ORIGINAL STUDIES

Two Dosages of Clarithromycin for Five Days, Amoxicillin/Clavulanate for Five Days or Penicillin V for Ten Days in Acute Group A Streptococcal Tonsillopharyngitis
George A. Syrogiannopoulos, MD,* Bu lent Bozdogan, MD, PhD, Ioanna N. Grivea, MD,* Lois M. Ednie, BS, Dimitra I. Kritikou, PhD,* George D. Katopodis, MD,* Nicholas G. Beratis, MD,* Peter C. Appelbaum, MD, PhD, and The Hellenic Antibiotic-Resistant Respiratory Pathogens Study Group

Background: Short course antimicrobial therapy is suggested for group A streptococcal tonsillopharyngitis. Methods: The bacteriologic and clinical efcacies of clarithromycin 30 or 15 mg/kg/day twice daily (b.i.d.) or amoxicillin/clavulanate (43.8/6.2 mg/kg/day b.i.d.) for 5 days or penicillin V (30 mg/kg/day 3 times a day) for 10 days were compared. In a randomized, open label, parallel group, multicenter study, 626 children (216 years old) with tonsillopharyngitis were enrolled; 537 were evaluable for efcacy. Follow-up evaluations were performed at 4 8 and 2128 days after therapy. Results: At enrollment, 26% of the Streptococcus pyogenes isolates were clarithromycin-nonsusceptible. All regimens had an apparently similar clinical efcacy. The long term S. pyogenes eradication rates were 102 of 123 (83%) with amoxicillin/clavulanate and 88 of 114 (77%) with penicillin V. In the 30- and 15-mg/kg/day clarithromycin groups, eradication occurred in 71 of 86 (83%) and 59 of 80 (74%) of the clarithromycin-susceptible isolates (P 0.33), and in 4 of 28 (14%) and 5 of 26 (19%) of the clarithromycin-resistant isolates, respectively (clarithromycin-susceptible versus -resistant, P 0.0001). Both clarithromycin dosages were well-tolerated. Conclusions: In group A streptococcal tonsillopharyngitis, 5 days of clarithromycin or amoxicillin/clavulanate treatment had clinical efcacy comparable with that of 10 days of penicillin V treatment;

however, amoxicillin/clavulanate and penicillin V were bacteriologically more effective than clarithromycin because of its failure to eradicate the clarithromycin-resistant S. pyogenes isolates. The 5-day clarithromycin regimens are not recommended for treatment of streptococcal tonsillopharyngitis in areas where in vitro resistance of group A streptococci to clarithromycin is common. Key Words: clarithromycin, amoxicillin/clavulanate, penicillin V, tonsillopharyngitis, group A streptococci (Pediatr Infect Dis J 2004;23: 857 865)

Accepted for publication May 6, 2004. From the *Division of Infectious Disease, Department of Pediatrics, University of Patras, Medical School, Patras, Greece; and the Department of Pathology, Hershey Medical Center, Hershey, PA Supported in part by a grant from Abbott Laboratories and grant 2491 from the Research Committee of the University of Patras. Address for reprints: George A. Syrogiannopoulos, MD, Department of Pediatrics, University of Thessaly, School of Medicine, Papakyriazi 22, 412 22 Larissa, Greece. Fax 30-2410-681136; E-mail syrogian@ otenet.gr. Copyright 2004 by Lippincott Williams & Wilkins ISSN: 0891-3668/04/2309-0857 DOI: 10.1097/01.inf.0000138080.74674.a2

he main bacterial cause of tonsillitis and/or pharyngitis is the group A -hemolytic streptococcus (Streptococcus pyogenes).1,2 Antibiotic therapy can shorten the clinical course of streptococcal tonsillopharyngitis and prevent suppurative complications.3,4 However, the main objective of antibiotic therapy is eradication of the organism from the pharynx, which is necessary for prevention of acute rheumatic fever.57 Penicillin G or penicillin V has been the standard treatment of streptococcal tonsillopharyngitis. Aminopenicillins, cephalosporins, macrolides and clindamycin are also effective in eradicating the organism.2,714 Although oral antibiotics have typically been administered for 10 days to maximize eradication of S. pyogenes from the pharynx, selected agents, including clarithromycin, are equally effective when given for shorter periods of time.1523 Short course antibiotic therapy for group A streptococcal tonsillopharyngitis might offer an effective alternative treatment to conventional regimens with the potential for a better compliance,16 and it is frequently used in some European countries. Although group A streptococcal strains remain uniformly susceptible to penicillin G, macrolide resistance is

