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#128 Evidence that’s tough to swallow: Short course antibiotics for pediatric strep throat


CLINICAL QUESTION
Is treatment with short course antibiotics as effective as a 10-day course of penicillin for children with Group A Streptococcal (GAS) pharyngitis?


BOTTOM LINE
In children with GAS pharyngitis, short course antibiotics (versus 10 days of penicillin) have similar clinical responses but higher rates of adverse events, likely due to drug selectionThe best evidence for rheumatic fever prevention remains with 10-day penicillin. 



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EVIDENCE
Systematic review: 20 randomized controlled trials (RCTs) of 13,102 children with GAS pharyngitis comparing short course (3-6 days) antibiotics (primarily cefuroxime, azithromycin, other macrolides) to 10 days of penicillin found:1  
  • Minimal and inconsistent differences in clinical outcomes.  
  • No significant difference in composite of complications (e.g. rheumatic fever (RF), glomerulonephritis). 
  • More adverse eventsPrimarily gastrointestinal (likely related to antibiotic choice). 
  • Limitations: 
    • Low quality studiesOnly three double-blinded. 
    • Only three studies reported long-term complications (like RF) 
    • Funding sources not reported.  
Largest RCT>4000 German children randomized to one of six antibiotics (including amoxicillin/clavulanate, erythromycin, and clarithromycin) for five days or 10 days of penicillin demonstrated:2  
  • No difference in overall clinical response at 1-2 weeks. 
  • Short course had fewer recurrences at one year (21.9% vs. 24.8%, number needed to treat=35).  
  • Three cases of RF in short course arm, none with penicillin. 
  • Limitations: Open-labeled study, outcomes for individual antibiotics not reported.   
Context:  
  • About 1/3 of pediatric sore throats due to GAS3; antibiotics are prescribed in 60% of cases.4 
  • Symptoms normally resolve in 2-5 days.5 Antibiotics improve symptoms by ~16 hours.6 Antibiotics (in GAS patients) help one more patient in four be symptom-free at day three.6 
  • RF incidence~1/100,000 in developed countries, higher in lower socio-economic areas and developing countries.7  
    • Only penicillin has high level evidence for RF treatment or prevention and is effective if given up to nine days after symptom onset.6,8,9 
  • Current recommendationsTreat laboratory proven GAS pharyngitis with 10-day penicillin8,10-12 or amoxicillin.8,10,11   
    • Cephalexin x 10 days if penicillin intolerance. 
    • Azithromycin (3-5 days)clindamycin or clarithromycin (10 days) if severely penicillin allergic.8,10-12 


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Author(s):

  • Kevin Haley MD CCFP
  • Michael R Kolber BSc MD CCFP MSc
  • Tony Nickonchuk BScPharm

1. Altamimi S, Khalil A, Khalaiwi KA, et al. Cochrane Database Syst Rev. 2012; 8:CD004872.

2. Adam D, Schoz H, Helmerking M. J Infect Dis. 2000; 182(2):509-16.

3. Shaikh N, Swaminathan N, Hooper EG. J Pediatr. 2012; 160:487-93.

4. Dooling KL, Shapiro DJ, Van Beneden C, et al. JAMA Pediatrics. 2014; 168 (11):1073-4.

5. Thompson M, Cohen HD, Vodicka TA, et al. BMJ. 2013; 347:f7027.

6. Del Mar CB, Glasziou PP, Spinks AB. Cochrane Database Syst Rev. 2013; 11:CD000023.

7. Cilliers AM. BMJ. 2006; 333:1153-6.

8. Gerber MA, Baltimore RS, Eaton CB, et al. Circulation 2009; 119:1541-51.

9. Robertson KA, Volmink JA, Mayosi BM. BMC Cardiovasc Disord. 2005; 5:11.

10. Blondel-Hill E, Fryters S. Recommended Empiric Therapy of Selected Infections in Neonatal/Pediatric Patients: Pharyngitis. In: Bugs and Drugs: An Antimicrobial/Infectious Disease Reference. 2012; p. 124-7.

11. Shulman ST, Bisno AL, Clegg HW, et al. Clin Infect Dis. 2012; 55:e86-102.

12. Hamilton K, Jensen B, Regier L. Anti-infectives for Common Infections: Pharyngitis. In: RxFiles Drug Comparison Charts. 10th ed. Saskatoon, SK: Saskatoon Health Region; 2014; p. 78. Available from: http://www.rxfiles.ca/rxfiles/uploads/documents/members/CHT-ABX-Common-Infections.pdf. Last accessed October 7, 2014.

Authors do not have any conflicts to disclose.