniae,

Chlamydophila pneumoniae, and Corynebacteriumdiphtheriae is discussed separately. (See related

topics.)
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The approach to treatment of infection due to F.

necrophorum is uncertain; further study is needed to

better define the role of F. necrophorum in the

epidemiology of pharyngitis and the associated risk

between F. necrophorum pharyngitis and Lemierres

syndrome. Some favor empiric treatment with

penicillins or cephalosporins in the setting of negative

diagnostic test results but at least three Centor

criteria (fever, tonsillar exudate, swollen tendercervical adenopathy, or lack of cough) among

patients 15 to 30 years of age, although it is uncertain

whether this approach is effective for prevention of

Lemierres syndrome [85,86]. Therefore, we favor

antibiotic therapy for pharyngitis only in the setting of

positive diagnostic data [41]. (See"Suppurative

(septic) thrombophlebitis", section on 'Jugular

vein'and"Evaluation of acute pharyngitis in adults",

section on 'Evaluation'.)

The antibiotics of choice for treatment of infection due

to Arcanobacterium haemolyticum

areerythromycinorazithromycin; data are limited to

case reports and in vitro studies [87,88]. In vitro

studies show most strains to be susceptible to beta-
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lactam agents, although treatment failure may occur

because of poor penetration into the intracellular

space [88].Clindamycin,doxycycline,ciprofloxacin,

andvancomycinare also effective agents.

Follow-upPatients with GAS pharyngitis should

have improvement in clinical symptoms within three

to four days of initiating antibiotic therapy. Failure to

observe a clinical response to antibiotics should

prompt diagnostic reconsideration or the possibility of

a suppurative complication. If acute streptococcal

pharyngitis was diagnosed by rapid testing, the result

may represent a false-positive finding; if the diagnosis

was made by culture, the patient may be a

pharyngeal carrier whose symptoms are likelyattributable to an alternate process.

(See 'Carriers'below.)

In general, test of cure is not necessary for

asymptomatic patients or their close contacts

following completion of a course of antimicrobialtherapy. The majority of patients with GAS remaining

in their upper respiratory tracts after completing a
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course of antimicrobial therapy are Streptococcus

carriers [89,90].

However, follow-up test of cure is appropriate testing

for asymptomatic index patients and their

asymptomatic household contacts in the following

circumstances:

Individuals with history of rheumatic fever

Individuals who develop acute pharyngitis

during an outbreak of acute rheumatic fever or

acute poststreptococcal glomerulonephritis [90]

Spread of GAS among several family

members

Asymptomatic patients and asymptomatic household

contacts in the above circumstances with positive

laboratory results should receive a standard course of

antimicrobial therapy with one of the agents outlined

above [91]. Repeat treatment should be administered

with an agent with greater beta-lactamase stability

than the previous agent [56]. If a penicillin was used

for initial therapy, repeat treatment withamoxicillin-

clavulanateor a first-generation cephalosporin may

be used; if initial treatment was with a first generation
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cephalosporin, a second or third generation

cephalosporin may be used. (See"Evaluation of

acute pharyngitis in adults"and'Antibiotics for group A

Streptococcus'above.)

Recurrent infectionIn the setting of recurrent

acute pharyngitis with positive repeat diagnostic

testing, there are several possible explanations

[89,91,92]:

Persistence of Streptococcus carriage in the

setting of viral infection

Nonadherence with the prescribed

antimicrobial regimen

New infection with GAS acquired from

household or community contacts

Treatment failure (eg, repeat episode of

pharyngitis caused by the original infecting

strain); treatment failure is rare.

In the setting of a second episode of acute

pharyngitis with positive repeat diagnostic testing, a

repeat course of treatment is appropriate (table 1).

Repeat treatment should be administered with an
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agent with greater beta-lactamase stability than the

previous agent [56].

If adherence is uncertain, intramuscularpenicillin G

benzathinemay be chosen as the second course of

therapy. If a full course of penicillin was completed as

initial therapy, a first-generation cephalosporin (such

ascephalexin,cefadroxil) may be used; if a first-

generation cephalosporin was used for initial therapy,

a second- or third-generation cephalosporin (such

ascefpodoxime,cefdinir) may be used. Alternative

agents include amoxicillin-clavulanateor clindamycin.