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prevalent among isolates in several European countries.24 29 During the 2-year period 1999 2000, 30% of group A streptococci in Greece have been reported to be macrolideresistant.28,30 Resistance rates in North America have been 3% until the late 1990s.31 More recent studies have noted that in some areas of North America resistance to the macrolide antibiotics might be increasing in group A streptococci.32,33 The main known mechanisms of macrolide resistance in S. pyogenes are a 14- and 15-membered macrolide-specic efux mechanism (M phenotype), encoded by the mef(A) gene,34 as well as modication of the ribosomal target by a methylase encoded by the conventional erm(B)35 and the recently described erm(TR) gene,36 hereafter designated erm(A) in accordance with recently accepted nomenclature.37 Methylation results in reduced binding of and coresistance to macrolide, lincosamide and streptogramin B (MLS) antibiotics. Methylase can be expressed either constitutively (cMLS phenotype) or inducibly (iMLS phenotype). In one report, a 10-day course of clarithromycin (15 mg/kg/day) eradicated 88% of the susceptible and 63% of the erythromycin-resistant group A streptococci, ie, all the erythromycin-resistant isolates with the efux mechanism and those with the inducible production of methylase.26 There has been no previous report on the efcacy of short course clarithromycin therapy in pediatric group A streptococcal tonsillopharyngitis in areas with high prevalence of macrolide-resistant S. pyogenes isolates. The aim of this study was to compare the bacteriologic and clinical efcacies of a 5-day course of clarithromycin given in 2 dosages (30 or 15 mg/kg/day), with a 5-day course of amoxicillin/clavulanate or the recommended 10-day course of penicillin V in children with acute onset group A streptococcal tonsillopharyngitis. Also we investigated the existing relationship between in vitro susceptibility and in vivo efcacy of the antimicrobial agents used.

MATERIALS AND METHODS

Patient Population, Initial Evaluation. Between November 2000 and December 2001, patients with acute tonsillopharyngitis were enrolled at the private ofces of 15 practicing pediatricians in various areas of Central and Southern Greece. These practitioners participate in the Hellenic AntibioticResistant Respiratory Pathogens Study Group. The study population consisted of children between 2 and 16 years of age, with signs and symptoms of acute tonsillopharyngitis (tonsil and/or pharyngeal erythema and/or exudate, with sore throat and/or dysphagia, and fever 37.8C) and a positive rapid identication test for streptococcal antigen (Strep A with OBC II; Abbott Laboratories), conrmed by a positive throat culture for S. pyogenes. Patients were excluded from the study for the following reasons: antibiotic treatment within 7 days before enrollment;

