今日の臨床サポート

急性咽頭炎 (溶連菌咽頭炎を含む)

著者: 上山伸也 倉敷中央病院 感染症科/感染制御室

監修: 山本舜悟 京都市立病院 感染症科/京都大学 医療疫学(非常勤講師) 

著者校正/監修レビュー済:2020/01/17
患者向け説明資料

概要・推奨   

  1. Centorスコアで3以上の場合、診断確定のために、A群溶連菌の迅速検査はおそらく推奨される(推奨度2)
  1. 成人の場合、Centorスコアで2点以上、かつA群溶連菌の迅速検査が陰性の場合、咽頭培養はおそらく推奨されない(推奨度3)
  1. 小児においては迅速検査が陰性でも咽頭培養がおそらく推奨される(推奨度2)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
閲覧にはご契
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。
※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、実際の保険適用の査定において保険適用及び保険適用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用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:
上山伸也 : 特に申告事項無し[2021年]
監修:山本舜悟 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、Centorスコアについて修正を行った。

病態・疫学・診察

疾患情報  
  1. 急性咽頭炎とは、アデノウイルス、コクサッキーウイルスなどのウイルスや、A群β溶血性レンサ球菌などの細菌によって起きる咽頭の炎症である。
  1. 急性咽頭炎の診断はCentorスコア(A群β溶連菌の診断基準)をもとに行う(発熱38℃以上:1点、咳がない:1点、圧痛を伴う前頚部リンパ節腫脹:1点、白苔を伴う扁桃腺炎:1点)。さらに年齢による修正(3~14歳:+1点、15~44歳:0点、45歳~:-1点)を行い、5点満点で診断する。
 
白苔を伴う扁桃腺炎

典型的なA群溶連菌による咽頭炎の所見。
軟口蓋、口蓋垂、扁桃の発赤を認め、扁桃には白苔の付着を認める。

 
  1. A群溶連菌による咽頭炎の確率は以下の通り。
  1. 0点以下 1%
  1. 1点 10%
  1. 2点 17%
  1. 3点 35%
  1. 4点以上 51%
  1. 1点以下は検査なし、2点以上の場合は迅速検査を行う。
  1. 急性咽頭炎の起炎菌は、小児の85%、成人の95%でウイルスか不明である。
  1. A群溶連菌が咽頭炎の起炎菌に占める割合は、小児で15~30%、成人で5~10%程度といわれている。
 
  1. 溶連菌感染症後糸球体腎炎の発症頻度については、15歳未満の小児では22.1/100,000 person-yearsであり、成人では0.16/100,000 person-yearsと報告されている。
  1. 溶連菌感染症後糸球体腎炎の発症頻度について報告しているシステマティックレビューがある[1]。この報告では、15歳未満の小児では0.0221% person-yearsであり、成人では0.00016%person-yearsとされている。
問診・診察のポイント  
  1. Centorスコアの症状を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Jonathan R Carapetis, Andrew C Steer, E Kim Mulholland, Martin Weber
雑誌名: Lancet Infect Dis. 2005 Nov;5(11):685-94. doi: 10.1016/S1473-3099(05)70267-X.
Abstract/Text The global burden of disease caused by group A streptococcus (GAS) is not known. We review recent population-based data to estimate the burden of GAS diseases and highlight deficiencies in the available data. We estimate that there are at least 517,000 deaths each year due to severe GAS diseases (eg, acute rheumatic fever, rheumatic heart disease, post-streptococcal glomerulonephritis, and invasive infections). The prevalence of severe GAS disease is at least 18.1 million cases, with 1.78 million new cases each year. The greatest burden is due to rheumatic heart disease, with a prevalence of at least 15.6 million cases, with 282,000 new cases and 233,000 deaths each year. The burden of invasive GAS diseases is unexpectedly high, with at least 663,000 new cases and 163,000 deaths each year. In addition, there are more than 111 million prevalent cases of GAS pyoderma, and over 616 million incident cases per year of GAS pharyngitis. Epidemiological data from developing countries for most diseases is poor. On a global scale, GAS is an important cause of morbidity and mortality. These data emphasise the need to reinforce current control strategies, develop new primary prevention strategies, and collect better data from developing countries.

