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 microbiologic 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 .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Baquero F, García-Rodríguez JA, de Lomas JG, Aguilar L. Antimicrobial resistance of 914 beta-hemolytic streptococci isolated from pharyngeal swabs in Spain: results of a 1-year (1996-1997) multicenter surveillance study. The Spanish Surveillance Group for Respiratory Pathogens. Antimicrob Agents Chemother 1999; 43:178.
- Cornaglia G, Ligozzi M, Mazzariol A, et al. Resistance of Streptococcus pyogenes to erythromycin and related antibiotics in Italy. The Italian Surveillance Group for Antimicrobial Resistance. Clin Infect Dis 1998; 27 Suppl 1:S87.
- Woodin KA, Lee LH, Pichichero ME. Milder symptoms occur in recurrent episodes of streptococcal infection. Am J Dis Child 1991; 145:389.
- Pichichero ME, Hoeger W, Marsocci SM, et al. Variables influencing penicillin treatment outcome in streptococcal tonsillopharyngitis. Arch Pediatr Adolesc Med 1999; 153:565.
- Pichichero ME, Marsocci SM, Murphy ML, et al. Incidence of streptococcal carriers in private pediatric practice. Arch Pediatr Adolesc Med 1999; 153:624.
- Pichichero ME, Disney FA, Talpey WB, et al. Adverse and beneficial effects of immediate treatment of Group A beta-hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J 1987; 6:635.
- el-Daher NT, Hijazi SS, Rawashdeh NM, et al. Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V. Pediatr Infect Dis J 1991; 10:126.
- Zahr SR, Kasse AS, Abou-Shleib H, et al. Differences in serum penicillin concentrations following intramuscular injection on benzathine penicillin G (BPG) from different manufacturers. J Pharmacol Med 1992; 2:17.
- Altamimi S, Khalil A, Khalaiwi KA, et al. Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev 2012; :CD004872.
- Casey JR, Kahn R, Gmoser D, et al. Frequency of symptomatic relapses of group A beta-hemolytic streptococcal tonsillopharyngitis in children from 4 pediatric practices following penicillin, amoxicillin, and cephalosporin antibiotic treatment. Clin Pediatr (Phila) 2008; 47:549.
- Pichichero ME. Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment. Ann Emerg Med 1995; 25:390.
- Brook I. Emergence and persistence of beta-lactamase-producing bacteria in the oropharynx following penicillin treatment. Arch Otolaryngol Head Neck Surg 1988; 114:667.
- Pichichero ME. Controversies in the treatment of streptococcal pharyngitis. Am Fam Physician 1990; 42:1567.
- Pichichero ME, Margolis PA. A comparison of cephalosporins and penicillins in the treatment of group A beta-hemolytic streptococcal pharyngitis: a meta-analysis supporting the concept of microbial copathogenicity. Pediatr Infect Dis J 1991; 10:275.
- Brook I, Gober AE. Role of bacterial interference and beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococcal pharyngotonsillitis. Arch Otolaryngol Head Neck Surg 1995; 121:1405.
- Roos K, Grahn E, Holm SE, et al. Interfering alpha-streptococci as a protection against recurrent streptococcal tonsillitis in children. Int J Pediatr Otorhinolaryngol 1993; 25:141.
- Roos K, Holm SE, Grahn E, Lind L. Alpha-streptococci as supplementary treatment of recurrent streptococcal tonsillitis: a randomized placebo-controlled study. Scand J Infect Dis 1993; 25:31.
- Lafontaine ER, Wall D, Vanlerberg SL, et al. Moraxella catarrhalis coaggregates with Streptococcus pyogenes and modulates interactions of S. pyogenes with human epithelial cells. Infect Immun 2004; 72:6689.
- Brook I, Gober AE. Recovery of interfering and beta-lactamase-producing bacteria from group A beta-haemolytic streptococci carriers and non-carriers. J Med Microbiol 2006; 55:1741.
- Kaplan EL. The group A streptococcal upper respiratory tract carrier state: an enigma. J Pediatr 1980; 97:337.
- Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics 2010; 126:e557.
- Neeman R, Keller N, Barzilai A, et al. Prevalence of internalisation-associated gene, prtF1, among persisting group-A streptococcus strains isolated from asymptomatic carriers. Lancet 1998; 352:1974.
- Facinelli B, Spinaci C, Magi G, et al. Association between erythromycin resistance and ability to enter human respiratory cells in group A streptococci. Lancet 2001; 358:30.
- Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med 1996; 335:547.
- Martin JM, Green M, Barbadora KA, Wald ER. Group A streptococci among school-aged children: clinical characteristics and the carrier state. Pediatrics 2004; 114:1212.
- 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
- SOCIETY GUIDELINE LINKS