EDITORIAL

Still learning about group A strep and penicillin

The link between infection with group A streptococci and rheumatic fever was made in the 1940s. In 1950, Denny and colleagues published the landmark study demonstrating that treatment of group A streptococcal pharyngitis with penicillin could prevent rheumatic fever.¹ Although prevention of debilitating and, often, life-threatening cardiac disease was the primary goal, penicillin was also shown to rapidly alleviate symptoms of streptococcal pharyngitis. In fact, the benefit of penicillin therapy is so rapid and so obvious that it has become the benchmark against which other therapeutic regimens generally are often compared ("Well, it's not like treating strep throat with penicillin . . .").

The group A streptococcus has—miraculously—remained susceptible to penicillins and other b-lactam antibiotics. Despite that susceptibility, however, the microorganism is not always eradicated when the host is treated with an appropriate dosage of penicillin, for an appropriate duration—even when treatment is given as benzathine penicillin. In fact, as discussed in the article by Drs. Pichichero and Casey ("Defining and dealing with carriers of group A streptococci"), there is reason to believe that persistence is more likely today than it was decades ago.

Does concern about persistence following penicillin therapy warrant reconsideration of the recommendation that penicillin is the treatment of choice for group A streptococcal pharyngitis? Most experts don't think so, citing the proven efficacy and safety, narrow antibacterial spectrum, and low cost of penicillin.² Nor is it recommended that a throat culture or rapid antigen test be performed on patients who are asymptomatic after treatment of streptococcal pharyngitis. A positive culture or antigen test in most such patients would only identify carriers who aren't in need of additional therapy.

For longer than 60 years, pediatricians have investigated the importance of group A streptococci among their patients. As the article here by Drs. Pichichero and Casey demonstrates, we're still learning.

REFERENCES

1. Denny FW, Wannamaker LW, Brink WR, et al: Prevention of rheumatic fever: Treatment of the preceding streptococcal infection. JAMA 1950;143:151

2. Bisno AL, Gerber MA, Gwaltney JM, et al: Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 2002;35:113

Julia A. McMillan, MD, editor-in-chief of Contemporary Pediatrics, is professor of pediatrics, vice chair for pediatric education, and director of the residency training program, Johns Hopkins University School of Medicine, Baltimore.

 

Julia McMillan. Editorial: Still learning about group A strep and penicillin. Contemporary Pediatrics 2003;1:9.