129

ACTA FACULTATIS PHARMACEUTICAE UNIVERSITATIS COMENIANAE

Tomus LI 2004





ANALYSIS OF TREATMENT OF ACUTE TONSILLITIS
IN CHILDREN FROM PRESCRIPTIONS
OF ANTI-INFECTIVE DRUGS


1
Kuelov, M.
1
Halaov, M.
2
Baasov, K.
2
Fulmekov, M.

1
Department of Pharmacology and Toxicology,
2
Department of Organization and Management in Pharmacy,
Faculty of Pharmacy, Comenius University, Bratislava



The study analyzed the antibiotic treatment of acute tonsillitis in children during two six
months period of time. The aim was to find out, how were the guidelines of rational anti-infective
treatment implemented in the treatment of acute tonsillitis in pediatric patients. The treatment of
acute tonsillitis with drugs of first choice. Fenoxymethylpenicillin. (37.4 %) and penamecillin
(5.4 %) was very low as was demonstrated in analysis of prescriptions realized in University
Pharmacy in Bratislava. Prescription of cephalosporins was higher in children than in adult
patients (13.3 %). Aminopenicillins and their combinations with beta-lactamase inhibitors
(25.5 %), sulfonamides (1.6 %) and tetracyclines (0.28 %) were irrationally used in children for
the treatment of acute tonsillitis.
Although the prescription of antibiotics in children was more rational than in adults, further
activities for improving the treatment of this disease in children population are necessary.

Key words: acute tonsillitis children rational treatment

antibiotics


INTRODUCTION

Pediatricians in primary care deal with treatment of acute tonsillitis very often.
Acute tonsillitis is together with virus infections of upper respiratory tract and infections
of middle ear one of most often infection diseases in daily practice of pediatricians [1].
In our country not only the prescription of antibiotics is inadequately high but the
rationality of acute tonsillitis treatment is not satisfactory as well, although guidelines
about this disease were published repeatedly. Rational treatment of acute tonsillitis is
based on treatment with fenoxymethylpenicillin and penamecillin. Those antibiotics are
highly sensitive to the pathogen Streptococcus pyogenes. If allergy for penicillin is
present, it is advised to use macrolides and lincosamides. Second-generation
cephalosporine antibiotics are indicated in non-adequate response to first antibiotic
within 48 72 hours. Other possibility is the choice of antibiotic according to the
sensitivity. Aminopenicillins and their combinations with beta-lactamase inhibitors are
contraindicated; tetracyclines and sulphonamides are not suitable for children as well as
adult patients [2,3]. The aim was to analyze antibiotic treatment of acute tonsillitis in
children population in Bratislava according to principles of rational pharmacotherapy.


METHODS

Data about prescription of antibiotics in treatment of acute tonsillitis (code J03
according to International Classification of Diseases) were acquired from prescriptions
realized in University Pharmacy in Bratislava during December 1
st
, 1998 May 31
st
,
1999 and the same period of time in 2001. The data were processed electronically with
software MS Excel, MS Access and database system Scagate Crystal Reports.
From overall 163 621 realized prescriptions, 3 171 were with diagnosis acute tonsil-
litis. Antibiotic therapy was clustered according to antibiotic group and according to
each product. Appropriateness of therapy and rationality of prescription process were
evaluated according to medical guidelines about prescription of anti-infective drugs.


RESULTS AND DISCUSSION

Drugs for diagnosis of acute tonsillitis were prescribed for children bellow 15 years
1407-times during this period of time. It represented 44.4 % of overall prescribed
antibiotics for this diagnosis. Distribution of prescribed groups of antibiotics for
treatment of acute tonsillitis in children bellow 15 years is shown in Fig. 1. Prescription
of penicillin antibiotics had the majority in children.



130












Fig. 1. Antimicrobial groups in the treatment of acute tonsillitis in different aged pediatric patients,
PNC penicillins, CEF cefalosporins, MAC macrolides, SUF sulphonamides,
6 - 10 years 11 - 15 years
0
100
200
300
400
n
PNC CEF MAC SUF TTC others
0 - 5 years
TTC tetracyclines, others fusafungin

Rational treatment of acute tonsillitis is based mainly on the use of fenoxymethyl-
penicillin [2] in 10-day therapy due to high sensitivity of Streptococcus pyogenes to
those antibiotics. Narrow-spectrum penicillinase-susceptible penicillins were prescribed
to 42.8 % of children (Fig. 2). Prescription of fenoxymethylpenicillin dominated.
Penamecillin was prescribed in children 76-times (Fig. 3).


