Nonsuppurative Complications Research Articles

A Prospective Study of Nonsuppurative Complications of Streptococcal Pharyngitis

Objective: Group A Streptococci (GAS) are the most important bacterial cause of pharyngitis. Antibiotic therapy can be prescribed and failure to treat it is associated with suppurative and nonsuppurative complications. Nonsuppurative complications occur after a latency period of a few weeks and include acute rheumatic fever, scarlet fever, streptococcal toxic shock syndrome, acute glomerulonephritis, and pediatric autoimmune neuropsychiatric disorder associated with group A streptococci. The aim of this study is to investigate the frequency of nonsuppurative complications in properly treated children with GAS pharyngitis. Methods: We investigated the frequency of nonsuppurative complications in 1030 proven GAS pharyngitis patients between 5 and 15 years old, who were properly treated by a prospective observational study. All patients diagnosed with GAS pharyngitis were followed up prospectively using a standard form for six months made by monthly phone calls. Results: All the isolates recovered from the patients were susceptible to penicillin. Twentyseven (2.6%) patients developed scarlet fever. No other nonsuppurative complications occured in our patient cohort. Conclusions: Penicillin remains the drug of choice for treatment of GAS pharyngitis. The rate of nonsuppurative complications of GAS pharyngitis has decreased significantly in the antibiotic era. J Microbiol Infect Dis 2016;6(1): 8-11 Key words: Group A Streptococci, nonsuppurative complications, scarlet fever

Recomendaciones para el manejo de la faringoamigdalitis aguda del adulto

Acute pharyngitis in adults is one of the most common infectious diseases seen in general practitioners’ consultations. Viral aetiology is the most common. Among bacterial causes, the main agent is Streptococcus pyogenes or group A β-haemolytic streptococcus (GABHS), which causes 5%-30% of the episodes. In the diagnostic process, clinical assessment scales can help clinicians to better predict suspected bacterial aetiology by selecting patients who should undergo a rapid antigen detection test. If these techniques are not performed, an overdiagnosis of streptococcal pharyngitis often occurs, resulting in unnecessary prescriptions of antibiotics, most of which are broad spectrum. Consequently, management algorithms that include the use of predictive clinical rules and rapid tests have been set up. The aim of the treatment is speeding up symptom resolution, reducing the contagious time span and preventing local suppurative and non-suppurative complications. Penicillin and amoxicillin are the antibiotics of choice for the treatment of pharyngitis. The association of amoxicillin and clavulanate is not indicated as the initial treatment of acute infection. Neither are macrolides indicated as first-line therapy; they should be reserved for patients allergic to penicillin. The appropriate diagnosis of bacterial pharyngitis and proper use of antibiotics based on the scientific evidence available are crucial. Using management algorithms can be helpful in identifying and screening the cases that do not require antibiotic therapy.

The Mysteries of Streptococcal Pharyngitis.

Streptococcal pharyngitis is common in children between 5 and 15 years of age. While there is a “classic” presentation, few patients have all of the characteristic signs and symptoms. Therefore, for those children who present with a sore throat in the absence of other respiratory symptoms such as nasal congestion and cough, the best method of determining the etiology of the illness is to obtain a swab of the tonsils and posterior pharynx and to test it for the presence of Group A Streptococci (GAS). Performing this testing, allows the clinician to safely avoid the use of antibiotics in children who do not test positive for this pathogen. These children are more likely to have a viral cause for their illness. Conversely, those who test positive for GAS can be offered antibiotics, such as penicillin or amoxicillin for treatment. Administering antimicrobial therapy will lead to more rapid clinical improvement and will decrease person to person transmission. In addition, it will prevent suppurative and some non-suppurative complications such as rheumatic fever. Some patients will have multiple episodes of illness during one school year associated with a positive test for GAS. This either represents true recurrent GAS infections or recurrent viral illnesses in children who have become streptococcal carriers. There are strategies to assist with the clinical management of both of these groups of children.

Effect of ethyl acetate fraction of urucum extract on cell viability of peripheral blood mononuclear cells and antimicrobial activity in human pathogenic bacteria.

Effect of ethyl acetate fraction of urucum extract on cell viability of peripheral blood mononuclear cells and antimicrobial activity in human pathogenic bacteria.

