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acute respiratory tract illnesses in the patients streptococcal pharyngitis because the presence of
households, the onset in late winter or early these antibodies reflects past infections and not
spring, the age of 3-4 years, the high fever, the ongoing infections10.
sore throat, intense headache and sore laterocer- Once diagnosed, patients with streptococcal
vical lymphadenopathy. pharyngo-tonsillitis should be treated with an
The viral forms, however, were thought to be appropriate antibiotic, in the correct dosage for
characterized by more modest acute systemic the duration necessary for the eradication of
symptoms, with less febrile temperature, but GABHS from the pharynx. Baseline antibiotics
concomitant involvement of the upper airways, for not allergic patients are penicillins, in partic-
the presence of family members with a similar ular amoxicillin. Treatment of streptococcal
disease, more gradual onset, usually in the sum- pharyngo-tonsillitis in patients allergic to peni-
mer, and elective involvement of the very first cillin should include (except cross-reactions) a
years of life. first-generation cephalosporin/second genera-
The symptoms of streptococcal pharyngo-ton- tion for 10 days (5-6 days for a third-generation
sillitis and non-streptococcal varieties overlap cephalosporin in case of dubious compliance to
and merge so widely that an accurate diagnosis 10-days therapy) or clarithromycin for 10 days
made only on the basis of clinical signs is virtual- or azithromycin for 5 days: recommended for
ly impossible, although some have been pro- patients with demonstrated IgE-mediated aller-
posed as clinical scores, such as the Mc Isaac3. gy to -lactam because of reporting macrolides
Considering that the acute pharyngo-tonsillitis resistant bacterial strains11-15.
is one of the diseases that pediatricians and gener-
al practitioners most frequently encounter (15 mil-
lion visits per year in the US alone), only a rela- Patients and Methods
tively small percentage of patients (20%-30% of
pediatric patients, even less in adults) are actually Patient
suffering from pharyngo-tonsillitis by GABHS. From November 2014 to April 2015, 50 adult
With the exception of other rare bacterial in- patients (mean age 27.48 years) with signs and
fections of the pharynx (caused by Corynebac- symptoms of acute pharyngo-tonsillitis were ob-
terium diphtheriae and Neisseria gonorrhoeae), served, in a study of general medicine. These pa-
antibiotic therapy is unnecessary for the acute tients, who in the absence of diagnostic tests
pharyngo-tonsillitis caused by other microorgan- (rapid test for GABHS), and even applying EBM
isms than GABHS even more so because most (Evidence Based Medicine), may be treated with
cases are caused by viruses and in particular ade- oral antibiotics (penicillin/cephalosporin or
novirus, influenza and parainfluenza viruses. It is macrolide if allergic). Informed consent was
extremely important to make the diagnosis accu- signed and reported in medical records.
rately to avoid unnecessary and potentially harm- Inclusion criteria (Figures 1 and 2): Major:
ful antibiotic prescriptions4-6. sore throat associated with erythema and/or pha-
At present, it is recommended to obtain a pha-
ryngeal tonsillar swab for rapid antigen testing
(RAD: Rapid antigen detection) in children or
adolescents with a history, signs and/or symp-
toms of suspected infection by GABHS. If RAD
test response is negative in subjects where there
is strong evidence or suspicion of infection, a
bacterial culture should be performed. In the case
of a positive RAD test response, the bacterial
culture is not necessary for the high reliability
and specificity of the tests7-9.
Bacterial culture is not necessary for the rou-
tine diagnosis of an acute pharyngitis by GABHS
in consideration of the correlation of the rapid
test with culture. The dosage of the anti strepto-
coccus antibodies ASO (Anti-streptolysin O) is
not recommended in the routine diagnosis of Figure 1.
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F. Di Muzio, M. Barucco, F. Guerriero
4952
Diagnosis and treatment of acute pharyngitis/tonsillitis
49.4% 34.4%
Amoxicillin
Expenditure for antibiotics
sense of a significant reduction in the use of un- 3) PALLA AH, KHAN RA, GILANI AH, MARRA F. Over pre-
scription of antibiotics for adult pharyngitis is
necessary and potentially harmful antibiotics prevalent in developing countries but can be re-
with a lower prevalence of drug-resistant forms duced using McIsaac modification of Centor
of bacteria. scores: a cross-sectional study. BMC Pulm Med
This small observational study in General 2012; 12: 70.
Medicine demonstrates that the use of rapid tests 4) WINDFUHR JP, TOEPFNER N, STEFFEN G, WALDFAHRER F,
has been proven both feasible and desirable. BERNER R. Clinical practice guideline: tonsillitis I. Di-
agnostics and nonsurgical management. Eur Arch
Otorhinolaryngol 2016 Jan 11. [Epub ahead of
print].
Conclusions
5) S UNJOO K. Optimal diagnosis and treatment of
group A streptococcal phar yngitis. Infect
Rapid tests, when the Guidelines are applied, Chemother 2015; 47: 202-204.
can help curb both pharmaceutical expenditure 6) AGARWAL M, RAGHUWANSHI SK, ASATI DP. Antibiotic
and the inappropriate use of antibiotics. use in sore throat: are we judicious? Indian J
Otolaryngol Head Neck Surg 2015; 67: 267-
270.
- 7) GUROL Y, AKAN H, IZBIRAK G, TEKKANAT ZT, GUNDUZ
Conflict of Interest TS, HAYRAN O, YILMAZ G. The sensitivity and the
The Authors declare that there are no conflicts of interest. specifity of the rapid test in streptococcal upper
respiratory tract infections. Int J Pediatr Otorhino-
laryngol 2010; 74: 591-593.
8) ESCMID SORE THROAT GUIDELINE GROUP, PELUCCHI C,
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