Clinical Question: Does treatment with a cephalosporin instead of a penicillin result in better bacteriologic or clinical cure in children with streptococcal tonsillopharyngitis?

Setting: Various (meta-analysis)

Study Design: Meta-analysis (randomized controlled trials)

Synopsis: The authors of this meta-analysis identified 35 studies that compared a cephalosporin with penicillin for 10 days in the treatment of children with group A beta-hemolytic streptococcal pharyngitis. The studies (all languages) were identified through MEDLINE and EMBASE searches, reference lists of identified trials, and abstracts from the meetings of the Society for Pediatric Research and the Interscience Conference on Antimicrobial Agents and Chemotherapy.

Not all of the studies were of high quality; 59 percent had a Jadad score of zero to 2 (on a scale of 1 to 5, in which 5 = highest quality), and the majority were not double-blinded and did not conceal allocation assignment. In other words, the studies may have had significant flaws that could not be overcome by meta-analytic methods. Fortunately, the results were stronger in the higher quality studies.

Overall, bacteriologic cure was significantly more likely with cephalosporin treatment (92.6 percent versus 80.6 percent; number needed to treat [NNT] = eight), as was clinical cure (93.6 percent versus 85.8 percent; NNT = 13). Bacteriologic cure rates did not differ, whether a first-, second-, or third-generation cephalosporin was used. Bacteriologic cure rates with penicillin decreased slightly, but significantly, from the 1970s (83.4 percent) to the 1990s (79.4 percent). The researchers found no evidence of publication bias.

Bottom Line: In children, treating streptococcal tonsillopharyngitis with a cephalosporin instead of penicillin produces significantly more bacteriologic and clinical cures. One additional child will benefit for every 13 children treated with a cephalosporin rather than penicillin. Only two cephalosporins, cefaclor and loracarbef, showed no advantage over penicillin in this meta-analysis. The effect of cephalosporin treatment on the prevention of rheumatic heart disease is unknown. (Level of Evidence: 1a)