Meskina E R, Stashko T V
Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia.
Vestn Otorinolaringol. 2020;85(6):90-99. doi: 10.17116/otorino20208506190.
Acute tonsillopharyngitis is one of the most frequent reasons for visiting a doctor and prescribing inappropriate antibiotic therapy (ABT). There are several reasons for this - from the difficulties of etiological diagnosis and the development of relapses and possible severe complications to the personal attitude of doctors and patients to the choice of treatment. At the same time, the issue of antibiotic resistance and other aspects associated with the prescription of ABT is one of the most important problems of modern healthcare worldwide. The purpose of this review is to demonstrate the best practical approaches to the choice of treatment tactics for acute tonsillitis (AT) in the treatment of children and adults, with an emphasis on reducing the load of ABT. The review examines the indications and disadvantages of clinical and laboratory diagnosis of AT. There are no highly sensitive clinical and laboratory instruments that differentiate viral and bacterial AT. Exudativeis AT in children is not an underlying symptom of streptococcal etiology. Despite the limitations, the modified Centor/McIsaac score ≥3 (taking into account age and the presence of respiratory symptoms) should be used as an indication for ABT in conjunction with a rapid streptotest and subsequent bacteriological culture for S. pyogenes if the screening test is negative. Additional examinations (determination of leukocytosis, CRP and procalcitonin test) are not required for most patients. ABT should not be given to low-risk patients for the treatment and prevention of rheumatic fever and acute glomerulonephritis. Prevention of purulent complications (paratonsillitis and retropharyngeal abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis) is not a specific indication for ABT in AT and is not required in most patients. The strategy of «delayed antibiotic prescriptions» with monitoring the patient's condition for 2-3 days is appropriate and highly effective in doubtful cases. The drugs of choice for treatment of AT are amoxicillin and oral forms of I and II generation cephalosporins. Macrolides are not indicated as first-line treatment for AT. The course of ABT for streptococcal AT is 10 days, which reduces the risk of recurrent episode. Topical drugs can be the only means of etiopathogenetic treatment with viral AT, or additional for bacterial AT. Their use not only relieves sore throat, but also shortens the duration of the disease, and also improves the patients prognosis. Benzalkonium chloride + tyrothricin + benzocaine (Dorithyrcin) may be a rational drug of choice for topical therapy due to the available clinical evidence. There is a significant reserve for reducing the load of ABT during AT. Further clinical trials are needed to assess the efficacy of short courses of ABT in the treatment of AT in high-income countries and provide a basis for strong recommendations for topical drug use. This can reduce the frequency of ABT prescribing and increase the level of interaction between specialists and patients.
急性扁桃体咽炎是就医和开具不恰当抗生素治疗（ABT）的最常见原因之一。造成这种情况有多种原因——从病因诊断困难、复发及可能出现的严重并发症，到医生和患者对治疗选择的个人态度。与此同时，抗生素耐药性问题以及与ABT处方相关的其他方面是全球现代医疗保健中最重要的问题之一。本综述的目的是展示在治疗儿童和成人急性扁桃体炎（AT）时选择治疗策略的最佳实用方法，重点是减少ABT的使用量。该综述研究了AT临床和实验室诊断的适应症及不足之处。目前尚无能够区分病毒性和细菌性AT的高灵敏度临床和实验室检测手段。儿童渗出性AT并非链球菌病因的潜在症状。尽管存在局限性，但改良的森托/麦基萨克评分≥3（考虑年龄和呼吸道症状的存在）应作为ABT的指征，同时结合快速链球菌检测，若筛查试验为阴性，则随后进行化脓性链球菌的细菌培养。大多数患者无需进行额外检查（白细胞增多症测定、CRP和降钙素原检测）。对于治疗和预防风湿热及急性肾小球肾炎的低风险患者，不应给予ABT。预防化脓性并发症（扁桃体周围炎和咽后脓肿、急性中耳炎、颈淋巴结炎、乳突炎或急性鼻窦炎）并非AT中ABT的特定指征，大多数患者也无需进行。在可疑病例中，采用“延迟抗生素处方”并对患者病情监测2 - 3天的策略是合适且高效的。治疗AT的首选药物是阿莫西林以及第一代和第二代头孢菌素的口服剂型。大环内酯类药物不被列为AT的一线治疗药物。链球菌性AT的ABT疗程为10天，这可降低复发风险。局部用药可以是病毒性AT病因治疗的唯一手段，或细菌性AT的辅助手段。其使用不仅能缓解咽痛，还能缩短病程，改善患者预后。由于现有临床证据，苯扎氯铵 + 短杆菌素 + 苯佐卡因（多利卡因）可能是局部治疗的合理选择药物。在AT期间减少ABT使用量仍有很大潜力。需要进一步的临床试验来评估高收入国家中短疗程ABT治疗AT的疗效，并为局部用药的有力推荐提供依据。这可以减少ABT处方的频率，提高专科医生与患者之间的互动水平。
