Penicillins or cephalosporins for streptococcal tonsillopharyngitis in children - what does the meta-analysis recommend?

For the past 5 decades, penicillin has been the drug of choice for the treatment of tonsillopharyngitis caused by group A β-hemolytic streptococcus (GABA). Since the early 1980s, there have been studies showing the ineffectiveness of penicillin in patients with GBSA infection. Cephalosporins have been used successfully for the treatment of GABA tonsillopharyngitis since the early 1970s. Two previous meta-analyzes have shown that cephalosporins produce a higher percentage of HBSA eradication in patients with tonsillopharyngitis acute. But since the publication of the last meta-analysis, 22 new studies comparing cephalosporins and penicillin have been performed.

A meta-analysis was performed based on all of the available randomized controlled trials devoted to this problem.

To be included in the meta-analysis, the study had to meet the following criteria: patients under 18 years of age, bacteriological confirmation of the etiology of BSA with an express test or a culture study, random distribution between the groups having received cephalosporins or penicillin for 10 days, and bacteriological monitoring of effectiveness after graduation from therapy.

The probability of bacteriological ineffectiveness was significantly lower (p less than 0.00001) when prescribing oral cephalosporins (cephalexin, cefadroxil, cefuroxime, cefpodoxime, cefprosil, cefprosil, ceftibutene). The effectiveness of cephalosporins compared to penicillin has been increasing for 3 decades, due to the increasing incidence of penicillin ineffectiveness over time. When comparing the effectiveness of individual cephalosporin preparations with penicillin, 8 of 11 cephalosporins showed greater bacteriological and clinical efficacy than penicillin. 3 cephalosporins (cefaclor, cefaloglycine, cefetameth proxetil) had the same efficacy as penicillin, however, the volume of studies was insufficient to detect statistically significant differences.

The influence of various factors on the conclusion regarding the higher efficacy of cephalosporins was evaluated. A similar conclusion was reached in double-blind studies (odds ratio (OR) = 2.31; 95% confidence interval (CI) 1.39-3.85), high quality studies (more than 2 points on the Jadad scale) (OS = 2.50; 95% CI 1.85-3.36), studies with well-described clinical manifestations (OS = 2.12; 95% CI 1.54-2.90 ), studies with close compliance monitoring (OS = 2.85; 95% CI 2.33-3.47), with serotyping of the pathogen (OS = 3.10; 95% CI 2.42-3.98 ), with elimination of carriers (OS = 2.51; 95% CI 1.55-4.08) and in studies with a bacteriological control study for 3-14 days after approximately the end of treatment (OS = 3.53; 95% CI 2.75-4.54).

Comparing the effectiveness of individual cephalosporins, as well as representatives of three generations of cephalosporins, there was no difference between them. During the research period (1970-1999), there was an increase in the differences between the efficacy of cephalosporins and penicillin.

Possible reasons for the higher activity of cephalosporins in relation to the eradication of BSA are:

Over the years, a decrease in the percentage of eradication of HBSS by penicillin can be explained by a wider use of antibiotics, the selection of the flora producing β-lactamase in the oropharynx and an increase in the prevalence of this flora.

The lack of cephalosporins can be considered as a broader spectrum of antibacterial action. Cephalosporins are more expensive than penicillin, but additional doctor visits, missed school days, and a temporary disability associated with the ineffectiveness of penicillin also have significant costs.

Based on the results of the study, the authors support the adoption of cephalosporins as the drugs of choice for the treatment of GBSA-tonsillopharyngitis.