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Evidence summaries

Antibiotic Treatments for Group A Streptococcal Pharyngitis in Adults

Penicillin is probably as effective as cephalosporins and macrolides in group A streptococcal pharyngitis in adults, but cephalosporins may be more effective than penicillin for preventing a relapse. Level of evidence: "C"

The quality of the evidence is downgraded by study quality (inadequate allocation concealment, more than 20% loss to follow-up) and indirectness of evidence (differences in outcomes).

Penicillin is recommended as first-line treatment for GABHS tonsillopharyngitis in adults.

The recommendation attaches a relatively high value to avoiding antibiotic resistance by use of narrow-spectrum antibiotics.

A Cochrane review [Abstract] 1 included 10 RCTs with patients over 12 years of age. The patients had confirmed acute group A beta-haemolytic streptococci tonsillopharyngitis. All studies compared penicillin with another antibiotic. Clinical outcome was defined in most studies as complete resolution of signs and symptoms. None of the trials reported data on the duration of illness.

Penicillinvs. cephalosporin

  • Resolution of symptoms at the end of treatment: there was no difference between the treatments (OR 0.78; 95% CI 0.60 to 1.01; 2 trials, n = 1163).
  • Incidence of relapse: there was benefit of treatment with cephalosporins over penicillin (OR 0.42, 95% CI 0.20 to 0.88; 2 trials, n = 770)

Penicillinvs. macrolide

  • Resolution of symptoms post-treatment: there was no difference between the treatment groups (OR 1.07, 95% CI 0.86 to 1.34; 5 trials; n = 1239).
  • Sore throat: there was no difference between the treatments (OR 0.97, 95% CI 0.64 to 1.46; 2 trials, n=371).
  • Fever: there was no difference between the treatments (OR 1.05, 95% CI 0.69 to 1.59; 2 trials, n=371).

Penicillin vs. carbacephem

  • Resolution of symptoms post-treatment: there was no difference between the treatment groups (OR 0.75; 95% CI 0.46 to 1.22; 2 trials, n = 562)

Clinical comment: In clinical practice, narrow-spectrum penicillin is preferred over wide-spectrum cephalosporins. Macrolides are third-line treatment options because of easily developing resistance problem.

    References

    • van Driel ML, De Sutter AI, Thorning S et al. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev 2021;(3):CD004406. [PubMed]

Primary/Secondary Keywords