Corticosteroids as standalone or add-on treatment for sore throat.

BACKGROUND: Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract. This review is an update to our review published in 2012. OBJECTIVES: To assess the clinical benefit and safety of corticosteroids in reducing the symptoms of sore throat in adults and children. SEARCH METHODS: We searched CENTRAL (Issue 4, 2019), MEDLINE (1966 to 14 May 2019), Embase (1974 to 14 May 2019), the Database of Abstracts of Reviews of Effects (DARE, 2002 to 2015), and the NHS Economic Evaluation Database (inception to 2015). We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared steroids to either placebo or standard care in adults and children (aged over three years) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis (glandular fever), sore throat following tonsillectomy or intubation, or peritonsillar abscess. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included one new RCT in this update, for a total of nine trials involving 1319 participants (369 children and 950 adults). In eight trials, participants in both corticosteroid and placebo groups received antibiotics; one trial offered delayed prescription of antibiotics based on clinical assessment. Only two trials reported funding sources (government and a university foundation). In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by 2.40 times (risk ratio (RR) 2.4, 95% confidence interval (CI) 1.29 to 4.47; P = 0.006; I² = 67%; high-certainty evidence) and at 48 hours by 1.5 times (RR 1.50, 95% CI 1.27 to 1.76; P < 0.001; I² = 0%; high-certainty evidence). Five people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 11.6 hours, respectively, although significant heterogeneity was present (moderate-certainty evidence). At 24 hours, pain (assessed by visual analogue scales) was reduced by an additional 10.6% by corticosteroids (moderate-certainty evidence). No differences were reported in recurrence/relapse rates, days missed from work or school, or adverse events for participants taking corticosteroids compared to placebo. However, the reporting of adverse events was poor, and only two trials included children or reported days missed from work or school. The included studies were assessed as moderate quality evidence, but the small number of included studies has the potential to increase the uncertainty, particularly in terms of applying these results to children. AUTHORS' CONCLUSIONS: Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat. Given the limited benefit, further research into the harms and benefits of short courses of steroids is needed to permit informed decision-making.

Antibacterial resistance in Streptococcus pyogenes (GAS) from healthy carriers and tonsillitis patients and association with antibacterial sale in the Faroe Islands.

The aim of this study was to investigate the antibacterial resistance of Streptococcus pyogenes (GAS), and correlate the findings with the sales of erythromycin and tetracycline. General practitioners in the Faroe Islands were recruited to send oropharyngeal swabs. From an ongoing pneumococcal study, nasopharyngeal swabs were sampled from healthy children 0-7 years of age. Erythromycin susceptibility data from Iceland were obtained from the reference laboratory at the Landspitali University Hospital. Susceptibility testing in the Faroe Islands and Iceland was performed according to CLSI methods and criteria. The resistance rate to erythromycin and tetracycline found in patients in the Faroe Islands in 2009/2010 was 6% and 30% respectively. Tetracycline resistance in patients declined significantly from 2009 to 2010 (37-10%, p-value = 0.006 < 0.05) and differed significantly between age groups (p-value = 0.03 < 0.05). In Iceland, there was a peak in erythromycin resistance in 2008 (44%) and a substantial decrease in 2009 (5%). Although the prevalence of erythromycin and tetracycline resistance in the Faroe Islands and Iceland may be associated with antimicrobial use, sudden changes can occur with the introduction of new resistant clones.

Antibiotic prescribing in primary care, adherence to guidelines and unnecessary prescribing--an Irish perspective.

