今日の臨床サポート

咽喉頭炎

著者: 余田敬子 東京女子医科大学附属足立医療センター 耳鼻咽喉科

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2022/06/08
参考ガイドライン:
  1. 日本性感染症学会:性感染症 診断・治療ガイドライン2020
患者向け説明資料

概要・推奨   

  1. 咽頭炎症状がメインの場合、A群β溶連菌感染を疑って、Centorスコア(①38℃以上の発熱、②咳がない、③前頚部リンパ節腫脹・圧痛、④滲出を伴う扁桃腫脹、の4つからスコア化)を使用し、2点以上であれば溶連菌迅速検査を行うことが強く推奨される(推奨度2)
  1. 急性咽頭炎でA群β溶連菌感染によるものなら、症状短縮、急性リウマチ熱予防のために(急性糸球体腎炎予防効果は不明)、抗菌薬使用が推奨される(推奨度2)
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
余田敬子 : 特に申告事項無し[2022年]
監修:森山寛 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、急性咽喉頭炎・A群溶連菌感染について加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 咽喉頭炎は、発症からの経過によって急性と慢性に分けられる。
  1. 急性咽喉頭炎は咽頭痛や嗄声、慢性咽喉頭炎は咽喉頭異常感や痰などの症状を訴える疾患である。
  1. 上咽頭に炎症の主体がある場合は、 耳閉感 ・難聴などの耳症状を伴う場合もある。また、喉頭に炎症の主体がある喉頭炎は、咽頭痛とともに嗄声( 嗄声・発声障害 )、痰、咳嗽を訴える。
問診・診察のポイント  
問診のポイント:
  1. 下記の症状の有無と経緯。

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文献 

M H Ebell, M A Smith, H C Barry, K Ives, M Carey
The rational clinical examination. Does this patient have strep throat?
JAMA. 2000 Dec 13;284(22):2912-8.
Abstract/Text CONTEXT: Sore throat is a common complaint, and identifying patients with group A beta-hemolytic streptococcal pharyngitis (strep throat) is an important task for clinicians. Previous reviews have not systematically reviewed and synthesized the evidence.
OBJECTIVE: To review the precision and accuracy of the clinical examination in diagnosing strep throat.
DATA SOURCE: MEDLINE search for articles about diagnosis of strep throat using history-taking and physical examination.
STUDY SELECTION: Large blinded, prospective studies (having > or =300 patients with sore throat) reporting history and physical examination data and using throat culture as the reference standard were included. Of 917 articles identified by the search, 9 met all inclusion criteria.
DATA EXTRACTION: Pairs of authors independently reviewed each article and used consensus to resolve discrepancies.
DATA SYNTHESIS: The most useful findings for evaluating the likelihood of strep throat are presence of tonsillar exudate, pharyngeal exudate, or exposure to strep throat infection in the previous 2 weeks (positive likelihood ratios, 3.4, 2.1, and 1.9, respectively) and the absence of tender anterior cervical nodes, tonsillar enlargement, or exudate (negative likelihood ratios, 0.60, 0.63, and 0.74, respectively). No individual element of history-taking or physical examination is accurate enough by itself to rule in or rule out strep throat. Three validated clinical prediction rules are described for adult and pediatric populations.
CONCLUSIONS: While no single element of history-taking or physical examination is sufficiently accurate to exclude or diagnose strep throat, a well-validated clinical prediction rule can be useful and can help physicians make more informed use of rapid antigen tests and throat cultures.

PMID 11147989
Jean-Paul Humair, Sylvie Antonini Revaz, Patrick Bovier, Hans Stalder
Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings.
Arch Intern Med. 2006 Mar 27;166(6):640-4. doi: 10.1001/archinte.166.6.640.
Abstract/Text BACKGROUND: How to use clinical score, the rapid streptococcal antigen test (RSAT), and culture results is uncertain for efficient management of acute pharyngitis in adults.
METHODS: This prospective cohort study included 372 adult patients with pharyngitis treated at a Swiss university-based primary care clinic. In eligible patients with 2 to 4 clinical symptoms and signs (temperature >or=38 degrees C, tonsillar exudate, tender cervical adenopathy, and no cough or rhinitis), we performed an RSAT and obtained a throat culture. We measured sensitivity and specificity of RSAT with culture as a gold standard and compared appropriate antibiotic use with cost per patient appropriately treated for the following 5 strategies: symptomatic treatment, systematic RSAT, selective RSAT, empirical antibiotic treatment, and systematic culture.
RESULTS: RSAT had high sensitivity (91%) and specificity (95%) for the diagnosis of streptococcal pharyngitis. Systematic throat culture resulted in the highest antibiotic use, in 38% of patients with streptococcal pharyngitis. Systematic RSAT led to nearly optimal treatment (94%) and antibiotic prescription (37%), with minimal antibiotic overuse (3%) and underuse (3%). Empirical antibiotic treatment in patients with 3 or 4 clinical symptoms or signs resulted in a lower rate of appropriate therapy (59%) but higher rates of antibiotic use (60%), overuse (32%), and underuse (9%). Systematic RSAT was more cost-effective than strategies based on empirical treatment or culture: 15.00 dollars, 26.00 dollars, and 32.00 dollars, respectively, per patient appropriately treated.
CONCLUSIONS: The RSAT we used is a valid test for diagnosis of pharyngitis in adults. A clinical approach combining this RSAT and clinical findings efficiently reduces inappropriate antibiotic prescription in adult patients with acute pharyngitis. Empirical therapy in patients with 3 or 4 clinical symptoms or signs results in antibiotic overuse.