history of hypersensitivity reaction to amoxicillin, amoxicillin/clavulanate, penicillin or clarithromycin; or severe underlying disease. Patients with signs and symptoms suggestive of viral infection (cough, conjunctivitis, rhinitis) or concomitant presence of a respiratory tract infection other than tonsillopharyngitis (eg, acute otitis media) were also excluded. The research protocol was approved by the Ethics Committee of the General University Hospital of Patras, and written informed consent was obtained from one of the parents or guardians of each participant. Study Design. This was a randomized, open label, parallel group, multicenter study. The treatment options were: clarithromycin (30 mg/kg/day given in 2 divided doses; maximum dose, 500 mg twice a day) for 5 days; clarithromycin (15 mg/kg/day given in 2 divided doses; maximum dose, 250 mg twice a day) for 5 days; amoxicillin/clavulanate (43.8/6.2 mg/kg/day given in 2 divided doses; maximum dose, 1 g twice a day) for 5 days; penicillin V 30 mg/kg/day given in 3 divided doses; maximum dose 450 mg (750,000 IU) 3 times a day for 10 days. All patients who were consecutively examined and considered eligible for enrollment into the study were randomized in a 1:1:1:1 ratio at each study center to receive 1 of the 4 treatment regimens. The only additional authorized medication was an antipyretic agent. Children returned to the pediatricians ofce 4 8 days and 2128 days after completion of therapy (visit 2 and visit 3, respectively) for clinical and bacteriologic assessment. In the event of no clinical response or relapse, the patient was reevaluated by the investigator at any time before the scheduled visit. Laboratory Procedures. Throat swabs were placed in Amies transport medium and sent by courier to the Laboratory of the Division of Pediatric Infectious Disease of the University of Patras. The maximum delay between collection and cultivation was 72 h. At the laboratory, the swabs were plated onto Columbia agar plates, supplemented with 5% debrinated horse blood, 10 g of colistin sulfate and 15 g of nalidixic acid per ml (Difco Laboratories, Detroit, MI). The plates were incubated at 35C anaerobically for 24 h. All negative plates were incubated for an additional 24 h and reread. Isolates were identied as S. pyogenes by colony morphology, by -hemolysis on horse blood agar and by the bacitracin disk (Difco Laboratories). In addition, in all strains, the group A antigen was conrmed by the latex agglutination test (Streptex; Abbott Murex, United Kingdom). All S. pyogenes isolates were screened for susceptibility to erythromycin by both the disk diffusion method and the E-test method on Mueller-Hinton agar supplemented with 5% debrinated horse blood. The plates with the disks and the strips were incubated overnight at 35C in ambient air. Erythromycin resistance phenotypes were identied by the double disk diffusion test.34,38 All group A streptococci isolated from children evaluable for efcacy were transported to Hershey Medical Center
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in accordance with local and international regulations. There all strains were tested for susceptibility and by molecular analysis. Susceptibility testing was performed by agar dilution on Mueller-Hinton agar plates supplemented with 5% debrinated sheep blood for erythromycin, clarithromycin and penicillin G.39 Amoxicillin/clavulanate minimal inhibitory concentrations (MICs) were determined for all isolates from children treated with this antibiotic by E-test (AB Biodisk, Solna, Sweden). MICs were interpreted according to the criteria of the National Committee for Clinical Laboratory Standards.40 Detection of Macrolide Resistance Genes in S. pyogenes Isolates. Polymerase chain reaction analyses for the identication of the macrolide resistance determinants were performed on the isolates that were designated as erythromycinresistant by agar dilution.34,36 Molecular Analysis of S. pyogenes Isolates. Pulse eld gel electrophoresis (PFGE) was used to compare group A streptococci isolated before and after treatment to distinguish between persistence or relapse and reinfection with a new strain. PFGE was performed as described previously.39 DNA in plugs was digested in 200 L nal volume containing 20 units of SmaI (Promega, Madison, WI) overnight at room temperature. The chromosomal DNA from some of the strains, especially the ones with mef(A), could not be digested with SmaI. If the digestion was not achieved with SmaI, restriction enzymes SI (50C) or SalI (37C) were used. Interpretation of the interrelationships of PFGE patterns was performed by use of the criteria of Tenover et al.41 Microbiologic and molecular studies of group A streptococci were conducted by investigators who were unaware of the treatment arm. Participating pediatricians were not informed the results of the susceptibility testing of the S. pyogenes isolates. Clinical and Bacteriologic Evaluations. Patients were considered evaluable for efcacy when all inclusion and exclusion criteria were met, they complied with the protocol and they came for at least the rst follow-up evaluation. The primary efcacy endpoint was the microbiologic response at visit 2. Microbiologic success was dened by eradication of the pathogen identied at enrollment or identication on the follow-up throat culture of a S. pyogenes isolate with a PFGE type different from that of the initial streptococcal isolate, that is, reinfection. Microbiologic failure or noneradication was considered when an isolate of the same PFGE type was recovered with the baseline one. The secondary efcacy endpoints were the microbiologic response at visit 3, as well as the clinical efcacy response at visits 2 and 3. Clinical response at visit 2 was classied as success (cure or improvement) or failure that was noted up to visit 2. Improvement was dened as complete defervescence and improvement or disappearance of other signs and symptoms, so that there was no need to administer
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any additional antibiotic therapy. Failure was considered as absence of improvement in clinical signs and/or symptoms requiring additional antimicrobial therapy. Relapse was characterized by reappearance after visit 2 of signs and symptoms of infection that required additional antibiotic therapy. Both failures and relapses were conrmed by recovering a streptococcal isolate with the same PFGE type as the baseline one. All children who received at least 1 dose of antibiotic were evaluated for tolerability on the basis of adverse events noted by the parents or pediatricians. At visit 2, the investigator determined compliance based on information provided by the parents on the way the study drug was administered and the amount of liquid dispensed. If a patient had missed 20% of the doses of the study drug, the patient was considered compliant. Sample Size. The required sample size was calculated using the formula given by Makunch and Simon,42 supposing the following values: 5%; 1 0.80 (ie, a power of 80%); an inferiority threshold of 10%; an actual nil effect between clarithromycin and penicillin V; and a bacteriologic success rate of 80%. The formula showed that 127 patients were needed for evaluation in each treatment group, as planned in the protocol. Because it was expected that 15% of patients would not be evaluable, the target was to enroll 155 patients in each treatment group. Statistical Analysis. For the statistical evaluation of the efcacy results, all patients eligible on the basis of clinical and bacteriologic criteria were analyzed. The noninferiority of clarithromycin compared with penicillin V was assessed by means of a 2-sided 90% condence interval, assuming an inferiority threshold of 10% (clarithromycin-penicillin V). Differences in discrete variables among the treatment groups were evaluated with 2-way contingency tables. The standard 2 test was used for comparison of proportions between groups, with the use of Yates continuity correction in 2 2 tables. In the event of low expected frequencies, exact P values were obtained from SPSS version 11 (SPSS, Inc., Chicago, IL). Differences in continuous variables among the treatment groups were tested by analysis of variance. P 0.05 (2-tailed) was considered signicant.

