Streptococcal pharyngitis in the 1980s

Streptococcal pharyngitis remains a common problem in children and adolescents. However, the incidence of acute rheumatic fever is now quite low except in developing countries. Proper management of streptococcal pharyngitis has contributed significantly to the decline in ARF. Penicillin treatment has clearly altered the natural history of streptococcal infection; the acute illness is shortened, risk of spread of infection is reduced, suppurative complications are prevented and ARF is prevented. Some cases of acute glomerulonephritis may be prevented. The decline in rheumatic fever has probably contributed to a greater interest in clinical benefits of therapy. Antigen detection tests appear promising for providing a more rapid bacteriologic diagnosis of streptococcal infection, which in turn permits prompt treatment. While penicillin has been the treatment of choice for four decades, a disturbing trend of increasing numbers of clinical relapses or recurrent infections has been noted in recent years. Alternative antibiotics, such as the oral cephalosporins, may now be superior to oral penicillin in terms of lessening the risk of relapse. This advantage must be weighed against other factors including cost effectiveness. The most pressing dilemma for the clinician is management of the patient with repeated episodes of acute streptococcal pharyngitis. Certain of these problem patients may benefit from a period of penicillin prophylaxis during the seasons when streptococcal infections are most prevalent. There is now agreement that posttreatment throat cultures need not be done in the child who remains asymptomatic following therapy. However, it is incumbent on the clinician to make certain that appropriate therapy is prescribed and that compliance with oral regimens of therapy is satisfactory in the management of the patient with acute streptococcal pharyngitis.