medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2016-4-56-63medsovet-78Research ArticleБОЛЕЗНИ ДЫХАТЕЛЬНЫХ ПУТЕЙRESPIRATORY TRACT DISEASESДиагностика и рациональная антибактериальная терапия А-стрептококковых инфекций глотки как основа первичной профилактики острой ревматической лихорадкиDiagnosis and rational antibiotic therapy of group A streptococcal infections as the basis for the primary prevention of acute rheumatic feverБеловБ. С.BelovB. S.noemail@neicon.ruНаучно-исследовательский институт ревматологии им. В.А. НасоновойРоссияNasonova Research Institute of RheumatologyRussian Federation201630122016045663Copyright © Белов Б.С., 20162016Белов Б.С.Belov B.S.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/78

Проблема острого тонзиллита, вызванного р-гемолитическим стрептококком группы А (БГСА), по-прежнему сохраняет свою актуальность как во врачебном, так и в общемедицинском плане. В настоящей статье представлены данные, свидетельствующие о возрождении высоковирулентной БГСА-инфекции и нарастании частоты осложнений (острая ревматическая лихорадка, синдром токсического шока), обоснована необходимость рациональной антибактериальной терапии данной патологии. Препаратами выбора для лечения острых форм БГСА-тонзиллита являются пенициллины (амоксициллин, бензатин-пенициллин, феноксиметилпенициллин) и цефалоспорины I поколения (цефадроксил), а при непереносимости р-лактамных антибиотиков - макролиды. При наличии хронического рецидивирующего БГСА- тонзиллита, когда вероятность колонизации очага инфекции микроорганизмами, продуцирующими р-лактамазы, достаточно высока, применяют ингибитор-защищенные пенициллины (амоксициллин-клавуланат) или цефалоспорины II-III поколения (цефу-роксим-аксетил, цефиксим). Антибиотики - линкозамины (линкомицин, клиндамицин) используют в терапии острого и хронического БГСА- тонзиллита как препараты резерва.

Acute tonsillitis caused by group A b-hemolytic streptococcus (GABHS) remains a challenge both for doctors and the healthcare in general. The article provides evidence of the revival of the highly virulent GABHS infection and the growing incidence of complications (acute rheumatic fever, toxic shock syndrome), and substantiates the need for rational antibiotic therapy of the disease. The drugs of choice for the treatment of acute GABHS tonsillitis are penicillins (amoxicillin, benzathine penicillin, phenoxymethylpenicillin) and 1st-generation cephalosporins (cefadroxil), and, in case of intolerance, b-lactam antibiotics - macrolides. In case of chronic recurrent GABHS tonsillitis, when the risk of colonization of the focal point by microorganisms producing b-lactamase is quite high, inhibitor-protected penicillins (amoxicillin-clavulanate) or 2nd- or 3rd-generation cephalosporins (cefuroxime axetil, cefixime) are administered. Lincosamides (lincomycin, clindamycin) are used in the treatment of acute and chronic GABHS tonsillitis as reserve antibiotics.

А-стрептококковый тонзиллитантибиотикотерапияA streptococcal tonsillitisantibiotic treatmentReferencesGerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, Taubert KA. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation, 2009, 119(11): 1541-51.Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, Taubert KA. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation, 2009, 119(11): 1541-51.Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, Remenyi B, Taubert KA, Bolger AF, Beerman L, Mayosi BM, Beaton A, Pandian NG, Kaplan EL; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Circulation, 2015, 131(20): 1806-18.Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, Remenyi B, Taubert KA, Bolger AF, Beerman L, Mayosi BM, Beaton A, Pandian NG, Kaplan EL; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Circulation, 2015, 131(20): 1806-18.Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis, 2012, 55(10): e86-102.Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis, 2012, 55(10): e86-102.Насонова В.А., Белов Б.С., Страчунский Л.С., Каманин Е.И., Богданович Т.М., Судиловская Н.Н., Кречикова О.И., Богомильский М.Р., Овчинников Ю.М. Антибактериальная терапия стрептококкового тонзиллита и фарингита. Клин. микробиол. антимикроб. тер. 1999; 1: 78-82.Насонова В.А., Белов Б.С., Страчунский Л.С., Каманин Е.И., Богданович Т.М., Судиловская Н.Н., Кречикова О.И., Богомильский М.