Since Dr. Spak believes we should treat non-group A strep and I do not (Items 114-25 and 115-26), I would like to see conclusive evidence-based data that “treatment is definitely indicated” in patients with significant clinical complaints and positive testing for non-group A strep. A number of references, including some from the Infectious Diseases Society of America, recommend treatment for group A beta-hemolytic strep only. In addition, I disagree with the statement that bacterial pharyngitis is a clinical diagnosis since non-bacterial pharyngitis can present exactly the same way.
—Russel W. Piper, MD, Washington, Pa.

Pharyngitis is a clinical diagnosis the etiology of which can be wide and varied, hence the difficulty in appropriate management. The morbidity associated with common pharyngitis is minimal; therefore it is reasonable to withhold treatment if associated clinical factors support that a particular case is not due to group A streptococcal infection (GAS). In confirmed cases of non-group A streptococcal disease, however, suppurative complications, though rare, have been known to occur, including otitis media, acute sinusitis, and quinsy. In one recent review, for example, 14 of 58 cases of peritonsillar abscess requiring hospitalization were due to non-GAS (Eur J Clin Microbiol Infect Dis. 2009;28:27-31). The real controversy stems from the lack of clear data, hence the equipoise for this important question. Cochrane Review evaluated all cases (only 2,835) of pharyngitis (GAS as well as all other causes) in the published literature from 27 studies across the world (Cochrane Database Syst Rev. 2006;[4]:CD000023). The most important conclusions drawn from these limited data were that (1) the incidence of rheumatic fever was vanishingly small in developed countries such as the United States, but (2) the use of antibiotics was associated with a reduction of up to 85% in local suppurative complications. The clinician needs to weigh such issues of uncertainty in decisions to treat—and then determine what steps are appropriate for the patient who presents with a sore throat.
—Cedric W. Spak, MD, MPH