在門(mén)診工作中稠肘，孩子生病時(shí)候的癥狀多種多樣媳纬，包括發(fā)熱、咳嗽蕉斜、流涕椿争、腹瀉等怕膛，但進(jìn)入診室的第一時(shí)間，醫(yī)生最關(guān)注的是孩子的精神狀態(tài)秦踪，然后基本檢查包括心肺聽(tīng)診褐捻，咽部看診，后續(xù)才是醫(yī)生選擇性的查體項(xiàng)目椅邓。
為什么咽部看診必不可少呢柠逞？因?yàn)槿祟愋枰恢焙粑拍苌妫【芏鄷r(shí)候存在空氣微粒中景馁，而咽部就好比是病菌進(jìn)入人體的入口板壮，就像一座城堡的大門(mén)，也是一道屏障合住，如果大門(mén)受到攻擊绰精，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(xiàng)目聊疲。
那么問(wèn)題來(lái)了茬底，什么是化膿性鏈球菌引起的扁桃體炎？有什么表現(xiàn)获洲？有那些危害？
化膿性扁桃體炎如何治療殿如？
為什么我的孩子十次生病九次都是扁桃體化膿贡珊，那么需要如何處理嗎最爬？
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(xiàn)急性起病的咽痛门岔、扁桃體滲出爱致、頸部淋巴結(jié)腫大伴觸痛和發(fā)熱，2-5日內(nèi)自行緩解寒随。咽痛持續(xù)超過(guò)1周通常不是GAS性扁桃體咽炎糠悯。
病原體主要通過(guò)飛沫、直接接觸等途徑傳入妻往，平時(shí)可隱藏在扁桃體小窩內(nèi)互艾，當(dāng)機(jī)體因勞累、受涼或其他原因而致抵抗力減弱時(shí)讯泣，病原體可迅速繁殖而引起發(fā)病纫普。
危害：化膿性并發(fā)癥(如扁桃體周?chē)撃[、頸淋巴結(jié)炎和乳突炎)非化膿性并發(fā)癥 ( 急性風(fēng)濕熱好渠，腎小球腎炎和A組鏈球菌相關(guān)性兒童自身免疫性神經(jīng)精神疾病)(pediatric autoimmuneneuropsychiatric disorder associated with group A streptococci, PANDAS)
治療時(shí)機(jī)：
GAS性咽炎的自然病程中昨稼，潛伏期為2-4日。即使不進(jìn)行抗生素治療拳锚，發(fā)熱和全身癥狀通常也會(huì)在3-4日內(nèi)緩解【11】研究發(fā)現(xiàn)假栓，與在發(fā)病后2日內(nèi)接受安慰劑的患者相比，接受青霉素治療的患者出現(xiàn)臨床改善的時(shí)間最多可早48小時(shí)【2-6】
在起病后2日內(nèi)開(kāi)始抗生素治療對(duì)迅速緩解癥狀最有效【2-6】霍掺。通過(guò)包含至少9-11日青霉素給藥的注射方案匾荆，GAS根除和AFR一級(jí)預(yù)防得到了優(yōu)化。如果在癥狀出現(xiàn)后9日內(nèi)開(kāi)始抗楔，則抗生素治療有助于預(yù)防風(fēng)濕熱[8]棋凳。
急性風(fēng)濕熱是GAS性咽炎的一種非化膿性并發(fā)癥，抗生素治療對(duì)減少其發(fā)生非常有用连躏∈Ｔ溃抗生素治療對(duì)于減少腎小球腎炎和A組鏈球菌相關(guān)性兒童自身免疫性神經(jīng)精神疾病(pediatric autoimmune neuropsychiatric disorder associated with group A streptococci, PANDAS)綜合征這兩種非化膿性并發(fā)癥的作用尚不明確[7]。
7歲以下兒童患鏈球菌感染后腎小球腎炎的風(fēng)險(xiǎn)似乎最大入热。盡管抗生素治療對(duì)ARF的一級(jí)預(yù)防有效拍棕，但是對(duì)GAS性扁桃體咽炎的患者而言，抗生素能否有效預(yù)防鏈球菌感染后腎小球腎炎尚不清楚勺良。
