amoxicillin treatment of streptococcal tonsillopharyngitis

Short-term treatment of streptococcal tonsillopharyngitis

Dtsch Arztebl 2001; 98 (48): A-3216 / B-2708 / C-2400 Scholz, Horst

rer to the post of lecturer Dr. Horst Scholz Prof. Dr. Dr. med. nat. Dr. hc. mult. Dieter Adam Helmer King Manfred in issue 21/2001
In the numerous letters to various aspects of antibiotic therapy with 
for streptococcal tonsillopharyngitis (such as selection of antibiotics, treatment costs and rates of penicillin dosage, resistance) critical comments. This illustrates how current discussion on the treatment of streptococcal tonsillopharyngitis after 50 years use of penicillin V is still.
First, be mentioned that the incidence of streptococcal sequelae in Germany before the start of the study was not known. In the case estimate was assumed that a frequency of three cases per 1000 children under the age of penicillin therapy, and an increase to more than eight children per 1 000 was a five-day regimen taken as significant difference. This hypothesis was tested whether complications occur in a short course of five days, significantly more than for a treatment period of ten days of penicillin V.
For the ten-day group (1530 patients) of amoxicillin penicillin V was chosen in the internationally usual dosage of 50 000 IU / kg / day. For the five-day group (3180 patients), six different antibiotics were used, was its effectiveness in earlier comparative studies, however, with lower numbers of cases detected. The DGPI could and would be aware of this large clinical trial is not set on an antibiotic for the five-day therapy, as there is for five-day treatment, no single substance that could be evaluated on behalf of all antibiotics.
The choice of  amoxicillin antibiotics according to the level of costs and many other criteria is still in the hands of the treating physician. The said in a letter costs per kg body weight / day, however, does not meet the specifications of the Red List. For instance, the price quoted for a daily dose of cefuroxime per kg DM, but not 4.09 0.75 DM


In the discussion of the treatment costs of a bacterial disease (causal therapy) should be borne in mind that the daily treatment costs are the deciding factor, but the medical effectiveness. The costs of an ineffective antibiotic therapy (additional diagnostic measures, secondary treatment, complications, though rare in-patient hospital stays, et cetera), the costs increase significantly. In addition, indirect (such as earnings and tax revenue, et cetera) and intangible costs are taken into account. The solidarity must pay finally for the total cost.
On the comment from a reader that the treatment of GAS tonsillopharyngitis, with amoxicillin-clavulanic acid would be wholly inappropriate to be received shortly. It was not the aim of the study, individual substances of the five-day treatment with each other or to compare against penicillin V. Such comparisons are shown in this study, however, outside the entire publication in individual contributions (1, 2). Amoxicillin-clavulanic acid was superior to penicillin in the study, the V in eradication of group A streptococci significantly (92.9 percent versus 84.4 percent). A major reason appears to be the degradation of penicillin by b-lactamases from other bacteria colonized the normal flora in Tonsillopharynxbereich. Among other factors (4, 5), this is a reason for the significantly superior eradication by amoxicillin-clavulanic acid and some cephalosporins. Compared with macrolides (clarithromycin) show the group A streptococci also a growing resistance in Germany, which is expressed in a lower clinical effectiveness (6).
The questions whether a shorter duration of therapy is possible with penicillin V, must be clearly denied by current knowledge. The present studies with five or seven days duration of therapy with penicillin V show significantly poorer results. This was the reason that penicillin V was not taken in addition to the five-day regimen.
A recent study of over 500 children with streptococcal tonsillopharyngitis has shown that is also inferior to treatment with penicillin V in the high dose, short-term treatment of the ten-day therapy in bacterial remediation rate significantly (P Guggenbichler, personal communication). Penicillin V is absorbed in the intestinal tract very poor, it has a short half-life and low penetration into the tonsil tissue (3). These are among other reasons, that the group A streptococci may be eradicated despite unchanged sensitivity to penicillin V and a shorter duration of treatment is not reliable. In addition, the long duration of therapy leads by ten days of penicillin V proved to be a poorer patient compliance, which in turn caused treatment failure.
Because of the low incidence of secondary diseases caused by streptococci in this respect was demonstrated by the study, no difference between the ten-day treatment and the five-day regimen. According to other results obtained, however, there is no reason to call the ten-day treatment with penicillin V as the standard therapy.
Literature
First Adam D, Scholz H, Helmer King M: Comparison of short-course (5 day) cefuroxime axetil with a standard 10-day oral penicillin V regimen in the treatment of tonsillopharyngitis. J Antimicrob Chemother 2000; 45 (Suppl): 23-30.
Second Adam D, Scholz H, Helmer M King, Ash K, Machka K: Acute streptococcal tonsillopharyngitis A 5-day amoxicillin / clavulanate versus 10-day penicillin V
treatment, clinical and bacteriological efficacy and incidence of poststreptococcal sequelae: In abstracts of the 22nd International Congress of Chemotherapy, Amsterdam, The Netherlands. June 30-July 3, 2001: p 17 049.
Third Holm SE: Treatment of recurrent tonsillopharyngitis.
J Antimicrob Chemother 2000; 45: 31-35.
4th Pichichero ME: Evaluating the need, timing and best choice of antibiotic therapy for acute otitis media and tonsillopharyngitis infections in children. Pediatr Infect Dis J 2000, 19: 131-140.
5th Sela S, Barzilai A: Why do we fail with penicillin in the treatment of group A streptococcus infections? The Finnish Medical Society Duodecim Ann Med 1999 31: 303-307.
6th Varaldo PE, Debbia EA, Nicoletti G, Pavesio D, Ripa S, Schito GC, Tempera G, and the Artemis-Italy Study Group: Nationwide survey in Italy of treatment of Streptococcus pyogenes pharyngitis in children: Influence of macrolide resistance on clinical and microbiological outcomes. Clin Infect Dis 1999; 29: 869-873.

Doz Dr med Horst Scholz
Institute of Infectious Diseases, Microbiology and Hygiene in the Hospital Book
Wiltbergstrasse 50
13125 Berlin