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Etiology and management of acute and recurrent group a Streptococcal tonsillitis

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Abstract

Tonsillitis is one of the most prevalent infections in children and adolescents. The etiologic agents might be viral or bacterial. About 30% of cases are reported to be of bacterial origin, mainly due to group A Streptococcus (GAS). Although in most instances GAS tonsillitis is a self-limited disease, antibiotic treatment is recommended, mainly to prevent the suppurative and nonsuppurative poststreptococcal sequelae of acute rheumatic fever and to prevent glomerulonephritis. In this paper we review the current knowledge of the etiology of acute and recurrent GAS tonsillitis, with special emphasis on a recent hypothesis regarding the etiology of bacterial eradication failure. While penicillin V remains the drug of choice for acute tonsillitis, other antibiotics are being approved and recommended for particular indications in both Europe and the United States.

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References and Recommended Reading

  1. Bisno AL, Gerber MA, Gwaltney JM Jr, et al.: Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Infectious Diseases Society of America. Clin Infect Dis 1997, 25:574–583.

    Article  PubMed  CAS  Google Scholar 

  2. Pichichero ME: Group A b-hemolytic streptococcal infections. Pediatr Rev 1998, 19:291–302.A comprehensive review summarizing the causes and management of GAS infections, as well as various theories for failure of penicillin treatment.

    Article  PubMed  CAS  Google Scholar 

  3. Scaglione F, Demartini G, Arcidiacono MM, et al.: Optimum treatment of streptococcal pharyngitis. Drugs 1997, 53:86–97.

    Article  PubMed  CAS  Google Scholar 

  4. Gillespie SH: Failure of penicillin in Streptococcus pyogenes Infection. Lancet 1998, 352:1954–1955.

    Article  PubMed  CAS  Google Scholar 

  5. Neeman R, Keller N, Barzilai A, et al.: Prevalence of internalisation-associated gene, prtF1, among persisting group-a streptococcus strains isolated from asymptomatic carriers. Lancet 1998, 352:1974–1977.An important report showing a significant correlation between continued carriage of GAS despite therapy, and the presence of the prtF1 gene, encoding fibronectin-binding protein, which mediates GAS internalization. The results support the theory that GAS internalization might be associated with intracellular bacterial persistence after antibiotic treatment.

    Article  PubMed  CAS  Google Scholar 

  6. Holm S, Henning C, Grahn E, et al.: Is penicillin the a ppropriate treatment for recurrent tonsillopharyngitis? Results from a comparative randomized blind study of cefuroxime azetil and phenoxymethylpenicillin in children. Scand J Infect Dis 1995, 27:221–228.

    Article  PubMed  CAS  Google Scholar 

  7. Pichichero ME, McLinn SE, Gooch WM III, et al.: Ceftibuten vs penicillin V in group-A b-hemolytic streptococcal pharyngitis. Pediatr Infect Dis J 1995, 14:S102-S108.

    Article  PubMed  CAS  Google Scholar 

  8. Bisno AL, Stevens D: Streptococcus pyogenes. In Principles and Practice of Infectious Diseases, edn 5. Edited by Mandell GL, Bennet JE, Dolin R. New York: Churchill Livingstone; 2000:2101–2116. A current overview of the epidemiologic, microbiologic, and clinical aspects of S. pyogenes infections, with special emphasis on streptococcal tonsillitis.

    Google Scholar 

  9. Pichichero ME, Green JL, Francis AB, et al.: Recurrent group A streptococcal tonsillotonsillitis. Pediatr Infect Dis J 1998, 17:809–815.

    Article  PubMed  CAS  Google Scholar 

  10. Kaplan EL, Gastanaduy AS, Huwe BB: The role of the carrier in the treatment failures after antibiotic therapy for group A streptococci in the upper respiratory tract. J Lab Clin Med 1981, 98:326–335.

    PubMed  CAS  Google Scholar 

  11. Kaplan El, Top FH Jr, Dudding BA, et al.: Diagnosis of streptoccocal pharyngitis: differentiation of acute infection from the carrier state in the symptomatic child. J Infect Dis 1971, 123:490–501.

    PubMed  CAS  Google Scholar 

  12. Kaplan EL: The group A streptococcal upper respiratory tract carrier state: an enigma. J Pediatr 1980, 97:337–345.

    Article  PubMed  CAS  Google Scholar 

  13. Begovac J, Bobinac E, Benic B, et al.: Asymptomatic pharyngeal carriage of beta-haemolytic streptococci and streptococcal pharyngitis among patients at an urban hospital in Croatia. Eur J Epidemiol 1993, 9:405–410.

    Article  PubMed  CAS  Google Scholar 

  14. Gerber MA, Tanz RR, Kabat W, et al.: Potential mechanisms for failure to eradicate group A streptococci from the pharynx. Pediatrics 1999, 104:911–917.