PMID 16567603
Stanford T Shulman, Alan L Bisno, Herbert W Clegg, Michael A Gerber, Edward L Kaplan, Grace Lee, Judith M Martin, Chris Van Beneden, Infectious Diseases Society of America
Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2012 Nov 15;55(10):e86-102. doi: 10.1093/cid/cis629. Epub 2012 Sep 9.
Abstract/Text The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

PMID 22965026
Michael R Wessels
Clinical practice. Streptococcal pharyngitis.
N Engl J Med. 2011 Feb 17;364(7):648-55. doi: 10.1056/NEJMcp1009126.
Abstract/Text
PMID 21323542
B Arroll, T Kenealy
Antibiotics for the common cold and acute purulent rhinitis.
Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000247. doi: 10.1002/14651858.CD000247.pub2. Epub 2005 Jul 20.
Abstract/Text BACKGROUND: It has long been believed that antibiotics have no role in treating common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections. Given the increasing concerns about antibiotic resistance it is important to examine the evidence for the benefit of antibiotics for the common cold.
OBJECTIVES: To determine:(1) the efficacy of antibiotics, in comparison with placebo, for reducing general symptoms and specific nasopharyngeal symptoms of acute upper respiratory tract infections; (2) if antibiotics have any influence on acute purulent rhinitis; (3) whether antibiotics cause significant adverse outcomes in patients with acute upper respiratory tract infections.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005); MEDLINE (January 1966 to March, Week 1, 2005); EMBASE (1980 to December 2004), the Family Medicine Database (1908, volume 1 to 1993, volume 13; this database was discontinued in 1993), and reference lists of articles, and we contacted principal investigators.
SELECTION CRITERIA: Randomised trials comparing any antibiotic therapy against placebo in people with acute upper respiratory tract infections and with less than seven days of symptoms, or acute purulent rhinitis less than ten days in duration.
DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data.
MAIN RESULTS: All analyses used the fixed-effect model unless otherwise stated. The overall quality of the included trials was variable. People receiving antibiotics did no better in terms of lack of cure or persistence of symptoms than those on placebo (relative risk (RR) 0.89, 95% confidence interval (CI) 0.77 to 1.04), based on a pooled analysis of six trials with a total of 1147 patients. Overall, the relative risk of adverse effects in the antibiotic group was RR 1.8 (95% CI 1.01 to 3.21), using a random-effects model. Adult patients had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random-effects model) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63). The pooled relative risk for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.57 (95% CI 0.37 to 0.87) (random-effects model), based on 6 studies with 772 participants.
AUTHORS' CONCLUSIONS: There is insufficient evidence of benefit to warrant the use of antibiotics for upper respiratory tract infections in children or adults. Antibiotics cause significant adverse effects in adults. The evidence on acute purulent rhinitis and acute clear rhinitis suggests a benefit for antibiotics for these conditions but their routine use is not recommended.

PMID 16034850
Centers for Disease Control and Prevention (CDC)
Cephalosporin susceptibility among Neisseria gonorrhoeae isolates--United States, 2000-2010.
MMWR Morb Mortal Wkly Rep. 2011 Jul 8;60(26):873-7.
Abstract/Text Neisseria gonorrhoeae is a major cause of pelvic inflammatory disease, ectopic pregnancy, and infertility, and it can facilitate human immunodeficiency virus (HIV) transmission. Emergence of gonococcal resistance to penicillin and tetracycline occurred during the 1970s and became widespread during the early 1980s. More recently, resistance to fluoroquinolones developed. Resistance was documented first in Asia, then emerged in the United States in Hawaii followed by other western states. It then became prevalent in all other regions of the United States. In Hawaii, fluoroquinolone resistance was first noted among heterosexuals; however, resistance in the United States initially became prevalent among men who have sex with men (MSM) before generalizing to heterosexuals. This emergence of resistance led CDC, in 2007, to discontinue recommending any fluoroquinolone regimens for the treatment of gonorrhea. CDC now recommends dual therapy for gonorrhea with a cephalosporin (ceftriaxone 250 mg) plus either azithromycin or doxycycline. This report summarizes trends in cephalosporin susceptibility among N. gonorrhoeae isolates in the United States during 2000-2010 using data from the Gonococcal Isolate Surveillance Project (GISP). During that period, the percentage of isolates with elevated minimum inhibitory concentrations (MICs) to cephalosporins (≥0.25 µg/mL for cefixime and ≥0.125 µg/mL for ceftriaxone) increased from 0.2% in 2000 to 1.4% in 2010 for cefixime and from 0.1% in 2000 to 0.3% in 2010 for ceftriaxone. Although cephalosporins remain an effective treatment for gonococcal infections, health-care providers should be vigilant for treatment failure and are requested to report its occurrence to state and local health departments. State and local public health departments should promote maintenance of laboratory capability to culture N. gonorrhoeae to allow testing of isolates for cephalosporin resistance. They also should develop enhanced surveillance and response protocols for gonorrhea treatment failures and report gonococcal treatment failures to CDC.

PMID 21734634
A W Tustin, A B Kaiser
Life-threatening pharyngitis caused by herpes simplex virus, type 2.
Sex Transm Dis. 1979 Jan-Mar;6(1):23-4.
Abstract/Text A 21-year-old man who had pharyngitis needed hospitalization for observation of airway patency and for parenteral fluid therapy. Infection with herpes simplex virus, type 2 (HSV-2), was diagnosed on the basis of the finding of significantly increased IgM indirect hemagglutination antibody titers. The pharyngitis appeared to have been contracted by heterosexual orogenital contact (cunnilingus). The results of this case study indicate that HSV-2 infection should be considered in the differential diagnosis in cases of severe pharyngitis in sexually active patients.

PMID 221994

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