PMID 16253886  Lancet Infect Dis. 2005 Nov;5(11):685-94. doi: 10.1016/・・・
著者: W J McIsaac, D White, D Tannenbaum, D E Low
雑誌名: CMAJ. 1998 Jan 13;158(1):75-83.
Abstract/Text OBJECTIVE: To validate a score based on clinical symptoms and signs for the identification of group A Streptococcus (GAS) infection in general practice patients with score throat.
DESIGN: A single throat swab was used as the gold standard for diagnosing GAS infection. Clinical information was recorded by experienced family physicians on standardized encounter forms. Score criteria were identified by means of logistic regression modelling of data from patients enrolled in the first half of the study. The score was then validated among the remaining patients.
SETTING: University-affiliated family medicine centre in Toronto.
PATIENTS: A total of 521 patients aged 3 to 76 years presenting with a new upper respiratory tract infection from December 1995 to February 1997.
OUTCOME MEASURES: Sensitivity, specificity and likelihood ratios for identification of GAS infection with the score approach compared with throat culture. Proportion of patients prescribed antibiotics, throat culture use, and sensitivity and specificity with usual physician care and with score-based recommendations were compared.
RESULTS: A score was developed ranging in value from 0 to 4. The sensitivity of the score for identifying GAS infection was 83.1%, compared with 69.4% for usual physician care (p = 0.06); the specificity values of the 2 approaches were similar. Among patients aged 3 to 14 years, the sensitivity of the score approach was higher than that of usual physician care (96.9% v. 70.6%) (p < 0.05). The proportion of patients receiving initial antibiotic prescriptions would have been reduced 48% by following score-based recommendations compared with observed physician prescribing (p < 0.001), without any increase in throat culture use.
CONCLUSIONS: An age-appropriate sore throat score identified GAS infection in children and adults with sore throat better than usual care by family physicians, with significant reductions in unnecessary prescribing of antibiotics. A randomized trial comparing the 2 approaches is recommended to determine the ability of the score approach to reduce unnecessary prescribing of antibiotics during routine clinical encounters.

PMID 9475915  CMAJ. 1998 Jan 13;158(1):75-83.
著者: Aaron M Harris, Lauri A Hicks, Amir Qaseem, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention
雑誌名: Ann Intern Med. 2016 Mar 15;164(6):425-34. doi: 10.7326/M15-1840. Epub 2016 Jan 19.
Abstract/Text BACKGROUND: Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI.
METHODS: A narrative literature review of evidence about appropriate antibiotic use for ARTI in adults was conducted. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. To identify evidence-based articles, the Cochrane Library, PubMed, MEDLINE, and EMBASE were searched through September 2015 using the following Medical Subject Headings terms: "acute bronchitis," "respiratory tract infection," "pharyngitis," "rhinosinusitis," and "the common cold."
HIGH-VALUE CARE ADVICE 1: Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.
HIGH-VALUE CARE ADVICE 2: Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
HIGH-VALUE CARE ADVICE 3: Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening).
HIGH-VALUE CARE ADVICE 4: Clinicians should not prescribe antibiotics for patients with the common cold.

PMID 26785402  Ann Intern Med. 2016 Mar 15;164(6):425-34. doi: 10.7326・・・
著者: R M Centor, J M Witherspoon, H P Dalton, C E Brody, K Link
雑誌名: Med Decis Making. 1981;1(3):239-46.
Abstract/Text Adult patients who presented to an urban emergency room complaining of a sore throat had cultures and clinical information recorded. Models were constructed, using logistic regression analysis, of both a positive culture for Group A beta streptococcus and a positive guess by a resident. The model of a positive culture consisted of four variables--tonsillar exudates, swollen tender anterior cervical nodes, lack of a cough, and history of fever. Patients with all 4 variables had a 56% probability of a positive culture; 3 variables, 32%; 2 variables, 15%; 1 variable, 6.5%; and 0 variables, 2.5%. The model of a positive guess by a resident demonstrated an over-reliance on physical exam and an underuse of history. The model of a positive culture allows stratification of patients to assist clinicians in the management strategies.