Acute rheumatic fever and streptococci: the quintessential pathogenic trigger of autoimmunity.

Acute rheumatic fever (ARF) is a non-suppurative complication of pharyngeal infection with group A streptococcus. Signs and symptoms of ARF develop 2 to 3weeks following pharyngitis and include arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum. In developing areas of the world, ARF and rheumatic heart disease are estimated to affect nearly 20 million people and remain leading causes of cardiovascular death during the first five decades of life. ARF still represents one of the quintessential examples of a pathogenic trigger culminating in autoimmune manifestations. In this review, we will focus on the pathogenesis and etiology of ARF and its complications, along with diagnostic and treatment approaches to both ameliorate and prevent long-term sequelae of this potentially debilitating disease.

Diagnosis and treatment of group A β-hemolytic Streptococcal pharyngitis

Group A β-hemolytic Streptococcus(GAS) can cause a variety of infectious diseases, acute pharyngitis, and impetigo are the most. Non-suppurative complications can be followed after GAS infections, such as acute rheumatic fever, acute glomerulonephritis. GAS pharyngitis has no specific differences with other pathogens. Throat culture or rapid antigen detection test(RADT) should be done to determine whether GAS infections. Children with acute GAS pharyngitis should receive antibiotic therapy. Penicillin is the recommended antimicrobial agent. Key words: Group A β-hemolytic Streptococcus; Acute pharyngitis; Rheumatic fever; Antistreptolysin O

Antibiotics for sore throat.

Sore throat is a common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it. To assess the benefits of antibiotics for sore throat for patients in primary care settings. We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to July week 1, 2013) and EMBASE (January 1990 to July 2013). Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications. Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. We contacted trial authors from three studies for additional information. We included 27 trials with 12,835 cases of sore throat. We did not identify any new trials in this 2013 update. 1. Symptoms Throat soreness and fever were reduced by about half by using antibiotics. The greatest difference was seen at day three. The number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six; at week one it was 21. 2. Non-suppurative complications The trend was antibiotics protecting against acute glomerulonephritis but there were too few cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio (RR) 0.27; 95% confidence interval (CI) 0.12 to 0.60). 3. Suppurative complications Antibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo. 4. Subgroup analyses of symptom reduction Antibiotics were more effective against symptoms at day three (RR 0.58; 95% CI 0.48 to 0.71) if throat swabs were positive for Streptococcus, compared to RR 0.78; 95% CI 0.63 to 0.97 if negative. Similarly at week one the RR was 0.29 (95% CI 0.12 to 0.70) for positive and 0.73 (95% CI 0.50 to 1.07) for negative Streptococcus swabs. Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall.

CURRENT ASPECTS OF ACUTE STREPTOCOCCAL TONSILLOPHARYNGITIS DIAGNOSTICS IN CHILDREN

Acute tonsillopharyngitis in children is one of the most common reasons for medical consultations. The majority of acute pharyngeal inflammatory diseases are viral. The frequency of bacterial tonsillopharyngitis in children (the main causative agent is group A Streptococcus, GAS) is about 20–30%. In spite of it antibiotics are prescribed for 95% of patients, thus it is inappropriate. On the other hand misdiagnosis of acute streptococcal tonsillopharyngitis and antibiotics refusal can lead to suppurative and nonsuppurative rheumatic complications. Some prominent trials have shown a poor ability of signs and inflammatory biomarkers to identify tonsillopharyngitis streptococcal vs. viral. So it is impossible to use them as indication for antibiotic. The experience of clinical score use (McIsaac etc.) have also demonstrated a poor prognostic value. As a result the throat swab culture is the «gold standard» of acute streptococcal tonsillopharyngitis. It has such limitations as rare microbiology labs, method technology, the price and the delay in obtaining result. An alternative technique is GAS rapid antigen detecting test (RADT) for the identification of GAS directly from throat swabs. The world data shows a high sensitivity and specificity of modern RADTs.

