Update on the management of acute pharyngitis in children

Regoli et al. Italian Journal of Pediatrics 2011, 37:10 http://www.ijponline.net/content/37/1/10 ITALIAN JOURNAL OF PEDIATRICS REVIEW Open Access Update on the management of acute pharyngitis in children Marta Regoli*, Elena Chiappini, Francesca Bonsignori, Luisa Galli, Maurizio de Martino* Abstract Streptococcal pharyngitis is a very common pathology in paediatric age all over the world. Nevertheless there isn’t a joint agreement on the management of this condition. Some authors recommend to perform a microbiological investigation in suspected bacterial cases in order to treat the confirmed cases with antibiotics so to prevent suppurative complications and acute rheumatic fever. Differently, other authors consider pharyngitis, even streptococcal one, a benign, self-limiting disease. Consequently they wouldn’t routinely perform microbiological tests and, pointing to a judicious use of antibiotics, they would reserve antimicrobial treatment to well-selected cases. It has been calculated that the number of patients needed to treat to prevent one complication after upper respiratory tract infections (including sore throat), was over 4000. Even the use of the Centor score, in order to evaluate the risk of streptococcal infection, is under debate and the interpretation of the test results may vary considerably. Penicillin is considered all over the world as first line treatment, but oral amoxicillin is also accepted and, due to its better palatability, can be a suitable option. Macrolides should be reserved to the rare cases of proved allergy to b-lactams. Cephalosporins can be used in patients allergic to penicillin (with the exception of type I hypersensibility) and have been also proposed to treat the relapses. Introduction Acute pharyngitis is defined as an infection of the pharynx and/or tonsils. It is a very common pathology among children and adolescents. Although viruses cause most acute pharyngitis episodes, group A Streptococcus (GABHS) causes 37% of cases of acute pharyngitis in children older than 5 years [1]. Other bacterial causes of pharyngitis are Group C Streptococcus (5% of total cases), C. pneumoniae (1%), M. pneumoniae (1%) and anaerobic species (1%). Between viruses Rhinovirus, Coronavirus and Adenovirus account for the 30% of the total cases, Epstein Barr virus for 1%, Influenza and Parainfluenza virus for about 4% [2]. Streptococcal pharyngitis has a peak incidence in the early school years and it is uncommon before 3 years of age. Illness occurs most often in winter and spring [3]. The infection is transmitted via respiratory secretions and the incubation period is 2-5 days. Communicability of the infection is highest during acute phase and in * Correspondence: ; Department of Sciences for Woman and Child’s Health, University of Florence, Florence, Italy untreated people gradually diminishes over a period of weeks; it ceases after 24 hours of antibiotic therapy [4]. Clinical manifestations include sore throat and fever with sudden onset, red pharynx, enlarged tonsils covered with a yellow, blood-tinged exudate. There may be petechiae on the soft palate and posterior pharynx. The anterior cervical nodes are enlarged and swollen. Headache and gastrointestinal symptoms (vomiting and abdominal pain) are frequent. Table 1 shows signs and symptoms of GABHS pharyngitis and their sensitivity and specificity for the diagnosis [5]. The onset of viral pharyngitis may be more gradual and symptoms more often include rhinorrhea, cough, diarrhea, hoarseness. Several clinical scores have been proposed to help the clinician in the diagnosis; they are illustrated in table 2. Anyway the clinical presentations of GABHS and viral pharyngitis show considerable overlap and no single element of the patient’s history or physical examination reliably confirms or excludes GABHS pharyngitis [5]. Complications of the infection can be distinguished in suppurative and nonsuppurative. Suppurative complications, due to the spread of GABHS to adjacent tissues, © 2011 Regoli et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Regoli et al. Italian Journal of Pediatrics 2011, 37:10 http://www.ijponline.net/content/37/1/10 Page 2 of 7 Table 1 Clinical signs and symptoms of GABSH pharingitis, their sensitivity and specificity [5] Symptoms and Clinical Findings Sensitivity (%) Specificity (%) Absence of cough 51-79 36-68 Anterior cervical nodes swollen or enlarged 55-82 34-73 Headache 48 50-80 Myalgia 49 60 Palatine petechiae 7 95 Pharyngeal exudates 26 88 Fever >38°C 22-58 52-92 Tonsillar exudate 36 85 include cervical lymphadenitis, peritonsillar abscess, retropharyngeal abscess, otitis media, mastoiditis and sinusitis. The use of antibiotics have reduced the incidence of this group of complications, that remain a reality when primary illness has gone unnoticed or untreated [3]. Not suppurative, immune-mediated sequelae are acute rheumatic fever (ARF), acute post-streptococcal glomerulonephritis, Sydenham chorea, reactive arthritis and Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus pyogenes. According to WHO, at least 15.6 million people have rheumatic hearth disease (RHD), and 233 000 deaths annually are directly attributable to ARF. Due to the limitations of reports related to limited resources in developing countries, it is likely that the prevalence and incidence of ARF are largely underestimated [6]. The prevalence of RHD in children aged 5-14 years is higher in sub-Saharan Africa (5.7 per 1000), in Indigenous populations of Australia and New Zealand (3.5 per 1000), and southcentral Asia (2.2 per 1000), and lower in developed countries (usually 0.5 per 1000) [7]. A systematic review of 10 population-based studies from 10 countries on all continents, except Africa, published from 1967 to 1996, describes the worldwide incidence of ARF. The overall mean incidence rate of first attack of ARF was 5-51/100,000 population (mean 19/ 100,000; 95% CI 9 to 30/100,000). A low incidence rate of ≤10/100,000 per year was found in America and Western Europe, while a higher incidence (> 10/100,000) was documented in Eastern Europe, Middle East (highest), Asia and Australasia. Studies with longitudinal data displayed a falling incidence rate over time [8]. In the United States, the number of ARF cases has fallen dramatically over the last half century. A national study conducted in 2000 detailing the characteristics of American pediatric patients hospitalized with ARF found that the incidence was 14.8 cases per 100,000 hospitalized children (though the true national incidence of ARF cases is 1 case per 100,000 population) [9]. The diagnosis of GABHS pharyngitis can be done b (...truncated)