PMID 6763125  Med Decis Making. 1981;1(3):239-46.
著者: K H Webb, C A Needham, S R Kurtz
雑誌名: J Fam Pract. 2000 Jan;49(1):34-8.
Abstract/Text BACKGROUND: Optimal diagnostic management of patients with pharyngitis is controversial. In our study, we compared streptococcal complication rates at a large suburban medical center during 2 time periods: when pharyngitis patients were managed almost exclusively with throat culture and when they were managed primarily with a high-sensitivity antigen test without culture confirmation of negative results.
METHODS: Using a combination of Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes, we studied all patients seen for either pharyngitis or known streptococcal complications during a 4-year period. We then reviewed all available charts of patients with known streptococcal complications for coding accuracy. We compared streptococcal complication rates during each -time period.
RESULTS: A total of 30,036 patients were seen for pharyngitis during the 4 years. A streptococcal diagnostic test was used in 66% of patient encounters. During the first 2 years (period 1), 99.9% of the tests ordered were blood agar plate throat cultures. During the second 2 years (period 2), 76.6% of tests ordered were high-sensitivity antigen tests without culture confirmation of negative results. Suppurative complications occurred in 37 patients in period 1 and 36 patients in period 2. There were no cases of acute rheumatic fever in either period. There was one case of poststreptococcal glomerulonephritis in period 2.
CONCLUSIONS: Use of a high-sensitivity antigen test without culture confirmation of all negative results has not been associated with an increase in suppurative and nonsuppurative complications of group A beta-hemolytic streptococci.

PMID 10678338  J Fam Pract. 2000 Jan;49(1):34-8.
著者: Alan L Bisno, Michael A Gerber, Jack M Gwaltney, Edward L Kaplan, Richard H Schwartz, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2002 Jul 15;35(2):113-25. doi: 10.1086/340949.
Abstract/Text
PMID 12087516  Clin Infect Dis. 2002 Jul 15;35(2):113-25. doi: 10.1086・・・
著者: Karen E Gieseker, Martha H Roe, Todd MacKenzie, James K Todd
雑誌名: Pediatrics. 2003 Jun;111(6 Pt 1):e666-70.
Abstract/Text OBJECTIVE: The American Academy of Pediatrics recommends that all negative rapid diagnostic tests for Streptococcus pyogenes pharyngitis be backed up by culture, which creates a dilemma for clinicians who must make treatment decisions without complete diagnostic information at the time of visit. The use of a follow-up serial rapid antigen test instead of a follow-up culture would provide a more timely result.
METHODS: Two swabs were collected from children who were suspected of having S pyogenes pharyngitis. Each swab was used for a culture and an OSOM Ultra Strep A Test rapid antigen test. The gold standard of comparison was defined as the identification of S pyogenes on either of the 2 culture plates. Three diagnostic strategies were evaluated: a single rapid antigen test, a rapid antigen test with follow-up rapid antigen test (rapid-rapid), and a rapid antigen test with follow-up culture (rapid-culture).
RESULTS: A total of 210 (23.7%) of 887 throat cultures with matched data were identified with S pyogenes. A single rapid antigen test had a sensitivity of 87.6% (95% confidence interval [CI]: 83.2%-92.1%), the sensitivity of the rapid-rapid follow-up was 91.4% (95% CI: 87.6%-95.2%), and the sensitivity of the rapid-culture follow-up was 95.7% (95% CI: 93.0%-98.5%), which was significantly higher than the others. As shown in Fig 1, when these test strategies were evaluated on a subgroup with clinical symptoms commonly associated with S pyogenes pharyngitis, the sensitivities all increased and were no longer significantly different. None of the strategies reliably exceeded a 95% sensitivity threshold.
CONCLUSIONS: The American Academy of Pediatrics strategy for S pyogenes detection in children with pharyngitis, requiring a backup culture for those with negative antigen tests, was not exceeded by any other test strategy; however, a rapid-rapid diagnostic strategy may approximate it with the use of judicious clinical selection of patients.

