Antibiotic failure in the treatment of streptococcal tonsillopharyngitis
- Michael E Pichichero, MD
Michael E Pichichero, MD
- Director, Research Institute
- Rochester General Hospital
- Section Editors
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
The natural course of group A streptococcal (GAS) tonsillopharyngitis consists of rapid onset of symptoms and signs of infection with spontaneous resolution of symptoms within two to five days. Given the self-limited nature of symptoms of this infection, goals of antimicrobial therapy include not only reduction in duration and severity of symptoms (if antimicrobial therapy is initiated early) but, more importantly, reduction in duration of infectiousness, prevention of suppurative complications (eg, otitis, sinusitis), and prevention of nonsuppurative complications (eg, acute rheumatic fever and possibly acute glomerulonephritis). (See "Complications of streptococcal tonsillopharyngitis".)
GAS is universally sensitive to penicillin and cephalosporins. Macrolide resistance has been reported in more than 25 percent of GAS strains in Europe and Scandinavia and has also been described in the United States [1,2].
Some patients with streptococcal tonsillopharyngitis fail to achieve clinically persistent and/or microbiological cure after antimicrobial therapy. Factors associated with antibiotic failure in the treatment of streptococcal pharyngitis are reviewed here. The approach to treatment of streptococcal tonsillopharyngitis is discussed separately. (See "Treatment and prevention of streptococcal tonsillopharyngitis".)
FACTORS ASSOCIATED WITH ANTIBIOTIC FAILURE
No single antibiotic regimen eliminates group A Streptococcus (GAS) from the pharynx in 100 percent of cases. There are several potential explanations for antibiotic failure; these include epidemiologic, clinical, and microbiologic factors.
Epidemiologic factors — Crowded living conditions facilitate GAS transmission in households, workplaces, schools, and daycare centers. Recurrent infection with the same serotype following initial treatment may be associated with milder symptoms; these individuals are contagious to others in their environment and are themselves susceptible to acute rheumatic fever .
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- FACTORS ASSOCIATED WITH ANTIBIOTIC FAILURE
- Epidemiologic factors
- Clinical factors
- - Patient age
- - Duration of illness prior to treatment
- - Antibiotic formulation
- - Antibiotic duration
- - Choice of antibiotic
- - Patient adherence
- Microbiologic factors
- - Presence of copathogens
- - Alteration of microbial ecology
- - Coaggregation
- - Streptococcal carriage
- MANAGEMENT OF RECURRENT INFECTION