RESULTS
A total of 626 patients (clarithromycin 30 mg/kg/day, 158; clarithromycin 15 mg/kg/day, 155; amoxicillin/clavulanate, 155; and penicillin V, 158) were enrolled. Of these 626 patients, 537 (86%) were evaluable by the previously stated criteria for bacteriologic and clinical efcacy analyses. Eighty-nine patients were excluded from the clinical and bacteriologic efcacy analysis for the following reasons: being culture-negative for S. pyogenes at initial visit (clarithromycin 30 mg, n 14; clarithromycin 15 mg, n 10; amoxicillin/clavulanate, n 14; penicillin V, n 16); failure to appear at both follow-up evaluations (the end of treatment

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evaluation was not performed) (clarithromycin 30 mg, n 4; clarithromycin 15 mg, n 6; amoxicillin/clavulanate, n 7; penicillin V, n 7); side effects leading to discontinuation of treatment (amoxicillin/clavulanate, n 1; penicillin V, n 1); noncompliance with the assigned treatment (penicillin V, n 1); and intercurrent infection with prescription of another antibiotic before the rst follow-up visit (clarithromycin 30 mg, n 4; clarithromycin 15 mg, n 2; amoxicillin/ clavulanate, n 1; penicillin V, n 1). Thirty-nine patients were evaluable clinically and bacteriologically for the rst, but not for the second, follow-up visit. The reasons for the exclusion were: failure to appear at visit 3 (clarithromycin 30 mg, n 5; clarithromycin 15 mg, n 7; amoxicillin/clavulanate, n 4; penicillin V, n 4); and intercurrent infection with prescription of another antibiotic (clarithromycin 30 mg, n 5; clarithromycin 15 mg, n 8; amoxicillin/clavulanate, n 1; penicillin V, n 5). Finally 41 patients were not evaluated bacteriologically at visit 3 because either they were clinical failures at visit 2 (n 21) or they were clinical successes, but the throat culture at visit 3 was delayed (clarithromycin 30 mg, n 5; clarithromycin 15 mg, n 3; amoxicillin/clavulanate, n 3; penicillin V, n 9). The treatment groups were similar at enrollment for demographic characteristics and pretreatment signs and symptoms of infection (Table 1). The number of patients younger than 3 years old was 1 of 135 (0.7%), 2 of 132 (1.5%), 2 of 135 (1.5%) and 5 of 135 (3.7%) of the evaluable children who were treated with clarithromycin 30 mg, clarithromycin 15 mg, amoxicillin/clavulanate and penicillin V, respectively (P 0.37). The number of patients younger than 5 years old was 26 of 135 (19%), 18 of 132 (14%), 24 of 135 (18%) and 25 of 135 (19%), respectively (P 0.62). Antimicrobial Susceptibility. Of the 626 enrolled patients, 572 were culture-positive for S. pyogenes at the initial visit. Clarithromycin results were available for the 537 isolates recovered from the evaluable patients; the remaining 35 isolates were screened only for erythromycin susceptibility. The 537 group A streptococci isolated from children evaluable for efcacy had penicillin G MICs ranging from

0.008 to 0.032 g/ml; MIC90 was 0.016 g/ml. The 135 isolates recovered from evaluable patients treated with amoxicillin/clavulanate had MICs of amoxicillin/clavulanate ranging from 0.008 to 0.064 g/ml; MIC90 was 0.032 g/ml. No -lactam-resistant isolates were found. Erythromycin resistance was seen in 40 of 144 (28%), 32 of 145 (22%), 44 of 141 (31%) and 32 of 142 (23%) of the group A streptococcal isolates recovered at the initial visit from the 572 culture-positive patients who were assigned to receive clarithromycin 30 mg/kg/day, clarithromycin 15 mg/ kg/day, amoxicillin/clavulanate and penicillin V, respectively (P 0.23). Nine of the total 149 patients with an erythromycin-resistant group A streptococcal isolate were excluded from the efcacy analysis (clarithromycin 30 mg, n 2; clarithromycin 15 mg, n 2; amoxicillin/clavulanate, n 2; penicillin V, n 3). Macrolide susceptibility data and molecular analysis were available for 537 streptococci isolated from the evaluable for efcacy patients. Twenty-six percent (140 of 537) of group A streptococcal isolates recovered from the pharynx before initiation of antibiotic therapy were resistant to erythromycin. Of the 140 erythromycin-resistant isolates, 135 (96%) were resistant also to clarithromycin (MICs 1 g/ml), whereas the remaining 5 isolates were intermediate to clarithromycin (Table 2). Clarithromycin MICs were 1 8 g/ml in 99 (73%) and high (MICs 32 g/ml) in 36 (27%) of the 135 clarithromycin-resistant group A streptococcal isolates, respectively. We did not nd any cases of bacteriologic treatment failures with S. pyogenes isolates with the same PFGE type with the baseline isolates that developed increased MICs of clarithromycin during treatment with clarithromycin 30 or 15 mg/kg/day for 5 days. Macrolide Resistance Determinants. We found that 40, 48 and 12% of the 140 S. pyogenes isolates with reduced susceptibility to clarithromycin carried 1 of the 3 distinct macrolide resistance determinants, the mef(A), erm(A) or erm(B) gene, respectively (Table 2). All these resistance determinants were distributed equally among the 4 treatment groups, except of a lower frequency of isolates harboring the

TABLE 1. Demographic and Clinical Characteristics of the Evaluable Patients at Enrollment in the Study According to the Treatment Regimen
No. Male 68 68 70 69 No. Female 67 64 65 66 Mean Age (yr) 8 (216)* 8 (216) 7 (215) 7 (216) Mean Body Wt (kg) 29 (10 66)* 31 (10 79) 26 (11 64) 28 (10 71) 1 Tonsillopharyngitis During the Preceding 3 mo 9 (7) 11 (8) 10 (7) 10 (7) Fever 37.8C 108 (80) 108 (82) 120 (89) 110 (81) Anterior Cervical Node Tenderness 63 (47) 60 (45) 61 (45) 77 (57)

Treatment Regimen

Dysphagia

Clarithromycin, 30 mg/kg/day Clarithromycin, 15 mg/kg/day Amoxicillin/clavulanate Penicillin V

*Numbers in parentheses, range. Numbers in parentheses, percent.

