Pichichero M E
University of Rochester School of Medicine and Dentistry, NY, USA.
Pediatr Rev. 1998 Sep;19(9):291-302. doi: 10.1542/pir.19-9-291.
GABHS is the most common bacterial cause of tonsillopharyngitis, but this organism also produces acute otitis media; pneumonia; skin and soft-tissue infections; cardiovascular, musculoskeletal, and lymphatic infections; bacteremia; and meningitis. Most children and adolescents who develop a sore throat do not have GABHS as the cause; their infection is viral in etiology. Other bacterial pathogens produce sore throat infrequently (e.g., Chlamydia pneumoniae and Mycoplasma pneumoniae), and when they do, other concomitant clinical illness is present. Classic streptococcal tonsillopharyngitis has an acute onset; produces concurrent headache, stomach ache, and dysphagia; and upon examination is characterized by intense tonsillopharyngeal erythema, yellow exudate, and tender/enlarged anterior cervical glands. Unfortunately only about 20% to 30% of patients present with classic disease. Physicians overdiagnose streptococcal tonsillopharyngitis by a wide margin, which almost always leads to unnecessary treatment with antibiotics. Accordingly, use of throat cultures and/or rapid GABHS detection tests in the office is strongly advocated. Their use has been shown to be cost-effective and to reduce antibiotic overprescribing substantially. Penicillin currently is recommended by the American Academy of Pediatrics and American Heart Association as first-line therapy for GABHS infections; erythromycin is recommended for those allergic to penicillin. Virtually all patients improve clinically with penicillin and other antibiotics. However, penicillin treatment failures do occur, especially in tonsillopharyngitis in which 5% to 35% of patients do not experience bacteriologic eradication. Penicillin treatment failures are more common among patients who have been treated recently with the drug. Cephalosporins or azithromycin are preferred following penicillin treatment failures in selected patients as first-line therapy, based on a history of penicillin failures or lack of compliance and for impetigo. GABHS remain exquisitely sensitive to penicillin in vitro. There are several explanations for penicillin treatment failures, but the possibility of copathogen co-colonization in vivo has received the most attention. Treatment duration with penicillin should be 10 days to optimize cure in GABHS infections. A 5-day regimen is possible and approved by the United States Food and Drug Administration for cefpodoxime (a cephalosporin) and azithromycin (a macrolide). Prevention of rheumatic fever is the primary objective for antibiotic therapy of GABHS infections, but a reduction in contagion and faster clinical improvement also can be achieved. Development of streptococcal toxic shock syndrome and necrotizing fasciitis ("flesh-eating bacteria") are rising concerns. The portal of entry for these invasive GABHS strains is far more often skin and soft tissue than the tonsillopharynx.
A群链球菌（GABHS）是扁桃体咽炎最常见的细菌病因，但这种病原体还会引发急性中耳炎、肺炎、皮肤及软组织感染、心血管、肌肉骨骼和淋巴系统感染、菌血症以及脑膜炎。大多数出现咽喉疼痛的儿童和青少年并非由A群链球菌引起；他们的感染病因是病毒性的。其他细菌性病原体很少引发咽喉疼痛（如肺炎衣原体和肺炎支原体），即便引发，也会伴有其他临床病症。典型的链球菌性扁桃体咽炎起病急；会同时出现头痛、胃痛和吞咽困难；检查时表现为扁桃体咽部剧烈红斑、黄色渗出物以及颈部前侧腺体压痛/肿大。不幸的是，只有约20%至30%的患者表现为典型病症。医生对链球菌性扁桃体咽炎的过度诊断情况严重，这几乎总会导致不必要的抗生素治疗。因此，强烈主张在诊所使用咽喉培养和/或A群链球菌快速检测试验。已证明其使用具有成本效益，能大幅减少抗生素的过度开具。目前，美国儿科学会和美国心脏协会推荐青霉素作为A群链球菌感染的一线治疗药物；对青霉素过敏者推荐使用红霉素。实际上，所有患者使用青霉素和其他抗生素后临床症状都会改善。然而，确实会出现青霉素治疗失败的情况，尤其是在扁桃体咽炎中，5%至35%的患者细菌未被根除。青霉素治疗失败在近期接受过该药物治疗的患者中更为常见。对于特定患者，基于青霉素治疗失败史或依从性差以及脓疱病情况，在青霉素治疗失败后，头孢菌素或阿奇霉素作为一线治疗药物更为可取。A群链球菌在体外对青霉素仍极为敏感。青霉素治疗失败有多种解释，但体内共病原体共同定植的可能性受到了最多关注。青霉素的治疗疗程应为10天，以优化A群链球菌感染的治愈效果。美国食品药品监督管理局已批准头孢泊肟（一种头孢菌素）和阿奇霉素（一种大环内酯类药物）采用5天疗程。预防风湿热是A群链球菌感染抗生素治疗的主要目标，但也可实现减少传染和更快临床改善的效果。链球菌中毒性休克综合征和坏死性筋膜炎（“食肉菌”）的发生日益受到关注。这些侵袭性A群链球菌菌株的侵入门户更多是皮肤和软组织，而非扁桃体咽部。