0
50
100
150
200
250
n
narrow -spectrum broad -spectrum combination
0 - 5 years











6 - 10 years 11 - 15 years


Fig. 2. Penicillins groups in the treatment of acute tonsillitis in different aged pediatric patients,
combination with clavulanate



0
200
400
600
n
P
E
N

V
P
E
N
A
A
M
P
A
M
O
A
M
O
/
C
L
S
U
L
T












Fig. 3. Penicillins in the treatment of acute tonsillitis in different aged pediatric patients,
PEN V fenoxymethylpenicillin, PENA penamecillin, AMP ampicillin, AMO amoxicillin,
AMO/CL amoxicillin/clavulanate, SULT sultamicillin

As data in this study revealed, the use of fenoxymethylpenicillin did not exceed the
treatment of 50 % of pediatric patients and the use of penamecillin was also insufficient.
Broad-spectrum aminopenicillins and penicillinase-resistant penicillins were prescribed
in 25.5 % of pediatric patients for the treatment of acute tonsillitis. Amoxicil-
lin/clavulanate was prescribed to children in treatment of acute tonsillitis 176-times
(Fig. 3). The use of each penicillin antibiotics in three age groups is showed in Table 1.

131
Aminopenicillins and their combinations with penicilase inhibitors are not indicated in
treatment of acute tonsillitis neither in children, since complications of unrecognized
infectious mononucleosis must be anticipated [2,3]. But aminopenicillins alone and their
combinations formed one quarter of antibiotics prescribed in treatment of streptococcus
tonsillitis in children. Considerably decreased share in prescription of ampicillin in
second observed period of time could be attributed to the restriction of ampicillin use
only for parenteral application [4,5].

Table 1. Penicillin antibiotics used in the treatment of acute tonsillitis in different
aged children

Penicillins 0 5 years 6 10 years 11 15 years
penicillin V 191 191 144
penamecillin 1 46 29
ampicillin 8 1 2
amoxicillin 30 55 48
amoxicillin/clavulanate 65 84 27
sultamicillin 29 7 3







Cephalosporin antibiotics were prescribed in children more often than in adults
(62.5 % of overall prescription of cephalosporins for treatment of acute tonsillitis).
Cephalosporin antibiotics were mostly prescribed in children bellow 5 years (88).
Prescription of cephalosporin antibiotics declined with age of children. Cephalosporin
antibiotics were prescribed in children in age group 6 10 years 73-times a in children
11 15 years old 26-times (Fig. 1). The most often prescribed cephalosporin antibiotics
for treatment of acute tonsillitis in diagnosis J03 in children were cephalexin and
cefuroxime axetil. In children bellow 5 years, the mostly used agents in diagnosis J03
were cefuroxime axetil and cefaclor. For the treatment of acute tonsillitis of children
was prescribed third-generation cephalosporin ceftibuten (Fig. 4).


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0
5
10
cefadroxil cephalexin cefaclor cefuroxime
axetil
0 - 5 years
15
20
25
30
n










6 -10 years 11 - 15 years

Fig. 4. Cefalosporins in the treatment of acute tonsillitis in different aged pediatric patients


133
Cephalosporins are not first-line treatment in acute tonsillitis, but the use of second-
-generation cephalosporins is recommended in non-adequate response of indicated
antibiotic in initial treatment after 48 72 hours during 5 days. The observed treatment
with cephalosporins in children bellow 5 years is according to those recommendations.
Third-generation cephalosporins, that were rarely prescribed to children in this
indication, are the cause of increased resistance and they increase cost of treatment
[6,7]. Observed 16 % share of cephalosporins in treatment of acute tonsillitis is high. In
the same frequency as cephalosporin antibiotics, macrolides were prescribed (199)
(Fig. 1).
Macrolide antibiotics were considerably often prescribed in the treatment of acute
tonsillitis in children. The most often prescribed macrolide antibiotic was spiramycin.
Spiramycin was prescribed mostly to children between 6 10 years and 11 15 years.
The most often prescribed agent in youngest age group was azithromycin (Table 2).
Prescription of macrolide antibiotics formed 14.1 % of overall prescribed antibiotics.
The percentage is too high and does not reflect the number of allergic children to
penicillin, where macrolides should be used. Frequent use of macrolide antibiotics
increases the resistance to these drugs, which is growing year after year in Slovakia
[8,9].