135 132 135 135

123 (91) 122 (92) 120 (89) 128 (95)

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TABLE 2. In Vitro Susceptibility and Macrolide Resistance Determinants Identified in the Initial Streptococcus pyogenes Isolates from 537 Evaluable Patients with Tonsillopharyngitis
Resistance Phenotype* N/S iMLS M iMLS iMLS cMLS Resistance Determinant N/S erm(A) mef(A) erm(A) erm(B) erm(B) No. of Isolates According to MICs (g/ml) to Clarithromycin 0.016 0.125 397 0.5 5 1 4 43 43 8 13 32 19 4 13

Susceptibility

Resistance Mechanism

Susceptible Intermediate Resistant

N/S Inducible methylase Active efflux Inducible methylase Inducible methylase Constitutive methylase

*M phenotype indicates resistance to 14- and 15-membered macrolides (M); iMLS phenotype, resistance to M and inducibly expressed resistance to lincosamides (L) and streptogramin B (S), MLS antibiotics; cMLS phenotype, constitutively expressed resistance to MLS antimicrobial agents. MIC90 0.064 g/ml. According to the National Committee for Clinical Laboratory Standards breakpoint. N/S indicates not studied.

mef(A) gene in the clarithromycin 15 mg group. Specically mef(A) was identied in 56 of the 140 clarithromycin-nonsusceptible isolates (clarithromycin 30 mg, 19 of 38; clarithromycin 15 mg, 4 of 30; amoxicillin/clavulanate, 19 of 41; penicillin V, 14 of 29) (P 0.008). erm(A) was identied in 67 S. pyogenes isolates with reduced susceptibility to clarithromycin (clarithromycin 30 mg, 14 of 38; clarithromycin 15 mg, 20 of 30; amoxicillin/clavulanate, 19 of 41; penicillin V, 14 of 29) (P 0.106). erm(B) was identied in 17 isolates (clarithromycin 30 mg, 5 of 38; clarithromycin 15 mg, 6 of 30; amoxicillin/clavulanate, 4 of 41; penicillin V, 2 of 29) (P 0.47). Efcacy. The number of patients classied as clinical success at visit 2 did not differ signicantly among the 4 treatment groups, although fewer patients treated with the lower dose of clarithromycin were clinically cured or improved. At visit 3, there was a further tendency for a lower rate of clinical success in the patients treated with clarithromycin 15 mg/kg/day, but it failed to reach the level of signicance (Table 3) (P 0.103). The in vitro susceptibility did not correlate with the clinical outcome in neither one of the two 5-day regimens of clarithromycin. No

subjects developed suppurative or nonsuppurative complications of group A streptococcal infection. Five days of amoxicillin/clavulanate therapy was similar to the 10-day course of penicillin V in eradicating S. pyogenes from the pharynx (Table 4). Amoxicillin/clavulanate and penicillin V were more effective than clarithromycin 30 or 15 mg in eradicating group A streptococci at visit 2 and 3, with the exception of the difference between penicillin

TABLE 4. Eradication of Initial Streptococcus pyogenes Isolate From Throat Cultures After Completion of Therapy
No. of Children With Eradication of S. pyogenes/Total No. Cultured Visit 2 Clarithromycin 30 mg/kg/day Clarithromycin-susceptible Clarithromycin-resistant All isolates Clarithromycin 15 mg/kg/day Clarithromycin-susceptible Clarithromycin-resistant All isolates Amoxicillin/clavulanate Clarithromycin-susceptible Clarithromycin-resistant All isolates Penicillin V Clarithromycin-susceptible Clarithromycin-resistant All isolates 78/97 (80)* 5/38 (13) 83/135 (61) 74/102 (73) 4/30 (13) 78/132 (59) 79/93 (85) 36/42 (86) 115/135 (85) 90/106 (85) 24/29 (83) 114/135 (84) Visit 3 71/86 (83) 4/28 (14) 75/114 (66) 59/80 (74) 5/26 (19) 64/106 (60) 67/82 (82) 35/41 (85) 102/123 (83) 69/89 (78) 19/25 (76) 88/114 (77)

Regimen, Susceptibility of Isolate to Clarithromycin

TABLE 3. Clinical Success at Visits 2 and 3 After Completion of Therapy

No. of Children With Clinical Success*/No. of Children Evaluated Visit 2 Clarithromycin 30 mg/kg/day Clarithromycin 15 mg/kg/day Amoxicillin/clavulanate Penicillin V 129/135 (96) 124/132 (94) 131/135 (97) 132/135 (98)

Regimen

Visit 3 118/125 (94) 104/117 (89) 122/130 (94) 118/124 (95)

*Children without clinical failure up to visit 2 or relapse up to visit 3 confirmed by reisolating the baseline strain. Visit 2, 4 8 days after the end of therapy; Visit 3, 2128 days after the end of therapy. Numbers in parentheses, percent.