It is not necessary to perform follow-up testing after

the second course of therapy unless the patient

remains or becomes symptomatic or unless special

circumstances as outlined above are present.

(See 'Antibiotics for group A Streptococcus'above

and'Follow-up'above.)

In the setting of multiple recurrent episodes, it may be

difficult to distinguish true GAS pharyngitis from viral

pharyngitis in the setting of streptococcal carriage. It

is likely that most of these patients are carriers

experiencing nonstreptococcal infections. This may
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be discernible by evaluating for the presence of GAS

during asymptomatic intervals and/or by typing

streptococcal isolates obtained during distinct

episodes (with the expertise of a specialized

laboratory). In these circumstances, treatment

withclindamycinor amoxicillin-clavulanatemay be

beneficial since these agents have demonstrated high

eradication rates for pharyngeal streptococci (table 1)

[56,61,93]. (See'Carriers'below.)

For patients with as many as six GAS infections in a

single year or three to four episodes in two

consecutive years, tonsillectomy may be an

appropriate therapeutic consideration [94,95]. This

was illustrated in a randomized trial including 187children with recurrent pharyngitis, of whom 95 were

managed with tonsillectomy [94]. The incidence of

pharyngitis during the first two years of follow-up was

significantly lower among the tonsillectomy group.

(See "Tonsillectomy and adenoidectomy in children:

Indications and contraindications", section on

'Recurrent infection'.)
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Antibiotic failure in the treatment of streptococcal

tonsillopharyngitis is discussed separately.

(See "Antibiotic failure in the treatment of

streptococcal tonsillopharyngitis".)

PREVENTION

CarriersIn general, group A Streptococcus (GAS)

resides in the oropharynx of Streptococcus carriers in

the absence of host immunologic response to theorganism [96]. In temperate climates during the winter

and spring, up to 20 percent of asymptomatic school-

aged children may be carriers. About 25 percent of

asymptomatic individuals in the households of index

patients harbor GAS in their upper respiratory tracts

[91]. Streptococcal carriage may persist for many

months. (See"Antibiotic failure in the treatment of

streptococcal tonsillopharyngitis", section on

'Streptococcal carriage'.)

Carriers may demonstrate evidence of GAS in the

upper respiratory tract during an episode of viral

pharyngitis, suggesting acute streptococcal

pharyngitis. In these circumstances, clinically

distinguishing viral from streptococcal pharyngitis can
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be difficult. Useful clues may include patient age,

season, local epidemiology, and the nature of

presenting signs and symptoms. In addition,

pharyngeal strep carriers tend to have very low

antistreptolysin O (ASO) titers; they may be just

above detectable. (See"Evaluation of acute

pharyngitis in adults".)

Streptococcus carriers are unlikely to spread the

organism to close contacts and are at very low risk for

developing suppurative complications or acute

rheumatic fever [96]. Moreover, eradication of GAS

from the upper respiratory tract of carriers is much

more difficult than eradication of GAS from patients

with acute infection [50,89,97]. In general, except forthe circumstances described above, streptococcus

carriers do not require antimicrobial therapy.

(See 'Follow-up'above.)

Foodborne illnessStreptococcal contamination of

food has been implicated in foodborne outbreaks ofpharyngitis [98-102], and foodborne transmission of

GAS pharyngitis by asymptomatic food service

workers with nasopharyngeal carriage has been
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reported [101,103,104]. Factors that can reduce

foodborne transmission of GAS pharyngitis include

thorough cooking, complete reheating, and use of

gloves while handling food [98,105].

ProphylaxisContinuous antimicrobial prophylaxis

is only appropriate for prevention of recurrent

rheumatic fever in patients who have experienced a

previous episode of rheumatic fever. (See"Treatment

and prevention of acute rheumatic fever", section on

'Secondary prevention'.)

VaccinationThere is no vaccine against GAS

available for clinical use, although development of

this preventive measure is under investigation

[106,107]. An important area of uncertainty is whether

vaccine-induced antibodies may cross-react with host

tissue to produce nonsuppurative sequelae in the

absence of clinical infection.

