Bacteriological aspects of treatment failures in streptococcal tonsillitis

Abstract: ß-hemolytic streptococci persist in 10-25% of patients with acute streptococal tonsillitis (about 10.000-25.000 per year in Sweden) in spite of treatment with a recommended dosage and schedule of Phenoxymethylpenicillin. The aim of the study was to investigate different bacteriological factors involved in treatment failures of streptococcal tonsillitis. Patients included in the study were 33 patients who underwent tonsillectomy, 62 persons included in a tonsillitis epidemic outbreak, 267 tonsillitis patients contacting the ENT-clinic, Sahlgrenska Hospital, Göteborg, and 20 healthy volunteers taking Phenoxymethylpenicillin. It was found that the Steer's steel pin replicator was a useful tool to study interference between a- and ß-hemolytic streptococci and a guantitative differen ce in. the inhibitory capacity of the different a-strains was noted, a-streptococci with a strong inhibitory capacity on ß-streptococci were isolated mainly from individuals seemingly resistant to ß-streptococcal tonsillitis, while from patients with repeated tonsillitis no or low numbers of inhibiting a-streptococci were demonstrated. Patients with clinical treatment failure had less a-streptococci with inhibiting capacity on their own ß-streptococcal strain compared with the healthy carriers. These treatment failures also showed beta-lactamase activity in their saliva pellet significantly more often than patients in the control groups. In volunteers penicillin was released from ordinary sugar coated tablets already in the mouth resulting in a decrease of the a-strep- tococcal flora. A synergistic effect on ß-hemolytic killing by low concentration of penicillin and inhibition of a-streptococci was noted in vitro and in vivo. Penicillin tolerance was registered in most strains from the treatment failure group, but in none of the strains from the group of successfully treated patients. A co-operation between different bacteriological factors (bacterial interference, beta-lactamase production, penicillin tolerance) seems to be important in treatment failures of streptococcal tonsillitis.