Pediatric ENT in 40 Minutes Gil C. Grimes, MD April 2007.
-
Upload
xavier-ray -
Category
Documents
-
view
220 -
download
0
Transcript of Pediatric ENT in 40 Minutes Gil C. Grimes, MD April 2007.
Pediatric ENT in 40 Minutes
Gil C. Grimes, MDApril 2007
Objectives Describe criteria for diagnosing Acute Otitis
Media Describe rationale for therapy for Acute
Otitis Media Describe Therapy for Serous Otitis Media Describe the role of Tympanostomy Tubes Describe the strategies for diagnosing
Strep Pharyngitis Describe Treatment options for Strep
Pharyngitis
My Bias I am a minimalist
If the evidence for intervention is not good I do nothing
Acute Otitis Media A diagnosis of AOM requires
a history of acute onset of signs and symptoms
the presence of middle ear effusion (MEE)
signs and symptoms of middle-ear inflammation.
Pediatrics 2004 May;113(5):1451-65 Level 1a
Acute Otitis Media The presence of MEE that is
indicated by any of the following: Bulging of the tympanic membrane Limited or absent mobility of the
tympanic membrane Air-fluid level behind the tympanic
membrane Otorrhea
Acute Otitis Media Signs or symptoms of middle-ear
inflammation as indicated by either Distinct erythema of the tympanic
membrane or Distinct otalgia
discomfort clearly referable to the ear(s) and
interference with or precludes normal activity or sleep
Acute Otitis Media Otitis Media?
Yes No
http://www.otol.uic.edu/research/microto/Microtoscopy/Case10origweb.jpg
Acute Otitis Media Otitis Media?
Yes No
www.orldoc.ch/index
Acute Otitis Media Prevalence Prevalence
10% US children diagnosed by 3 months 90% by 2 years (1)
Prospective cohort of children (2)
62% with AOM by 1 year 83% with AOM by 3 years
9th most common diagnosis during FM visits(3)
Coded 3.2% visits (3)
1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b2)J Infect Dis 1989 Jul;160(1):83 Level 2b3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c
Acute Otitis Media Etiology Viral pathogens found Tympanocentesis and
Nasal Aspirate in AOM RSV and coronavirus RNA in 75% children
5% dual viral infections
Bacterial pathogens detected 62%
Viral RNA detected in 57% bacteria-negative and 45% bacteria-positive samples
Pediatrics 1998 Aug;102(2):291 Level 1c
Acute Otitis Media Etiology Bacteria shifts
Streptococcus pneumoniae S. pneumoniae is the most common bacterial organism
identified non-typeable Haemophilus influenzae
H. flu identified primarily in children < 5, but reduced with routine immunization
Moraxella (Branhamella) catarrhalis
May be changing due to heptavalent pneumococcal vaccine
decrease in S. pneumoniae and increase in H. influenzae
Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b
Acute Otitis Media Risk Factors Formula feeding
incidence of otitis media is higher in formula-fed infants vs. breast-fed infants
incidence of prolonged ear infections was 5x higher among formula-fed infants
Duration OM episodes longer (8.8 vs. 5.9 days)
J Pediatric 1995 May;126(5 Pt 1):696 Level 2b
Acute Otitis Media Risk Factors Day Care Attendance
day care associated with increased risk of upper and lower respiratory tract illnesses in first year of life for children with familial history of atopy
prospective birth cohort study of 498 children with parental history of allergy or asthma followed prospectively for first year of life
Pediatrics 1999 Sep;104(3):495 Level 2b
Acute Otitis Media Risk Factors. Associated with 2 or more doctor-
diagnosed ear infections (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.7-3.6)
For children attending day care independent predictors of 2 or more doctor-diagnosed ear infections included exposure to pets in day care presence of rug or carpet in area where child
