Penicillin Failures?!

To the Editor.—

How can a “treatment of choice” have a failure rate of 35% to 42% and remain a preferred agent? Members of the American Academy of Pediatrics (AAP), it is time for a change. The paper by Kaplan’s group¹ on penicillin treatment results for group A streptococcal (GAS) tonsillopharyngitis puts an exclamation point to my position for the past decade.² In 1991 our group made the observation that penicillin, whether administered by injection or the oral route, produced inferior microbiologic results when compared with past eradication rates and compared with oral cephalosporins²; we accumulated more data pointing to the need for change³ and controversy followed.^4,5 More recently our group was able to show that the drop in penicillin efficacy occurred around 1980,⁶ as hypothesized earlier by Kaplan.⁷ We also found that the major variables associated with penicillin treatment failure include the number of days ill before initiation of treatment and the patient’s age, with adolescents and adults experiencing reasonable cure rates.⁸ Despite the evidence, penicillin remained the recommended antibiotic of choice for treating these infections according to guidelines published by respected national and international advisory bodies. Why have these committees over the past 10 years …