3/6223, 943 PM ‘Treatment and prevention of streptococcal pharyngitis in adults and children - UpToDate os UptoDate In gi chinh thee tir UpToDate ® wwwuptodate.com © 2023 UpToDate, Inc. va/hoac céc chi nhdnh cua UpToDate. Ba dang ky Ban quyn. 3 Wolters Kluwer Diéu tri va phdng ngira viém hong lién cau & ngu di lén va tréem Tac gid: Michael E Pichichero, MD Bién tp chuy€n myc: Daniel J Sexton, MD, Morven $ Edwards, MD Phé tng bién tp: Trdi phiéu Sheila, MD, Jane Givens, MD, MSCE Tat ca cac chil G8 duzge cap nhat khi cé bang ching mdi va quy trinh dénh gid ngang hang clia ching toi da hoan tat. Banh gid tai ligu hign tai dén hét: Thang 2 nm 2023. | Chi #8 nay durgc cp nhat lan cudl: ngay 02 thing 3 nam 2023. GIGI THIEU Lién cau khudn nhém A (GAS), hay Streptococcus pyogenes, la nguyén nhan vi khudn hang dau gay vim amidan & ngudi ln va tré em trén toan thé gidi. KHi la mét trong sé it nguyén nhan gay viém amidan hoc viém hong dugc khuyén cdo diéu tri baing khang sinh. bigu phdng ngta vier amidan do lién cau khuan nhém A duge xem xét tai day. Céc dac diém lam sang va danh gia chan doan bénh nhan viém amidan dugc thao luan riéng. (Xem "Viém amidan do lién cau nhém A & tré em va thanh thiéu nién: Dac diém 1am sang va chén doan" va "Banh gid viém hong cap & nui |én" .) CAC BINH NGHIA Lién cu khudn nhém A (GAS) cé thé gay nhiém triing cé trigu chtfng hodc cé thé xém chiém vung hau hong. + Nhiém tring hoat dng d@ cp dén nhiém tring cé trigu chirng do KHi gay ra + Nhiém tring dai dang dé cp dén nhiém tring cé trigu chiing do GAS gay ra ma khong khdi sau khi diéu tri bang khdng sinh thich hgp. Bigu nay ding nghia véi that bai trong digu tri, hitpslwwn-uptodate.comlcontenttreatment-and-prevertion-of streptococcal pharyngits-n-adults-and-chléren/pri?search=vigm hong cps... 1/516123, 249 PM ‘Treatment and prevention of streptococcal pharyngitis in adults and children - UpToDate [N shiém tring tdi phat a8 cap dén mét nhiém trung GAS cé trigu chting méi xay ra sau khi diéu tri bang khang sinh thich hgp. Nhiém tring tai phat c6 thé do cuing mét kigu huyét thanh GAS da gay ra nhiém tring ban dau hoac do mét kiéu huyét thanh khac. Nhiém tring tai phat thurng xay ra nhat gita cdc thanh vién trong cling mét hd gia dinh hodc trong céc méi trudng khdc nhu truding hoc hodc trung tm cham séc ban ngay, noi tip xtc gan tao diéu kign lay truyén GAS [ 1]. * Van chuyén man tinh dé cp dén su xam ln khéng cé triéu ching hoc sy hién dién dai dang cla GAS trong vung hau hong ma khéng cé triéu chéing hodc phan ting mién dich cua vat chu. Ty l@ van chuyén man tinh chua dugc nghién ctu toan dién, nhung ty 1 duge bdo cdo la khoang 4 dén 5 phan tram & ngudi lén khde manh [ 2] va khoang tir 2 d&n 20 phan tram 6 tré em [ 2-9 ]. Van chuyén cé thé kéo dai hang thang dén hang nam [8,10]. Viéc phan biét gitfa cdc trang thai nay rat quan trong vi chi nhting bénh nhan bi nhiém GAS cé trigu chéing méi cin diéu tri. MUC TIEU DIEU TRI Muc tiéu ctia diéu tri bing khang sinh déi véi viém hong do lién cau khudn rat da dang va bao gdm: * Gidm metic 46 nghiém trong va théi gian cua trigu ching * Phang ngifa cc bién chting cap tinh, chang han nhu viém tai gitta, 4p xe quanh amidan hoc cdc nhiém trung xém lan khdc * Phang ngira cc bién chting muén hodc di chting