slept in day care nonresidential setting for day care
Pediatrics 1999 Sep;104(3):495 Level 2b
Acute Otitis Media Risk Factors Passive Smoking
625 Children Calgary first graders Middle ear disease
2 or more household smokers (crude odds ratio) [OR], 1.85; 95% confidence interval [CI], 1.15-2.97
10 or more cigarettes smoked by the mother per day (crude OR, 1.68; 95% CI, 1.12-2.52)
10 or more cigarettes smoked in total in the household per day (crude OR, 1.40; 95% CI, 0.98-2.00) during the first 3 years of life
Arch Pediatric Adolescent Med. 1998 Feb;152(2):127 Level 2c
Acute Otitis Media History
Poor predictive value Studies are not good
Statistics LR+ greater than 5 good LR- less than 0.5 good Specificity to rule in Sensitivity to rule out
Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
Acute Otitis Media
Symptom LR+ LR- Sensitivity Specificity
Ear rubbing 3.20 0.670 42% 87%
Ear pain 3.00 0.560 54% 82%
Excessive crying 1.80 0.650 55% 69%
Rhinitis 1.30 0.580 75% 43%
Restless sleeping 1.30 0.710 64% 51%
Poor appetite 1.10 0.970 36% 66%
Vomiting 1.00 1.000 11% 89%
Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
Acute Otitis Media Physical Findings
Based on prospective study of 8,859 ear-related visits among children 0.5-2.5 years with acute symptoms
myringotomy performed if middle ear effusion suspected on exam
51.5% had acute otitis media (i.e. middle ear effusion confirmed on myringotomy)
Color not particularly helpful but cloudy membrane predictive
red color was not highly predictive cloudy tympanic membrane had 80-96% positive predictive
value normal color dramatically reduces likelihood of AOM (2-5%
probability of middle ear effusion if normal color)
Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1a
Acute Otitis Media Physical Continued
Position helpful if clearly bulging bulging tympanic membrane had 89-96%
positive predictive value retracted tympanic membrane had 47-
50% positive predictive value normal position had 22-32% probability of
AOM
Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1a
Acute Otitis Media Mobility helpful if distinctly impaired
or clearly normal distinctly impaired mobility had 78-94%
positive predictive value slightly impaired mobility had 33-60%
positive predictive value normal mobility dramatically reduces
likelihood of AOM (2-5% probability of middle ear effusion if normal mobility)
Acute Otitis MediaTest Name
Positive Likelihood Ratio
TM position: bulging 51.00
TM color: cloudy 34.00
TM mobility: distinctly impaired
31.00
TM color: distinctly red 8.40
TM mobility: slightly impaired 4.00
TM position: retracted 3.50
TM color: slightly red 1.40
TM position: normal 0.50
TM color: normal 0.20
TM mobility: normal 0.20
Acute Otitis Media Type A pattern is
normal Type B pattern is
consistent with MEE
Type C is seen with retracted TM
Acute Otitis Media Prognosis Spontaneous resolution is the
norm 81% spontaneously resolve (1)
5000 children with otitis >90% resolved with supportive care 2.7% had a severe course (required
antibiotics or myringotomy at 5 days)
1) Arch Pediatr Adolesc Med 2001;155(10):1097Level 1a
Acute Otitis Media Prognosis Recurrent otitis media no long term
consequences usually spontaneous recovery study of 222 children with recurrent otitis
media who received no prophylaxis 4% developed chronic otitis media with effusion 12% continued having recurrent episodes most significant risk factor for continued
recurrence was age < 16 months (1)
1) Pediatrics 5 May 2004 113:1452 Level 1a
Acute Otitis Media Prognosis
Persistent effusion Watchful Waiting recommended in children
without the following: Permanent hearing loss independent of OME Suspected or diagnosed speech and language
