ENT  |  Sore Throat Pathway - Episode 3 or more of GAS




ENT

Sore Throat Pathway - Episode 3 or more of GAS

Table: Recommendations for Antibiotics Regimes for Third or More Episode of GAS Pharyngitis in a Three Month Period and GAS Carriage

 

Antibiotic

 

Route

 

Dose

Duration

 References

IDSA Evidence
Rating 
2012*

 

Benzathine penicillin†,‡

IM

Children <30kg: 450mg (600,000 U)

Adults &

children ≥30kg: 900mg (1,200,000 U)

One dose

Stollerm an

1955255

§

Antibiotic options requiring Specialist Approval II:

Benzathine penicillin†,‡ and rifampicin II, ¶

PO and IM

Benzathine penicillin:

Children <30kg: 450mg (600,000 U)

Adults &

children ≥30kg:  900mg (1,200,000 U)

Plus

Rifampicin starting day of benzathine penicillin injection for 4 days:

20mg/kg/day orally in two divided doses

Max dose 600mg daily

One dose

4 days

Tanz

256

1985

Strong, high

Clindamycin II,

**

PO

 

150mg three times a day

Max dose 450mg a day

10 days

Tanz

257

1991,

Shulman

20129

Strong, high

Penicillin V† and rifampicin II, ¶

PO

Penicillin:              50mg/kg/day in 4 divided doses for 10 days

Max dose 2000mg daily

Plus

Rifampicin for last 4 days (days 7-10):

20mg/kg/day in one single dose daily

Max dose 600mg daily

10 days

Chaudhary

1985,258

Shulman

20129

Strong, high

Amoxicillin†,††

with rifampicin

II, ¶

PO

Amoxicillin for 10 days:

Once daily:           50mg/kg once daily

Or Weight < 30kg: 750mg once daily Weight ≥ 30kg: 1000-1500mg once daily

Twice daily:          25mg/kg twice daily

Max dose 1000-1500mg daily

Plus

Rifampicin for last 4 days (days 7-10):

20mg/kg/day in one single dose daily

Max dose 600mg daily

10 days

‡‡

§§

Antibiotic options not requiring Specialist Approval:

Cephalexin†,§§

PO

Children:              20mg/kg/dose twice daily

Max dose 500mg twice daily

Adults:                   500mg twice daily

10 days

‡‡

§

Amoxicillin,†, ††, II II

 

clavulanic acid

PO

 

40mg/kg/day of amoxicillin divided into

3 doses daily

Max 2000mg of amoxicillin daily

10 days

Kaplan

1988259

Strong, moderate

Ask about adherence to antibiotic regime, recommend family/household screening and consider end of treatment swab.


Source:
Modified from Table Two in Shulman ST et al. 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; 55: 1279 -12829 © by permission of Oxford University Press.


*    The IDSA used the GRADE  (Grading  of Recommendations Assessment,  Development  and Evaluation) system (see Appendix 3 for description).

†    Do  not  give  beta  lactam  antibiotics  if  patient  has  suspected immediate  or  type  1.

Hypersensitivity (anaphylaxis) to penicillin, amoxicillin or cephalexin. Up to 5% of patients who are allergic to penicillin or amoxicillin  will  also be allergic  to  1st   generation cephalosporins.259.  

Clindamycin  may  be  offered  as alternative, as tabled.260.

‡    Benzathine penicillin can be given with lignocaine to reduce injection site pain. (see page 33 and Appendix 4).

§    The IDSA recommendation is not available for this indication.

II   For rifampicin, Specialist Approval by: internal medicine physician, clinical microbiologist,  dermatologist, paediatrician or public health physician.

For clindamycin, Specialist Approval by: Infectious diseases or clinical microbiologist (or by protocol) in the hospital or any vocationally registered medical practitioner in the community.

¶   Rifampicin relatively contraindicated in pregnancy.   Rifampicin interacts with many drugs and should be checked before being prescribed, in particular care with prescribing in combination with oral contraceptives, anti-convulsants and warfarin.

**    No elixir available in New Zealand.

††   Amoxicillin can be given with food.

‡‡   Once  daily  amoxicillin  has  been  shown  to  be  non-inferior  to  oral  penicillin  but  has  not  been  trialled specifically with rifampicin.

§§   Cephalexin is recommended by Advisory Group if compliance with other antibiotics is a concern.

9,261-264 Superiority of cephalosporins over penicillin V is questionable as the trials are of poor quality.265.

II II  Maximum dose in amoxicillin with clavulanic acid is 2000mg of amoxicillin per day.9.

Note: a preliminary trial (as yet unpublished) on a group of children in Kawerau (n=23) has identified that a 30 day course of Blis, given after treatment for 3+ episodes of GAS, significantly (p<0.001) reduces the recurrence rate and should therefore be considered. 

Reference: New Zealand Guidelines for Rheumatic Fever; 2014 Update; pg35.

Warfarin and Antibiotics:

Patients taking warfarin should have their INR monitored at the time of treatment change. i.e. both when starting and stopping antibiotics and at day three or four.

Macrolides i.e. erythromycin, azithromycin, roxithromycin, clarithromycin, clindamycin, interact with many drugs by inhibiting an enzyme involved in metabolising approximately 50% of all prescribed drugs. Check for interactions before prescribing these agents (www.medsafe.govt.nz).

Drug interactions with warfarin are of particular importance because they are potentially life threatening. Particular attention should be paid when considering starting warfarinised patients on macrolide antibiotics such as roxithromycin and erythromycin, with which increased symptomatic interactions have been reported.148 Beta-lactam antibiotics such as penicillin, amoxicillin and augmentin are good choices for patients on warfarin as they only occasionally elevate international normalised ratio (INR). INR monitoring is still required with these comparatively "safe" antibiotics. Specialist advice should be sought concerning patients requiring antibiotic therapy, who have anaphylactic reactions to beta lactam antibiotics and are taking warfarin.

Rifampicin will induce the metabolism of warfarin and will likely result in subtherapeutic INRs.



Last updated : Friday, August 21, 2015
Next review date : Saturday, August 20,2016


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