*Numbers in parentheses, percent. Isolates with clarithromycin MICs of 0.5 g/ml included. Clarithromycin 30 mg versus 15 mg: visit 2, difference 2.4%, 90% CI 7.512.2%, P 0.78; visit 3, difference 5.4%, 90% CI 5.316.1%, P 0.49. Clarithromycin 30 mg versus penicillin V: visit 2, difference 23.0%, 90% CI 14.4 31.6%, P 0.0001; visit 3, difference 11.4%, 90% CI 1.6 21.2%, P 0.08. Clarithromycin 15 mg versus penicillin V: visits 2 and 3, P 0.0001 and P 0.01, respectively. Clarithromycin 30 or 15 mg versus amoxicillin/clavulanate: visits 2 and 3, P 0.0001 and P 0.004, respectively. For further statistical analyses, see text.

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V and clarithromycin 30 mg at visit 3 that failed to reach the level of signicance. The analysis of patients seen at both the convalescent visits, visits 2 and 3, showed that eradication of the initial S. pyogenes isolate from both the follow-up throat cultures occurred in 69 of 114 (61%), 56 of 106 (53%), 97 of 123 (79%) and 87 of 114 (76%) of the children treated with clarithromycin 30 mg, clarithromycin 15 mg, amoxicillin/ clavulanate and penicillin V, respectively (P 0.0001). The eradication rate was signicantly greater in the patients treated with amoxicillin/clavulanate than in those who received clarithromycin 30 mg (P 0.003) or 15 mg (P 0.0001). Also penicillin V eradicated S. pyogenes more frequently than did clarithromycin 30 mg (P 0.015) or 15 mg (P 0.0005). The analysis of the bacteriologic efcacy of the 4 treatment regimens according to the in vitro susceptibility showed that the reduced bacteriologic efcacy of the short course clarithromycin was mainly caused by its inability to eradicate clarithromycin-resistant S. pyogenes isolates (Tables 4 and 5). The eradication rates of the clarithromycinsusceptible and -resistant isolates in patients treated with clarithromycin 30 and 15 mg were signicantly lower in those with the clarithromycin-resistant group A streptococci (P 0.0001). In patients with clarithromycin-susceptible isolates, clarithromycin 30 mg had an eradication rate similar to that of amoxicillin/clavulanate (visit 2, P 0.53; visit 3, P 0.95) and penicillin V (visit 2, P 0.51; visit 3, P 0.52). Also the eradication rate of clarithromycin 15 mg did not differ signicantly from that of amoxicillin/clavulanate (P 0.70) or penicillin V (P 0.30) at visit 3, whereas at visit 2 it was signicantly lower than that with amoxicillin/clavulanate (P 0.05) or penicillin V (P 0.044). In patients with clarithromycin-resistant isolates, clarithromycin 30 mg was less effective than amoxicillin/clavulanate (visits 2 and 3, P 0.0001) and penicillin V (visits 2 and 3, P 0.0001). Similarly clarithromycin 15 mg was less effective than amoxicillin/clavulanate (visits 2 and 3, P 0.0001) and penicillin V (visit 2, P 0.0001; visit 3, P 0.0002).

Amoxicillin/clavulanate and penicillin V did not differ signicantly in eradicating clarithromycin-susceptible and -resistant group A streptococci at visits 2 and 3. The reduced bacteriologic efcacy of clarithromycin was similar among patients with S. pyogenes isolates carrying the mef(A), erm(A) or erm(B) macrolide resistance determinant. At visit 2, clarithromycin 30 mg eradicated 1 of 19 (5.3%), 3 of 14 (21%) and 1 of 5 (20%) of the isolates carrying the mef(A), erm(A), or erm(B) gene, respectively (P 0.41). At the same visit, clarithromycin 15 mg eradicated 0 of 4, 3 of 20 (15%) and 1 of 6 (17%) of the mef(A)-, erm(A)- or erm(B)-positive isolates, respectively (P 0.83). At visit 3, clarithromycin 30 mg eradicated 2 of 16 (12%), 2 of 10 (20%) and 0 of 2 of the isolates carrying the mef(A), erm(A) or erm(B) gene, respectively (P 1.00). At the same visit, clarithromycin 15 mg eradicated 2 of 3 (67%), 3 of 18 (17%) and 0 of 5 of the mef(A)-, erm(A)-, or erm(B)-positive isolates, respectively (P 0.083). The analysis of patients seen at both the convalescent visits, visits 2 and 3, showed that in the clarithromycin 30 mg group eradication of group A streptococci from both the follow-up throat cultures occurred in 1 of 16 (6.2%), 2 of 10 (20%) and 0 of 2 of the patients with isolates carrying the mef(A), erm(A) or erm(B) gene, respectively (P 0.63). Therapy with clarithromycin 15 mg eradicated from both the follow-up throat cultures 0 of 3, 1 of 18 (5.6%) and 0 of 5 of the mef(A)-, erm(A)- or erm(B)-positive isolates, respectively (P 1.00). Molecular Study of Isolates Recovered at Follow-up Visits. Nine (5.8%) and 25 (16%) of the 156 and 153 S. pyogenes isolates recovered at visits 2 and 3, respectively, had a PFGE type different from that of the initial isolate (Table 6). On the basis of the molecular analysis of the S. pyogenes isolates recovered at follow-up visits and applying the protocol definitions, there was no signicant difference among the 4 treatment groups regarding the rates of microbiologic relapse and reinfection. At visit 3, spontaneous eradication of S. pyogenes from the throat occurred in 3 of 52 (5.8%), 7 of 54 (13%), 5 of 20