delay or disorder Autism-spectrum disorder and other pervasive
developmental disorders syndromes (e.g., Down) Craniofacial disorders that include cognitive,
speech, and language delays Blindness or uncorrectable visual impairment Cleft palate with or without associated syndrome Developmental delay
Pediatrics 2004 113:5; 1412-1429 Level 1a
Acute Otitis Media Prognosis
Persistent effusion Change from B to non-B tympanogram
favorable 25% of OME of unknown duration
resolves in 3 months Warn parents of decreased hearing while
effusion present Recheck every three months
Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a
Acute Otitis Media Treatment Treat Pain
Acetaminophen and ibuprofen (1)
219 children treated with cefaclor evaluated pain at 2 days
Ibuprofen 7% with pain NNT 5 Acetaminophen 10% with pain NNT 6 Placebo 25%
1) Fundam Clin Pharmacol. 1996;10(4):387 Level 1c
Acute Otitis Media Treatment Topical analgesics effective 1
Systematic review of 4 RCT Anesthetic ear drops have significant
reduction in pain at 30 minutes Naturopathic herbals had similar results
at 30 minutes Longer duration of relief with
naturopathic drops
1- Cochrane Library 2006 Issue 3:CD005657 Level 1a
Acute Otitis Media Treatment Initial treatment options are observation or
antibiotics for children < 6 months old, antibiotics recommended for children 6 months to 2 years old observation
option recommended only if all of the following are present
otherwise healthy child uncertain diagnosis non-severe illness follow-up can be ensured so antibiotics can be started if
symptoms persist or worsen
antibiotics recommended if certain diagnosis of AOM, severe illness, or follow-up cannot be ensured
Acute Otitis Media Treatment
For children > 2 years old Observation option recommended only if the
following are present otherwise healthy child uncertain diagnosis OR non-severe illness follow-up can be ensured so antibiotics can be
started if symptoms persist or worsen
Antibiotics recommended if certain diagnosis of AOM and severe illness, or follow-up cannot be ensured
Am Fam Physician 2004 Jun 1;69(11):2713 Level 1a
Acute Otitis Media Treatment No improvement in 48-72 hours
Confirm the diagnosis If AOM certain then begin antibiotics if
not already started Change antibiotics if already started
Acute Otitis Media Treatment Wait and see approach is reasonable 283 children 6 month to 12 years with
acute otitis seen in ER At 4-6 days
Wait and see group not to fill Rx unless not better or if worse in 48 hours
Everyone got ibuprofen, otic drops and antibiotic Rx
94% follow up 62% of wait and see did not fill RX 13% in
standard care (NNT 2)
Acute Otitis Media Treatment Wait and See continued
No difference in otalgia severity or duration No difference in fever No difference in unscheduled follow up
appointment 8% of wait and see vs. 23% of standard care
had diarrhea (NNH 7) Data persisted to 11-14 days and 30-40
days
JAMA 2006 Sep 13;296(10):1235 Level 1b
Acute Otitis Media Treatment Antibiotics
CDC guidelines for management and surveillance of acute otitis media in era of pneumococcal resistance
You must know your community
1) Pediatrics 2004;113(5):1452 Level 1a
Acute Otitis Media Treatment
Amoxicillin 80-90 mg/kg/day divided TID for 10 days
Failure at 3 days switch to one of the following cefuroxime axetil (Ceftin) 15 mg/kg BID for 10
days amoxicillin-clavulanate (Augmentin)
Augmentin 45 mg/kg/day divided BID or 40 mg/kg/day divided TID, both for 10 days
ceftriaxone (Rocephin) IM 50mg/kg for 3 days
1) Pediatric Infect Dis J. 1999 Jan;18(1):1 Level 1a
Acute Otitis Media Treatment Penicillin Sensitive patients
Not Type I reaction (no urticaria or anaphylaxis) (1)
