Revisiting non-group A strep

Cedric W. Spak, MD, MPH, says non-group A streptococcal pharyngitis should always be treated “to be on the safe side” (Item 114-25). But group A strep is treated primarily to avoid rheumatic fever, which the other groups don't cause, and treatment of non-group A strep apparently doesn't prevent glomerulonephritis, so why should we treat?
—Russel W. Piper, MD, Washington, Pa.

I second Dr. Piper's concerns about whether treatment of non-group A strep can prevent glomerulonephritis and wonder if Dr. Spak has considered all the ramifications of his suggestion: First, the number of prescriptions for antibiotics would rise, leading to increased costs. And the widespread use of antibiotics will likely be associated with the development of resistant organisms. Second, all in-office rapid strep tests and standard strep screens would have to be modified to include non-group A strep, at a great increase in cost, considering the millions of strep tests that are done. In more than 25 years, I have rarely given antibiotics for non-group A strep pharyngitis. The only ill effects were, perhaps, a few more days of sore throat.
—Richard G. Fried, MD, Kimberton, Pa.

This is a good example of using clinical judgment in patients presenting with pharyngitis. Dr. Piper is worried about immune-mediated glomerulonephritis, but local pyogenic complications may in fact occur from non-group A streptococcal species. If the patient has significant clinical complaints, treatment is definitely indicated. As for Dr. Fried, there are no data to support the claims that development of resistant organisms is associated with antibiotic use for streptococcal species in humans. If a patient has clinical evidence of pharyngitis and microbiologic cultures are consistent with streptococci, treatment is indicated to reduce morbidity, which is either immune complex-mediated disease or symptom duration. Bacterial pharyngitis is a clinical diagnosis, and rapid strep tests are used for confirmation.
—Cedric W. Spak, MD, MPH
(115-26)

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