Antibiotic Treatments for Group A Streptococcal Pharyngitis in Children

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

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

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

A Cochrane review [Abstract] 1 included 9 studies with only, or predominantly, children. The patients had confirmed acute group A beta-haemolytic streptococci (GABHS) tonsillopharyngitis. All but two of the included 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.

Penicillin vs. cephalosporin

• Resolution of symptoms at the end of treatment: there was no difference between treatments (OR 0.83, 95% CI 0.40 to 1.73; 3 trials, n = 855).
• Sore throat: there was no difference between treatment groups for resolution of sore throat (OR 0.97, 95% CI 0.23 to 4.04; one trial, n = 138).
• Fever: there was no difference between treatment groups for resolution of fever (OR 0.97, 95% CI 0.19 to 4.98; one trial, n = 138).
• Incidence of relapse: there was no difference between the treatments (OR 0.89, 95% CI 0.33 to 2.43; 2 trials, n=616)

Penicillin vs. macrolide

• Resolution of symptoms post-treatment: there were no differences between the treatment groups (OR 1.25, 95% CI 0.85 to 1.84; one trial, n=489).

Clinical comment: Macrolides should be avoided in the treatment of GABHS because of resistance problems. Resistance to penicillin is almost non-existent among strains of GABHS.

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].