Cefdinir (Omnicef) 14 mg/kg divided once daily or BID for 5 days (BID dosing) or 10 days (once daily dosing) slightly better taste (2)
Cefpodoxime (Vantin) 10 mg/kg once daily for 10 days or divided BID for 5 days
Cefuroxime (Ceftin or Zinacef) 30 mg/kg divided BID for 10 days
Ceftriaxone (Rocephin) 50mg/kg IM once
1) Pediatrics 5 May 2004;113(5):1452 Level 1a 2) Pediatrics 2005 Apr;115(4):1048 Level 1a
Acute Otitis Media Treatment Penicillin Sensitive Patients
Type I reaction Azithromycin (Zithromax) 10 mg/kg day one then
5 mg/kg days 2-5 Clarithromycin (Biaxin) 15 mg/day divided BID for
10 days Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg
daily of erythromycin divided TID to QID for 10 days
Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10 mg/kg daily of trimethoprim divided BID for 10 days
Pediatrics 5 May 2004;113(5):1452 Level 1a
Acute Otitis Media Reality Shorter therapy 5 days is likely as
beneficial as longer therapy (1)
Early treatment with antibiotics may lead to increased resistance (2)
Side effects are as common as benefit NNT 15-17 at 1 week NNH 17 at one week
Delayed antibiotics result in decreased use and decreased likelihood of asking for antibiotics in the future (3)
1) JAMA. 1998 Jun 3;279(21):1736 Level 1a2) J Infect Dis. 2001 Mar 15;183(6):880 Level 43) BMJ 2001 Feb 10;322:336 Level 1c
Acute Otitis Media Guideline Review
Pediatrics 2004 May;113(5):1451 Summary can be found in Am Fam
Physician 2004 Jun 1;69(11):2713 editorial can be found in Am Fam
Physician 2004 Jun 1;69(11):2537 commentary can be found in Pediatrics
2004 Sep;114(3):898 commentary can be found in Pediatrics
2005 Feb;115(2):513
Serous Otitis Media
www.pedisurg.com/ PtEducENT/Default.htm
Serous Otitis Media Causes Causes
Overgrowth of lymphoid tissue in the nasopharynx
Chronic sinus infection Allergies of nose and nasopharynx Gastric reflux implicated
Pepsin seen in MEE 45 of 54 children with SOM (1)
Pepsin seen in MEE 59 of 65 children with SOM (2)
1) Lancet 2002 Feb 9;359(9305):493 Level 42) Laryngoscope. 2002 Nov;112(11):1930 Level 4
Serous Otitis Media Complications Permanent hearing loss (?) (5)
Tympanosclerosis Fibrosis of middle ear space Balance problems (1)
Minor language deficits (+/-) (2)
No association with attention or behavior in first 6 years of life (3)
Possible behavior problems in teens (4)
1) Pediatrics. 1997 Mar;99(3):334 Level 42) Pediatrics. 2000 May;105(5):1119 Level 2c3) Pediatrics. 2001 May;107(5):1037 Level 1b
4) Arch Dis Child. 2001 Aug;85(2):91 Level 1b5) Pediatrics. 2000 Sep;106(3):E42 Level 1c
Serous Otitis Media Physical Physical examination
Pearly gray Minimal dullness Minimal retraction Presence of effusion
Serous Otitis Media Tests Key tests
Pneumo-otoscopy with limited movement (1)
Sensitivity of 94% (95% CI: 92%-96%) Specificity of 80% (95% CI: 75%-86%)
Tympanogram B-curve (2)
81% sensitivity 56% specificity
1) Pediatrics. 2003 Dec;112(6 Pt 1):1379 Level 1a2) Clin Otolaryngol. 2003 Jun;28(3):183 Leve 1c
Serous Otitis Media Prognosis High rate of spontaneous resolution (1)
Most resolve in 3 months Meta-analysis 11 trials (2)
No significant hearing loss No speech/language delay
Tubes have consequences (3)
140 children followed 8 years Sequela higher at 3-5 years
47% for retraction pocket 67% for tympanic membrane atrophy 40% for myringosclerosis 23% for hearing loss
1) J Fam Pract 2000 Jul;49(7):605,612 Level 1a2) Pediatrics 2004 March; 113(3): e238 Level 1a3) Arch Otolaryngol Head Neck Surg. 2003 May;129(5):517 level 1b
Serous Otitis Media Treatment Medications
Antibiotics not beneficial (1)
Most rigorous meta-analysis find no benefit long-term
Some short-term benefit may exist Steroids