BACKGROUND: Information about antibiotic prescribing practice in primary care is not available for Ireland, unlike other European countries. The study aimed to ascertain the types of antibiotics and the corresponding conditions seen in primary care and whether general practitioners (GPs) felt that an antibiotic was necessary at the time of consultation. This information will be vital to inform future initiatives in prudent antibiotic prescribing in primary care. METHODS: Participating GPs gathered data on all antibiotics prescribed by them in 100 consecutive patients' consultations as well as data on the conditions being treated and whether they felt the antibiotic was necessary. RESULTS: 171 GPs collected data on 16,899 consultations. An antibiotic was prescribed at 20.16% of these consultations. The majority were prescribed for symptoms or diagnoses associated with the respiratory system; the highest rate of prescribing in these consultations were for patients aged 15-64 years (62.23%). There is a high rate of 2nd and 3rd line agents being used for common ailments such as otitis media and tonsillitis. Amoxicillin, which is recommended as 1st line in most common infections, was twice as likely to be prescribed if the prescription was for deferred used or deemed unnecessary by the GP. CONCLUSION: The study demonstrates that potentially inappropriate prescribing is occurring in the adult population and the high rate of broad-spectrum antimicrobial agents is a major concern. This study also indicates that amoxicillin may be being used for its placebo effect rather than specifically for treatment of a definite bacterial infection.

[Study of nasal and tonsillar mucosal microbiocenoses as one of the health indices].

The qualitative and quantitative compositions of nasal and tonsillar mucosal biocenoses were studied in healthy individuals and patients with chronic tonsillitis as an ecological criterion for assessing the stability of biocenosis and human health. The qualitative composition of tonsillar mucosal biocenosis turned out to be steady-state both in health and disease. The human nasal mucosa showed itself as an indicator system. Staphylococcal strains with a high persistent potential and polyantibiotic resistance, which may cause an exacerbation of the inflammatory process on translocation to the tonsillar mucosa, were selected on the nasal mucosa of patients with chronic tonsillitis.

Pathogen shifts and changing cure rates for otitis media and tonsillopharyngitis.

Pneumococcal conjugate vaccine use has caused a decrease in the incidence of recurrent and refractory acute otitis media in the United States and a shift in the predominant pathogens. Now Haemophilus influenzae is the most commonly isolated organism (about 60% of the total), and more than half the strains make beta-lactamase, rendering them resistant to amoxicillin. Penicillin nonsusceptible pneumococci, the main target of antibiotic therapy in the 1990s, has become a much less common isolate (10%- 25% of the total). These changes impact antibiotic selection for acute otitis media. Penicillin treatment of group A streptococcal tonsillopharyngitis does not meet the minimum United States Food and Drug Administration standards for first-line treatment, which is 85% or greater eradication at the end of therapy. Recent results with amoxicillin suggest its efficacy is also waning. Cephalosporins have the highest bacteriologic and clinical efficacy. This has implications for optimal antibiotic therapy.

[Implication of middle-mass molecule peptides of blood plasma in assessment of intoxication syndrome in patients with bacterial tonsillitis].

The level of middle-mass molecule peptides (MMMP) of blood plasma was investigated in 98 patients with tonsillitis. A significant increase in the level of MMMP with a maximal rise at the height of the disease with normalization in early and late convalescence was revealed. The changes in plasma MMMP in tonsillitis depended on the clinical form, stage and severity of the disease, complications, concomitant diseases, completeness of convalescence. High therapeutic efficacy of an immunomodulating drug tamerit in combined therapy of patients with bacterial tonsillitis is shown.

Explaining the poor bacteriologic eradication rate of single-dose ceftriaxone in group a streptococcal tonsillopharyngitis: a reverse engineering solution using pharmacodynamic modeling.