    Article  PubMed  CAS  Google Scholar 

  15. Macris MJ, Hartman N, Murray B, et al.: Studies of the continuing susceptibility of group A streptococcal strains to penicillin during eight decades. Pediatr Infect Dis J 1998, 17:377–381.

    Article  PubMed  CAS  Google Scholar 

  16. Holm SE: Reasons for failure in penicillin treatment of streptococcal tonsillitis and possible alternative. Pediatric Infect Dis 1994, 13:S66-S69.

    Article  CAS  Google Scholar 

  17. Gerber MA: Antibiotic resistance in group A streptococci. Pediatr Clin North Am 1995, 42:539–551.

    PubMed  CAS  Google Scholar 

  18. Gerber MA: Effect of early antibiotic therapy on recurrence rates of streptococcal pharyngitis. Pediatr Infect Dis J 1991, 10(suppl):S56-S60.

    Article  PubMed  CAS  Google Scholar 

  19. Pichichero ME, Hoeger W, Marsocci SM, et al.: Variables influencing penicillin treatment outcome in streptococcal tonsillopharyngitis. Arch Pediatr Adolesc Med 1999, 153:565–570.

    PubMed  CAS  Google Scholar 

  20. Gerber MA, Randolph MF, DeMeo KK, et al.: Lack of impact of early antibiotic therapy for streptocpharyngitis on recurrence rates. J Pediatr 1990, 117:853–858.

    Article  PubMed  CAS  Google Scholar 

  21. Kaplan JM, McCracken GA, Culburtson MC: Penicillin and erythromycin concentrations in tonsils. Am J Dis Child 1974, 127:206–211.

    Google Scholar 

  22. Gerber MA, Randolph MF, Chanatry J, et al.: Five vs ten days of penicillin V therapy for streptococcal pharyngitis. Am J Dis Child 1987, 141:224–227.

    PubMed  CAS  Google Scholar 

  23. Brook I, Gober AE: Role of bacterial interference and betalactamase- producing bacteria in the failure of penicillin to eradicate group A streptococcal pharyngotonsillitis. Arch Otolaryngol Head Neck Surg 1995, 121:1405–1409.

    PubMed  CAS  Google Scholar 

  24. Roos K, Grahn E, Holm SE: Evaluation of beta-lactamase activity and microbial interference in treatment failures of acute streptococcus tonsillitis. Scand J Infect Dis 1986, 18:313–319.

    Article  PubMed  CAS  Google Scholar 

  25. Sprunt K, Redman W: Evidence suggesting importance of role of interbacterial inhibition in maintaining balance of normal flora. Ann Intern Med 1968, 68:579–590.

    PubMed  CAS  Google Scholar 

  26. Crowe CC, Sanders E, Longley S: Bacterial interference, II: the role of the normal flora in prevention of colonization by group A streptococcus. J Infect Dis 1973, 128:527–532.

    PubMed  CAS  Google Scholar 

  27. Sanders CC, Nelson GE, Sanders WE: Bacterial interference, IV: epidemiologic determinants of the antagonistic activity of the normal flora against group A streptococci. Infect Immun 1977, 16:599–603.

    PubMed  CAS  Google Scholar 

  28. Brook I, Gober AE: Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis. Arch Otolaryngol Head Neck Surg 1999, 125:552–554.

    PubMed  CAS  Google Scholar 

  29. Falck G, Grahn-Hakansson E, Holm SE, et al.: Tolerance and efficacy of interfering alpha-streptococci in recurrence of streptococcal pharyngopharyngitis: a placebo-controlled study. Acta Otolaryngol 1999, 119:944–948.

    Article  PubMed  CAS  Google Scholar 

  30. Fujimori I, Goto R, Kikushima K, et al.: Investigation of oral alpha-streptococcus showing inhibitory activity against pathogens in children with tonsillitis. Int J Pediatr Otorhinolaryngol 1995, 33:249–255.

    Article  PubMed  CAS  Google Scholar 

  31. Roos K, Holm SE, Grahn-Hakansson E, et al.: Recolonization with selected alpha-streptococci for prophylaxis of recurrent streptococcal pharyngotonsillitis: a randomized placebocontrolled multicentre study. Scand J Infect Dis 1996, 28:459–462.

    Article  PubMed  CAS  Google Scholar 

  32. Brook I: The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis 1984, 6:601–607.

    PubMed  CAS  Google Scholar 

  33. Brook I: Penicillin failure and copathogenicity in streptococcal pharyngotonsillitis. J Fam Pract 1994, 38:175–179.

    PubMed  CAS  Google Scholar 

  34. Tanz RR, Shulman ST, Sroka PA, et al.: Lack of influence of beta-lactamase-producing flora on recovery of group A streptococci after treatment of acute pharyngits. J Pediatr 1990, 117:859–863.