Nasal steroids no evidence of benefit (2)
Systemic steroids no difference long term (3)
1) J Fam Pract. 2003 Apr;52(4):321 FPIN network answer2) Cochrane Library 2006 Issue 3:CD001935 Level 1a3) Pediatrics. 2002 Dec;110(6):1071 Level 2b
Serous Otitis Media Treatment Antihistamines or decongestants
are not beneficial Cochrane review of trials of limited
quality Systematic review of 14 RCT No benefit found for any outcome Antihistamines were associated with
side effects (NNH 8)
Cochrane Library 2006 Issue 4:CD003423 Level 2a
Serous Otitis Media Treatment Surgery no clear evidence of benefit
RCT of a birth cohort that developed MEE (1) Randomized to early tube placement or delay of 6
months (unilateral MEE) to 9 months (bilateral MEE) Delayed group had better outcomes cognition,
language (not significant) at age 3 Follow up through 11 years of age no developmental
or speech delay 3
Reduced time with MEE but no change in language or hearing (2)
No change in quality of life
1) N Engl J Med. 2001 Apr 19;344(16):1179 Level 1b2) Cochrane Library 2005 Issue 1:CD001801 Level 1a3) N Engl J Med 2007 Jan18:356(3):248 Level 1b
Serous Otitis Media Treatment
Surgery no clear evidence of benefit Cohort 30,099 children born in the Netherlands
Routine hearing screening at age 9 months 1,081 who failed 3 successive hearing screens were
referred to ENT surgeon 386 found to have persistent bilateral otitis media with
effusion for 4-6 months 187 children (mean age 19.5 months) were
randomized to ventilation tubes vs. watchful waiting and followed for 1 year with language tests
Ventilation tubes reduced diagnoses of bilateral otitis media with effusion at all measurements (NNT 2-4),
No differences in language development Pediatrics 2000 Sep;106(3):e42 Level 1c
Serous Otitis Media Treatment Post-tube precautions
unrandomized trial in 533 children who underwent tympanostomy tube placement
parents self-selected into 1 of 3 "treatments" to prevent complications of swimming
no additional precautions antibiotic drops following swimming ear molds worn during swimming control group consisted of children who never went
swimming all were given precautions against deep water swimming
(> 180 cm), diving and soapy water in ears during bathing no benefit was noted from antibiotic ear drops or ear
plugs
Arch Otolaryngol Head Neck Surg. 1996 Mar;122(3):276 Level 2b
Strep Pharyngitis
http://web.indstate.edu/thcme/micro/strep/sld009.htm
Strep Pharyngitis Basics Bacteria Streptococcus pyogenes
AKA Group A beta-hemolytic streptococcus (GABHS)
More than 80 sero-types based on M protein Transmission
Person-person Aerosol Water NOT household pets (1)
Incubation period 2-4 days
Pediatric Infect Dis J 1995 May;14;372
Strep Pharyngitis Risk Factors More common during school year Crowded living situation Exposure to GABHS Youth Immunosuppression Smoking Excessive alcohol consumption Diabetes mellitus Recent illness
Griffin's 5 Minute Clinical Consult from InfoRetriever Level 5
Strep Pharyngitis Complications Acute Rheumatic Fever (1)
Develops in 1-3% children with GABHS Only throat infections not skin Common in developing nations (2)
30 million children in the developing world have heart disease due to rheumatic fever
70% of whom will die prematurely at average age of 35 Acute Glomerulonephritis
Less common than rheumatic fever Most patients recover
Tonsillitis Peritonsillar Abscess
1) Pediatrician. 1986;13(4):180 Level 32) Tropical Doctor 1999 Jul;29(3):129 Level 5
Strep Pharyngitis History Abrupt onset of symptoms Fever may last 4-5 days Constitutional symptoms
Fever and chills Myalgias Headache Nausea and vomiting
Unlikely to have runny nose, cough, conjunctivitis, hoarseness, diarrhea
