Defining the optimum treatment regimen for azithromycin in acute tonsillopharyngitis

Abstract

Pharyngitis is one of the most common infectious diseases affecting children. Group A streptococci are the leading bacterial cause of pharyngitis in children and adults. Because inappropriate antibiotic treatment for pharyngitis is becoming a major issue, only true group A beta-hemolytic streptococcus (GABHS) infections, proven by rapid antigen test or culture, should be treated with antibiotics. GABHS pharyngitis is often a mild and self-limiting infection in the absence of antimicrobial therapy. However, antimicrobial treatment must be administered to eradicate the pathogen from the throat, limit the spread of the infection and prevent possible progression to rheumatic fever, suppurative disease or toxin-mediated complications. Penicillin V for 10 days is the standard therapy and is effective in the management of GABHS pharyngitis. However, there are drawbacks to penicillin V therapy, including the length of the dosing regimen, which are leading to decreasing penicillin prescription rates in many countries. In addition bacteriologic treatment failures have been documented in up to 35% of GABHS patients treated with penicillin V, particularly in children <6 years old. A number of mechanisms may be responsible for these failures, but poor compliance with the standard 10-day penicillin treatment is likely to be a major factor. There is growing evidence to suggest that children with GABHS pharyngitis can be effectively treated with non-penicillin V antibiotics, which have the advantage of simpler and shorter dosing regimens compared with penicillin V. Among the antibiotics that have been tested clinically, azithromycin is the most widely studied. A total dose of 60 mg/kg azithromycin, given either as 12 mg/kg once daily for 5 days or 20 mg/kg once daily for 3 days, provides the best rate of GABHS eradication. Thus a total dose of 60 mg/kg azithromycin given during 3 or 5 days constitutes an alternative treatment to standard penicillin therapy in cases of penicillin hypersensitivity, when patient nonadherence to a 10-day penicillin regimen is suspected or for patients who fail therapy with a beta-lactam.

Higher Dosages of Azithromycin Are More Effective in Treatment of Group A Streptococcal Tonsillopharyngitis

“…The duration of azithromycin treatment is 3-5 days because of its unique pharmacokinetic profile, and in children, this analysis shows that a treatment dose of 60 mg/kg is more effective than a 10-day comparator antibiotic regimen. Azithromycin's shortened course is a compliance-enhancing factor [51].…”

Evaluation of short-term clinical efficacy of 3-day therapy with azithromycin in comparison with 5-day cefcapene-pivoxyl for acute streptococcal tonsillopharyngitis in primary care

“…For instance, meta-analyses [4,15] have demonstrated that cephalosporins, commonly prescribed alternatives to penicillin, have better clinical efficacy. Particularly, newer cephalosporins, for example cefditoren [16] and CFPN-PI [7], have been documented to have cure rates comparable with that of penicillin in a shorter treatment period, which is advantageous because poor compliance with the relatively longer treatment period, typically 10 days, is a common cause of treatment failure associated with penicillin regimens [8]. Furthermore, a longer treatment period may increase the risk of carriage of resistant S. pneumoniae strains [17].…”

“…Azithromycin (AZM), a newer macrolide, was shown to have comparable T. Koga (&) Asakura Medical Association Hospital, 422-1 Raiharu, Asakura 838-0069, Japan e-mail: koga.tk@asakura-med.or.jp T. Rikimaru Fukuoka Sanno Hospital, Momochihama 3-6-45, Sawara-ku, Fukuoka 814-0001, Japan N. Tokunaga Tokunaga Clinic, Yokote 3-40-2, Minami-ku, Fukuoka 811-1311, Japan efficacy with penicillin [8,9] in a shorter administration period, indicating that AZM was an alternative treatment for GAS pharyngitis. However, few studies have compared the efficacy of a AZM with that of newer cephalosporins.…”

Trends in rheumatic fever: clinical aspects and perspectives in prophylactic treatments

“…Several compounds with simple and shorter dosing regimens (amoxicillin, cefadroxil, cefuroxime, cefpodoxime, cefixime, cefotiam, cefdinir, azithromycin, clarithromycin) can provide similar or better results than 10-day penicillin V in terms of GABHS eradication [71,72]. Probably because of its pharmacokinetic properties, azithromycin is the most extensively studied drug in the setting of pediatric GABHS pharyngitis [50,63,73,74].…”

“…Therefore, trials comparing the clinical efficacy of various antibiotic regimens use the end point of bacteriological eradication of GABHS as a surrogate marker of prevention [61]. This is reflected in the guidelines of the Food and Drug Administration and the European Medicines Evaluation Agency for the development of new antibiotics for GABHS pharyngitis, with both agencies using bacteriological eradication of the initial pathogens as the main efficacy end point [50,52,62,63].…”