Pediatric Pharyngitis Medication

Penicillin is the typical therapy for group A beta-hemolytic streptococci (GABHS) pharyngitis, in conjunction with prevention of dehydration and supportive care for pain. Improved compliance with regimens has been noted when penicillin treatment is administered 2-3 times daily, as compared with traditional regimens with 4 daily doses. Administer a minimum of 20 mg/kg/d; larger children are generally administered 500 mg divided into 2 daily doses for 10 days.

Several other medications, including some that are more palatable and meet with better compliance (eg, amoxicillin), have been approved to treat GABHS. Treat relapses or failure to improve with an antibiotic active against beta-lactamase–producing organisms (ie, macrolides, cephalosporins, amoxicillin/clavulanate). The hypothesis is that colonizing pharyngeal bacteria that produce penicillinase have inactivated penicillin, resulting in treatment failure.

Recently, corticosteroids (eg, oral dexamethasone) have been suggested as an adjunctive therapy to decrease pain and length of symptoms in adults with pharyngitis. 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 the time to complete pain relief.^[7] However, for the subset of children with positive rapid streptococcal test results, improvement in the time to onset of pain relief was statistically significant (but marginally clinically significant).

Class Summary

These agents are used to treat recurrent GABHS pharyngitis.

Amoxicillin (Amoxil, Polymox, Trimox, Pro-Amox, Wymox)

Often used in place of penicillin, but it has not been demonstrated to be more effective. Amoxicillin binds to PBPs, inhibiting bacterial cell wall growth.

Azithromycin (Zithromax)

Binds to the 50S ribosomal subunit of the bacteria, inhibiting protein synthesis.

Penicillin G benzathine (Bicillin L-A)

Has been shown to be effective in more than 90% of cases. Penicillin binds to PBPs, inhibiting bacterial cell wall growth.

Penicillin VK (Pen VK, Pen-Vee K, Veetids)

DOC for patients who can tolerate PO therapy. 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.

Erythromycin ethyl succinate (E.E.S, EryPed)

Recommended by the AAP for patients who are allergic to penicillin. Erythromycin binds to the 50S ribosomal subunit of the bacteria, inhibiting protein synthesis.

Clindamycin (Cleocin)

Can be used for recurrent GABHS pharyngitis or in carrier-state cases. Inhibits bacterial protein synthesis by its action at the bacterial ribosome. The antibiotic binds preferentially to the 50S ribosomal subunit and affects the process of peptide chain initiation. Some prefer this medication when treating disease related to peritonsillar abscesses that have been drained.

Rifampin (Rifadin, Rimactane)

Recommended in conjunction with penicillin for recurrent GABHS and for carrier states. Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.

Cefuroxime (Ceftin)

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

Resists degradation by beta-lactamase. Very effective against copathogens. A broad variety of cephalosporins (especially second-generation) have been used; however, their ability to prevent rheumatic heart disease is not known.

The oral susp and tabs are not bioequivalent and require different dosage regimens.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Cefditoren (Spectracef)

Semisynthetic 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.

Class Summary

These agents may be used adjunctively to antibiotics to improve pain relief onset and are especially useful in patients with positive rapid streptococcal antigen test results.

Dexamethasone (Decadron, Dexasone)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Possesses many pharmacologic benefits but also 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.

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.

For pharyngitis, corticosteroids must be administered in conjunction with antibiotics. Provides symptomatic relief for severe pharyngitis. A one-time IM dose is convenient and avoids compliance issues.