INFORMATION FOR PATIENTSUpToDate offers

two types of patient education materials, The Basics

and Beyond the Basics. The Basics patient

education pieces are written in plain language, at the

5thto 6

thgrade reading level, and they answer the
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four or five key questions a patient might have about

a given condition. These articles are best for patients

who want a general overview and who prefer short,

easy-to-read materials. Beyond the Basics patient

education pieces are longer, more sophisticated, and

more detailed. These articles are written at the 10thto

12thgrade reading level and are best for patients who

want in-depth information and are comfortable with

some medical jargon.

Here are the patient education articles that are

relevant to this topic. We encourage you to print or e-

mail these topics to your patients. (You can also

locate patient education articles on a variety of

subjects by searching on patient info and thekeyword(s) of interest.)

Basics topics (see"Patient information: Sore

throat in adults (The Basics)"and"Patient

information: Strep throat in children (The

Basics)"and"Patient information: Scarlet fever(The Basics)")

Beyond the Basics topics (see "Patient

information: Sore throat in children (Beyond the
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20/23

Basics)"and"Patient information: Sore throat in

adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Goals of antimicrobial therapy for eradication

of group A Streptococcus (GAS) from the

pharynx in the setting of acute streptococcal

pharyngitis include (see'Goals of

therapy'above):

Reducing duration and severity of clinical

signs and symptoms, including

suppurative complications

Reducing incidence of nonsuppurative

complications (eg, acute rheumatic fever)

Reducing transmission to close contacts

by reducing infectivity

We recommend initiating treatment with

antimicrobial therapy for patients with

symptomatic pharyngitis if the presence of

group A streptococci in the pharynx is confirmedby culture or rapid antigen detection testing

(RADT) (Grade 1A). (See'Treatment'above.)
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We suggest initiating treatment with

antimicrobial therapy for patients whose

clinical and/or epidemiologic factors point to a

high index of suspicion for GAS pharyngitis

while laboratory results are pending (Grade

2B). (See 'Treatment'above.)

Oral penicillin Vis the agent of choice for

treatment of GAS pharyngitis in many clinical

settings given its proven efficacy, safety, narrowspectrum, and low cost.Amoxicillinis often used

in place of oral penicillin in children, since the

taste of the amoxicillin suspension is more

palatable than that of penicillin (table 1). First-

generation cephalosporins are an acceptable

alternative to penicillin and amoxicillin in the

setting of treatment failure or beta-lactam

hypersensitivity. (See'Selection'above.)

Although most patients improve clinically

within the first few days of treatment, the

conventional duration of oral antibiotic therapyis 10 days to achieve maximal pharyngeal GAS

eradication rates. Intramuscular penicillin G

benzathinemay be administered to patients
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who cannot complete a 10-day course of oral

therapy. (See 'Duration'above.)

We suggest NOT treating with antibiotics forpharyngitis in the absence of positive diagnostic

culture data (Grade 2C). We

suggesterythromycinorazithromycinfor

treatment of pharyngitis due to A. haemolyticum

(Grade 2C). (See'Antibiotics for other

organisms'above.)

In general, test of cure is not necessary for

asymptomatic patients or their close contacts

following completion of a course of antimicrobial

therapy, except in unique circumstances.

(See 'Follow-up'above.)

We suggest a repeat course of treatment for

patients with a repeat episode of acute

pharyngitis and positive repeat diagnostic

testing (Grade 2C). Patients warranting a

repeat course of treatment may receive an

agent with greater beta-lactamase stability thanthe previous agent. (See'Recurrent

infection'above.)
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Patients who are long-term streptococcal

carriers may develop multiple episodes of

pharyngitis due to viral infection. In such cases,

repeatedly positive cultures or rapid antigen

tests for GAS may be misleading, and further

treatment for streptococcal pharyngitis may not

be warranted. Carriers are unlikely to spread

the organism to close contacts and are at very

low risk for developing suppurativecomplications or acute rheumatic fever.

Moreover, eradication of GAS from the upper

respiratory tract of carriers can be difficult and is

not necessary. (See'Carriers'above.)
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