Intended for healthcare professionals

Primary Care

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

BMJ 2003; 327 doi: (Published 04 December 2003) Cite this as: BMJ 2003;327:1324

Non sequitur

To the Editors:

The authors correctly state that sequelae of infections due to Streptotoccus pyogenes have become "[...] rare in affluent western communities. [...]" This good news, in my humble opinion, is both a consequence of the standard treatment of these infections, which includes Penicillin V for 10 (not seven!) days or another drug active against group A streptococci, and of changes in the relative distribution of different strains of those bacteria.

It has been known for decades that the signs and symptoms of streptococcal pharyngitis are hardly alleviated by treatment with antimicrobials: "[...] The course is shortened little by treatment, which is given primarily to prevent suppurative complications and rheumatic fever [...]"1

The authors correctly point to the growing concerns about rising resistance to antimicrobials; S. pyogenes, however, has remained exceptionally sensitive against Penicillin G until today, despite the widespread use of this drug against streptococcal diseases.

The authors state that in their patient group, which included but 96 patients with diagnoses of S. pyogenes, suppurative complications which could have been prevented by antimicrobial therapy occurred rarely and
could safely be treated "[...] at the moment of their occurrence.[...]". One should keep in mind that ambulatory patients will not always have medical support available without delays. In addition, I would expect larger studies to support the tendency the present study has documented, i.e., patients deprived of antimicrobial therapy for group A streptococcal disease have a higher risk of suppurative sequelae.

The authors do not discuss nonsuppurative sequelae of infections by group A streptococci. The attack rates of poststreptococcal glomerulonephritis, Sydenham's chorea, erythema marginatum, and rheumatic fever vary widely and depend, among other factors, on the antigenic structure of the streptococcal strains involved. With attack rates of generally less than 3 percent, it does not come as a surprise that the authors have not seen such a complication in any of the 43 patients in their placebo group from which S. pyogenes has been isolated. With a carrier rate of 30 % reported by the authors, some of the 43 patients in the placebo group in which group A streptococci have been detected may have been mere carriers in which a sore throat has been caused by a viral infection, resulting in a still lower expected rate of nonsuppurative sequelae in this small group of patients. Of note, these sequelae will not resolve despite treatment in many of those hit by them. Nonsuppurative sequelae have been seen with varying rates; during the 1970s, they had almost disappeared in the United States, only to reappear in the mid and late 1980s2.

The present study, in my opinion, does not present data to support the conclusions the authors draw with respect to antimicrobial treatment of group A streptococcal diseases. In my view, it can hardly be justified to deny antimicrobial treatment to patients suffering from diseases due to S. pyogenes; infections that might be caused by this bacterial species need diagnostic workup, and diseases caused by group A streptococci need antimicrobial treatment sufficient to eradicate the infection so as to prevent nonsuppurative and suppurative sequelae.

[1] Isselbacher et al.: Harrison' Principles of Internal Mecidine, 13th ed., MacGraw Hill, 1994, p. 618.

[2] Behrman et al. (eds.): Nelson Textbook of Pediatrics, 14th ed., W.B.Saunders, p. 640.

Competing interests:
None declared

Competing interests: No competing interests

19 January 2004
Ernst Molitor
medical microbiologist
53105 Bonn, Germany