Exposure to strep throat infection in previous 2 weeks associated with increased likelihood of strep throat
Strep Pharyngitis Therapy Reasons patients visit the physician for
sore throat 298 patient >12 year old in Belgium Most frequent reasons for visit
Establish cause (85.5%) Pain relief (84.5%) Information on disease course (82.7%) Seriousness of problem (76.4%) Time to recovery (75.7%) Education on treatments (73.2%) Desire antibiotic (37.6%)
Ann Fam Med 2006 Nov-Dec;4(6):494 Level 3c
Strep Pharyngitis Tests Rapid Strep Tests
Results available in 5-10 minutes 76-87% sensitivity > 95% specificity depending on specific test
kit used Genzyme's OSOM Ultra Strep A test
92.6% sensitivity 92.8% specificity
Biostar's Strep A OIA Max Test 75.5% sensitivity 97.1% specificity
Pediatric Infect Dis J 2002 Oct;21(10):922 Level 1c
Strep Pharyngitis Tests Rapid strep test
15% false positive rate in adults (1)
Study of 522 adults with acute pharyngitis and/or tonsillitis who had positive rapid antigen detection test results
77 (15%) had negative cultures for group A streptococci
Low sensitivity If sensitivity below 90% consider backup
culture (3)
Physicians should validate the sensitivity of their own Rapid strep tests
1) J Infect Dis. 2001 Apr 1;183(7):1135 Level 2b2) Br J Gen Pract 1998 Feb;48;959 Level 2b
3) Pediatrics 2004 Apr;113(4):924
Strep Pharyngitis Rules Canadian Approach
One Point Each Temp >38 C No Cough Tender anterior lymph nodes Tonsillar swelling or exudate Age 3-14 years
No Points Age 15-44 years
Subtract One point Age >44 years
CMAJ. 1998 Jan 13;158(1):75 Level 1c
Strep Pharyngitis RulesScore Overall (%) Cx (-) Cx(+) LR(+)
0 160 (31.8) 156(97.5) 4(2.5) 0.14
1 138(27.4) 131(94.9) 7(5.1) 0.32
2 98(19.5) 87(88.8) 11(11.2) 0.84
3 54(10.7) 39(72.2) 15(27.8) 2.49
4 53(10.5) 25(47.2) 28(52.8) 6.43
Strep Pharyngitis Strategies Canadian Scoring System Authors' recommendations
withhold antibiotics and culture if score 0-1
culture if score 2-3 empiric antibiotics if score 4-5
CMAJ. 2000 Oct 3;163(7):811 Level 1a
Strep Pharyngitis Strategies Study of 621 patients seen by 97
Canadian family physicians 600 had throat culture of which 17% were
positive risk of strep throat was 1% if score 0 or -1 10% if 1 17% if 2 35% if 3 51% if 4 or 5
following clinical rule would have reduced unnecessary antibiotic prescriptions by 64% and use of throat cultures by 35%
CMAJ. 2000 Oct 3;163(7):811 Level 1a
Strep Pharyngitis Rules Centor clinical prediction rule validated in
3 adult populations 1 point if tonsillar exudate 1 point if swollen tender anterior cervical
nodes 1 point if absence of cough 1 point of history of fever 0-1 points suggests very low risk 3-4 points suggests increased risk for strep
throat JAMA 2000 Dec 13;284(22);2912 Level 1a
Strep Pharyngitis Strategies CDC evidence-based guidelines Adults (1)
4 empiric treatment 3 empiric treatment or rapid antigen
testing with treatment only if positive 2 rapid antigen testing (treatment only
if positive) or no testing or antibiotic treatment
1 or 0 no testing or antibiotic treatment
1) Ann Intern Med 2001 Mar 20;134(6):479 Level 1a
Strep Pharyngitis Therapy Comfort Medications
systemic analgesics and antipyretics - such as acetaminophen (Tylenol) or NSAIDs (e.g., ibuprofen [Motrin])
topical analgesics (e.g., nonprescription throat sprays) and anesthetics (e.g., viscous lidocaine 2%)
warm salt water gargles throat lozenges, hard candy or frozen desserts soft foods or cold thick liquids (e.g., ice cream,
nectars, pudding) humidifier
Strep Pharyngitis Therapy Antibiotics
Penicillin is the gold standard for prevention of Rheumatic Fever (Historically)
