French recommendations recommend prescribing an antibiotic in adults and children aged over 3 years suffering from acute angina with a positive rapid diagnostic test (RDT) for group A beta-hemolytic streptococcus (GAS). The National College of Teaching Generalists (CNGE) questions the relevance of maintaining these recommendations.
What is the data?
These French recommendations have 3 objectives: avoid the risk of acute rheumatic fever (ARF), avoid local complications and limit contagiousness. However, according to current data:
- The risk of AAR is <1/100,000 angina in mainland France. It mainly affects children aged 5 to 15 and is due to poorly circulating strains of streptococci. Concerning the benefit of antibiotic therapy to prevent RAA, the trials date from before 1960 and were of low methodological quality.
- The risk of local complications was assessed by a Cochrane meta-analysis, essentially based on a study published in 1951 with a high risk of bias, which indicated, for example, a reduction in the risk of phlegmon from 1% to 0.16% with antibiotic therapy. European recommendations do not consider the prevention of local complications as an indication for antibiotic therapy because they consider that the clinical benefits do not outweigh the risks (adverse effects and induced antibiotic resistance).
- Limiting contagiousness is the main argument for offering antibiotic therapy according to the recommendations of many countries, but the data available to demonstrate this are weak. According to two studies, the duration of carriage would be 24-48 hours under antibiotic therapy (absence of a control group) and according to another study, 32% of patients treated for one week with penicillin were still carriers at 2 weeks compared to 72% of patients not. treated.
As for the expected individual clinical benefits of antibiotic therapy, they are only to reduce the intensity of sore throats on the 3rd day, without improvement in fever.
Concerning the risk of antibiotic resistance, we have no proof that the use of amoxicillin induces resistance to GAS, but a study showed that the consumption of penicillin was associated with an increased risk of multi-resistant enterobacteria in cases urinary infection within 3 months.
Should the current recommendations be maintained?
Faced with these data and the example of neighboring countries, such as Belgium and Scotland, which recommend not prescribing antibiotics in cases of uncomplicated angina, unless the patient is at risk of a serious form, the CNGE estimate that :
- “ In front of a patient suffering from angina, if the pain is tolerable, without risk of serious form and the patient’s entourage is not at risk of serious form in the event of contamination, it is reasonable to treat only with analgesics. , without doing RDT or prescribing antibiotics “.
- “ In all other cases, a RDT is legitimate with antibiotic prescription if it is positive “.
Therefore, the prescription of antibiotic therapy should not depend only on the RDT result, but also on an overall clinical assessment of the patient’s situation.
The indication for performing a RDT must be assessed on a case-by-case basis. Overall, we can recall that it is not necessary to perform a RDT in children under 3 years of age (rare GAS angina and exceptional RAA) and in adults with Mac Isaac score < 2.
It is important to note that this advice does not concern scarlet fever, for which antibiotic therapy is necessary.