    Article  PubMed  CAS  Google Scholar 

  35. Van Asselt GJ, Mouton RP, Van Boven CP: Penicillin tolerance and treatment failure in group A streptococcal pharyngotonsillitis. Eur J Clin Microbiol Infect Dis 1996, 15:107–115.

    Article  PubMed  Google Scholar 

  36. Eagle H: Experimental approach to the problem of treatment failure with penicillin. I. Group A streptococcal infection in mice. Am J Med 1952, 13:389–399.

    Article  PubMed  CAS  Google Scholar 

  37. Stevens DL, Bryant-Gibbons AE, Bergstorm R, et al.: The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis 1988, 158:23–28.

    PubMed  CAS  Google Scholar 

  38. Stevens DL, Yan S, Bryant AE: Penicillin binding protein expression at different growth stages determines penicillin efficacy in vitro and in vivo: an explanation for the inoculum effect. J Infect Dis 1993, 167:1401–1405.

    PubMed  CAS  Google Scholar 

  39. LaPenta D, Rubens C, Chi E, et al.: Group A streptococci efficiently invade human respiratory epithelial cells. Proc Natl Acad Sci U S A 1994, 91:12115–12119.

    Article  PubMed  CAS  Google Scholar 

  40. Greco R, De Martino L, Donnarumma G, et al.: Invasion of cultured human cells by Streptococcus pyogenes. Res Microbiol 1995, 146:551–560.

    Article  PubMed  CAS  Google Scholar 

  41. Osterlund A, Engstrand L: Intracellular penetration and survival of Streptococcus pyogenes in respiratory epithelial cells in vitro. Acta Otolaryngol (Stockh) 1995, 115:685–688.

    Article  CAS  Google Scholar 

  42. Osterlund A, Engstrand L: An intracellular sanctuary for Streptococcus pyogenes in human tonsillar epithelium—studies of asymptomatic carriers and in vitro cultured biopsies. Acta Otolaryngol (Stockh) 1997, 117:883–888.

    Article  CAS  Google Scholar 

  43. Osterlund A, Popa R, Nikkila T, et al.: Intracellular reservoir of Streptococcus pyogenes in vivo: a possible explanation for recurrent pharyngotonsillitis. Laryngoscope 1997, 107:640–647.

    Article  PubMed  CAS  Google Scholar 

  44. Molinari G, Chhatwal GS: Invasion and survival of Streptococcus pyogenes in eukaryotic cells correlates with the source of the clinical isolates. J Infect Dis 1998, 177:1600–1607.

    PubMed  CAS  Google Scholar 

  45. Jadoun J, Ozeri V, Burstein E, et al.: Protein F1 is required for efficient entry of Streptococcus pyogenes into epithelial cells. J Infect Dis 1998, 178:147–158.

    PubMed  CAS  Google Scholar 

  46. Dombek PE, Cue D, Sedgewick J, et al.: High-frequency intracellular invasion of epithelial cells by serotype M1 group A streptococci: M1 protein-mediated invasion and cytoskeletal rearrangements. Mol Microbiol 1999, 31:859–870.

    Article  PubMed  CAS  Google Scholar 

  47. Hagman MM, Dale JB, Stevens DL: Comparison of adherence to and penetration of a human laryngeal epithelial cell line by group A streptococci of various M protein types. FEMS Immunol Med Microbiol 1999, 23:195–204.

    PubMed  CAS  Google Scholar 

  48. Bennett-Wood VR, Carapetis JR, Robins-Browne RM: Ability of clinical isolates of group A streptococci to adhere to and invade HEp-2 epithelial cells. J Med Microbiol 1998, 47:899–906.

    Article  PubMed  CAS  Google Scholar 

  49. Schlievert PM, Assimacopoulos AP, Cleary PP: Severe invasive group A streptococcal disease: clinical description and mechanisms of pathogenesis. J Lab Clin 1996, 127:13–22.

    Article  CAS  Google Scholar 

  50. Bisno AL, Stevens DL: Streptococcal infections of skin and soft tissues. N Engl J Med 1996, 334:240–245.

    Article  PubMed  CAS  Google Scholar 

  51. Schrager HM, Rheinwald JG, Wessels MR: Hyaluronic acid capsule and the role of streptococcal entry into keratinocytes in invasive skin infection. J Clin Invest 1996, 98:1954–1958.

    Article  PubMed  CAS  Google Scholar 

  52. Molinari G, Talay SR, Valentin-Weigand P, et al.: The fibronectin- binding protein of Streptococcus pyogenes, SfbI, is involved in the internalization of group A streptococci by epithelial cells. Infect Immun 1997, 65:1357–1363.