mién dich, dac biét la sét thdp khép cap * Phang tranh lay lan cho nuvi khac Giam trigu chi¢ng — biéu tri bang khang sinh da duge chting minh la am giam mic dé nghiém trong cua trigu chting va dy nhanh téc d6 hoi phuc & bénh nhan viém hong do lién cau khudn [11,12]. Tuy nhién, ngay ca khi khong digu tri bang khang sinh, cdc trigu chttng thuéng hét sau khoang 3 dén 5 ngay déi voi hau hét bénh nhn [ 13 J, khién viéc ngan ngira bién chting tr thanh muc tigu chim séc chinh. Ngn ngira cdc bién chtrng — Cac bién ching ciia vim hong do lién cau cé thé la két qua cia viéc lan réng nhiém tring ra ngoai ving hau hong, dugc goi la bién chttng mung mi, hod do hién tugng mién dich, durgc goi la bién chting khéng mung mu. Cac bin ching mung mii cla viém hong KHi bao gdm viém tai gitta, viém mé té bao hdc 4p xe quanh amidan, vim xoang, vigm mang nao, nhiém khudn huyét va viém can hoai tt. Céc bién hitpsilwwn-uptodate,comicontentstreatment-and-prevenion-ofstreptococcal-pharyngitis-n-adults-and-cildreniprint?search=vigm hong cps... 2/5121623, 049 PM ‘Tratment and prventon of streptococcal pharygitsin adults and chiren - UpToDate chtfng khéng cé mdi cia viém hong KHi bao gdm sét thép khép cp tinh, viém cau than sau hava vin khép phan ting. Phé bién ching lién quan dén viém hong lién cau duge tho luan chi tiét riéng. (Kem "Cac bién chting cia viém amidan do lién cau khun" .) Bign chérng mu — Ty Ié viém tai gitfa va 4p xe quanh amidan déu gidm khi str dung khang sinh. Trong mét phan tich téng hgp Ién vé cdc thir nghiém ngdu nhién so sénh khang sinh véi gid duge & ngudi Ién va tré em bi viém hong do lién cau khudn, khang sinh lam gidm ty 1é viém tai gitfa cp trong vang 14 ngay (0,47 so véi 2,0%; ty 1é rui ro [RR] 0,30, KTC 95% 0,15- 0,58) va 4p xe quanh amidan sau hai thang (0,24 so vdi 2,3%; RR 0,15, KTC 95% 0,05-0,47) [ 11]. Gidm ty 16 viém xoang cp tinh cling dug ghi nhan nhung khéng dat duge y nghia théng ké. Anh hung déi véi cdc bién chitng mung md it phé bién hon nhung nghiém trong bao gdm nhiém khudn huyét va viém can hoai tir chufa dugc nghién cifu, mac dui cé thé phéng doan rang khang sinh sé c6 tac dung bao vé. Bign ching khéng mu Sét thdp khép cap tinh — Phdng ngiva sét thap khdp cép tinh la mdt trong nhting chi dinh chinh trong diéu tri khang sinh déi vai viém hong do lién cau. Sét thdp khép cdp tinh va bénh thdp tim a nhirng nguyén nhan quan trong gay tir vong do tim mach trén toan thé giéi [14,15 ]. Trong mét phan tich téng hgp ciia 14 thiy nghiém ngdu nhién so sdnh penicillin véi gid dugc & han 8000 ngudi In va tré em bi viém hong, penicillin lam giam khong 2/3 nguy co sét thap khép [ 11] . Kha nang giém nguy co tuyét déi cao nhat & tré em tu’5 én 15 tuéi sdng & cdc quéc gia dang phat trign, noi ty Ié mac bénh thp khép cao nhat [15,16 ]. Chi tiét bé sung vé sét thap khdp cp tinh duigc cung cp riéng. (Nhin thay "St thap khép c§j va chén doan" va "Sét thdp khép cap: Bigu tri va phdng ngira" .) Dich t& hoc va co ché bénh sinh" va "Sét thdp khép cp: Bigu hién lam sang Cac bign chtrng khéng nhiém tring khac — Dé liéu vé I9i ich cua khdng sinh trong viée ngain nga cdc bién chtrng khéng nhiém trung khac cn han ché. Khang sinh cé thé ngan ngira viém cau th4n sau lién cu dya trén phan tich téng hop 10 thir nghiém ngau nhién