Benzathine penicillin G 1.2 million U (600-900,000 U if age < 12) IM once
Penicillin V 500 mg PO tid for 10 days In children, penicillin VK 25-50 mg/kg/day
divided bid to qidCDC Recommendations
Strep Pharyngitis Therapy Amoxicillin
in children, 20-50 mg/kg/day divided bid to tid short-course amoxicillin (1 g PO bid for 6 days)
as effective as penicillin 500 mg tid for 10 days in trial of 338 patients > 15 years old (1)
clinical cure rate was 96.4% vs. 96.5% at 72 hours after treatment and 93.5% vs. 96.3% at 1 month
10 vs. 6 recurrences throat pain resolved more quickly on amoxicillin 3% vs. 5.2% adverse effects
1) Scand J Infect Dis. 1996;28(5):497 Level 1c
Strep Pharyngitis Therapy Amoxicillin
once-daily amoxicillin 750 mg PO qd for 10 days No significant difference in clinical or bacteriologic
responses at 18-24-hour follow-up visit
5% vs. 11% bacteriologic treatment failures at subsequent follow-up visits over 4 days through 3
weeks, 16% vs. 21% had positive throat cultures many were considered a "new acquisition" since the
organism was a different strain of group A beta-hemolytic streptococci;
among 79 patients in amoxicillin group 2 had macular rash 3 had diarrhea 3 had abdominal pain
Pediatrics. 1999 Jan;103(1):47 Level 1c
Strep Pharyngitis Therapy Oral Cephalosporins
Systematic review and meta-analysis of 35 randomized trials with 7,125 children
Most trials were low quality 59% with Jahad Score 0-2 Jahad score rates quality of study 0 (low) to 5 (high)
Bacteriologic cure rates (92.6% vs. 80.6%, NNT 8) Clinical cure rates (93.6% vs. 85.8%, NNT 13) Differences in clinical cure occurred among
studies of cefuroxime and loracarbef
Pediatrics 2004 Apr;113(4):866 Level 1a
Strep Pharyngitis Therapy Clarithromycin for 5 days as
effective as penicillin for 10 days 349 patients aged 12-40 with acute strep Randomized to clarithromycin modified-
release 500 mg once daily for 5 days vs. penicillin 590 mg tid for 10 days
No significant differences in clinical cure rates (88% vs. 92%) or eradication rates (83% vs. 84%)
Open Label Phase III Study
J Antimicrob Chemother 2002 Feb;49(2):337 Level 2c
Strep Pharyngitis Therapy Azithromycin
60 mg/kg total dose more effective than lower doses
20 mg/kg/day for 3 days 12 mg/kg/day for 5 days
Systematic review of 19 low to poor quality trials
NNT 7 for 60 mg/kg dose NNH 6 for 30 mg/kg dose
Clin Infect Dis 2005 Jun 15;40(12):1748 Level 2c
Strep Pharyngitis Therapy Dexamethasone 0.6 mg/kg up to 10
mg PO or IM in single dose associated with faster pain relief (median 4 hours) and may reduce return visits;
118 patients >15 years old presenting to emergency department
Randomized to dexamethasone 10 mg PO vs. dexamethasone 10 mg IM vs. double placebo
All patients given penicillin VK 500 mg (erythromycin 333 mg if penicillin-allergic) PO tid for 10 days and 6 doses of acetaminophen for 24 hours
Pain measured on 0-10 scaleLaryngoscope 2002 Jan;112(1):87 Level 2b
Strep Pharyngitis Therapy Median reduction in pain scores
IM dexamethasone 12 hours -4 24 hours -5 19% resolution at 24 hours
PO dexamethasone 12 hours -3 24 hours -4 20% resolution pain at 24 hours
Placebo 12 hours -2 24 hours -4 3% resolution of pain at 24 hours
Strep Pharyngitis Therapy Time to onset of pain relief was
5.8 hours with IM dexamethasone 6 hours with PO dexamethasone 10.1 hours with placebo (p = 0.029)
Return Visits within 5 days No patients receiving IM dexamethasone 7% receiving PO dexamethasone 16% receiving placebo returned to
emergency department for sore throat within 5 days (p = 0.23)
Strep Pharyngitis Guidelines Sore Throat Encounter Form
http://www.aafp.org/afp/20030901/pocform.html American Family Physician 2003
Sep1;68(5):938