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Metronidazole treatment questioned.

The study described by Dr. Itzhak Brook showed minimal benefit for patients who took oral metronidazole for treatment of non-group A [beta]-hemolytic streptococcal tonsillitis ("Metronidazole Treats Non-GABHS Tonsillitis," February 2005, p. 12).

Namely, the benefits include lower rates of fevers over 38[degrees] C and fewer sore throats.

Since this is a very small study that does not have enough power to prove any benefit, I am sure that no serious physician is giving any thought to such treatment for children for a condition that is not known to have any acute or chronic consequences.

It is worth remembering that the reason we treat group A [beta]-hemolytic streptococcal tonsillitis is to prevent acute and chronic complications.

However, we should consider the results of this study from the perspective of judicious use of antibiotics.

In an era of increased bacterial resistance to almost every old and new antibiotic, great efforts have been made to reeducate providers so that we use antibiotics with respect and only for the approved indications.

Why would we want to use metronidazole to treat a poorly defined disease that in most cases is caused by viruses, and that almost always is taken care of by the patient's immune system?

Francisco Enriquez, M.D.


Dr. Brook replies:

I am grateful to Dr. Enriquez for his insightful and correct remarks.

We should definitely not overuse antibiotics in self-limited infections. Our report does not endorse or advocate the use of metronidazole or any other antibiotic for the treatment of non-group A [beta]-hemolytic streptococcal (non-GABHS) tonsillitis.

It merely shares our experience in using this treatment in a selected group of children who had massive tonsillar enlargement and at least one of the following: anterior cervical adenitis, temperature higher than 38.3[degrees] C (101[degree] F), and pharyngeal or tonsillar exudates or pharyngeal injection.

Rapid streptococcal antigen tests were negative and cultures of the tonsils showed no growth of any [beta]-hemolytic streptococci, including GABHS.

Our evaluation illustrated that metronidazole therapy was more efficacious than no therapy in relieving the signs and symptoms of the acute episodes of nonstreptococcal tonsillitis.

Since these were very sick children who were in great pain and discomfort, this treatment seemed to provide them with some relief. We postulated that the superiority of metronidazole may be due to its activity against anaerobic bacteria.

Since this study was not randomized or blinded, the conclusion that metronidazole therapy may be more efficacious than no therapy is not evidence based and should not change the treatment policies for nonstreptococcal tonsillitis.

Further studies that are prospective and blinded are needed to evaluate the use of antimicrobials effective against anaerobic bacteria in the treatment of non-GABHS tonsillitis.

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Title Annotation:Letters
Author:Enriquez, Francisco; Brook
Publication:Pediatric News
Article Type:Letter to the Editor
Date:May 1, 2005
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