so s4nh khang sinh véi gid dugc & nguéi |én va tré em bi viem hong, mac dil cé qu truéng hgp trong cdc thir nghiém nay dé két ludn diéu nay mat cach chac chan [11]. Tac dung ctia khng sinh déi véi cdc bién chting khéng sinh mu khac nhu vim khép sau lién cau khuén va réi loan tam than kinh tu mién 6 tré em lién quan dén lién cau khudn nhém A (PANDAS) chu dug nghién cttu ky. Chi tiét bd sung vé cdc bién chifng nay dugc cung cap riéng. (Kem "Viém cau than sau lién cu" va "Cac bién chting cla viém amidan do lién cau khuan".) Ngan ngira lay truyén — GAS cé thé lay lan gitfa nhéing nguai tigp xuc gan, dan dén cdc cum ca bénh va lay nhiém tai phat trong cdc hé gia dinh hodc cdc co’ sé tiép xtic gan khac. TY Ie lay truy€n GAS tir mot ca nhiém bénh sang nhitng ngudi tiép xc gn duge usc tinh [a tir 5 dn 50 nan tram [17-191 Mac dit khAna cA nahidn eit nan AAnh aid trite tién hidis aA hitps:lwwn-uptodate,comlcontentstreatment-and-prevention-otstreptococcal-pharyngitis-n-adults-and-cildreniprint?search=viem hong cps... 3/51623, 249 PA ‘Treatment and prevention of streptococcal pharyngitis in adults and children - UpToDate Suen oy poe en Cy cage iige ae RHUnY Co nylon Cou Hay aan gia ge Oep mig que (fu tri bang khang sinh 46i véi sy lay truy€n, nhung viéc sir dung khdng sinh dung 1. .ai bd GAS khéi hau hong trong khoang 80 dén 90% truténg hgp sau 24 gid diéu tri [ 20,21 J. Khi khéng dude digu tr, dir ligu dich t& hoc lich str cho thy khoang 50 phan tram bénh nhan bi viém hong do lién cau sé tigp tuc chifa GAS trong hau hong ba dén bén tuan sau khi khéi phat trigu chting [ 13,22]. DIEU TRI CHO AI Chting téi khuyén nghi digu tri bang khang sinh cho bat ky bénh nhan nao bi vim hong h tinh véi Streptococcus nhém A(GAS)( — thuat ton 1 ). (Kem phn "Banh gid viém hong cap viém amidan cé trigu chifng cé xét nghiém khang nguyén nhanh hoac nuéi cdy dung tinh & ngudi |Gn", phan ‘Banh gia’ va "Viém amidan do lién cau nhém A ¢ tré em va thanh thiéu nién: Bac diém lam sang va chan doan" .) iéu tri theo kinh nghiém thuéng khéng dugc khuyén cdo, vi cdc dac diém lam sang cla viém hong do GAS va viém hong khéng do lién cau thuéng chdng chéo lén nhau(—hinh 1) [23,24 ]. Tri hoan diéu tri trong thai gian ngan (vi du, trong khi cho két qua nudi cdy) khong lign quan dén viéc tang ty Ié bién ching nhu sét thdp khép cdp tinh [ 22 ]. Tuy nhién, ligu sy cham tré nhur vay cé anh huéng dén ty [é bién chitng khdc hay khéng (vi dy, sy phat trién ca dp xe quanh amidan) van chua dugc biét. Néu nghi ngé lam sng déi véi viém hong GAS cao va két qua xét nghiém khéng thé thu dugc nhanh chéng, thi viéc bat dau digu tri bang khang sinh trong khi cha két qua xét nghiém la hgp ly [25 ]. Néu xét nghiém khéng xac nhan chan dodn, nén ngimng st dung khdng sinh. iu tr] bang khang sinh khéng dugc khuyén cdo cho nhéing ngudi mang GAS mén tinh u chting hoa cho nhitng ngudi mang GAS bj nhiém virus béi nhiém [ 23,24,26 1. Kem 'Ngusi mang GAS man tinh’ bén duéi.) DIEU TRI CAC GIAI DOAN BAU TIEN ‘Dieu tri khang sinh |a co sé cham séc chinh. Cc bién phdp chim séc hé tro nhu thuéc chéng viém khéng steroid (NSAID) hodc acetaminophen cé thé dugc dung dé giam sét va giam dau. iéu tri bang khang sinh — Cac khuyén nghi diéu tri bang khang sinh dugc trinh bay dui day phan Ién phu