OBJECTIVE: To explore pharmacokinetic factors underlying the poor bacteriologic eradication rate with a single 500-mg dose of ceftriaxone for streptococcal tonsillopharyngitis and to identify the minimum ceftriaxone dose required for effective treatment. METHODS: Population modeling techniques were applied to pharmacokinetic data derived from paired plasma and tonsil samples from 153 children to assess the contribution of pharmacokinetic variability to patients' responses to ceftriaxone. In addition, a Monte Carlo simulation was performed to determine (1) the amount of time that free ceftriaxone concentrations must exceed the minimum inhibitory concentration (MIC) of group A Streptococcus to achieve bacteriologic eradication and (2) the ceftriaxone dose required to maintain free drug concentrations above the target MIC for the requisite amount of time. Ceftriaxone MICs for group A Streptococcus were obtained from a previous trial, in which all MICs (n = 115) were < or = 0.064 mg/L; 33.9% were susceptible at < or = 0.016 mg/L, 66.4% were susceptible at 0.032 mg/L, and 1.7% were susceptible at 0.064 mg/L. RESULTS: Mean population pharmacokinetic parameters and their variances reflected substantial variability of clearance and half-life in the target population. Tonsillar ceftriaxone protein binding was 89.1%. The proportions of 1000 simulated patients with free ceftriaxone concentrations that exceeded MICs of 0.016 mg/L, 0.032 mg/L, and 0.064 mg/L at 24 hours were 71.7%, 65.4%, and 57.2%, respectively, and at 48 hours were 41.8%, 35.8%, and 28.6%, respectively. The amount of time that free ceftriaxone concentrations need to exceed MIC to achieve bacteriologic success was estimated to be 36 hours. Using this time criterion, two 500-mg doses of ceftriaxone separated by 18 hours should achieve a bacteriologic cure rate of approximately 95%. CONCLUSIONS: Pharmacokinetic variability and high ceftriaxone tonsillar protein binding explain the high microbiologic failure rate for a single 500-mg dose of ceftriaxone in group A streptococcal tonsillopharyngitis. Monte Carlo simulation suggests that a second dose administered 18 hours after the first will be required to achieve an acceptable bacteriologic cure rate.

Cost-effective workup for tonsillitis. Testing, treatment, and potential complications.

Despite increased strictness in surgical criteria, tonsillectomy continues to be one of the most common outpatient surgical procedures performed in the United States. The primary care physician is integrally involved in the diagnosis and treatment of tonsillitis, the chief reason for tonsillectomy. This article gives guidelines for diagnosis and management of tonsillitis and provides an overview of its potential complications.

Rapid test, throat culture and clinical assessment in the diagnosis of tonsillitis.

OBJECTIVES: Our aim was to identify a group of patients with clinical signs of tonsillitis to whom antibiotics could be prescribed without further diagnostic actions, and to compare the outcome of clinical assessment with the result of an antigen detection test using culture as the gold standard. METHODS: During two winter months, patients aged > or =4 years attending for sore throat at three primary health care centres in Malmö, Sweden, were examined. Odds ratios, sensitivities, specificities and predictive values were calculated for clinical assessment and for an antigen detection test. RESULTS: Among the 169 participating patients, growth of group A beta-haemolytic streptococci (GAS) was found in 53 cultures, and 23 patients (14%) were clinically assessed as 'absolutely positive', representing positive clinical assessment. Nineteen had positive cultures for GAS. The sensitivity, specificity and predictive positive and negative value for the antigen detection test were 82, 96, 90 and 93%, respectively, and for positive clinical assessment 36, 97, 83 and 77%. CONCLUSION: It is possible to identify a small group of patients with convincing signs of tonsillitis in which the specificity as well as the predictive positive value of the rapid test and the clinical assessment are close to equal. Antibiotics may be prescribed to these patients without further diagnostic actions.

A simple intervention to improve hospital antibiotic prescribing.

OBJECTIVE: To evaluate changes in prescribing behaviour after distribution of antibiotic guidelines printed on a 9 x 6 cm laminated card suitable for clipping to a hospital identification badge. INTERVENTION: Guidelines for appropriate antibiotic prescribing for 20 common and important paediatric infections were printed on a laminated 9 x 6 cm card suitable to clip to a hospital identification badge and distributed to all medical staff. DESIGN: We collected data from medical records for three marker conditions (tonsillitis, pneumonia, and orbital/periorbital cellulitis) on samples of patients from the six-month periods either side of the month in which the cards were distributed. Prescribers were unaware of the study and investigators analysed the prescriptions without knowledge of the period in which they were written. Prescriptions were rated for appropriate choice of antibiotic and appropriate dose. Data were also collected on antibiotic costs. MAIN OUTCOME MEASURES: Proportion of cases in which antibiotic choice was appropriate; proportion of cases in which antibiotic dose was appropriate; annualised costs of third-generation cephalosporins. RESULTS: For tonsillitis there was little change in prescribing practice after the cards were introduced. For pneumonia, cases with appropriate choice increased from 77% to 92% (P = 0.028) and cases with appropriate dose increased from 48% to 81% (P = 0.001). For orbital/periorbital cellulitis, cases with appropriate choice increased from 19% to 78% (P < 0.001) and cases with appropriate dose increased from 30% to 51% (P = 0.11). Annualised costs of third-generation cephalosporins were $193 245 pre-cards and $89 814 post-cards. CONCLUSION: The cards appeared to have a beneficial effect on prescribing practice for the three marker conditions. This simple intervention is likely to be cost-effective and useful in reducing inappropriate use of antibiotics.

