Amoxicillin for tooth abscess

Primary amoxicillin 250g prevention of ARF depends on accurate diagnosis of an antecedent streptococcal infection as well as adequate therapy.

Penicillin given orally for 10 days or intramuscularly one time will prevent rheumatic fever.

Erythromycin is considered the drug of choice f the treatment of GAS pharyngitis in penicillin-allergic patients, but it has not been shown to prevent ARF (17). Approximately one third of patients who develop ARF have streptococcal infections that are either subclinical or too mild to be brought to medical attention; as a result, they receive no antibiotic therapy for the infection.

Recent reports have suggested that up to 75% of patients with ARF either had no history of a preceding streptococcal infection or had an infection that was amoxicillin for infected tooth so mild they did not seek medical attention. In contrast, in the past, preceding streptococcal infections were noted to be severe (55).

Of even more concern are reports of patients who develop ARF despite receiving adequate therapy for GAS pharyngitis (21).

Possible explanations for this include poor patient compliance with antibiotic therapy, a shorter latency period, documented streptococcal infections were not the cause of the resultant episodes of ARF, or currently recommended therapies for GAS pharyngitis have become inadequate for prevention of ARF (15).

Only one series of studies has ever documented prevention of ARF following antimicrobial therapy for GAS pharyngitis. These studies were conducted during the 1940s on army recruits at Fort Warren, Wyoming. Penicillin G

suspended

Following these studies, researchers compared orally administered penicillin with parenterally administered penicillin and found equivalent bacteriologic effects.

It was then assumed that bacterial eradication from the pharynx was the necessary step in prevention of ARF.

As a result, penicillins as a class were assumed to be efficacious in preventing ARF.

No study has investigated the efficacy of other antibiotics in prevention of ARF. Patients who develop ARF require continuous prophylaxis to prevent intercurrent and recurrent streptococcal infections and recurrent episodes of ARF. The preferred regimen consists of penicillin G benzathine, 1.2 million units given intramuscularly every 4 weeks (17). The recurrence

rate

less

However, the risk of recurrence of ARF decreases with patient age and the number of years since the last attack and increases with the presence of rheumatic heart disease or previous recurrences. The physician must take into account all factors when deciding when to discontinue prophylaxis. In general, it is recommended that prophylaxis continue until patients are in their early twenties and at least 5 years have passed since the most recent episode of ARF.

In 1995, the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association, released a special statement on the treatment of GAS pharyngitis and prevention of rheumatic fever. The committee recommended that patients who had rheumatic fever without rheumatic carditis should receive prophylaxis until the age of 21 or until at least 5 years had passed since their last attack.

Patients who had rheumatic fever with carditis but no valvular disease should receive prophylaxis until adulthood and until at least 10 years had passed since their last attack of ARF.

Patients with valvular disease should receive prophylaxis until age 40 and until at least 10 years had passed since their last attack (20). Patients with residual rheumatic valvular disease must receive antibiotic prophylaxis

whenever

Antimicrobial regimens recommended for the prevention of bacterial endocarditis are entirely distinct from regimens used in the prevention of ARF (14). Currently, investigators are attempting to develop a polyvalent M-protein vaccine for the prevention of streptococcal infection and ARF.

A cute Glomerulonephritis: Unlike rheumatic fever, post-streptococcal acute glomerulonephritis (AGN) has shown no increase in incidence. Indeed, nephritogenic strains (particularly serotype M type 12) have decreased in prevalence (54).

Treatment strategies in the approach to post-streptococcal acute glomerulonephritis are directed toward management of acute problems.

All patients should be treated with penicillin to eradicate the nephritogenic strain regardless of culture results of group A streptococci or immunologic tests. Paralleling the recent changes in the pathogenesis of ARF, a substantial number of patients who develop post-streptococcal AGN do not have a history of a preceding pharyngitis or soft tissue infection. Penicillin-allergic patients can be treated with erythromycin in doses adequate for treatment of streptococcal pharyngitis. It is generally recommended that family members be cultured for group A streptococcus. Family members with positive cultures should be treated appropriately.

Treatment of patients with post-streptococcal AGN or of family contacts is for epidemiologic purposes only. Therapy will not alter pre-existent post-streptococcal AGN or prevent the disease in patients who are in the latent period. Some data suggest that antibiotic therapy may have a small effect on prevention of post-streptococcal AGN, but this has not been substantiated.