The Role of Antibiotics to Prevent Non-Suppurative Complications of Streptococcal Infections

Ist es gerechtfertigt, eine Infektion mit Gruppe-A-Streptokokken wie z.B. eine Tonsillitis alleine deshalb antibiotisch zu behandeln, um damit nicht-eitrigen Folgeerkrankungen (Glomerulonephritis, Akutes rheumatisches Fieber mit Karditis) vorzubeugen? Die internationalen Leitlinien sind sich darüber einig, dass in unseren Breiten der Einsatz von Antibiotika mit dem einzigen Ziel der Prävention einer nicht-eitrigen Komplikation bei Streptokokkeninfekten nicht gerechtfertigt ist. Eine antibiotische Therapie ist dagegen sehr wohl indiziert bei entsprechender klinischer Schwere der Primärerkrankung, dem Auftreten von eitrigen Komplikationen und potenziell gefährlichen Verläufen, bei Risikopatienten sowie unter besonderen Umständen, wie z.B. epidemischem Auftreten.

Rapidly progressing subperiosteal orbital abscess: an unexpected complication of a group-A streptococcal pharyngitis in a healthy young patient

IntroductionComplications associated to group-A streptococcal pharyingitis include non-suppurative complications such as acute rheumatic fever and glomerulonephritis and suppurative complications such as peritonsillar or retropharyngeal abscess, sinusitis, mastoiditis, otitis media, meningitis, brain abscess, or thrombosis of the intracranial venous sinuses.Case presentationWe described a case of a 15-year-old patient with a history of acute pharyngodinia early followed by improvise fever and a progressive formation of a diffuse orbital edema, corneal hyperaemia, diplopia and severe decrease of visual acuity.The patient was surgically treated with functional endoscopic sinus surgery (FESS) after the response of a maxillofacial computed tomography scans that showed a pansinusitis complicated by a left orbital cellulites. Numerous colonies of Streptococcus pyogenes were found in the samples of pus and an antibiotic therapy with meropenem was initiated on the basis of the sensitivity test to antibiotics. The patient was finally discharged with diagnosis of left orbital cellulites with periorbital abscess, endophtalmitis and acute pansinusitis as a consequence of streptococcal pharyngitis.ConclusionThe case highlights the possible unusual complication of a group-A streptococcal pharyingitis in a immunocompetent child and the needing of a prompt surgical and medical approach toward the maxillofacial complications associated to the infection.

Streptococcal pharyngitis: a prospective study of compliance and complications.

Background. Uncertainty exists concerning the necessity of 10-day antibiotic treatment of group A beta hemolytic streptococcus (GABHS) pharyngitis. Objective. To assess the incidence of GABHS recurrence and suppurative and nonsuppurative complications in relation to compliance. Methods. (Design). Prospective cohort observational study. (Subjects). 2,000 children aged 6 months to 18 years with sore throat and positive GABHS culture. (Main Outcome Measures). Recurrence of symptomatic culture positive GABHS pharyngitis, incidence of suppurative, and long-term, regional, nonsuppurative complications of GABHS pharyngitis, over a ten year period. Results. 213 (11%) of the children received no treatment. Most children received antibiotics for only 4–6 days (in correlation with the duration of fever, which in most cases lasted up to 3 days). Three hundred and six (15.3%) children had clinically diagnosed recurrent tonsillopharyngitis; 236 (12.3%) had positive GABHS findings within 10 to 14 days and thirty-four (1.7%) within 21–30 days after the index positive GABHS culture. The remaining 1.3% had no positive culture despite the clinical findings. Almost all recurrences [236 (11.6%)] occurred within 14 days and 156 (7.6%) in the fully treated group. The presence of fever during the first 3 days of the disease was the most significant predictor for recurrence. Other predictors were the age younger than 6 years and the presence of cervical lymphadenitis. No increase in the incidence of nonsuppurative or suppurative complications was noted during the 10-year follow-up period, compared to the past incidence of those complications in Israel. Conclusions. Our data suggests that the majority of children discontinue antibiotics for GABHS tonsillopharyngitis a day or two after the fever subsides. The incidence of complications in our study was not affected by this poor compliance.