Р., Овчинников Ю.М. Антибактериальная терапия стрептококкового тонзиллита и фарингита. Клин. микробиол. антимикроб. тер. 1999; 1: 78-82.Wannamaker LW. Perplexity and precision in the diagnosis of streptococcal pharyngitis. Am J Dis Child, 1972, 124: 352-358.Wannamaker LW. Perplexity and precision in the diagnosis of streptococcal pharyngitis. Am J Dis Child, 1972, 124: 352-358.Pfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A strepto-coccal pharyngitis. Pediatrics, 2008, 121(2): 229-34.Pfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A strepto-coccal pharyngitis. Pediatrics, 2008, 121(2): 229-34.Беляков В.Д. Сюрпризы стрептококковой инфекции. Вестн. РАМН, 1996, 11: 24-28.Беляков В.Д. Сюрпризы стрептококковой инфекции. Вестн. РАМН, 1996, 11: 24-28.Pastore S, De Cunto A, Benettoni A, Berton E, Taddio A, Lepore L. The resurgence of rheumatic fever in a developed country area: the role of echocardiography. Rheumatology, 2011, 50(2): 396-400.Pastore S, De Cunto A, Benettoni A, Berton E, Taddio A, Lepore L. The resurgence of rheumatic fever in a developed country area: the role of echocardiography. Rheumatology, 2011, 50(2): 396-400.Vinker S, Zohar E, Hoffman R, Elhayany A.Incidence and clinical manifestations of rheumatic fever: a 6 year community-based survey. Isr Med Assoc J, 2010, 12(2): 78-81.Vinker S, Zohar E, Hoffman R, Elhayany A.Incidence and clinical manifestations of rheumatic fever: a 6 year community-based survey. Isr Med Assoc J, 2010, 12(2): 78-81.Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol, 2011, 22(3): 67-84.Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol, 2011, 22(3): 67-84.Mclsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ, 2000, 163(7): 811-815.Mclsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ, 2000, 163(7): 811-815.Regoli M, Chiappini E, Bonsignori F, Galli L, de Martino M. Update on the management of acute pharyngitis in children. Ital J Pediatr, 2011 Jan 31, 37: 10.Regoli M, Chiappini E, Bonsignori F, Galli L, de Martino M. Update on the management of acute pharyngitis in children. Ital J Pediatr, 2011 Jan 31, 37: 10.Chiappini E, Regoli M, Bonsignori F, Sollai S, Parretti A, Galli L, de Martino M. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther, 2011, 33(1): 48-58.Chiappini E, Regoli M, Bonsignori F, Sollai S, Parretti A, Galli L, de Martino M. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther, 2011, 33(1): 48-58.Chovel-Sella A, Ben Tov A, Lahav E, Mor O, Rudich H, Paret G, Reif S. Incidence of rash after amoxicillin treatment in children with infectious mononucleosis. Pediatrics, 2013, 131(5): e1424-7.Chovel-Sella A, Ben Tov A, Lahav E, Mor O, Rudich H, Paret G, Reif S. Incidence of rash after amoxicillin treatment in children with infectious mononucleosis. Pediatrics, 2013, 131(5): e1424-7.Casey JR, Pichichero ME. Higher dosages of azithromycin are more effective in treatment of group A streptococcal tonsillopharyngitis. Clin Infect Dis, 2005, 40(12): 1748-55.Casey JR, Pichichero ME. Higher dosages of azithromycin are more effective in treatment of group A streptococcal tonsillopharyngitis. Clin Infect Dis, 2005, 40(12): 1748-55.Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute strepto-coccal pharyngitis in children. Cochrane Database Syst Rev, 2009, (1): CD004872.Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute strepto-coccal pharyngitis in children. Cochrane Database Syst Rev, 2009, (1): CD004872.Kaplan EL, Chhatwal GS, Rohde M. Reduced ability of penicillin to eradicate ingested group A streptococci from epithelial cells: clinical and pathogenetic implications. Clin Infect Dis, 2006, 43(11): 1398-406.Kaplan EL, Chhatwal GS, Rohde M. Reduced ability of penicillin to eradicate ingested group A streptococci from epithelial cells: clinical and pathogenetic implications. Clin Infect Dis, 2006, 43(11): 1398-406.Fiedler T, Koller T, Kreikemeyer B. Streptococcus pyogenes biofilms - formation, biology, and clinical relevance. Front Cell Infect Microbiol Published online: 11 February 2015.Fiedler T, Koller T, Kreikemeyer B. Streptococcus pyogenes biofilms - formation, biology, and clinical relevance. Front Cell Infect Microbiol Published online: 11 February 2015.Shen Y, Koller T, Kreikemeyer B, Nelson DC. Rapid degradation of Streptococcus pyogenes biofilms by PlyC, a bacteriophage-encoded endolysin. J Antimicrob Chemother, 2013, 68(8): 1818-24.Shen Y, Koller T, Kreikemeyer B, Nelson DC. Rapid degradation of Streptococcus pyogenes biofilms by PlyC, a bacteriophage-encoded endolysin. J Antimicrob Chemother, 2013, 68(8): 1818-24.