Orrling Arne, Kamme Carl, Stjernquist-Desatnik Anna
From the Departments of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Lund, Sweden.
Scand J Infect Dis. 2005;37(6-7):429-35. doi: 10.1080/00365540410020947.
Patients with acute group A- strepotococcal pharyngotonsillitis were randomly assigned to treatment for 10 d with either phenoxymethylpenicillin (PcV), loracarbef or clindamycin. The concentrations of the drugs, respectively, were determined in tonsillar surface fluid (TSF), serum and the saliva in each patient on altogether 5 occasions; before, during and 4 d after end of therapy. On the same occasions blood was drawn for analysis of C-reactive protein (CRP) and orosomucoid. On the last d of treatment PcV could be detected in TSF in 1 of 6 patients only. Loracarbef had a slower decrease in TSF during therapy and measurable levels did occur 2 d after end of therapy corresponding to MIC 100 for GAS. This may be related to the somewhat better clinical results of the cephalosporins than of PcV, and possibly indicates that an extended therapy with these drugs in primary GAS pharyngotonsillitis for more than the arbitrarily chosen 10 d could reduce the number of recurrent episodes. PcV and loracarbef were not detected in serum after the end of treatment. The concentration of clindamycin in both TSF and the saliva was fairly longstanding during therapy and reached levels exceeding MIC 100 for GAS, in both TSF and serum 2 d after the end of treatment. Several investigations have shown that GAS, especially in the stationary phase may invade respiratory epithelial cells and are present intracellularly in patients with acute pharyngotonsillitis as well as in asymptomatic carriers. The same T-type, identical DNA fingerprints and arbitrarily primed patterns are found in GAS before and after treatment failure indicating that the primary episode and the failures are caused by the same strain. The longstanding concentrations of clindamycin in TSF, roughly independent of the degree of the local inflammation combined with its intracellular accumulation and activity against resting GAS seem to explain the efficiency of the drug in recurrent GAS pharyngotonsillitis. CRP and orosomucoid were of limited value in differing between bacterial and viral pharyngtonsillitis and a correlation between antibiotic concentration and CRP/orosomucoid levels was not found.
患有急性A组链球菌性咽扁桃体炎的患者被随机分配接受10天的治疗，治疗药物分别为青霉素V钾（PcV）、氯碳头孢或克林霉素。在治疗前、治疗期间以及治疗结束后4天，共5次测定每位患者扁桃体表面液（TSF）、血清和唾液中的药物浓度。在相同时间采集血液，用于分析C反应蛋白（CRP）和类粘蛋白。在治疗的最后一天，仅在6名患者中的1名患者的TSF中检测到了PcV。氯碳头孢在治疗期间TSF中的浓度下降较慢，在治疗结束后2天仍可检测到可测量的水平，相当于对A组链球菌（GAS）的最低抑菌浓度（MIC）的100倍。这可能与头孢菌素类药物比青霉素V钾的临床效果稍好有关，并且可能表明在原发性GAS咽扁桃体炎中，使用这些药物进行超过任意选择的10天的延长治疗可能会减少复发次数。治疗结束后，血清中未检测到PcV和氯碳头孢。在治疗期间，克林霉素在TSF和唾液中的浓度相当持久，并在治疗结束后2天在TSF和血清中均达到超过对GAS的MIC 100的水平。多项研究表明，GAS，尤其是在稳定期，可能侵入呼吸道上皮细胞，并在急性咽扁桃体炎患者以及无症状携带者的细胞内存在。在治疗失败前后的GAS中发现相同的T型、相同的DNA指纹和任意引物模式，表明初次发作和治疗失败是由同一菌株引起的。克林霉素在TSF中的持久浓度，大致与局部炎症程度无关，再加上其细胞内积累以及对静止GAS的活性，似乎可以解释该药物在复发性GAS咽扁桃体炎中的疗效。CRP和类粘蛋白在区分细菌性和病毒性咽扁桃体炎方面价值有限，并且未发现抗生素浓度与CRP/类粘蛋白水平之间存在相关性。
