Prevention of streptococcal sequelae by penicillin prophylaxis: a reassessment

In conclusion, the diagnosis of streptococcal infection lacks precision, and as long as this is so, reliance must be placed on trained clinical judgement together with bacteriological studies. There is some evidence for an evolutionary drift in the relationship between the streptococcus and man, a drift that is compatible with the natural history of other diseases and with the accomodations observed in nature among other species during the course of evolutionary events. If, as a result of recent accomodations between man and the group A streptococcus, the risk of rheumatic fever is less, an undefinable risk nevertheless remains. There was even a military outbreak of rheumatic fever in England several years ago, and on that island--we are told--rheumatic fever has been banned for years. The current recommendations of the American Heart Association for the secondary prevention of rheumatic fever I judge acceptable for use in the United States. I have, however, raised the possibility that they may be inadequate for the prevention of second attacks in other populations where the environmental, socioeconomic, bacteriological, and nutritional circumstances are different from our own. Studies designed to reexamine these questions may, in the end, refocus our attention on the importance of host factors in the occurrence and pathogenesis of rheumatic fever.