SELECTED ARTICLES FROM THE RECENT LITERATURE 2004

11/15/04

Penicillin or cephalosporin better for strep throat?

Summary
Background - Tonsillopharyngitis with Group A beta hemolytic reptococcus (GABHS), called "strep throat" for short, has traditionally been treated with penicillin drugs. However, an increased incidence of penicillin treatment failures on strep throat cases has been reported in recent years.

Findings - Casey and Pichichero of the Univ of Rochester in NY carried out a meta-analysis of randomized controlled trials comparing penicillin (PC) to cephalosporin (Ceph) agents in 10 day treatment courses for bacteriologically proven strep throat (1) in 2,113 patients (< 12 years old). The failure rate for bacteriologic clearance rate was twice as high for the PC than the Ceph agents. The clinical cure rate also favored the Ceph treatment. The authors pointed out the importance of obtaining bacteriologic clearance to prevent suppurative and non-supppurative complications of strep throat as well as reducing contagion and facilitating resolution of symptoms.

However, in an accompanying editorial (2), Bisno of the Univ of Miami raised questions about the study design in some of the studies cited in this meta-analysis. Bisno also noted that the difference in bacteriologic clearance rates was not striking (5.4%), of yet uncertain clinical significance. Therefore, though Ceph are often effective in strep throat, there still can be a role for the less expensive PC agents.

Reference
1. Clin Infect Dis 2004;38:1526-34
2. Clin Infect Dis 2004;38:1535-37

Editor's Comments
The findings described above suggest that Ceph agents are the treatment of choice for strep throat but the evidence is not completely convincing. It would have been very instructive to determine whether the cases with failure to achieve bacteriologic clearance were characterized by GABHS strains resistant during in vitro sensitivity testing to the antibiotic used in treatment (and may have been susceptible to the other antibiotic used in the study group). It could be that non-compliance with prescribed antibiotic treatment was the reason for treatment failure.

Perhaps, most important, bacteriologic confirmation of GABHS infection before undertaking a 10 day course of antibiotic treatment is very important to reduce inappropriate over use of antibiotics.

 

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