TABLE 5. Eradication of Streptococcus pyogenes After the Completion of Clarithromycin Therapy in Relationship to the Level of Clarithromycin Resistance of the Initial Isolate
No. of Children with Eradication of S. pyogenes/Total No. of Children Cultured at Following MICs (g/ml) of Clarithromycin of the Initial Isolate 0.5 Clarithromycin 30 mg Visit 2 Visit 3 Clarithromycin 15 mg Visit 2 Visit 3 0/1 0/0 0/2 0/2 1 4 3/22 (14) 2/17 (12) 3/16 (19) 3/14 (21) 8 0/7 1/6 (17) 0/1 1/1 (100) 32 2/8 (25) 1/5 (20) 1/11 (9) 1/9 (11) Total 5/38 (13) 4/28 (14) 4/30 (13) 5/26 (19)

Regimen, Visit*

*Visit 2, 4 8 days after the end of therapy; visit 3, 2128 days after the end of therapy. Numbers in parentheses, percent.

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TABLE 6. Molecular Study of Streptococcus pyogenes Isolates Recovered from Children After the Completion of Therapy in Relationship to the Initial Isolate
Visit, Microbiologic Evaluation According to the Electrophoretic Type of S. pyogenes Isolate Visit 2 Total no. of patients No growth Persistence New strain Visit 3 Total no. of patients No growth at Visits 2 and 3 No growth at Visit 3, growth at Visit 2 Growth at Visits 2 and 3 Growth of the initial isolate at Visit 3, no growth at Visit 2 New strain Clarithromycin 30 mg/kg/day 135 81 (60)* 52 (39) 2 (1) Clarithromycin 15 mg/kg/day 132 74 (56) 54 (41) 4 (3) Amoxicillin/ Clavulanate 135 113 (84) 20 (15) 2 (1) Penicillin V

135 113 (84) 21 (15) 1 (1)

114 65 (57) 4 (4) 31 (27) 8 (7) 6 (5)

106 51 (48) 7 (7) 34 (32) 8 (7) 6 (6)

123 90 (73) 5 (4) 10 (8) 11 (9) 7 (6)

114 81 (71) 1 (1) 14 (12) 12 (11) 6 (5)

*Numbers in parentheses, percent. Identified only at visit 2: clarithromycin 30 mg (n 1), clarithromycin 15 mg (n 4), amoxicillin/clavulanate (n 2) and penicillin V (n 1). Persistence.

(25%) and 1 of 21 (4.8%) of patients with positive culture at visit 2 in the clarithromycin 30 mg, clarithromycin 15 mg, amoxicillin/clavulanate and penicillin V treatment arms, respectively (P 0.085). Overall at 2128 days after the completion of treatment, there was a spontaneous eradication of group A streptococci in 11% of the patients with a previously positive throat culture. Safety. Adverse events were recorded in 77 (12%) of the 626 patients enrolled in the study. Adverse events occurred in 25 (16%) of the 158, 21 (14%) of the 155, 23 (15%) of the 155 and 8 (5.1%) of the 158 assigned to the clarithromycin 30 mg, clarithromycin 15 mg, amoxicillin/clavulanate and penicillin V groups, respectively. The 2 clarithromycin dosages were comparable in tolerability (P 0.68). Adverse events, mainly gastrointestinal, were mild to moderate. Only 2 children, one in the amoxicillin/clavulanate and another in the penicillin V group, had to discontinue the treatment because of diarrhea and an allergic rash, respectively.