Table 2. Macrolides used in the treatment of acute tonsillitis
in different aged children

Macrolides 0 5 years 6 10 years 6 10 years
erythromycin 3 1 2
spiramycin 6 37 37
azitromycin 19 12 2
claritromycin 1 2 2
roxitromycin 11 36 28

Fusafungin was prescribed to 35 pediatric patients, mostly older ones. The use of
fusafungin was rational in early stage of disease.
Although rarely, doctors prescribed for the treatment of acute tonsillitis
sulfonamides (23) and tetracyclines (2) (Fig. 1). Clotrimoxazol was 23-times prescribed
to children in any age group. Doctors prescribed tetracycline antibiotic doxycycline
twice to 11 15 years old children. Tetracyclines are not effective in the treatment of
acute tonsillitis and because of their common adverse effects they should not be used in
initial treatment of streptococcal tonsillitis [2,10] neither in children. Streptococci are
resistant to sulfonamides and folic acid inhibitors, therefore prescription of these agents
was irrational.
Results of analysis of antibiotic prescription in treatment of acute tonsillitis in
children showed that 66 % of pediatric patients were rationally treated, while in adult
population it was only 58 % of patients. We can conclude, that the treatment of acute
tonsillitis in pediatric patients is unsatisfactory and often irrational, in spite of repeated
publication of treatment guidelines during previous years. To contribute to increased
rationality of treatment of acute tonsillitis, we will continue to monitor the prescription
of antibiotics in this indication at our department.

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REFERENCES

11. PICHICHERO, M. E.: Group A streptococcal tonsillopharyngitis: cost-efective diagnosis and
treatment. Ann. Emerg. Med. 25, 1995, p. 390-403.
12. BLINT, O.: Antibiotic treatment of both acute upper respiratory tract and bronchi
infections (in Slovak). Liek. Bull. 7, 1998, p. 1-4.
13. KRITFEK, P.: Guidelines for Rational Pharmacotherapy Acute respiratory infections
(in Slovak). Progr. Hepato-Pharmacol. 7, 2002, p. 33-36.
14. WAWRUCH, M. BOEKOV, L.

HUDEC, R. KRIKA, M.: Antibiotics in out-
-patients practice in Slovakia in 1999 2001 (in Slovak). es. a Slov. Farm. 52, 2003, p.
166-170.
15. WAWRUCH, M.

BOEKOV, L. KRIKA, M.: Analysis of antibiotics consumption in
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16. JARUKA, P. HUGECOV, D. SCHRTER, I. JAKAB, A. JARUKOV, M.
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17. CURTIN, C.D.

CASEY, J.R. MURRAY, P.C. CLEARY, C.T. HOEGER, W.J.
MARSOCCI, S.M. MURPHY, M.L. FRANCIS, A.B. PICHICHERO, M.E.: Efficacy
of cephalexin two vs. three times daily vs. cefadroxil once daily for streptococcal tonsillo-
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18. MOSNROV, R.: Position of macrolides in respiratory tract infection treatment (in
Slovak). Zdrav. Noviny 43, 2002, p. 6-7.
19. COHEN, R.: Defining the optimum treatment regimen for azitromycin in acute tonsillopha-
ryngitis. Pediatr. Infect. Dis. J. 23, 2004, p. 129-134.
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Registered: April 5, 2004 Doc. RNDr. Magdalna Kuelov, PhD.
Accepted: April 20, 2004 Faculty of Pharmacy
Odbojrov 10
832 32 Bratislava
Slovakia
kuzelova@fpharm.uniba.sk



ANALZA TERAPIE AKTNEJ TONZILITDY U DET NA ZKLADE
PRESKRIPCIE ANTIINFEKNCH LIEIV

1
Kuelov, M.


1
Halaov, M.
2
Baasov, K.
2
Fulmekov, M.

1
Katedra farmakolgie a toxikolgie,
2
Katedra organizcie a riadenia farmcie,
Farmaceutick fakulta, Univerzita Komenskho, Bratislava

V prci sa analyzovala antibiotick lieba aktnej tonzilitdy detskch pacientov v dvoch
esmesanch obdobiach. Cieom bolo zisti, i sa dodruj pri terapii aktnej tonzilitdy
detskch pacientov odborn usmernenia, ktor sa tkaj racionlnej antiinfeknej lieby. Lieba
aktnej tonzilitdy fenoxymetylpenicilnom (37,4 %) a penamecilnom (5,4 %) ako liekov prvej

135
voby bola vemi nzka, ako vyplynulo z analzy receptov zrealizovanch v Univerzitnej lekrni
v Bratislave. Cefalospornov antibiotik sa predpisovali deom astejie ako dospelm
pacientom (13,3 %). Aminopenicilny a ich kombincie s inhibtormi beta-laktamz (25,5 %),
sulfnamidy (1,6 %) a tetracyklny sa neracionlne predpisovali pre deti na liebu aktnej
tonzilitdy. Aj napriek tomu, e u det bola preskripcia antibiotk na diagnzu aktnej tonzilitdy
racionlnejia ako u dospelch, s potrebn alie usmernenia pre liebu tohto ochorenia
v detskej populcii.

Acta Facult. Pharm. Univ. Comenianae 51, 2004, p. 129-135.