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Archives ofDisease in Childhood 1990; 65: 249-250 249

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ARCHIVES Arch Dis Child: first published as 10.1136/adc.65.3.249 on 1 March 1990. Downloaded from DISEASE IN

CHILDHOOD The Journal of the British Paediatric Association

Annotation

Sore throats

After four decades of treating sore throats with , could find no evidence that penicillin was any longer and on the assumption that medicine is a scientific protective, although the numbers are surely too small for discipline, it would be reasonable to expect that we know dogmatism. If these figures are correct they are a little too whether or not this method of treatment is logical. close in the risk-benefit equation to penicillin anaphylaxis at " General practitioners are unsure: in a two practice audit one in 10 000,9 and fatal reactions at one in 50 000. We can exercise, partners varied in their prescribing rates only wait to see if makes enough of a " for sore throat between 0% and 100%.1 Paediatricians are no comeback to tip the balance firmly on the side of benefit. less uncertain. A study in a Connecticut paediatric practice There are other reasons for treating group A j3 haemolytic showed that fever, lymphadenitis, pharyngeal injection, streptococci with respect: septicaemia complicates a small sore throat, , and abdominal all rapidly number of cases and can be fatal. It may follow on from responded to penicillin or cefadroxil but there was no such or, very occasionally, from -a toxic prompt resolution with placebo,2 provided the sore throat consequence of group A , haemolytic streptococci-now so was caused by group A , haemolytic streptococci. So uncommon as to be distinctly difficult for general prac- convinced was the editor of the Joumnal ofPediatrics that he titioners to differentiate from the many viral appended the comment, 'This clinical study seems to which can cause sore throat, fever, and rash. Recently there

