Cochrane review: Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children

Abstract Background The standard duration of treatment for acute group A beta hemolytic streptococcus (GABHS) pharyngitis with oral penicillin is 10 days. Shorter duration antibiotics may have comparable efficacy. Objectives To summarize the evidence regarding the efficacy of two to six days of newer oral antibiotics (short duration) compared to 10 days of oral penicillin (standard duration) in treating children with acute GABHS pharyngitis. Search strategy We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 4), which contains the Acute Respiratory Infections Group's Specialized Register; the Database of Abstracts of Reviews of Effects (DARE); MEDLINE (1966 to October 2007); OLDMEDLINE (1950 to December 1965); and EMBASE (January 1990 to November 2007). Selection criteria Randomized controlled trials (RCTs) comparing short duration oral antibiotics to standard duration oral penicillin in children aged 1 to 18 years with acute GABHS pharyngitis. Data collection and analysis Two review authors scanned the titles and abstracts of retrieved citations and applied the inclusion criteria. We retrieved included studies in full and extracted data. Two review authors independently assessed trial quality. Main results Twenty studies were included with 13,102 cases of acute GABHS pharyngitis. Compared to standard duration treatment, the short duration treatment had shorter periods of fever (mean difference (MD) ‐0.30 days, 95% CI ‐0.45 to ‐0.14) and throat soreness (MD ‐0.50 days, 95% CI ‐0.78 to ‐0.22); lower risk of early clinical treatment failure (OR 0.80, 95% CI 0.67 to 0.94); no significant difference in early bacteriological treatment failure (OR 1.08, 95% CI 0.97 to 1.20), or late clinical recurrence (OR 0.95, 95% CI 0.83 to 1.08). However, the overall risk of late bacteriological recurrence was worse in the short duration treatment (OR 1.31, 95% CI 1.16 to 1.48), although no significant differences were found when studies of low dose azithromycin (10mg/kg) were eliminated (OR 1.06, 95% CI 0.92 to 1.22). Three studies reported long duration complications with no statistically significant difference (OR 0.53, 95% CI 0.17 to 1.64). Authors' conclusions Three to six days of oral antibiotics had comparable efficacy compared to the standard duration 10 day oral penicillin in treating children with acute GABHS pharyngitis. In countries with low rates of rheumatic fever, it appears safe and efficacious to treat children with acute GABHS pharyngitis with short duration antibiotics. In areas where the prevalence of rheumatic heart disease is still high, our results must be interpreted with caution. Plain Language Summary The effect of short duration versus standard duration antibiotic therapy for streptococcal throat infection in children Streptococcal throat infection is very common. A 10‐day course of penicillin is prescribed mainly to protect against the complication of acute rheumatic fever, which occurs approximately 20 days after streptococcal throat or scarlet fever, and causes damage to the heart valves. Cases of acute rheumatic fever have dropped dramatically in high‐income countries, with an annual incidence amongst school‐aged children of 0.5 cases per 100,000, compared to 100 to 200 cases per 100,000 in low‐income countries. Newer antibiotics, taken for a shorter duration, may have a comparable effect to penicillin taken for 10 days. We summarized the evidence in the medical literature regarding the effect of two to six days of oral antibiotics (short duration) in treating children with streptococcal throat infection, compared with 10 days of oral penicillin (standard duration). We searched the literature from 1951 to November 2007. Twenty studies were included with a total of 13,102 cases of streptococcal throat infection. The most common antibiotic studied was azithromycin (n = 6). Compared to standard duration, the short duration treatment had a shorter period of fever (mean difference (MD) ‐0.30 days, 95% CI ‐0.45 to ‐0.14) and sore throat (MD ‐0.50, 95% CI ‐0.78 to ‐0.22), and lower risk of early clinical treatment failure (OR 0.80, 95% CI 0.67 to 0.94), but there was no significant difference in early bacteriological treatment failure (OR 1.08, 95% CI 0.97 to 1.20), or late clinical recurrence (OR 0.95, 95% CI 0.83 to 1.08). The overall risk of late bacteriological recurrence was worse in the short duration treatment (OR 1.31, 95% CI 1.16 to 1.48). However, no significant difference was found when eliminating studies of low‐dose azithromycin (10 mg/kg) (OR 1.06, 95% CI 0.92 to 1.22). The short duration treatment resulted in better compliance (non‐compliance OR 0.21, 95% CI 0.16 to 0.29), but more side effects (OR 1.85, 95% CI 1.55 to 2.21). All side effects were self‐limiting: mostly mild to moderate diarrhea, vomiting, and abdominal pain. Three studies reported the rate of long duration complications with no statistically significant difference (OR 0.53, 95% CI 0.17 to 1.64). Three to six days of oral antibiotics for children with streptococcal (strep) throat infection is a safe treatment with a comparable effect to the standard duration of 10 days of penicillin. However, our results must be interpreted with caution in low‐income countries where acute rheumatic fever is still a problem.

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