Tools for Practice Outils pour la pratique


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


CLINICAL QUESTION
QUESTION CLINIQUE
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
RÉSULTAT FINAL
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. 



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session



EVIDENCE
DONNÉES PROBANTES
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 


Latest Tools for Practice
Derniers outils pour la pratique

#367 Oral Calcitonin Gene-related Peptide Antagonists: A painfully long name for the acute treatment of migraines

What are the risks and benefits of ubrogepant for the acute treatment of episodic migraines?
Read Lire 0.25 credits available Crédits disponibles

#366 Looking for Closure: Managing simple excisions or wounds efficiently

What are some options for efficiency in wound closure?
Read Lire 0.25 credits available Crédits disponibles

#365 Shrooms for Glooms: Evidence for psilocybin for depression

What are the benefits and harms of psilocybin for treatment-resistant/recurrent depression?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session


Author(s)
Auteur(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.