Antibiotic therapy for tonsillopharyngitis caused by group A β-hemolytic streptococcus (BHCA) has the following objectives: to stop clinical manifestations, prevent rheumatic fever (rheumatic fever) and purulent complications, and prevent the spread of the pathogen. Since the clinical symptoms of streptococcal tonsillopharyngitis are non-specific, it is recommended that antibiotics be prescribed only after laboratory confirmation of the HBAS etiology of the disease. This allows you to reduce the irrational use of antibiotics. In this article, the researchers evaluated different approaches to identify and treat tonsillopharyngitis in children and adults.

The study involved 787 children and adults aged 3 to 69 years. The following diagnostic criteria were used for the diagnosis of acute streptococcal tonsillopharyngitis: Centor's clinical scale, rapid diagnosis and culture of the oropharynx smear. The Centrator scale, designed for adults, includes 4 indicators, each of which is assessed at 1 point: body temperature above 38 ° C, lack of cough, enlarged and painful cervical lymph nodes, and swelling of the tonsils with exudation. The modified Centrator scale also takes into account the patient's age and is used in both adults and children. The age is estimated as follows: if the patient is 3 to 14 years old, then +1 point, 15 to 44 years - 0 points, 45 years and over - -1 point.

Current guidelines for the treatment of tonsillopharyngitis (IDSA - Infectious Diseases Society of America, ASIM - American College of Physicians-American Society of Internal Medicine, American Academy of Family Physicians and US Centers for Disease Control and Prevention) differ in approaches of empirical therapy and the need for mandatory laboratory confirmation of the presence of group A β-hemolytic streptococci (BHSA). According to IDSA guidelines, a culture study should not be performed in children and adults at very low risk of streptococcal infection and in adults whose rapid test result is negative. It is recommended that antibiotics be prescribed only if the result of a culture test or a rapid test is positive. ASIM guidelines support the IDSA approach only for children and allow empirical antibiotic therapy for adult patients based on clinical data. There are other approaches for the treatment of tonsillopharyngitis.

In the United States, approximately 70% of adults and children are currently receiving antibiotics for tonsillopharyngitis. Prescribing an antibiotic to a patient who has 3 or more points on a modified Centrator scale leads to the fact that the antibiotic is prescribed to 60% of patients and in 40% of cases, their use is irrational. A culture study for all adults or only those selected on the basis of clinical symptoms has a sensitivity of 100% and a specificity of 96-100%. In the treatment of children, it is necessary to conduct a cultural study or a rapid test with cultural confirmation of a negative result. Such a study has a sensitivity of 100% and a specificity of 99-100%.

The identification of all cases of HHSA-tonsillopharyngitis is only possible with the standard approach, consisting of a cultural study of a swab from the oropharynx in all patients with sore throat. The IDSA and ASIM guidelines detect all cases of GABA tonsillopharyngitis in children. But in adults, if cultural confirmation of the negative rapid test is not performed, up to a quarter of tonsillopharyngitis GABA may be missed.

The study included patients with a Centrator score of 2 points or more. According to the guidelines, patients with a score below 2 points have a low risk of HBAS infection and are not subject to laboratory examination. According to published data, up to 25-30% of BSA tonsillopharyngitis occurs in individuals with a score less than 2 points on a modified Centrator scale. Therefore, the IDSA and ASIM guidelines cannot provide 60% detection of GABA-tonsillopharyngitis in all patients with tonsillopharyngitis. In a population where the prevalence of acute respiratory infections is low, even such a level of detection of GBSA is amply sufficient. Symptom relief is most pronounced in febrile patients. These are mainly patients with a score of 3 or 4 points. Carrying out rapid tests in these patients and prescribing an antibiotic only in the event of a positive result lead to a significant reduction in the unreasonable use of antibiotics in adults. Even if the clinical picture is not expressed, confirmation of the negative result of the rapid test by cultural research is necessary.

Performing rapid tests allows you to prescribe early antibiotic treatment, which prevents the development of acute respiratory infections and relieves the symptoms of the disease.

IDSA recommends rapid diagnosis for all children and adults. About 70% of children will need a negative culture test. This significantly increases the burden on medical personnel, which hinders compliance with these recommendations. The use of the modified Centrator scale is accompanied by a minimum frequency of diagnostic tests, provides sensitivity and specificity of more than 90% in children and adults, and leads to a significant reduction in use. irrational antibiotics.

Analysis showed that among children with a score of 4 or higher on the modified Centor scale, 68% had a positive culture test of an oropharynx swallow and only 31% in adults. Therefore, the empirical prescription of an antibiotic in children is acceptable, but in adults (with a probability of streptococcal etiology of 31%) - no.

The sensitivity of the rapid tests was 83%. According to ASIM guidelines, it is not necessary to conduct a culture study if the sensitivity of rapid tests exceeds 80%.

The sample culture study recommended by the guidelines serves the purpose of reducing the frequency of prescribing antibiotics, including those that are unreasonable. ASIM recommended the empirical prescription of antibiotics for patients with a score of 3 or higher on the Centrator scale can lead to the fact that in 40% of cases, the antibiotic will be used in an irrational way. In children, for optimal identification of GABA-etiology of tonsillopharyngitis, cultural choice or cultural confirmation of a negative rapid test result remains the method of choice. Although such widespread use of diagnostic research is under discussion, the IDSA strategy remains very sensitive and specific compared to other strategies in children and leads to the lowest incidence of poor allocation of antibiotics. The recommendations not to conduct laboratory studies on adult patients with a low probability of GABA etiology according to clinical data and not to confirm the negative result of the rapid test by a cultural study worsen the diagnosis of GABA-tonsillopharyngitis.