provide the definitive answer to a frequently debated have been reports from the United Kingdom,'2 United http://adc.bmj.com/ question'. Thankfully he used the word 'seems' because States,'3 and Australia'4 of a toxic shock like syndrome after three years later he published, without editorial gloss, a group A streptococcal . Manifestations include multicentre double blind study which concluded that acute renal failure, coagulopathy, and hepatic dysfunction. penicillin failed to provide significant symptomatic relief in The virulence factors involved are diverse: in particular, the sore throat caused by group A ,1 haemolytic streptococci.3 American cases being associated with pyrogenic exotoxin A One thing that is, however, clear is that penicillin is not of while the B toxin was found in the British patients. After a' represents 60% of all from value in viral pharyngitis, which about decade or two of loudly declared injunctions paedia- on September 29, 2021 by guest. Protected copyright. episodes of sore throat. Clinical manifestations are not such tricians that they use antibiotics too readily, who can blame that it is easy to distinguish viral from bacterial disease, general practitioners for sending infected children away although experience must tell as the Connecticut paedia- with a prescription for ? tricians made a correct diagnosis in advance of culture Should we then turn a double somersault and tell general results on 194 occasions out of 260, while the multicentre practitioners they were right all the time? Penicillin just collaborators managed only 123 out of 271. might be life saving; if group A ,3 haemolytic streptococci Even choosing an antibiotic is not totally straightforward cannot be reliably diagnosed clinically should all pharyngitis as that organism, which has been sent to try paediatricians, be treated to avoid the rare disaster? The answer depends on Mycoplasma hominis, may be responsible for a small how much unnecessary treatment we countenance to protect proportion of cases.4 Treating Epstein-Barr viral pharyngitis the few who might not have recovered spontaneously. with ampicillin has led to litigation successful for the Might consensus be easier to achieve if rapid diagnostic plaintiff.5 aids become available in the United Kingdom (and the NHS Symptomatic reliefis not, of course, the major justification were prepared to meet their cost)? Numerous antigen offered for antibiotic treatment. In the 1950s the knowledge detection test kits are available in the United States, so that rheumatic fever and acute glomerulonephritis were many indeed that one group of investigators has published a provoked by group A 13 haemolytic streptococci infection Consumers' Association style report and suggested a 'best led to the advice that these complications would be buy'.'5 In general the kits are highly specific but not quite prevented by using penicillin to treat sore throats.6 In the so sensitive: the response of American physicians has been United Kingdon in 1960, rheumatic fever was believed to to start treatment earlier because of the backup of a positive follow about one in 300 streptococcal sore throats. In recent test, but the problem of false negative results has led to no years, the risk of immunological problems with group A 13 reduction in antibiotic prescribing for clinically suggestive haemolytic streptococci has fallen dramatically; the chance cases. 13 If, therefore, the aim is to make antibiotic treatment of developing rheumatic fever has been estimated at about more precisely targeted these kits will need to be much more one in 30 000 group A haemolytic streptococci infections,7 sensitive than their reported 60-70%. 16 and that of nephritis one in 13 000.8 Moreover the authors Asymptomatic carriers and family contacts pose a further 250 Marcovitch problem. It is often stated that infants rarely carry group A 1 Pitts J, Vincent S. What influences doctors' prescribing? Sore throats i haemolytic streptococci'7; this is true for an unselected revisited. J R Coll Gen Pract 1989;39:65-6. 2 Randolph MF, Gerber MA, DeMeo KK, Wright L. Effect of antibiotic population but after an outbreak of streptococcal upper Arch Dis Child: first published as 10.1136/adc.65.3.249 on 1 March 1990. Downloaded from therapy on the clinical course of streptococcal pharyngitis. J Pediatr respiratory infection in an American day nursery, there was 1985;106:870-5. a carriage rate of 22% in children under 3-5 years (and 43% 3 Middleton DB, D'Amico F, Merenstein JH. Standardized symptomatic in older children). 8 An effective way to eradicate carriage is treatment versus penicillin as initial therapy for streptococcal pharyngitis. to use a single dose of intramuscular penicillin (300-600 mg) J Pediatr 1988;113:1089-94. 4 Putts A. Febrile exudative : viral or streptococcal? Pediatrics and oral rifampicin (10 mg/kg every 12 hours for eight 1987;80:6-12. doses).'9 A good case can be made out for treating chronic 5 Medical Defence Union. Annual report. London: Medical Defence Union, carriers who are in closed communities with high rates of 1987. streptococcal disease or who are hospital staff or long term 6 Bywaters GGL. Rheumatic fever and rheumatoid arthritis. Br Med J 1%5;i: 1655-7. inpatients. There is not yet any documented indication for 7 Howie JGR, Foggo BA. Antibiotics, sore throat and rheumatic fever. J R Coll treating carriers in the general population or within a Gen Pract 1985;35:223-4. family; indeed, asymptomatic carriage might protect from 8 Taylor JL, Howie JGR. Antibiotics, sore throats and acute nephritis.J R Coll clinical disease and wholesale use of rifampicin might Gen Pract 1983;33:783-6. 9 Levine BB. Prediction of penicillin allergy by immunological tests. Journal of eventually destroy its effectiveness. Allergy 1969;43:231-44. How should all this affect our teaching and practise? I 10 Idsoe 0, Guthe T, Wilcox RR. Nature and extent of penicillin side reactions instruct my juniors that when they become general prac- with particular reference to fatalities from anaphylactic shock. Bull WHO titioners they should treat streptococcal sore throats with 1%8;38:159-88. 11 Veasey LG, Wiedmeier SE, Osmons GS, et al. Resurgence of acute rheumatic penicillin even though we remain uncertain whether it fever in the intermountain area of the United States. N Engl J Med makes patients feel better more quickly, because septic 1987;316:421-7. complications, though rare, might be avoided thereby. 12 Kavi J, Wise R. Group A beta-haemolytic streptococcus causing disseminated They should not conclude that by so doing they will prevent intravascular coagulation and maternal death. Lancet 1988;i:993-4. 13 Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal rheumatic fever or glomerulonephritis unless a 10 day infections associated with a toxic shock-like syndrome and scarlet fever course is prescribed,20 and they should not expect too many toxin A. N Engl7Med 1989;321:1-7. patients to comply with such a regime. To avoid treating 14 Hansman D, Jarvinen A. Group A streptococcal infections and a toxic viral pharyngitis too frequently they should obtain throat shock-like syndrome. N EnglJ Med 1989;321:1546. swabs so that as the years go by they can test their own 15 White CB, Lieberman MM, Morales E. An in vitro comparison of eight rapid streptococcal antigen detection tests. J Pediatr 1988;113:691-3. diagnostic accuracy. 16 Redd SC, Facklam RR, Collins S, et al. Rapid group A streptococcal antigen They should consider treating the non-responder with detection kit: effect on antimicrobial therapy for acute pharyngitis. erythromycin but not forget that there is an association Pediatrics 1988;82:576-81. between antibiotic prescribing for children and anxiolytic 17 Loda FA, Glezzen WP, Clyde WA. Respiratory disease in group day care. Pediatrics 1972;49:428-37. prescribing for their mothers.2' They must learn how to 18 Smith TD, Wilkinson V, Kaplan EL. Group A streptococcal associated cope with the occasional patient who becomes seriously ill. upper respiratory tract infection in a day care center. Pediatrics 1989;83: This means, among other things, instructing parents- 380-4. either verbally or through a handout-on the signs of sepsis, 19 Tanz RR, Shulman ST, Barthel MJ, Willert C, Yogev R. Penicillin plus rifampicin eradicates pharyngeal carriage of group A streptococci. 7 Pediatr and how to recognise an ill child rather than simply advising 1985;106:876-80. them to return if they are worried. At the same time a 20 Committee on Rheumatic Fever and Endocarditis of the Council on http://adc.bmj.com/ simple explanation of fever control can be offered together Cardiovascular Disease in the Young. Prevention of rheumatic fever: a with a prescription for paracetamol (or aspirin if over 12), statement for health professionals. Circulation 1984;70:1118-22A. 21 Howie JER, Bigg AR. Family trends in psychotropic and antibiotic especially for those at risk of febrile convulsions. prescribing in general practice. Br Med J 1980;280:836-8. Horton General Hospital, H MARCOVITCH Oxford Road, Banbury, Oxfordshire OX16 9AL on September 29, 2021 by guest. Protected copyright.