However, antibiotic therapy is effective in epidemiologic efforts at eradicating nephritogenic strains of group A streptococcus.

In high risk settings during an acute epidemic of AGN, universal penicillin prophylaxis can be considered.

Recurrent episodes of AGN are rare, and continuous anti-streptococcal

prophylaxis

Long-term prognosis is generally thought to be excellent, but some

studies

Invasive Streptococcal Infections: For necrotizing streptococcal infections, early and aggressive surgical debridement of the site of infection as well as amoxicillin 150 mg appropriate antimicrobial therapy is required.

The patient with StrepTSS also requires intensive management of hemodynamic abnormalities and vital functions. Some investigators have suggested use of hyperbaric oxygen therapy (HBO) in treatment of necrotizing fasciitis (reviewed in (7)), however, HBO therapy is not without risks, and its use has not been well studied.

Other proposed therapeutic interventions include the use of intravenous immunoglobulin (IVIG) and monoclonal antibodies.

It is thought that IVIG may act by binding and inactivating toxins (3); however, use of IVIG in the treatment of StrepTSS has not been thoroughly evaluated. Investigators are studying the use of monoclonal antibodies against specific group A streptococcal toxins and the neutralization of circulating cytokines in managing invasive streptococcal disease caused by toxin-producing strains.

It was recently suggested that the use of nonsteroidal antiinflammatory drugs (NSAIDS) in the treatment of fever in patients with GAS infections may predispose the patient to a more severe invasive infection.

NSAIDs may inhibit neutrophil function and enhance cytokine production (79). In addition, their use may mask some of the early signs

and

It may also be desirable as a method to eliminate the carrier state in a select group of patients such as those with a family history of rheumatic fever. Other alternative therapies that have been suggested to reduce the incidence of treatment failures in GAS pharyngitis include using ?-streptococci to replace normal pharyngeal flora, delaying treatment of GAS pharyngitis 48 h to promote the host's immune system (discussed above), and using topical antibiotics. Elimination of ?-streptococci from the pharynx after therapy for acute GAS pharyngitis has been proposed as a possible explanation for treatment failures, development of the carrier phenomenon, and frequent recurrences (76). ?-Streptococci interfere strongly against GAS (73).

?-Streptococci share pharyngeal epithelial receptor sites in the posterior pharynx with GAS, and elimination of ?-streptococci may provide more attachment sites for GAS (33). looked at 31 patients with recurrent GAS pharyngitis who were given antibiotics for 10 days and then had the oropharynx sprayed with ?-streptococci (73). None of the patients treated with ?-streptococci had a recurrence of GAS pharyngitis over a period of 3 months, while the control group had an 8% recurrence rate (73).

A cute Rheumatic Fever: Salicylates and steroids are very effective in suppressing the acute manifestations of rheumatic fever, but neither has been shown to proven chronic valvular rheumatic heart disease (55). Patients with definite clinical evidence of arthritis should receive aspirin starting at a total dose of 100 mg/kg/day in divided doses for the first two weeks, then reduced to 75 mg/kg/day for the next 2 - 4 weeks until all laboratory manifestations of inflammatory disease

are

Corticosteroid therapy is only for patients with significant carditis, especially cardiomegaly or congestive heart failure. Prednisone is the drug of choice, starting at 2 mg/kg/day in divided doses not to exceed a total dose of 80 mg/day (55). After 2 - 3 weeks, a slow taper may begin, decreasing the daily dose at the rate of 5 mg every 2 - 3 days. When tapering is started, aspirin at 75 mg/kg/day should be added and continued for 6 weeks after prednisone is stopped (55). The problem of bacteriologic and clinical failures in the treatment of GAS pharyngitis has led some investigators to suggest that all patients should receive a test of cure at the end of treatment.

The patient who is symptomatic and culture positive at the end of treatment for acute pharyngitis may represent either failed treatment or acquisition of a new strain of GAS and

should

Clearly, patients with previous rheumatic fever who have symptoms of strep throat should be re-cultured at

the

Development of an effective group A streptococcal vaccine continues to be of interest; currently, none are commercially available. Researchers have looked at the conserved region of the M protein since this region is shared by all serotypes of GAS and because long-term exposure to group A streptococci results in acquired immunity (29).