Acute streptococcal pharyngitis in pediatric medicine: current issues in diagnosis and management

Group A beta-hemolytic streptococcus (GABHS) is the most common bacterial cause of acute pharyngitis. Although children infected with GABHS will recover clinically without antibiotics, treatment is recommended in order to prevent acute rheumatic fever and probably suppurative complications, hasten resolution of clinical signs and symptoms, and prevent transmission to close contacts. Streptococcal pharyngitis usually cannot be reliably distinguished from other etiologies on the basis of epidemiologic or physical findings, and therefore a throat culture or a rapid antigen detection test is generally necessary to confirm the diagnosis. All isolates of GABHS are sensitive to penicillins and cephalosporins, whereas resistance to macrolides has been identified in some geographic regions. The recommended first-line therapy for streptococcal pharyngitis is a 10-day course of penicillin V, usually given 2 or 3 times per day. A number of alternatives to penicillin V are available, including other penicillins, macrolides, and cephalosporins. As a class, the cephalosporins are noteworthy because they may provide somewhat higher bacteriologic eradication rates than penicillin V. Many cephalosporins can be administered twice daily, but they also must be given for 10 days. Two third-generation cephalosporins, cefdinir and cefpodoxime proxetil, are approved for use in a more convenient 5-day dosing schedule, thus possibly increasing the likelihood of adherence to the full course of therapy. Palatability is also an important consideration when prescribing antibiotics to children. In a series of studies, children preferred the pleasant strawberry-cream taste of cefdinir to that of amoxicillin/clavulanate, cefprozil, and azithromycin. Cefdinir may offer an alternative to penicillin V for children with streptococcal pharyngitis, particularly when compliance is a clinical concern.