The Journal of Pediatrics
Volume 145, Issue 1 , Pages 136-137, July 2004

Penicillin for acute sore throat in children: Randomised, double blind trial☆

University of Southampton Southampton SO16 55T, United Kingdom

Zwart S, Rovers MM, de Melker RA, Hoes AW. BMJ 2003;327:1324-8

Article Outline

 

Context Pharyngitis is a common reason for a physician visit. A prior study in adults had documented superiority of seven days versus three days of antibiotics for pharyngitis.

Objective To assess the effectiveness of penicillin for three days and treatment for seven days compared with placebo in resolving symptoms in children with sore throat.

Design Randomized, double-blind, placebo-controlled trial.

Setting 43 family practices in The Netherlands.

Participants 156 children aged 4 to 15 years who had a sore throat for less than 7 days and at least two of the 4 Centor criteria (history of fever, absence of cough, swollen tender anterior cervical lymph nodes, and tonsillar exudate).

Interventions Patients were randomly assigned to receive penicillin for 7 days, penicillin for 3 days followed by placebo for 4 days, or placebo for 7 days.

Main outcome measures Duration of symptoms, mean consumption of analgesics, number of days of absence from school, occurrence of streptococcal sequelae, eradication of the initial pathogen, and recurrences of sore throat after six months.

Results Penicillin treatment was not more beneficial than placebo in resolving symptoms of sore throat, neither in the total group nor in the 96 children with group A streptococci. In the groups randomized to 7 days of penicillin, 3 days of penicillin, or placebo, 1, 2, and 8 children, respectively, experienced a streptococcal sequela.

Conclusion Penicillin treatment had no beneficial effect in children with sore throat on the average duration of symptoms. Penicillin may, however, reduce streptococcal sequelae.

Comment This welcome study by Zwart et al shows that among a select group of more unwell children who have two of the “Centor” criteria—the absence of cough, a history of fever, cervical nodes, and purulent pharynx—antibiotics are unlikely to help symptoms, and 7 children need to be treated to prevent worsening illness in one child. However the results must be applied with caution, for a number of reasons. First, the study was not powered a priori to detect deterioration of illness. Second, all cases resolved with further antibiotics. Third, by design, efficacy trials enhance compliance and overestimate effect sizes compared with routine practice. Finally, any benefits of antibiotics must be balanced against the disadvantages of side effects, reduced local and systemic immunity, and the cycle of recurrence.1., 2., 3., 4. The study also highlights the need for more valid criteria: the Centor criteria and others5 predict the presence of Streptococcus, which is flawed due to the high asymptomatic carriage rates in the upper respiratory tract, particularly among children.6 Until more evidence is available, it would be reasonable to share the results of this study with parents, and if parents were keen to have antibiotics, a “delayed” prescription could be offered.2., 3., 4.

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References 

  1. Roos K, Holm S, Grahn-Hakansson E, Lagergren L. Recolonization with selected alpha streptococci for prophylaxis of recurrent streptococcal pharyngotonsillitis. Scand J Infect Dis. 1996;28:459–462
  2. Gerber M, Randolph M, DeMeo K, Kaplan E. Lack of impact of early antibiotic therapy for streptococcal pharyngitis on recurrence rates. J Pediatr. 1990;117:853–858
  3. Pichichero ME, Disney F, Talpey W, Green J, Francis A, Roghmann K, et al.  Adverse and beneficial effects of immediate treatment of Group A beta haemolytic streptococcal pharyngitis. Pediatr Infect Dis J. 1987;6:635–643
  4. El-Daher N, Hijazi S, Rawashdeh N, Al-Kalil I, Abu-Ektaish F, Abdel-Latif D. Immediate versus delayed treatment of Group A beta-haemolytic streptococcal pharyngitis with penicillin V. Pediatr Infect Dis J. 1991;10:126–130
  5. Attia M, Zaoutis T, Eppes S, Klein J, Meier F. Multivariate predictive models for group A beta-hemolytic streptococcal pharyngitis in children. Acad Emerg Med. 1999;6:8–13
  6. Del Mar C. Managing sore throat: a literature review I: making the diagnosis. Med J Austr. 1992;156:572–575

☆ Professor Little has received consultancy fees for 2 half-day meetings in the last 2 years funded by Abbott Pharmaceuticals regarding the role of antibiotics in preventing complications of lower respiratory tract infection.

PII: S0022-3476(04)00343-9

doi:10.1016/j.jpeds.2004.04.040

The Journal of Pediatrics
Volume 145, Issue 1 , Pages 136-137, July 2004

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