Economic benefit of tonsillectomy in adults with chronic tonsillitis.

To determine the economic impact of adult chronic tonsillitis and the economic improvement from adult tonsillectomy, we studied patients who underwent adult tonsillectomy for chronic tonsillitis with the Glasgow Benefit Inventory and a questionnaire for disease severity parameters before and after tonsillectomy. The economic impact of chronic tonsillitis and adult tonsillectomy were computed with a break-even time analysis model. Eighty-three adult patients (average age, 27.3 years) completed the study with an average duration of follow-up of 37.7 months. The patients exhibited a mean improvement in quality of life of +27.54 +/- 4.63 after tonsillectomy according to the Glasgow Benefit Inventory. In the 12 months following the procedure, tonsillectomy resulted in yearly mean decreases in number of weeks on antibiotics by 5.9 weeks, number of workdays missed because of tonsillitis by 8.7 days, and physician visits for tonsillitis by 5.3 visits. In considering the medical costs of tonsillectomy only, the break-even point was found to be 12.7 years, whereas considering the overall economic impact of tonsillectomy resulted in a break-even point of 2.3 years after the procedure. We conclude that tonsillectomy results in significant improvement in quality of life, decreases health-care utilization, and diminishes the economic burden of chronic tonsillitis in the adult patient population.

Differences in antibiotic prescribing patterns between general practitioners in Scandinavia: a questionnaire study.

There has been a dramatic increase in the prevalence of antibiotic-resistant bacteria worldwide. In the Scandinavian countries at least 90% of total antibiotic use relates to outpatients and therefore it has become increasingly important to know the antibiotic prescription pattern of general practitioners (GPs) in order to implement and monitor changes in antibiotic prescribing. The aim of the present study was to evaluate the prescription patterns of GPs in Denmark, Norway and Sweden. In order to achieve a reasonable comparison, a questionnaire consisting of 7 case reports concerning upper and lower respiratory tract infections, urinary tract infections and skin and soft tissue infections was sent to 1,000 GPs in the 3 countries. In general, the guidelines for the treatment of bacterial infections in the individual countries were followed by the responders. In all 3 countries, penicillin V was still the drug most frequently used in upper and lower respiratory tract infections. The greatest difference in prescribing patterns among the countries was seen in the treatment of urinary tract infections, recurrent pharyngeal tonsillitis, acute otitis media and acute exacerbation of chronic bronchitis. There were also differences in the dosing regimens, length of treatment and use of diagnostic techniques.

Short course antibiotic therapy for respiratory infections: a review of the evidence.

BACKGROUND: The judicious use of antibiotics entails achieving the appropriate balance between prescribing them with sufficient frequency and duration to effect a clinical cure for bacterial infections and overprescribing them, a practice that increases prescription drug costs as well as the risks of bacterial resistance, noncompliance with therapy and side effects. The recognition that the traditional 10-day or greater duration of therapy for acute otitis media, tonsillopharyngitis and sinusitis does not derive from a strong scientific or medical rationale (with the exception of penicillin therapy for tonsillopharyngitis) and the increasing awareness of the adverse sequelae of long-duration antibiotic therapy have led some clinicians to call for shortening the duration of antibiotic therapy in these infections. The soundness of this recommendation hinges on the demonstration that shortened courses of antibiotic therapy are at least as effective as traditional courses of therapy. SYNOPSIS: Data relevant to determining the optimum duration of therapy in acute otitis media, tonsillopharyngitis and sinusitis are reviewed in this article. The review demonstrates particularly strong justification for shortening the duration of therapy from the standard 10 days to 5 days in acute otitis media, in which numerous open label and controlled studies have shown equivalent efficacy of the two durations of regimen. A growing body of evidence indicates that tonsillopharyngitis, too, can be effectively treated with non-penicillin antibiotics given for fewer than 10 days. Although sinusitis data are less plentiful than those for acute otitis media and tonsillopharyngitis, the results available to date are encouraging in suggesting that shortened courses of therapy may also be appropriate for acute maxillary sinusitis.

