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Antibiotics to eradicate Streptococcus pyogenes pharyngeal carriage in asymptomatic children and adults: A systematic
Te-Yu Hung1, Linny K Phuong2, Anneke Grobler3
1Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Department of Paediatrics, Royal Darwin Hospital, Top End Health Service, Northern Territory, Australia.
Insights
Oral clindamycin for 10 days appears most effective for eradicating Streptococcus pyogenes carriage. However, evidence is limited, and more research is needed on various antibiotics for S. pyogenes.
Area of Science:
- Microbiology
- Infectious Diseases
- Clinical Pharmacology
Background:
- Streptococcus pyogenes (S. pyogenes) causes diverse illnesses, from mild infections to severe sepsis.
- Close contacts of S. pyogenes cases face a significantly elevated risk of invasive disease.
- Management of asymptomatic S. pyogenes carriage and prevention of secondary infections remain inconsistent.
Purpose of the Study:
- To systematically review antibiotic regimens for eradicating S. pyogenes from the pharynx in asymptomatic individuals.
- To assess the comparative efficacy of different antibiotic treatments for S. pyogenes carriage.
Main Methods:
- Systematic review of randomized controlled trials (RCTs) sourced from PubMed, EMBASE, OVID Medline, and Cochrane CENTRAL.
- Inclusion criteria: asymptomatic participants with S. pyogenes pharyngeal culture positivity, microbiological confirmation (culture +/- PCR), and English language publication.
- Two independent reviewers performed data extraction and risk of bias assessment.
Main Results:
- Three RCTs were included from 1166 identified records.
- Oral clindamycin for 10 days demonstrated superior efficacy compared to benzathine penicillin G with rifampicin, or monotherapy with penicillin or erythromycin.
- Two RCTs had a high risk of bias; one had a low/some risk of bias.
Conclusions:
- Limited evidence currently exists for the optimal antibiotic to eradicate pharyngeal S. pyogenes carriage.
- Future RCTs should investigate penicillin, cephalosporins, rifampicin, macrolides (e.g., azithromycin), and clindamycin.
Abstract:
Streptococcus pyogenes (S. pyogenes) is a Gram-positive bacteria which causes a spectrum of diseases ranging from asymptomatic infection to life-threatening sepsis. Studies report up to 2000 times greater risk of invasive S. pyogenes disease in close contacts of index cases within 30-days of symptom onset. Despite this, there is variability in the management of asymptomatic carriage of S. pyogenes and those at risk of secondary cases of invasive S. pyogenes infection.
Objective:
Our systematic review assessed the efficacy of different antibiotic regimens used for eradication of S. pyogenes from the pharynx in asymptomatic individuals.
Methods:
We searched Pubmed, EMBASE (1974-), OVID Medline (1948-) and the Cochrane CENTRAL registry. We included randomised controlled trials (RCTs) with asymptomatic participants with >50% with pharyngeal cultures positive with S. pyogenes at baseline. Only studies with microbiological methods including culture (+/- polymerase chain reaction, PCR) were included. We included studies published in English. Each included study was assessed by two independent reviewers for data extraction and risk of bias.
Results:
Of 1166 unique records identified, three RCTs were included in the review. Two of the three included RCTs found oral clindamycin for 10-days was the most efficacious regimen, compared to intramuscular benzathine penicillin G followed by 4 days of oral rifampicin, or monotherapy using benzathine penicillin, phenoxymethylpenicillin or erythromycin. Two RCTs were assessed as being at high risk of bias, with the third study demonstrating low/some risk of bias.
Conclusions:
Current available evidence for the optimal antibiotic in eradicating pharyngeal S. pyogenes carriage is limited. Future RCTs should include penicillin, first-generation cephalosporins, rifampicin, macrolides (such as azithromycin) and clindamycin.
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