Streptococcal pharyngitis

Author: Robert Guthrie
Date: Dec, 1990

In this issue, Dr. Pichichero presents an excellent overview of the treatment of streptococcal pharyngitis. (1) He outlines what may be the emergence of new therapeutic issues in streptococcal pharyngitis--primarily, increased failure rates in eradicating streptococci from the pharynx with traditional penicillin therapy.

A look back at the history of streptococcal pharyngitis shows that the treatment of this once-dreaded infection, particularly with its serious systemic sequela of rheumatic fever, has been one of the great success stories of post-World War II medicine. The prevalence rate of rheumatic fever, which ran as high as 41 per 100,000 population in earlier decades of this century, has dropped to an almost negligible rate (as low as 0. 046 per 100,000 in the same communities) during the past 15 years. (2) Isolated outbreaks of rheumatic fever in the 1980s appeared to result from particularly pathogenic streptococci rather than inadequate medical care. (3,4 ) Thus, there is no reason to question the effectiveness of traditional parenteral or oral penicillin therapy in the prevention of rheumatic fever.

In the last six years, however, several new questions have emerged about the treatment of streptococcal pharyngitis. Will pharyngitis symptoms resolve more quickly with immediate treatment, compared with waiting 48 hours for the results of a positive throat culture? (5,6) This is a complex issue. An early intervention study by Dr. Pichichero showed a higher rate of recurrence and/or persistence of streptococci in the pharynx with immediate antibiotic administration when compared with treatment instituted after obtaining a positive throat culture. (7) The question of whether we are reducing patients' symptoms while increasing the carrier rate and/ or making patients more susceptible to recurrent infection remains unanswered and emphasizes the need for further research.

What is the significance of the increasing rates of failure to eradicate streptococci from the pharynx with penicillin? A series of studies document that even though penicillin treatment prevents acute rheumatic fever and reduces symptoms, it may not necessarily eradicate streptococci from the pharynx. (8,9) However, all of the studies revealing increased persistence of streptococci have not shown that this persistence correlates with an increased risk of acute rheumatic fever or a continuation of clinical symptoms, which raises doubts about whether this problem has any clinical significance. If the patient does not suffer the serious sequelae of acute rheumatic fever or even prolonged clinical discomfort, is the failure to completely eradicate streptococci from the pharynx really important?

The extraordinarily successful treatment of streptococcal pharyngitis in the United States has nearly eliminated acute rheumatic fever and rheumatic carditis. Therefore, bacteriologic concerns over streptococcal eradication and/or a carrier state may not be of clinical significance but may primarily be of academic and microbiologic interest. (10,11) Evaluation of this question offers no significant evidence that we must move quickly to alter our treatment patterns and begin regular use of other more broad-spectrum antibiotics.

I urge physicians to remember that the highest priority in treating streptococcal pharyngitis is the prevention of acute rheumatic fever. The question of early-versus-delayed treatment remains unanswered. Although early antibiotic intervention seems to reduce symptoms, it also may place the patient at risk of recurrent episodes. In any case, the traditional throat culture with subsequent penicillin treatment continues to be an accepted and valuable treatment for streptococcal pharyngitis.

ROBERT GUTHRIE, M.D.

Ohio State University

Columbus, Ohio

REFERENCES

1. Pichichero ME. Controversies in the treatment of streptococcal pharyngitis. Am Fam Physician 1990;42:1567-76.

2. Hutten-Czapski P. Management of streptococcal pharyngitis: the conundrum of acute rheumatic fever. Fam Pract 1988; 5:200-8.

3. Hosier DM, Craenen JM, Teske DK Wheller JJ. Resurgence of acute rheumatic fever. Am J Dis Child 1987;141:730-3.

4. Veasy LG, Wiedmeier SE, Orsmond GS, et al. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med 1987;316:421-7.

5. Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis. JAMA 1985;253:1271-4.

6. Randolph MF, Gerber MA, DeMeo KK, Wright L. Effect of antibiotic therapy on the clinical course of streptococcal pharyngitis. J Pediatr 1985;106:870-5.

7. Pichichero ME, Disney FA, Talpey WB, et al. Adverse and beneficial effects of immediate treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J 1987;6:635-43.

8. Kim KS, Kaplan EL. Association of penicillin tolerance with failure to eradicate group A streptococci from patients with pharyngitis. J Pediatr 1985;107:681-4.

9. Gastanaduy AS, Kaplan EL, Huwe BB, McKay C, Wannamaker LW. Failure of penicillin to eradicate group A streptococci during an outbreak of pharyngitis. Lancet 1980;2(8193): 498-502.

10. Brook I. Emergence and persistence of beta-lactamase-producing bacteria in the oropharynx following penicillin treatment. Arch Otolaryngol Head Neck Surg 1988; 114:667-70.

11. Tanz RR, Shulman ST, Barthel MJ, Willert C, Yogev R. Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci. J Pediatr 1985;106:876-80.

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