An epidemiologic approach to drug prescribing quality assessment: a study in primary care practice in France.

OBJECTIVE: To assess drug prescribing by primary care physicians in France for various types of conditions, and to identify patterns and risk factors for poor prescribing quality. METHODS: The orders (n = 23,080) written for patients with five target diseases (acute nasopharyngitis, acute tonsillitis, essential hypertension, osteoarthrosis, and back and periarticular disorders), by primary care physicians (n = 1,049) were extracted from a nationwide prescription database and analyzed according to 17 quantitative indicators of drug prescribing quality constructed on explicit a priori criteria. RESULTS: Ineffective drugs were prescribed in 32% to 88% of orders according to the target disease. Six percent to 40% of orders resulted in drug interactions, age problems, and overdosage. A consistent pattern of associations between indicators was found, which suggests that drug prescribing quality is multidimensional and is composed of at least five dimensions: placebo, novelty, exoticism, misdosage, and interaction. Several factors associated with indicators were also identified, some of them defining groups of patients at risk (women, elderly, and less educated), physicians at risk (women, aged, and isolated), and contexts at risk (patient's home and disease frequently treated by the physician) of poor drug prescribing quality. CONCLUSIONS: Drug prescribing by French primary care physicians appears nonoptimal, in terms of both risk of iatrogeny and waste of money. This study further documents the complexity and the multidimensionality of drug prescribing quality. It suggests that more attention must be paid to patients' and physicians' risk factors for poor drug prescribing quality if educational programs and regulatory processes are to succeed in promoting safer and more cost-effective practices.

Estudo clínico-imunológico da eficácia de timomodulina (Leucogen©) na otite média aguda recorrente e na amigdalite de repetição / Assessment of efficacy and safety of thymomodulin (Leucogen©) in the prevention of recurrent otitis media and recurrent tonsillitis

Os autores realizaram estudo em 35 crianças portadoras de otite média aguda recorrente e amigdalite de repetiçäo em um estudo duplo-cego com timomodulina e placebo. As crianças tratadas com timomodulina© receberam 4mg/kg/dia do medicamento diariamente durante três meses. Foi realizado controle bioquímico antes do tratamento e com cinco meses e nove meses após o término do tratamento. Além da avaliaçäo clínica foram realizados os seguintes exames: hemograma, TGO, TGP dosagem de IgA, IgG, IgM e IgE antes do início do tratamento e nos controles. Os resultados evidenciaram tendência à diminuiçäo do número de infecçöes e o número de ciclos de antibióticos, em relaçäo a informaçäo do último ano (pré-tratamento), principalmente no grupo tratado com timomodulina, assim como tendência ao aumento do IgA e IgG após tratamento com timomodulina, o que näo ocorreu no grupo placebo. Os exames laboratoriais, contagem de eritrócitos, de hematócrito, hemoglobina, leucócitos e transaminases (TGO e TGP) näo mostraram diferenças entre os grupos, nem alteraçöes 12 meses após o início da medicaçäo, evidenciando a ausência total de toxicidade da timomodulina. Houve apenas um efeito colateral com o uso de timomodulina (náusea e vômito) numa criança com amigdalite purulenta que tomou cefalexina concomitantemente

Avaliaçäo comparativa da eficácia e tolerabilidade do nimesulide, diclofenaco e dipirona sódica aplicados aos processos inflamatórios do trato respiratório superior em populaçäo pediátrica / Comparative assessment on the efficacy and tolerability of nimesulide, diclofenac potassium and dipyrone applyed to inflammatory processes of the superior respiratory tract in the pediatric population

