Considerations in the use of antibiotics for streptococcal pharyngitis.

Microbiologic testing is recommended to diagnose GABHS pharyngitis and is required to maximize the selection of patients at highest risk of complications from true infection. The primary goal of therapy is eradication of GABHS. Penicillin has been the first-line treatment of choice for nonallergic patients; yet, there may be reason to reexamine the role of penicillin since there are now considerable data from clinical trials, pooled multicenter studies, and meta-analyses demonstrating frequent bacteriologic and clinical failure. While the contribution of pathogen resistance remains unclear, evolving evidence suggests that these failures also may be related to bacterial coaggregation or copathogenicity; GABHS reinfection; antibiotic nonadherence or subtherapeutic drug levels; penicillin tolerance; or blunting of an effective immune response. At the same time, some clinical evidence suggests that treatment failure with some cephalosporins may occur less frequently than with penicillin. Although cephalosporins are generally more expensive than oral penicillin, the benefits of cephalosporins include activity against BLPB and evolving data that support less frequent dosing than penicillin. Consequently, a reassessment of the role of cephalosporins in the treatment of pharyngitis may be appropriate.