hgp véi cac khuyén nghj cua Higp hdi Bénh truyén nhiém Hoa Ky, Hi Tim mach Hoa Ky va Hoc vin Nhi khoa Hoa Ky(_thuat toan 2) [ 23,26-28 ]. Huéng dan tir cdc khu vue khde khac nhau [ 29-31 ]. Peni — Penicillin la Iya chon diéu tri viém hong do Streptococcus nhém A (GAS) do hitpslwwn-uptodate,comicontentstreatment-and-prevention-ofstreptococcal-pharyngitis-n-adutts-and-childreniprint?search=vigm hong cps... 4/51100. * Sudden onset core throat * Scarlatiniform rash 1 Hictory of GAS exposure ‘Suspiion for GAS based on clinical features? .4°F/38°C) * Tonsillopharyngeal or uvular edema ® Patchy tonsilar or pharyngeal exudates ' Tender cervical lymphadenitis Yer Uncertain Center crteriat = Fever (temperature 100, * Absence of cough Total points 2375 ‘Assign 1 point for eath of the falowing -4°F/38"C) *Tonsillar or pharyngeal exudate * Tender cervical lymphadenitis —— Yes + + tps lw. uptodate. comicontentstteatment-and-prevertion-ofstreptococcal-pharyngis-n-adults-and-children/rint?search=vidm hong cép&. Perform RADT ‘Consider other causes of acute pharyngitis (€9, respiratory viruses, acute HIV infection, ‘gonorthea, or noninfectious causes) Testing for specific pathegens is typically not needed unlace characteristic Gnieal features or specific risk factors are present > + ‘Any of the following ‘= Rasidence in area with high GAS 251516123, 249 PM ‘Treatment and prevention of streptococcal pharyngitis in adults and children - UpToDate prevalence (eg, college dormitory) History of ARF All adults presenting with acute pharyngitis shot ical, including = Immurosuppression * Close contact with a person with a history assessment for risk factors for acute|HIV infection ard sexually transmitted infettions. ¥ COVID-19: coronavirus disease 2019] GAS: growprestrebtiepccus; RADT: rapid antigen detection test; HIV: human immunodeficiency pirus; ARFracute Trreumatic fever. Positive Nagative * Asitting position with the trunk leqning forwprd, neck hyperextended, and chip thrust forward in an effort to maximize the diamet4T oF (he OBStrUt4T GHWAYpsartve core Nox patents with ‘sete pharynsitis who test negative for {Refer to UpToDate content on GOVIQ:d.8 fas additjonalcchetbilnaethnieai-féateires, testing, and wae aa sel imitad slnesses. infection control. ? pharyngitis Testing fer specific pathogens's typically A Refer to UpToDate topics on evaluation of phaninigithehisssantss eal asmitar iF ncaault with dyspnea, and deep neck space inf © Refer to UpToDate content on symptomatic treatment of pharyngitis in adults. 5 Some practitioners test patients with Centor scores >2. § Refer to UpToDate topic on evaluation of pharyngitis in adults, + Refer to UpToDate content on treatment and prevention of streptococcal pharyngitis. Graphic 116711 Version 5.0 tps lw. uptodate. comicontentstreatment-and-prevertion-ofstreptococcal-pharyngiis-n-adults-and-children/rint?search=vidm hong cép&. 