Management of streptococcal pharyngitis reconsidered.

Adequate treatment of GABHS pharyngitis with penicillin shortens the course of illness, reduces the spread of streptococci and prevents suppurative complications. It has also been a major factor in the markedly accelerated decline in the incidence of acute rheumatic fever in this country. Difficulties in the clinical diagnosis of GABHS pharyngitis make bacteriologic confirmation highly desirable. Currently a properly performed throat culture is the best way to obtain this bacteriologic confirmation. However, it is possible that rapid antigen detection tests will replace the throat culture in the future. These diagnostic tools should be used more selectively and only in conjunction with clinical and epidemiologic data. Greater selectivity will help control costs and will increase the chances of identifying patients who are truly infected and are not merely streptococcal carriers. Penicillin is still the drug of choice and an oral preparation given twice daily is as effective as more frequent doses. Patients at risk for noncompliance should be treated with a single injection of benzathine penicillin combined with procaine penicillin to lessen the local discomfort. Routine follow-up cultures of asymptomatic patients should be abandoned. Persistence of GABHS following a course of treatment may no longer be an important risk factor for the development of rheumatic fever. However, there are exceptional cases, as noted in the text, in which eradication of GABHS carriage with a short course of rifampicin may be desirable.