DISCUSSION
The 15-mg/kg/day dose of clarithromycin is the conventional one used in studies that evaluated 10-day as well as 5-day therapy for streptococcal tonsillopharyngitis.8,22 We thought that it would be useful to test a regimen with double that dosage of clarithromycin (30 mg/kg/day) to achieve higher concentrations in the blood and tissues. The larger dosage had higher clinical and bacteriologic success rates, but the difference between the 2 dosages failed to reach statistical signicance. The 4 regimens used did not differ signicantly in clinical efcacy, but there were signicant differences in bacteriologic efcacy. Specically, both the 5-day course of amoxicillin/clavulanate and the 10-day course of penicillin V had greater eradication rates than the two 5-day regimens of clarithromycin because of failure of clarithromycin to eradi 2004 Lippincott Williams & Wilkins

cate most of the S. pyogenes isolates with clarithromycin MICs 0.5 g/ml. Twenty-six percent of the S. pyogenes isolates recovered in this study were clarithromycin-nonsusceptible. Clarithromycin failed to eradicate the clarithromycin-resistant isolates irrespectively of the macrolide resistance determinant of the strains or the clarithromycin MICs. Previous published studies give variable results regarding the S. pyogenes eradication rate after macrolide therapy in relationship to the in vitro susceptibility ndings. Published studies evaluating macrolide therapy do not have consistent ndings. Varaldo et al25 failed to nd a correlation between in vitro resistance to macrolides and rate of noneradication in children with tonsillopharyngitis caused by S. pyogenes. In 2 other reports from Italy, clarithromycin therapy eradicated S. pyogenes in 60 63% of patients with erythromycin-resistant group A streptococci and in 88 92% of patients with erythromycin-susceptible isolates.26,29 Seppa la et al24 found that erythromycin failed to cure 47% of patients infected with erythromycin-resistant group A streptococci (including moderately resistant strains), as compared with 4% of patients with erythromycin-susceptible isolates. The last 3 studies seem to suggest a relationship between macrolide resistance and bacteriologic failure. In our study, there was a strong relationship between in vitro resistance to clarithromycin and the rate of noneradication of S. pyogenes in patients with tonsillopharyngitis who received 5-day clarithromycin therapy. The lower eradication rate of clarithromycin-resistant group A streptococci observed in our study might be related to differences in the applied protocols, such as the shorter duration of antibiotic therapy we used and the different timing of the follow-up throat cultures. It is a speculation that the absence of treatment failures with emergence of S. pyogenes isolates of the same PFGE type with the baseline isolates that had developed increased MICs of clarithromycin in the course of treatment with any of

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the 2 clarithromycin regimens used might indicate that a short course of clarithromycin does not particularly promote the emergence of strains with resistance to this antibiotic. The emergence of resistance has been reported in S. pyogenes strains after treatment with other macrolides, such as azithromycin and miocamycin.29,43 45 In several of these resistant strains, development of ribosomal protein mutations was detected.44,45 We did not observe emergence of S. pyogenes strains with resistance to clarithromycin attributed to the development of ribosomal protein mutations as a consequence of the 5-day clarithromycin therapy. The molecular analysis data indicate that in the majority of cases, bacteriologic failure was the result of persistence of the same S. pyogenes strain and that bacteriologic relapse was also caused by the same S. pyogenes strain, presumably derived from an endogenous source. Clarithromycin therapy was not associated with a signicant rate of relapse. Moreover the rate of reinfection with a S. pyogenes strain with a PFGE type different from that of the initial isolate was similar in the 4 treatment regimens, occurring at the long term follow-up visit in 6% of the patients in each group. At this visit, there was an average 11% spontaneous eradication of S. pyogenes in the patients with a previously positive throat culture. A potential limitation of the study is that we did not attempt to identify any group A streptococcal carriers beyond the fact that we included in the study only children with a typical clinical picture of streptococcal tonsillopharyngitis. However, any carriers included in the sample would be distributed equally among the 4 arms of the study. In conclusion, the clinical efcacy of a 5-day course of clarithromycin (30 or 15 mg/kg/day 3 times a day) did not differ signicantly from a 5-day course of amoxicillin/clavulanate (43.8/6.2 mg/kg/day twice a day) or a 10-day course of penicillin V (30 mg/kg/day 3 times a day) in the treatment of pediatric group A streptococcal tonsillopharyngitis; however, amoxicillin/clavulanate and penicillin V were bacteriologically more effective than clarithromycin because of its failure to eradicate most of the clarithromycin-resistant S. pyogenes isolates. The 5-day clarithromycin regimens are not recommended for treatment of streptococcal tonsillopharyngitis in areas where in vitro resistance of group A streptococci to clarithromycin is common.

Preveza; and Ioannis Psaras, Egion. In addition, we thank Dr. Clive Richardson, Panteion University, Athens, Greece, for performing the statistical analysis. REFERENCES
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ACKNOWLEDGMENTS
We thank the investigating physicians who enrolled evaluable patients: Vassilios Angelis, Karditsa; Georgia Danasi-Loukopoulou, Nafpaktos; Argyro Chereti, Kiato; Panagiotis Fakos, Patras; Garyfalia Chioti, Kalamata; Ekaterini Ifanti, Egion; Anthi Kakogianni, Patras; Kyriaki Kotsioni, Amaliada; Elias Mamalis, Agrinio; Christos Mitselos, Pyrgos; Constantinos Panagopoulos, Patras; Dimitrios Papalabrou, Patras; Irini Papanagiotou, Agrinio; Eugenia Passa,

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