* CLINICAL QUESTION
Does the treatment of children with streptococcal tonsillopharyngitis with a cephalosporin instead of a penicillin result in better bacteriologic or clinical cure?
* BOTTOM LINE
Treating streptococcal tonsillopharyngitis in children with a cephalosporin instead of penicillin produces significantly more bacteriologic and clinical cures. One additional child will benefit for every 13 children treated with a cephalosporin rather than penicillin. 0nly the cephalosporins cefaclor (Ceclor) and loracarbef (Lorabid) did not show an advantage over penicillin. The effect of cephalosporin treatment on prevention of rheumatic heart disease is not known. (LOE=la)
* STUDY DESIGN
Meta-analysis (randomized controlled trials)
The authors of this meta-analysis identified 35 studies comparing a cephalosporin with penicillin for 10 days in the treatment of children with group A beta-hemolytic streptococcal pharyngitis. The studies (in all languages) were identified through MEDLINE and EMBASE searches, reference lists of identified trials, and abstracts from the meetings of the Society for Pediatric Research and the Interscience Conference on Antimicrobial Agents and Chemotherapy.
The studies were not all of high quality: 59% of the studies had a Jadad score of 0 to 2 (on a scale of 0 to 5, where 5=highest quality) and the majority were not double-blinded and did not conceal allocation assignment. In other words, there is a strong possibility that the studies have significant flaws that cannot be overcome by meta-analytic methods. Fortunately, the results were stronger in the better-quality studies.
Overall, bacteriologic cure was significantly more likely with cephalosporin treatment (92.6% vs 80.6%; number needed to treat [NNT]=8), as was clinical cure (93.6% vs 85.8%; NNT=13). Bacteriologic cure rates did not differ whether a first-, second-, or third-generation cephalosporin was used. Bacteriologic cure rates with penicillin decreased slightly, but significantly, from the 1970s (83.4%) to the 1990s (79.4%).
The researchers found no evidence of publication bias. Study results were similar with regard to bacterial cure (ie, no heterogeneity), but differences in clinical cure occurred among studies of cefuroxime and loracarbef.
Casey JR, Pichichero ME. Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics 2004; 113:866-882.
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