PMID 12777583  Pediatrics. 2003 Jun;111(6 Pt 1):e666-70.
著者: K G Ragosta, R Orr, M J Detweiler
雑誌名: J Am Osteopath Assoc. 1997 Apr;97(4):227-9.
Abstract/Text A retrospective review was done on the medical records (March 1986 through December 1989) of patients referred to Pittsburgh Children's Hospital with the presumptive diagnosis of epiglottitis. Data obtained included age, final diagnosis, referring physician's radiographic evaluation/interpretation, procedures (intubation, IV administered, aerosol, cultures obtained), transport times, and long-term morbidity and mortality. The diagnostic value of lateral neck radiographs was analyzed. Lateral neck radiographs were found to be of little value in the primary evaluation of epiglottitis. Rather, skilled personnel, using an established protocol, did limit morbidity and mortality in patients with symptoms consistent with epiglottitis. All medical centers should develop a protocol for management of patients presenting with symptoms suggestive of epiglottitis.

PMID 9154741  J Am Osteopath Assoc. 1997 Apr;97(4):227-9.
著者: K B Tibazarwa, J A Volmink, B M Mayosi
雑誌名: Heart. 2008 Dec;94(12):1534-40. doi: 10.1136/hrt.2007.141309. Epub 2008 Jul 31.
Abstract/Text BACKGROUND: There is no systematic overview of prospective studies of incidence of acute rheumatic fever (ARF) in the world.
AIM: To summarise all population-based studies of the incidence of ARF world wide.
METHOD: A systematic review of prospective population-based studies of the overall mean and annual specific incidence of the first episode of ARF was carried out.
RESULTS: A systematic literature search identified 10 eligible studies from 10 countries on all continents, except Africa. The overall mean incidence rate of first attack of ARF was 5-51/100,000 population (mean 19/100,000; 95% CI 9 to 30/100,000). A low incidence rate of 10/100,000) was documented in Eastern Europe, Middle East (highest), Asia and Australasia. Studies with longitudinal data displayed a falling incidence rate over time.
CONCLUSION: Despite an apparent fall in incidence over time, ARF incidence rates remain relatively high in non-Western countries. No information is available for Africa.

PMID 18669552  Heart. 2008 Dec;94(12):1534-40. doi: 10.1136/hrt.2007.1・・・
著者: Christina Y Miyake, Kimberlee Gauvreau, Lloyd Y Tani, Robert P Sundel, Jane W Newburger
雑誌名: Pediatrics. 2007 Sep;120(3):503-8. doi: 10.1542/peds.2006-3606.
Abstract/Text OBJECTIVE: The goal was to describe characteristics of children discharged from hospitals in the United States in 2000 with the diagnosis of acute rheumatic fever.
METHODS: We explored characteristics of children <21 years of age who were hospitalized with a diagnosis of acute rheumatic fever by using the 2000 Kids' Inpatient Database, weighted to estimate the number and rate of acute rheumatic fever-associated hospitalizations in the United States.
RESULTS: In 2000, an estimated 503 acute rheumatic fever hospitalizations occurred among children <21 years of age, at a rate of 14.8 cases per 100,000 hospitalized children, with a mean age of 10 years. In comparison with all Kids' Inpatient Database admissions, acute rheumatic fever hospitalizations were more common in the age group of 6 to 11 years and among male patients. Chorea was more common in female patients (61.7%). White patients were significantly underrepresented, whereas Asian/Pacific Islander patients and patients of other races were overrepresented. Hospitalizations of patients with acute rheumatic fever were significantly more common in the Northeast and less common in the South. The highest rates of acute rheumatic fever hospitalizations occurred in Utah, Hawaii, Pennsylvania, and New York. Significantly more acute rheumatic fever admissions occurred in March. The expected payor was more likely to be private insurance and less likely to be Medicaid. Acute rheumatic fever hospitalizations were more likely to occur in teaching hospitals, freestanding children's hospitals, and children's units in general hospitals and in urban locations. The median length of stay for acute rheumatic fever hospitalizations was 3 days, and the median total charges were $6349. The in-hospital mortality rate was 0.6%.
CONCLUSIONS: In 2000, we found that hospitalizations for acute rheumatic fever were infrequent and varied according to race, season, location, and type of hospital.

