Treatment of streptococcal pharyngitis revisited

Penicillin has remained the drug of choice for treatment of patients with streptococcal pharyngitis for the past four decades. From the early 1950s into the 1970s, a single injection of intramuscular penicillin G benzathine, alone or in combination with penicillin G procaine, was the preferred treatment. Because this regimen consistently produced the highest cure rate and because compliance was assured, it evolved as the gold standard with which other treatment regimens were compared. In the late 1960s and the 1970s, studies showed that in private practice settings with counseling as to the need to take oral penicillin for a full ten days to prevent rheumatic fever, good compliance with results equal to intramuscular penicillin G benzathine could be achieved. By the early 1980s, oral treatment was preferred by most primary physicians in the United States. Oral penicillin V in a dosage of 250 mg, twice daily for ten days, affords optimal treatment for children. In areas where rheumatic fever is still prevalent, particularly in poor and crowded inner-city populations where medical care is episodic, follow-up may be lacking, and compliance in taking oral penicillin cannot be relied on, treatment with intramuscular penicillin G benzathine remains preferred. Studies now confirm that early treatment of streptococcal pharyngitis can reduce the duration of symptoms to less than 24 hours in most cases, decrease the incidence of suppurative complications, limit spread of the disease in the family and community, and permit earlier return of the child to school. Recently developed tests that permit rapid, laboratory-confirmed diagnosis of streptococcal pharyngitis directly on the throat swab at the initial clinic visit may soon guide early treatment with these inherent benefits.