Pediatric Pharyngitis Medication

The criterion standard for treatment of GABHS pharyngitis is penicillin (PCN) in conjunction with supportive care for pain, fever, and prevention of dehydration.^[2] Ampicillin or amoxicillin often have been used in place of PCN; however, no microbiologic advantages exist over PCN therapy. Compliance has been better with bid/tid PCN than with traditional qid regimens. Amoxicillin taken once daily has even been shown effective in a recent preliminary report.

A Cochrane Database of Systematic Reviews article recently compared short duration of antibiotic therapy versus standard duration of therapy in treating acute streptococcal pharyngitis in children. The review consisted of 20 studies including 13,102 acute GABHS pharyngitis cases. The short duration treatment had shorter periods of fever and throat soreness; lower risk of early clinical treatment failure; and no significant difference in early bacteriological treatment failure, or late clinical recurrence. The authors concluded that 3-6 days of oral antibiotics had comparable efficacy compared with the standard duration 10-day oral penicillin in treating children with acute GABHS pharyngitis.^[3] Shorter courses of antibiotics could limit antibiotic use, cost, and potentially antibiotic resistance; however, the long-term impact on the prevention of rheumatic heart disease is not known. Further studies looking at this aspect as well are necessary.

Cephalosporins also have been used with questionably improved failure rates compared with PCN. Cephalosporins resist degradation by beta-lactamases and are very effective against copathogens. First- or second-generation cephalosporins are best. Some of the cephalosporins include cephalexin, cefadroxil, cefuroxime, cefixime, cefdinir, and cefpodoxime.

Macrolide antibiotics are recommended for penicillin-allergic patients.

Corticosteroids (oral dexamethasone) have been suggested as an adjunct therapy to decrease pain and length of symptoms in adults with pharyngitis. The one randomized controlled study in children found that the use of single-dose oral dexamethasone (0.6 mg/kg, not to exceed 10 mg) did not decrease the time to onset of clinically significant pain relief or time to complete pain relief.^[4] However, for the subset of children with positive rapid strep test results, a statistically significant (but marginally clinically significant) improvement in time to onset of pain relief occurred. Therefore, use of steroids is not routinely recommended but can be considered. This was also supported by a systematic review on pharyngitis for adult patients where there was a slight decrease in time to resolution and amount of pain, but, given the heterogeneity of results, the use of steroids was not routinely recommended but offered for consideration on a patient-by-patient basis.^[5]

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.

Penicillin G benzathine (Bicillin L-A, Permapen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Effective in over 90% of cases.

Not to be administered IV/IA/SC.

Penicillin VK (Veetids)

Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached, and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Treatment of choice if patients can tolerate PO therapy.

Treatment regimens as low as 2 doses/d are proven effective. Krober et al found failure rates of 31%, 6%, and 11% for qd, bid, and qid dosing, respectively.^[6]

Erythromycin (E.E.S., Eryc, Ery-Tab, EryPed)

For PCN allergic patients, the AAP recommends erythromycin ethylsuccinate. (Other macrolides, such as clarithromycin for 10 d or azithromycin for 5 d, have also been approved.)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.

Cefuroxime (Ceftin)

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis.

Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.

Administer with food to minimize GI adverse effects.

Cefixime (Suprax)

By binding to one or more of the PCN-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.

Administer with food to minimize GI adverse effects.

Cefpodoxime proxetil (Vantin)

A second-generation cephalosporin indicated for the management of infections caused by susceptible mixed aerobic-anaerobic microorganisms.

Cefpodoxime inhibits bacterial cell wall synthesis by binding to one or more of the PCN-binding proteins. Bacteria eventually lyse because of the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.

Cefditoren (Spectracef)

Semi-synthetic cephalosporin administered as prodrug. Hydrolyzed by esterases during absorption and distributed in circulating blood as active cefditoren.

Bactericidal activity results from inhibition of cell wall synthesis via affinity for penicillin-binding proteins.

No dose adjustment necessary for mild renal impairment (CrCl 50-80 mgL/min/1.73 m²) or mild to moderate hepatic impairment.

Indicated for the treatment of acute exacerbation of pharyngitis/tonsillitis caused by susceptible strains of Streptococcus pyogenes.

Azithromycin (Zithromax)

Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Treats mild-to-moderate microbial infections.

Shorter course and one-a-day dosing make this a good alternative for patients who are sensitive to penicillin.

Rifampin (Rifadin)

Recommended in conjunction with PCN for recurrent GABHS and for carrier states.

Inhibits DNA-dependent RNA polymerase activity in susceptible cells. Specifically, it interacts with bacterial RNA polymerase but does not inhibit the mammalian enzyme.

Take on an empty stomach.

Cephalexin (Keflex)

First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.

Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococcal or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected.

Used orally when outpatient management is indicated. At least as effective as erythromycin in eradicating GABHS infection.

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Used for recurrent GABHS pharyngitis or in cases of carrier state.

Take capsule with full glass of water.

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Dexamethasone (Decadron)

Has many pharmacologic benefits but significant adverse effects. Stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6, IL-2, and IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of inflammatory cells into affected areas. Suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. Breaks down granulocyte aggregates, and improves pulmonary microcirculation. For symptom relief in patients with severe exudative pharyngitis.

Adverse effects are hyperglycemia, hypertension, weight loss, GI bleeding or perforation synthesis, cerebral palsy, adrenal suppression, and death. Most of the adverse effects of corticosteroids are dose-dependent or duration-dependent.

Readily absorbed via the GI tract and metabolized in the liver. Inactive metabolites are excreted via the kidneys. Lacks salt-retaining property of hydrocortisone.

Patients can be switched from an IV to PO regimen in a 1:1 ratio.