PMID 17766522  Pediatrics. 2007 Sep;120(3):503-8. doi: 10.1542/peds.20・・・
著者: Michael A Gerber, Robert S Baltimore, Charles B Eaton, Michael Gewitz, Anne H Rowley, Stanford T Shulman, Kathryn A Taubert
雑誌名: Circulation. 2009 Mar 24;119(11):1541-51. doi: 10.1161/CIRCULATIONAHA.109.191959. Epub 2009 Feb 26.
Abstract/Text Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A beta-hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by combining clinical judgment with diagnostic test results, the criterion standard of which is the throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) is the treatment of choice, because it is cost-effective, has a narrow spectrum of activity, and has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. For penicillin-allergic individuals, acceptable alternatives include a narrow-spectrum oral cephalosporin, oral clindamycin, or various oral macrolides or azalides. The individual who has had an attack of rheumatic fever is at very high risk of developing recurrences after subsequent GAS pharyngitis and needs continuous antimicrobial prophylaxis to prevent such recurrences (secondary prevention). The recommended duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is again the agent of choice for secondary prophylaxis, but sulfadiazine or a macrolide or azalide are acceptable alternatives in penicillin-allergic individuals. This report updates the 1995 statement by the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee. It includes new recommendations for the diagnosis and treatment of GAS pharyngitis, as well as for the secondary prevention of rheumatic fever, and classifies the strength of the recommendations and level of evidence supporting them.

PMID 19246689  Circulation. 2009 Mar 24;119(11):1541-51. doi: 10.1161/・・・
著者: C B Del Mar, P P Glasziou, A B Spinks
雑誌名: Cochrane Database Syst Rev. 2006 Oct 18;(4):CD000023. doi: 10.1002/14651858.CD000023.pub3. Epub 2006 Oct 18.
Abstract/Text BACKGROUND: Sore throat is a very common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it.
OBJECTIVES: To assess the benefits of antibiotics for sore throat.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library, Issue 1, 2006), MEDLINE (January 1966 to March 2006) and EMBASE (January 1990 to December 2005).
SELECTION CRITERIA: Trials of antibiotic against control with either measures of the typical symptoms (throat soreness, headache or fever), or suppurative or non-suppurative complications of sore throat.
DATA COLLECTION AND ANALYSIS: Potential studies were screened independently by two authors for inclusion, with differences in opinion resolved by discussion. Data were then independently extracted from studies selected by inclusion by two authors. Researchers from three studies were contacted for additional information.
MAIN RESULTS: There were 27 studies with 2835 cases of sore throat. 1. Non-suppurative complications: There was a trend for antibiotics to protect against acute glomerulonephritis, but there were insufficient cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two thirds (relative risk (RR) 0.22; 95% CI 0.02 to 2.08). 2. Suppurative complications: Antibiotics reduced the incidence of acute otitis media (RR 0.30; 95% CI 0.15 to 0.58); of acute sinusitis (RR 0.48; 95% CI 0.08 to 2.76); and of quinsy (peritonsillar abscess) compared to those taking placebo (RR 0.15; 95% CI 0.05 to 0.47). 3.
SYMPTOMS: Throat soreness and fever were reduced by antibiotics by about one half. The greatest difference was seen at about 3 to 4 days (when the symptoms of about 50% of untreated patients had settled). By one week about 90% of treated and untreated patients were symptom-free. The overall number need to treat to prevent one sore throat at day 3 was just under six (95% CI 4.9 to 7.0); at week 1 it was 21 (95% CI 13.2 to 47.9). 4. Subgroup analyses of symptom reduction: Analysis by: age; blind versus unblinded; or use of antipyretics, found no significant differences. Analysis of results of throat swabs showed that antibiotics were more effective against symptoms at day 3, RR 0.58 (95% CI 0.48 to 0.71) if the swabs were positive for Streptococcus, compared to RR 0.78 (95% CI 0.63 to 0.97) if negative. Similarly at week 1, RRs 0.29 (95% CI 0.12 to 0.70) for positive, and 0.73 (95% CI 0.50 to 1.07) for negative swabs.
AUTHORS' CONCLUSIONS: Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in modern Western society can only be achieved by treating many with antibiotics, most of whom will derive no benefit. In emerging economies (where rates of acute rheumatic fever are high, for example), the number needed to treat may be much lower for antibiotics to be considered effective. Antibiotics shorten the duration of symptoms by about sixteen hours overall.