261516123, 249 PM ‘Treatment and prevention of streptococcal pharyngitis in adults and children - UpToDate oN Distinguishing viral pharyngitis from streptococcal pharyngitis in adults hitpslwwn-uptodate,comicontents.treatment-and-prevention-ofstreptococcal-pharyngitis-n-adults-and-cildreniprint?search=vigm hong cip8...._ 27/516123, 249 PM [NN Viral Pharyngitis ‘Treatment and prevention of streptococcal pharyngitis in adults and children - UpToDate Streptococcal Pharyngitis - in Adults - Viral Pharyngitis conjza CLINICAL HISTORY Typically present eg, cough. congestion, conjunctith, hoarse woe) Fever: Low-grade or absent ore threat onset: Subacute ASSOCIATED FINDINGS (veriabe) ‘Streptococcal Pharyngitis CLINICAL HISTORY Absent Fever Typical present Keown group A Streptococci exposure: May be present ASSOCIATED FINDINGS (avabie Cesar tlt Fidings that involve other aspects ofthe upper respiratory hitpsslwwn-uptodate,comlcontentstreatment-and-prevenion-of streptococcal ‘pharyngiis-n-aduls-and-chiléreniprin?search=vigm hong c4p8. ee Ge eer Pecan 28151316123, 9:43 PM De rae ee cea uct Graphic 139794 Version 1.0, https:viwww.uptodate.com/contents/treatment-and-prevention-of-streptococcal-pharyngits-in-adults-and-children/print?search=viem hong cp... 29/516123, 249 PM ‘Treatment and prevention of streptococcal pharyngitis in adults and children - UpToDate [NN Treatment of streptococcal pharyng is in children and adults Penicilinalleray? ee ves ¥ — Tipe of peril Mil, noretge IgE mediated Anaphylaxis severe ver eed (without severe engiondeme engoedome, or vere, cr anephyaes) clay reaction | ‘ ¥ ¥ Sslec an ort corhalorporn elect any ofthe flow * Cephalexin * Oral peiciin V + cefadrond Oral monn Cefuroxime ‘conser fpeimecrolite Concern for macrolide | | «1M penicilin = Cefpodoxme + Cee ves No ve No ¥ ¥ ¥ ¥ Salad any ofthe fallowing] [Salact any ofthe following oral anibcies 38 oral artbiotes: 3 Scetinir scene oa oa = Cefuroxime = Cefuroxime SHedamycin’ | |:acithromyans: * Cafe + Cefiime * cingaryein + aaihromyein IgE: immunoglobulin €; IM: intramuscular. * Examples of mild, non-IgE-mediated reactions include maculopapular rashes. Examples of IgE-mediate hives, wheezing, angioedema, and anaphylaxis. Examples of severe, delayed reactions include Steven-Jo epidermal necrolysis, acute interstitial nephritis, drug-induced hepatitis, and serum sickness. 4 Approach to selecting among cephalosporins varies among experts. Some prefer to use a first-genera cephalexin) because of its narrow spectrum and low likelihood of cross reactivity. Others select a third-gi with a side chain that is dissimilar to penicillin (eg, cefpodoxime, cefdinir), although these agents have a A Macrolide resistance varies considerably by region, with higher rates observed in Asia and Europe whe United States. Knowledge of local resistance patterns should guide antibiotic selection. © Selection among these agents should be based on drug availability and patient preference. For patien rheumatic fever and penicillin allergy, antibiotic selection should be individualized. § Many patients with IgE-mediated reactions can tolerate cephalosporins. These patients should be refe consultation following treatment for streptococcal pharyngitis. ¥ Approach to selecting among these agents varies among experts. Some prefer cephalosporins due the risk of cross-reactivity, while others favor selecting a non-cephalosporin alternative to avoid any possibil Graphic 115985 Version 10.0, hitpsilwwn-uptodate,comicontentstreatment-and-prevention-of streptococcal-pharyngitis-n-adults-and-childreniprint?search=vigm hong cip8...._ 30/51