    PubMed  CAS  Google Scholar 

  53. Sela S, Neeman R, Keller N, et al.: Relationship between asymptomatic carriage of Streptococcus pyogenes and ability of the strains to adhere and internalise cultured epithelial cells. Med Microbiol 2000, 49:499–502.An important study showing a significant correlation between continued carriage of GAS despite therapy and the capacity of GAS to internalize culture epithelial cells. These results further support the theory that GAS internalization might enable extended intracellular persistence during antibiotic treatment.

    Google Scholar 

  54. Kaplan El, Gerber MA: Group A streptococcal infections. In Textbook of Pediatric Infectious Diseases, edn 4. Edited by Feigin RD, Cherry JD. Philadelphia: WB Saunders; 1998:1076–1084. Review of all aspects of streptococcal infections in children. Special emphasis is given to streptococcal tonsillitis, including diagnosis, therapy, and complications.

    Google Scholar 

  55. Tanz RR: Convenient schedules and short course treatment of acute streptococcal pharyngitis. Pediatr Infect Dis J 2000, 19:560–570.

    Google Scholar 

  56. Bingen E, Fitoussi F, Doit C, et al.: Resistance to macrolides in Streptococcus pyogenes in France in pediatric patients. Antimicrob Agents Chemother 2000, 44:1453–1457.

    Article  Google Scholar 

  57. Derrick CW, Dillon HC.: Erythromycin therapy for streptococcal pharyngitis. Am J Dis Child 1976, 130:175–178.

    PubMed  CAS  Google Scholar 

  58. Shvartzman P, Tabenkin H, Rosentzwaig A, et al.: Treatment of streptococcal pharyngitis with amoxycillin once a day. Br Med J 1993, 306:1170–1172.

    CAS  Google Scholar 

  59. Feder HM Jr, Gerber MA, Randolf MF, et al.: Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics 1999, 103:47–51.

    Article  PubMed  Google Scholar 

  60. Pichichero ME, Disney FA, Aronovitz GH, et al.: Randomized, single-blind evaluation of cefadroxil and phenoxymethylpenicillin in the treatment of streptococcal pharyngitis. Antimicrob Agents Chemother 1987, 31:903–906.

    PubMed  CAS  Google Scholar 

  61. Stillerman M: Comparison of oral cephalosporins with penicillin therapy for group A streptococcal pharyngitis. Pediatr Infect Dis J 1986, 5:549–654.

    Google Scholar 

  62. Adam D, Scholz H, Helmerking M: Comparison of shortcourse (5 day) cefuroxime axetil with a standard 10 day oral penicillin V regimen in the treatment of tonsillopharyngitis. J Antimicrobial Chemother 2000, 45:23–30.

    Article  Google Scholar 

  63. Gerber MA: Treatment failures and carriers: perception or problems? Pediatr Infect Dis J 1994, 13:576–579.

    Article  PubMed  CAS  Google Scholar 

  64. Committee on Infectious Diseases of the American Academy of Pediatrics. 1997 Red Book: Report of the Committee on Infectious Diseases, edn 24. Elk Grove Village, IL: American Academy of Pediatrics; 1997:483–494.

  65. Paradise JL, Bluestone CD, Bachman RZ, et al.: Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984, 310:674–683.

    Article  PubMed  CAS  Google Scholar 

  66. Dana ST, Bogdasarian RS, Bugress LP, et al.: 1992 Clinical Indicators Compendium. Alexandria, VA: American Academy of Otolaryngology Head and Neck Surgery; 1992.

    Google Scholar 

  67. Deutsch ES, Isaacson GC: Tonsils and adenoids: an update. Pediatr Rev 1995, 16:17–21.

    Article  PubMed  CAS  Google Scholar 

  68. Cue D, Dombek PE, Lam H, et al.: Streptococcus pyogenes serotype M1 encodes multiple pathways for entry into human epithelial cells. Infect Immun 1998, 66:4593 In 4601.

    Google Scholar 

  69. Ozeri V, Rosenshine I, Mosher DF, et al.: Roles of integrins and fibronectin in the entry of Streptococcus pyogenes into cells via protein F1. Mol Microbiol 1998, 30:625–637.

    Article  PubMed  CAS  Google Scholar 

  70. Cue D, Southern SO, Southern PJ, et al.: A nonpeptide integrin antagonist can inhibit epithelial cell ingestion of Streptococcus pyogenes by blocking formation of integrin alpha 5beta1-fibronectin-M1 protein complexes. Proc Natl Acad Sci U S A 2000, 97:2858–2863.

    Article  Google Scholar 

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Barzilai, A., Miron, D. & Sela, S. Etiology and management of acute and recurrent group a Streptococcal tonsillitis. Curr Infect Dis Rep 3, 217–223 (2001). https://doi.org/10.1007/s11908-001-0023-6

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