PMID 17054126  Cochrane Database Syst Rev. 2006 Oct 18;(4):CD000023. d・・・
著者: Olli-Pekka Alho, Petri Koivunen, Tomi Penna, Heikki Teppo, Markku Koskela, Jukka Luotonen
雑誌名: BMJ. 2007 May 5;334(7600):939. doi: 10.1136/bmj.39140.632604.55. Epub 2007 Mar 8.
Abstract/Text OBJECTIVE: To determine the short term efficacy and safety of tonsillectomy for recurrent streptococcal pharyngitis in adults. Design Randomised controlled trial.
SETTING: Academic referral centre in Finland.
PARTICIPANTS: 70 adults with documented recurrent episodes of streptococcal group A pharyngitis.
INTERVENTION: Instant tonsillectomy (n=36) or remaining on waiting list as control (n=34).
MAIN OUTCOME MEASURES: Percentage change in the risk of an episode of streptococcal pharyngitis at 90 days. Rates of all episodes of pharyngitis and days with symptoms and adverse effects.
RESULTS: The mean (SD) follow-up was 164 (63) days in the control group and 170 (12) days in the tonsillectomy group. At 90 days, streptococcal pharyngitis had recurred in 24% (8/34) in the control group and 3% (1/36) in the tonsillectomy group (difference 21%; 95% confidence interval 6% to 36%). The number needed to undergo tonsillectomy to prevent one recurrence was 5 (3 to 16). During the whole follow-up, the rates of other episodes of pharyngitis and days with throat pain and fever were significantly lower in the tonsillectomy group than in the control group. The most common morbidity related to tonsillectomy was postoperative throat pain (mean length 13 days, SD 4).
CONCLUSIONS: Adults with a history of documented recurrent episodes of streptococcal pharyngitis were less likely to have further streptococcal or other throat infections or days with throat pain if they had their tonsils removed.
TRIAL REGISTRATION: Clinical Trials NCT00136877.

PMID 17347187  BMJ. 2007 May 5;334(7600):939. doi: 10.1136/bmj.39140.6・・・
著者: J L Paradise, C D Bluestone, R Z Bachman, D K Colborn, B S Bernard, F H Taylor, K D Rogers, R H Schwarzbach, S E Stool, G A Friday
雑誌名: N Engl J Med. 1984 Mar 15;310(11):674-83. doi: 10.1056/NEJM198403153101102.
Abstract/Text We studied the efficacy of tonsillectomy, or tonsillectomy with adenoidectomy, in 187 children severely affected with recurrent throat infection. Ninety-one of the children were assigned randomly to either surgical or nonsurgical treatment groups, and 96 were assigned according to parental preference. In both the randomized and nonrandomized trials, the effects of tonsillectomy and of tonsillectomy with adenoidectomy were similar. By various measures, the incidence of throat infection during the first two years of follow-up was significantly lower (P less than or equal to 0.05) in the surgical groups than in the corresponding nonsurgical groups. Third-year differences, although in most cases not significant, also consistently favored the surgical groups. On the other hand, in each follow-up year many subjects in the nonsurgical groups had fewer than three episodes of infection, and most episodes among subjects in the nonsurgical groups were mild. Of the 95 subjects treated with surgery, 13 (14 per cent) had surgery-related complications, all of which were readily managed or self-limited. These results warrant the election of tonsillectomy for children meeting the trials' stringent eligibility criteria, but also provide support for nonsurgical management. Treatment for such children must therefore be individualized.

PMID 6700642  N Engl J Med. 1984 Mar 15;310(11):674-83. doi: 10.1056/・・・

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