Penicillin for acute sore throat in children: randomised, double blind trial

To the Editors:

I disagree with Zwart et al. in their recommending against the
routine
use of antibiotics for streptococcal pharyngitis. From both my teaching
in medical school and as a pediatric resident, I counsel my patients that
antibiotics are always indicated for streptococcal pharyngitis to prevent
complications, including rheumatic fever.

I agree with Zwart et al. that giving penicillin to all children with

pharyngitis is inappropriate. However, the non-significant trend
towards less sequelae of streptococcal infections in the treated group
suggests a role for penicillin. In the conclusion, Zwart et al. argues
that
"the extremely low incidence of potentially severe post-streptococcal
sequelae such as rheumatic fever in affluent Western communities",
supports "prudent prescription behaviour with respect to penicillin". The
incidence of rheumatic fever in the U.S. exceeded 100 per 100,000 at
the turn of the 20th century and has dropped to 2 per 100,000 at the
turn of this century, which corresponded with the use of penicillin in
treating streptococcal pharyngitis (1). Therefore, it seems that Zwart et

al. is somehow arguing that penicillin should not be prescribed for
streptococcal pharyngitis due its success in preventing the sequelae this
disease! Given this success, it seems reasonable to follow the guidelines
from the Infectious Diseases Society of America that all children with
symptomatic pharyngitis with laboratory confirmation of streptococcus
in the throat receive antibiotic therapy (2).

Although it is worthwhile to not prescribe antibiotics to avoid
unnecessary costs, side-effects, and resistance, prudent prescription of
penicillin to the rapid-antigen positive patients with a clinical picture
consistent with streptococcal pharyngitis should still be done to prevent
rheumatic fever and other sequalae.

Sincerely,

Paul I Pelavin MD PGY-2

NYU School of Medicine

References:

1. Dajani, AS. "Rheumatic Fever" in Braunwald, E. Heart Disease: A
Textbook of Cardiovascular Medicine, 6th ed, 2001, p. 2192.

2. Bisno AL. "Practice guidelines for the diagnosis and management
of
group A streptococcal pharyngitis. Infectious Diseases Society of
America." Clin Infect Dis, 15 Jul 2002; 35(2): 113-25.

Competing interests:
None declared