Em um estudo randomizado, comparativo e prospectivo se analizou a eficácia e a tolerabilidade de dois antiinflamatórios (nimesulide e diclofenaco potássico) e uma droga analgésica/antitérmica (dipirona) diante de processos inflamatórios do trato respiratório superior (faringites e/ou amigdalites) em uma populaçäo pediátrica. Os sinais e sintomas próprios a essas patologias foram analisados e a febre monitorizada durante um período de 24 horas. Observou-se uma melhora significativa e homogênea dos sinais e sintomas em todos os grupos de tratamento. A febre apresentou queda pronunciada após a administraçäo de nimesulide e diclofenaco e também após a administraçäo da dipirona, sendo que ocorreu uma reversäo do efeito da dipirona após algumas horas. Dois pacientes apresentaram efeitos adversos que, no caso do diclofenaco devido a intensidade, forçaram a retirada do medicamento. Os dados obtidos ressaltam a eficácia antipirética do nimesulide tal qual a da dipirona com as vantagens em tolerabilidade que näo säo encontradas com o uso de diclofenaco potássico. Assim concluímos que o nimesulide, além de uma poderosa açäo antitérmica, apresenta vantagens no combate ao processo inflamatório, principalmente com relaçäo a sua segurança.

Streptococcal diagnostic testing and antibiotics prescribed for pediatric tonsillopharyngitis.

BACKGROUND: This study examined a 1-year cross-sectional sample of Kentucky Medicaid claims for the use of streptococcal diagnostic tests for pediatric tonsillopharyngitis and the empiric use of antibiotics. METHODS: Subjects were individuals older than 3 and younger than 18 years old seen in an ambulatory setting for tonsillopharyngitis; 3478 individuals accounted for the 5067 separate outpatient and emergency room encounters for pediatric tonsillopharyngitis; 849 encounters coded as streptococcal sore throat were also examined. RESULTS: Diagnostic tests for group A streptococcal tonsillopharyngitis were performed in only 22% (n = 1130) of the tonsillopharyngitis encounters and 36% (n = 306) of the streptococcal sore throat encounters. Urban physicians were more likely than rural physicians to use a diagnostic test (P = 0.0001). Emergency room encounters and outpatient encounters were not significantly different in the likelihood of having a diagnostic test (P = 0.16). In encounters for tonsillopharyngitis antibiotics were prescribed in 72% of the total encounters and in 73% of the encounters without a diagnostic streptococcal test. In encounters for streptococcal sore throat, antibiotics were prescribed for 68% of the total encounters and 69% of the encounters without a diagnostic streptococcal test. CONCLUSIONS: Current practices in the Kentucky Medicaid program do not follow the American Academy of Pediatrics guidelines for streptococcal tonsillopharyngitis.

Cost saving of 5-day therapy with cefpodoxime proxetil versus standard 10-day beta-lactam therapy for recurrent pharyngotonsillitis in adults. A prospective general practice study.

A prospective economic evaluation was undertaken as part of a randomised clinical trial conducted in French general practice. Its aim was to compare the costs and therapeutic outcomes of a 5-day course of cefpodoxime proxetil 100 mg twice daily with 10-day courses of phenoxymethylpenicillin (penicillin V) 1 MIU 3 times daily and amoxicillin-clavulanic acid 500/125 mg 3 times daily for the treatment of recurrent pharyngotonsillitis in 575 adults. Over the 6-month study period, the total cost to society per patient treated with cefpodoxime proxetil was 123 French francs (FF; 1993 values) lower than that for patients treated with phenoxymethylpenicillin and FF227 lower than that for patients treated with amoxicillin-clavulanic acid. This cost saving was primarily attributable to a lower initial drug acquisition cost, and a reduction in the cost associated with lost productivity and general practitioner consultations. Furthermore, as a consequence of a lower relapse rate, the cost-saving ratio for cefpodoxime proxetil, expressed as FF per month free of recurrence, was FF50 less than for phenoxymethylpenicillin and FF60 less than for amoxicillin-clavulanic acid. Thus, a 5-day course of cefpodoxime proxetil is likely to be less costly for treatment of pharyngotonsillitis in the general practice setting than standard 10-day courses of phenoxymethylpenicillin and amoxicillin-clavulanic acid.