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So What’s Wrong With Penicillin for Strep Throat?

Division of Infectious Diseases
Children’s Memorial Hospital
Feinberg School of Medicine
Northwestern University
Chicago, IL 60614
Division of Infectious Diseases
Children’s Hospital Medical Center
University of Cincinnati College of Medicine
Cincinnati, OH 45229-3039

Abbreviations: GABHS, group A ß-hemolytic streptococcal

The first 300 words of the full text of this article appear below.

"Change is one thing, progress is another." Bertrand Russell (1872–1970)

Group A ß-hemolytic streptococcal (GABHS) pharyngitis is one of the most common infections of children. For 5 decades, penicillin has been the treatment of choice for this infection, and it is currently recommended by the American Academy of Pediatrics,¹ the American Heart Association,² the World Health Organization,³ and the Infectious Diseases Society of America.⁴ Amoxicillin is often utilized in young children in place of penicillin V because of taste considerations. Although the problem of increasing antimicrobial resistance among bacteria is one of the most important infectious disease issues of our time,⁵ GABHS remarkably have never developed resistance to any of the penicillins or cephalosporins or shown any increase in penicillin minimal inhibitory concentrations over at least 5 decades.⁶ However, it is appropriate to reconsider periodically whether penicillin should remain the treatment of choice or whether a compelling argument can be made to change the recommendation to a different agent such as a cephalosporin. In the April issue of Pediatrics, Casey and Pichichero⁷ presented a meta-analysis of 35 clinical trials performed between 1970 and 1999 in which a cephalosporin was compared with penicillin for the treatment of GABHS pharyngitis.⁷ Based on this analysis, they concluded that cephalosporins should be added as a "treatment of choice for GABHS tonsillopharyngitis." However, their report has several major flaws that make it impossible to accept the validity of their conclusion.

Meta-analysis is "a statistical analysis which combines or integrates the results of several clinical trials considered by the analyst to be ‘combinable.’"⁸ Over time, meta-analysis research is thought to have led to improved conduct and reporting of clinical trials, including the removal of major sources of bias that, for example, occur in studies that are not double-blinded.⁹ Meta-analysis can be a powerful analytical tool . . . [Full Text of this Article]

Address correspondence to Stanford T. Shulman, MD, Division of Infectious Diseases, Children’s Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL 60614. E-mail: sshulman@nwu.edu

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