Ebell MH, Smith MA, Barry HC, Ives K, Carey M.
The rational clinical examination. Does this patient have strep throat?
JAMA. 2000 Dec 13;284(22):2912-8. doi: 10.1001/jama.284.22.2912.
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.
Humair JP, Revaz SA, Bovier P, Stalder H.
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.
Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C; 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.
青木眞. レジデントのための感染症マニュアル 第4版. 医学書院, 2020; 567-9, 1110-5.
林達哉. 咽頭・扁桃炎に対する抗菌薬の適正使用に関する諸問題. 口咽科, 23: 17-21, 2010.
荒牧 元. 口腔咽頭粘膜疾患アトラス. 第一版. 東京: 医学書院, 2001.
佐久間孝久. アトラスさくま小児咽頭所見. 第一版. 福岡:メディカル情報センター, 2005.
余田敬子：咽頭炎 口腔咽頭の臨床 第3版 医学書院 東京 2015，60-61.
Wessels MR.
Clinical practice. Streptococcal pharyngitis.
N Engl J Med. 2011 Feb 17;364(7):648-55. doi: 10.1056/NEJMcp1009126.
Abstract/Text
余田敬子. 口腔咽喉頭科学・気管食道科学領域 咽頭に多発性のアフタがあり、咽頭痛を訴える. JOHNS, 30: 1261-3, 2014.
上原由紀. 上気道感染と適正抗菌薬使用. 日医雑誌, 141: 997-9, 2012.
天津久郎. 急性咽頭炎・扁桃炎 桃周囲膿瘍. JOHNS, 27: 1428-30, 2011.
Arroll B, Kenealy T.
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.
余田敬子. 口腔咽頭領域の粘膜病変――性感染症を中心に. 日耳鼻, 122: 984-8, 2019.
口腔咽頭と性感染症．日本性感染症学会, 性感染症 診断・治療ガイドライン2020, 診断と治療社, 東京, pp29-34, 2020.
日本性感染症学会ガイドライン委員会：梅毒．日本性感染症学会, 性感染症 診断・治療ガイドライン2020, 診断と治療社, 東京, pp46-52, 2020.
日本性感染症学会ガイドライン委員会：淋菌感染症．日本性感染症学会, 性感染症 診断・治療ガイドライン2020, 診断と治療社, 東京, pp53-59, 2020.
安田満. 氾濫する性感染症（STI）を再考する 淋菌・クラミジアの咽頭感染. Urology View, 7: 87-92, 2009.
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.
木全奈都子, 中川尚, 荒木博子ほか. 成人型封入体結膜炎と上咽頭クラミジア感染. 臨眼, 49: 443-5, 1995.
余田敬子. 特殊な上咽頭炎の臨床. 口腔咽頭科, 19: 225-34, 2007.
加藤達夫. 耳鼻咽喉科の新興・up date 再興感染症 ジフテリア. MB ENT, 24: 24-29, 2003.
Tustin AW, Kaiser AB.
Life-threatening pharyngitis caused by herpes simplex virus, type 2.
Sex Transm Dis. 1979 Jan-Mar;6(1):23-4. doi: 10.1097/00007435-197901000-00007.
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.
余田敬子, 宮野良隆, 荒牧元ほか. STDとしての単純ヘルペス感染による急性扁桃炎の2例. 日扁桃誌, 32: 71-5, 1993.
余田敬子. 耳鼻咽喉科とウイルス 口腔・咽頭ヘルペス. JOHNS, 30: 1633-7, 2014.
古谷信彦：グローバル時代の感染症学 細菌感染症 グラム陽性桿菌感染症 放線菌症. 日本臨床61 増2: 368-372, 2003.
佐藤尚夫. マイコプラズマ感染症における上咽頭の炎症性腫大 特にアデノイドについて. 日本医事新報, 3809: 29-31, 1997.