Азитромицин и биопленки. Данные на сайте: www.antibiotic.ru/forum.php? t=930.Азитромицин и биопленки. Данные на сайте: www.antibiotic.ru/forum.php? t=930.Азовскова О.В., Иванчик Н.В., Дехнич А.В., Кречикова О.И. , Козлов Р.С. , исследовательская группа «ПеГАС». Динамика антибиотико-резистентности респираторных штаммов Streptococcus pyogenes в России за период 1999-2009 гг. Клин Микробиол Антимикроб Химиотер, 2012, 14(4): 309-321.Азовскова О.В., Иванчик Н.В., Дехнич А.В., Кречикова О.И. , Козлов Р.С. , исследовательская группа «ПеГАС». Динамика антибиотико-резистентности респираторных штаммов Streptococcus pyogenes в России за период 1999-2009 гг. Клин Микробиол Антимикроб Химиотер, 2012, 14(4): 309-321.Logan LK, McAuley JB, Shulman ST. Macrolide treatment failure in streptococcal pharyngitis resulting in acute rheumatic fever. Pediatrics, 2012, 129(3): e798-802.Logan LK, McAuley JB, Shulman ST. Macrolide treatment failure in streptococcal pharyngitis resulting in acute rheumatic fever. Pediatrics, 2012, 129(3): e798-802.Feinstein AR, Wood HF, Epstein JA, Taranta A, Simpson R, Tursky E.A controlled study of three methods of prophylaxis against streptococcal infection in a population of rheumatic children. II. Results of the first three years of the study, including methods for evaluating the maintenance of oral prophylaxis. N Engl J Med, 1959, 260(14): 697-702.Feinstein AR, Wood HF, Epstein JA, Taranta A, Simpson R, Tursky E.A controlled study of three methods of prophylaxis against streptococcal infection in a population of rheumatic children. II. Results of the first three years of the study, including methods for evaluating the maintenance of oral prophylaxis. N Engl J Med, 1959, 260(14): 697-702.McNeil SA, Halperin SA, Langley JM et al. Safety and immunogenicity of 26-valent group A streptococcus vaccine in healthy adult volunteers. Clin Infect Dis, 2005, 41: 1114-1122.McNeil SA, Halperin SA, Langley JM et al. Safety and immunogenicity of 26-valent group A streptococcus vaccine in healthy adult volunteers. Clin Infect Dis, 2005, 41: 1114-1122.Bisno AL. Acute rheumatic fever: a present-day perspective. Medicine, 1993, 72(4): 278-283.Bisno AL. Acute rheumatic fever: a present-day perspective. Medicine, 1993, 72(4): 278-283.Nasonova V.A., Belov B.S., Stratchounskiy L.S., Kamanin E.I., Bogdanovich T.M., Sudilovskaya N.N., Krechikova O.I., Bogomilsky M.R., Ovchinnikov Y.M. Antibiotic treatment of streptococcal tonsillitis and pharyngitis. Klin. Mikrobiol. Antimikrob. Ter. 1999; 1: 78-82.Nasonova V.A., Belov B.S., Stratchounskiy L.S., Kamanin E.I., Bogdanovich T.M., Sudilovskaya N.N., Krechikova O.I., Bogomilsky M.R., Ovchinnikov Y.M. Antibiotic treatment of streptococcal tonsillitis and pharyngitis. Klin. Mikrobiol. Antimikrob. Ter. 1999; 1: 78-82.Wannamaker LW. Perplexity and precision in the diagnosis of streptococcal pharyngitis. Am J Dis Child, 1972, 124: 352-358.Wannamaker LW. Perplexity and precision in the diagnosis of streptococcal pharyngitis. Am J Dis Child, 1972, 124: 352-358.Pfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A streptococcal pharyngitis. PediatricsPfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A streptococcal pharyngitis. PediatricsBelyakov V.D. Surprises of streptococcal infection. Vestnik RAMN, 1996, 11: 24-28.Belyakov V.D. Surprises of streptococcal infection. Vestnik RAMN, 1996, 11: 24-28.Azithromycin and biofilms. Data on the site: www.antibiotic.ru/forum.php? t=930.Azithromycin and biofilms. Data on the site: www.antibiotic.ru/forum.php? t=930.Azovskova O.V., Ivanchik N.V., Dekhnich A.V., Krechikova O.I. , Kozlov R.S. Pegasus Research Group. Dynamics of antibiotic resistance of the Streptococcus pyogenes strains in Russia in 1999-2009. Klin. Mikrobiol Antimikrob Khimiter, 2012, 14 (4): 309-321.Azovskova O.V., Ivanchik N.V., Dekhnich A.V., Krechikova O.I. , Kozlov R.S. Pegasus Research Group. Dynamics of antibiotic resistance of the Streptococcus pyogenes strains in Russia in 1999-2009. Klin. Mikrobiol Antimikrob Khimiter, 2012, 14 (4): 309-321.

The authors declare that there are no conflicts of interest present.