Treatment Challenges of Group A Beta-hemolytic Streptococcal Pharyngo-Tonsillitis

Abstract

Introduction Despite its in vitro efficacy, penicillin often fails to eradicate Group A β-hemolytic streptococci (GABHS) from patients with acute and relapsing pharyngo-tonsillitis (PT). Objective This review of the literature details the causes of penicillin failure to eradicate GABHS PT and the therapeutic modalities to reduce and overcome antimicrobial failure. Data Synthesis The causes of penicillin failure in eradicating GABHS PT include the presence of β lactamase producing bacteria (BLPB) that “protect” GABHS from any penicillin; the absence of bacteria that interfere with the growth of GABHS; co-aggregation between GABHS and Moraxella catarrhalis; and the poor penetration of penicillin into the tonsillar tissues and the tonsillo-pharyngeal cells, which allows intracellular GABHS and Staphylococcus aureus to survive. The inadequate intracellular penetration of penicillin can allow intracellular GABHS and S. aureus to persist. In the treatment of acute tonsillitis, the use of cephalosporin can overcome these interactions by eradicating aerobic BLPB (including M. catarrhalis), while preserving the potentially interfering organisms and eliminating GABHS. Conclusion In treatment of recurrent and chronic PT, the administration of clindamycin, or amoxicillin-clavulanic acid, can eradicate both aerobic and anaerobic BLPB, as well as GABHS. The superior intracellular penetration of cephalosporin and clindamycin also enhances their efficacy against intracellular GABHS and S. aureus.

A Presumed Etiology of Kawasaki Disease Based on Epidemiological Comparison With Infectious or Immune-Mediated Diseases

“…However, pharyngitis caused by GAS without complications is not uncommon, and a relatively high proportion of GAS carriers among healthy children have been reported in the developed countries (46, 47). In addition, GAS strains have been susceptible to penicillin throughout the antibiotic era, with few genetic variations (48). Given that the evolutional purpose of external pathogens may be to become a species of normal flora in the host, these findings suggest that GAS strains may be changing to be part of normal flora in humans, though ARF still occurs in small populations (49).…”

Antibacterial Effect of Zinc Oxide Nanoparticles on Group A β-Hemolytic Streptococci with Macrolide Resistance Isolated from University Student Carriers in North of Iran

“…In the current study, susceptibility of GABHS to cefalexin and cefazolin was reported 82% and 91%, respectively. Although these agents seem to be more effective than penicillin, the use of penicillin is still regarded to be reasonable as the first choice in treating streptococcal pharyngitis due to the high price of cephalosporins compared with penicillin on one hand, and insignificant statistical difference in susceptibility to cephalosporins in comparison with penicillin on the other hand (23).…”

Revisiting cefditoren for the treatment of community-acquired infections caused by human-adapted respiratory pathogens in adults

“…Overall, the post-treatment microbiological response (eradication) was significantly ( p < 0.01) higher with cefditoren versus penicillin (used as comparator): 90.4% versus 82.7% at the end-of-treatment visit, and 84.7% versus 76.7% at the end of follow up visit, respectively [ 100 ]. In a recent revision of eight published clinical studies, failure rates with penicillin in the treatment of pharyngotonsillitis ranged from 14 to 40%, and one of the main reasons advocated by the author was penicillin inactivation by β-lactamases present in the environment produced by β-lactamase producing bacteria [ 110 ], as H. influenzae . This “indirect pathogenicity” was demonstrated in a pharmacodynamic simulation using a mixed inocula of S. pyogenes , penicillin-resistant S. pneumoniae , β-lactamase positive NTHi and a BLPACR strain exposed to simulated serum concentrations of amoxicillin, amoxicillin/clavulanic acid or cefditoren [ 81 ].…”

“…For the BLPACR strain the accumulation of two resistance traits (β-lactamase production and fts I gene) represented a competitive advantage in the presence of amoxicillin/clavulanic acid [ 82 ], this compound not being able to completely counter indirect pathogenicity as cefditoren did. These data acquire relevance since antibiotic-treated individuals are sources for spread of β-lactamase producing bacteria to other individuals [ 110 ], and carriage of H. influenzae has been associated with vaccination with PCVs [ 111 ].…”