有人擔(dān)心早期治療可能抑制宿主的抗體應(yīng)答绰播，從而增加咽炎復(fù)發(fā)的風(fēng)險(xiǎn)。在一項(xiàng)納入142例疑診GAS性咽炎兒童的研究中尚困，在首次就診時(shí)給予青霉素治療的患兒蠢箩，感染復(fù)發(fā)的發(fā)生率高于治療延遲了至少48小時(shí)的患兒(前一類患者的復(fù)發(fā)感染率是后一類的8倍)[9]。
但是，大多數(shù)GAS性扁桃體咽炎病例并不需要延遲治療谬泌。延遲治療對(duì)于經(jīng)常復(fù)發(fā)的輕至中度感染患者可能有用滔韵，可容許機(jī)體產(chǎn)生針對(duì)感染菌株的免疫力而又不增加ARF的風(fēng)險(xiǎn)。延遲至癥狀出現(xiàn)后9日給予抗生素治療仍然有助于預(yù)防風(fēng)濕熱(盡管預(yù)防化膿性并發(fā)癥的有效性可能降低)[12]掌实。然而陪蜻，如果患者病情嚴(yán)重或者當(dāng)高毒力或致風(fēng)濕源性菌株在社區(qū)內(nèi)活躍流行時(shí)，不應(yīng)考慮該方法贱鼻⊙缏簦抗生素治療24小時(shí)后患者不再有傳染性[14]
治療藥物：
兒童患者時(shí)，經(jīng)常用阿莫西林替代口服青霉素邻悬，因?yàn)榘⒛髁只鞈乙旱目诟斜惹嗝顾睾弥⒒琛Ｒ恍?shù)據(jù)表明口服阿莫西林略優(yōu)于青霉素，很可能是由于前者的胃腸道吸收更好[44,45]拘悦。阿莫西林對(duì)1/3的常見(jiàn)中耳炎病原體有活性齿兔，而中耳炎兒童(特別是小于4歲的兒童)有高達(dá)15%合并GAS性扁桃體咽炎。
不能完成10日口服療程或風(fēng)濕熱風(fēng)險(xiǎn)增高的患者础米，例如既往有風(fēng)濕性心臟病史和/或生活環(huán)境擁擠的患者分苇，可肌內(nèi)注射單劑芐星青霉素。
在兒童中屁桑，首選藥物為含有90萬(wàn)U芐星青霉素和30萬(wàn)U普魯卡因青霉素的復(fù)方制劑(即長(zhǎng)效西林/普魯卡因)医寿。
已經(jīng)證實(shí)頭孢菌素類較青霉素具有更高的微生物學(xué)治愈率及臨床治愈率；這些差異在兒童中較成人中更顯著蘑斧，一些臨床醫(yī)師傾向于用第一代頭孢菌素作為兒童的一線治療藥物靖秩。然而，第二代和第三代頭孢菌素可能促進(jìn)抗生素耐藥性的產(chǎn)生竖瘾，不支持將其作為一線治療沟突。
對(duì)青霉素過(guò)敏的患者，在無(wú)危及生命的青霉素過(guò)敏反應(yīng)史時(shí)可使用頭孢菌素類(頭孢呋辛捕传、頭孢泊肟惠拭、頭孢地尼及頭孢曲松)[18,21-27]；后幾代頭孢菌素與青霉素不太可能出現(xiàn)交叉反應(yīng)[22,26庸论，27]职辅。因耐藥率可能高達(dá)20%，根據(jù)當(dāng)?shù)氐哪退幥闆r聂示，青霉素過(guò)敏患者可選用大環(huán)內(nèi)酯類(阿奇霉素域携、克拉霉素或紅霉素)
為什么扁桃體炎容易復(fù)發(fā)呢？療程短鱼喉，沒(méi)有根除鏈球菌秀鞭。
療程— 盡管患者通常在治療的最初幾日內(nèi)就可得到臨床改善趋观，但一般情況下，為達(dá)到咽部GAS的最大根除率气筋，口服抗生素的常規(guī)療程為10日拆内。治療3日后停用青霉素旋圆，復(fù)發(fā)的可能性比治療7日后停藥高(50% vs 34%)】9宠默，11，12】
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