sore throat in acute bacterial pharyngitis
Simon C. Schams Ran D. Goldman MD FRCPC
Question I see many children suffering from sore throat and acute pharyngitis. Some adult studies describe faster pain relief when sore throat is treated with steroids. Would a single dose of a steroid, as an anti-inflammatory agent, provide accelerated pain relieffor sore throat in children?
Answer A single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) leads to significantly (P < .05) faster onset of pain relief and shorter suffering, especially in children with severe or exudative group A -hemolytic streptococcus–positive acute pharyngitis.
Acute pharyngitis is one of the most frequent indications for medical attention, accounting for 1% to2% of all outpatient visits in the United States. Group A -hemolytic streptococcus (GABHS) accounts for approximately 25% of acute pharyngitis infections in children, causing inflammation of the pharynx and surrounding lymphatic tissue. Streptococcal pharyngitis is primarily a disease of school-aged children, with a peak incidence between 5 and 15 years of age. The illness results in at least 2missed days of school and possible dehydration due to odynophagia or dysphagia.1-5 Current treatment recommendations for acute pharyngitis vary. While antibiotics such as penicillin are commonly prescribed in cases of bacterial origin, they have been shown to reduce the duration of illness by only 1 day. They are recommended to prevent complications such as peritonsillar abscess, mastoiditis, andrheumatic fever.6 Over-the-counter analgesic drugs and gargling or drinking warm liquids are common supportive treatments to manage pain.
Corticosteroids are used effectively as anti-inflammatory agents in asthma, bronchiolitis, and croup, and have also been shown to be effective in patients with upper respiratory tract infections, acute sinusitis, and infectious mononucleosis, leading toreduction of inflammation-induced pain.7,8 Whether steroids can serve as treatment of pain related to pharyngeal inflammation is a question clinicians have asked for more than half a century.9 Several prospective trials, mostly in adults, explored the effectiveness of steroids as adjuvant therapy for acute pharyngitis. Six randomized controlled trials (N = 661) have
been conducted in outpatientsettings, 3 with children (n = 393; mean age 8 to 11 years)10-12 and 3 including children and adults (n = 268; mean age 26 to 30 years).13-15 Oral10-12,15 or intramuscular13 dexamethasone (0.6 mg/kg, maximum 10 mg) was given as a single dose or over 3 consecutive days, sometimes with supportive analgesics such as acetaminophen or ibuprofen. One group was given a single dose of betamethasone (8 mgintramuscularly).14 Based on a positive rapid streptococcal antigen test result, patients received additional penicillin or erythromycin. Throat swab cultures positive for streptococci were reported for 30% to 60% of patients in most studies. Primary outcomes were defined mostly as time to onset of symptom reduction and time to complete pain relief. To quantify severity of symptoms, the patients wereasked to grade their pain on a visual analogue scale at the start of treatment and at different points during follow-up, usually once a day until day 2 to 5 after treatment.
Preliminary findings in adults
In a study from Florida, 58 patients 12 years of age and older with exudative acute pharyngitis who were taking antibiotics (penicillin or erythromycin) received a single intramuscularinjection of either 10 mg of dexamethasone or saline placebo. Their mean baseline pain score reached 2.5 (scale 0.0 to 3.0). After 24 hours, the pain improved to an average of 0.8 (SD 0.8) in the 26 patients from the dexamethasone group and 1.3 (SD 0.9) in the 25 patients from the placebo group (P < .05). Time to onset of pain relief was also faster in steroidtreated patients, who demonstrated relief...