由化膿性鏈球菌引起的扁桃體咽炎
為什麽咽部看診必不可少呢？因為人類需要壹直呼吸才能生存，病菌很多時候存在空氣微粒中，而咽部就好比是病菌進入人體的入口，就像壹座城堡的大門，也是壹道屏障，如果大門受到攻擊，就代表可能存在病菌在入侵，所以咽部看診是兒科看診的必備項目。
那麽問題來了，什麽是化膿性鏈球菌引起的扁桃體炎？有什麽表現？有那些危害？
化膿性扁桃體炎如何治療？
為什麽我的孩子十次生病九次都是扁桃體化膿，那麽需要如何處理嗎？
由化膿性鏈球菌(Streptococcus pyogenes)[也稱為A組鏈球菌(group A streptococcus, GAS)]引起的扁桃體咽炎。表現急性起病的咽痛、扁桃體滲出、頸部淋巴結腫大伴觸痛和發熱，2-5日內自行緩解。咽痛持續超過1周通常不是GAS性扁桃體咽炎。
病原體主要通過飛沫、直接接觸等途徑傳入，平時可隱藏在扁桃體小窩內，當機體因勞累、受涼或其他原因而致抵抗力減弱時，病原體可迅速繁殖而引起發病。
危害：化膿性並發癥(如扁桃體周圍膿腫、頸淋巴結炎和乳突炎)非化膿性並發癥 ( 急性風濕熱，腎小球腎炎和A組鏈球菌相關性兒童自身免疫性神經精神疾病)(pediatric autoimmuneneuropsychiatric disorder associated with group A streptococci, PANDAS)
治療時機：
GAS性咽炎的自然病程中，潛伏期為2-4日。即使不進行抗生素治療，發熱和全身癥狀通常也會在3-4日內緩解11研究發現，與在發病後2日內接受安慰劑的患者相比，接受青黴素治療的患者出現臨床改善的時間最多可早48小時2-6
在起病後2日內開始抗生素治療對迅速緩解癥狀最有效2-6。通過包含至少9-11日青黴素給藥的註射方案，GAS根除和AFR壹級預防得到了優化。如果在癥狀出現後9日內開始，則抗生素治療有助於預防風濕熱[8]。
急性風濕熱是GAS性咽炎的壹種非化膿性並發癥，抗生素治療對減少其發生非常有用。抗生素治療對於減少腎小球腎炎和A組鏈球菌相關性兒童自身免疫性神經精神疾病(pediatric autoimmune neuropsychiatric disorder associated with group A streptococci, PANDAS)綜合征這兩種非化膿性並發癥的作用尚不明確[7]。
7歲以下兒童患鏈球菌感染後腎小球腎炎的風險似乎最大。盡管抗生素治療對ARF的壹級預防有效，但是對GAS性扁桃體咽炎的患者而言，抗生素能否有效預防鏈球菌感染後腎小球腎炎尚不清楚。
有人擔心早期治療可能抑制宿主的抗體應答，從而增加咽炎復發的風險。在壹項納入142例疑診GAS性咽炎兒童的研究中，在首次就診時給予青黴素治療的患兒，感染復發的發生率高於治療延遲了至少48小時的患兒(前壹類患者的復發感染率是後壹類的8倍)[9]。
但是，大多數GAS性扁桃體咽炎病例並不需要延遲治療。延遲治療對於經常復發的輕至中度感染患者可能有用，可容許機體產生針對感染菌株的免疫力而又不增加ARF的風險。延遲至癥狀出現後9日給予抗生素治療仍然有助於預防風濕熱(盡管預防化膿性並發癥的有效性可能降低)[12]。然而，如果患者病情嚴重或者當高毒力或致風濕源性菌株在社區內活躍流行時，不應考慮該方法。抗生素治療24小時後患者不再有傳染性[14]
治療藥物：
兒童患者時，經常用阿莫西林替代口服青黴素，因為阿莫西林混懸液的口感比青黴素好。壹些數據表明口服阿莫西林略優於青黴素，很可能是由於前者的胃腸道吸收更好[44,45]。阿莫西林對1/3的常見中耳炎病原體有活性，而中耳炎兒童(特別是小於4歲的兒童)有高達15%合並GAS性扁桃體咽炎。
不能完成10日口服療程或風濕熱風險增高的患者，例如既往有風濕性心臟病史和/或生活環境擁擠的患者，可肌內註射單劑芐星青黴素。
在兒童中，首選藥物為含有90萬U芐星青黴素和30萬U普魯卡因青黴素的復方制劑(即長效西林/普魯卡因)。
已經證實頭孢菌素類較青黴素具有更高的微生物學治愈率及臨床治愈率；這些差異在兒童中較成人中更顯著，壹些臨床醫師傾向於用第壹代頭孢菌素作為兒童的壹線治療藥物。然而，第二代和第三代頭孢菌素可能促進抗生素耐藥性的產生，不支持將其作為壹線治療。
對青黴素過敏的患者，在無危及生命的青黴素過敏反應史時可使用頭孢菌素類(頭孢呋辛、頭孢泊肟、頭孢地尼及頭孢曲松)[18,21-27]；後幾代頭孢菌素與青黴素不太可能出現交叉反應[22,26，27]。因耐藥率可能高達20%，根據當地的耐藥情況，青黴素過敏患者可選用大環內酯類(阿奇黴素、克拉黴素或紅黴素)
為什麽扁桃體炎容易復發呢？療程短，沒有根除鏈球菌。
療程 — 盡管患者通常在治療的最初幾日內就可得到臨床改善，但壹般情況下，為達到咽部GAS的最大根除率，口服抗生素的常規療程為10日。治療3日後停用青黴素，復發的可能性比治療7日後停藥高(50% vs 34%)9，11，12
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