Experimental poststreptococcal glomerulonephritis elicited by IgG Fc‐binding M family proteins and blocked by IgG Fc fragment

The pathogenesis of acute poststreptococcal glomerulonephritis (APSGN), a major nonsuppurative complication of group A streptococcal (GAS) throat or skin disease, remains unclear. During the years, various theories based on certain streptococcal extracellular factors, as well as immunological mimicry between streptococci and renal tissue, have been forwarded. We earlier reported that many clinical GAS isolates with documented nephritogenic capacity show non-immune binding of monomeric or aggregated IgG. Moreover, in a rabbit model of APSGN we obtained evidence for an important role of streptococcal IgG Fc binding proteins (IgGFcBPs) belonging to the M family surface proteins; thus, hyperimmunization by whole IgGFcBP-positive streptococci was shown to induce renal glomerular changes with deposition of IgG and complement C3, resembling the picture recorded in human APSGN. These typical renal changes were always preceded by the appearance of circulating anti-IgG antibodies. In the present work, using the same rabbit model, each of two purified IgGFcBPs, isolated from type M22 GAS, were found to elicit glomerular degenerative damage comparable to that caused by whole bacteria, as well as formation of anti-IgG. In addition, the induction by whole streptococci (type M1) of experimental APSGN was inhibited by the i.v. administration of purified human or rabbit IgG Fc, but not Fab, fragment, supporting the importance of Fc-mediated mechanisms in causation of glomerulonephritis. We propose that anti-IgG antibody, induced by streptococcal IgGFcBP, facilitated renal accumulation of IgG-containing complexes, which in turn triggered complement deposition and proinflammatory cascades. Further studies on the possible beneficial effect of IgG Fc fragment in APSGN should be of interest.

Group A Streptococcal Infections

• GAS is a common cause of upper respiratory tract and skin infections.• Based on strong research evidence, (1) throat culture is the gold standard for diagnosing GAS pharyngitis.• Based on strong research evidence, (1) oral penicillin V K is the antibiotic treatment of choice for GAS pharyngitis because of its efficacy, safety, and narrow spectrum.• Based on strong research evidence, (2) primary prevention of complications of GAS such as ARF involves prompt diagnosis and antibiotic treatment of GAS pharyngitis.• GAS nonsuppurative and suppurative complications may occur and are mediated by interactions between GAS antigens or exotoxins and the patient’s immunesystem.

Manifestations inflammatoires réactionnelles multifocales après infection invasive àStreptococcus pyogenes de type M1

We report on a case of Streptococcus pyogenes invasive disease with toxic shock syndrome due to an M1 strain producing SpeA and SmeZ superantigenic toxins. Post-streptococcal sequelae included several episodes of reactive arthritis and orchitis whose outcome was favorable with corticosteroid therapy. Invasive streptococcal infections are increasingly reported and may associate septic, toxinic, and immunological diseases. High-grade systemic inflammation may induce nonsuppurative complications and autoimmune diseases by molecular mimicry. Among them, reactive arthritis has been recognized as a separate entity from acute rheumatic fever and post-streptococcal orchitis has not been described before. Treatment should be quickly started and should be effective on the etiologic agent but also on its toxins due to the severity of the invasive infections associated with the spread of highly virulent bacterial clones and the potential development of multifocal nonsuppurative sequelae.

Perimyocarditis following streptococcal group A infection: From clinical cases to bioinformatics analysis

Background Streptococcal infection is known to be associated with non-suppurative complications, including rheumatic fever. A less well recognized complication is perimyocarditis. Methods We report 4 cases of myocarditis in young males associated with acute streptoccal infection. Following this clinical observation we employed bioinformatic techniques to identify common epitopes between Streptococcus group A and human muscle proteins. We used Blast to search all the proteome (1697 proteins) of the Streptococcus pyogenes M1 GAS against the human proteome of 34,180 proteins. Results 4 patients with streptococcal A related myocarditis were treated and made a complete recovery. One cardiac protein, ATP2A2 ( NP_733765.1)), a cardiac Ca2+ ATPase, shared an epitope with Streptococcus group A and a high probability of being presented on a MHC Class II molecule. Conclusion Streptococcal myocarditis may be a commoner entity than previously appreciated. Bioinformatic techniques have identified a suspected common epitope between the streptococcal proteins and a cardiac Ca2+ ATPase.

Index of Suspicion

Index of Suspicion

Once-daily amoxicillin eradicates group a beta-hemolytic strep as well as penicillin twice a day

Question Among children with group A β-hemolytic streptococcal (GABHS) pharyngitis and a high risk for rheumatic fever, how does once-daily oral amoxicillin compare with the recommended twice-daily (BID) oral penicillin V with respect to eradicating GABHS? Design Randomized, non-inferiority (≤10% difference in eradication rates) trial. Setting School-based clinic in New Zealand. Participants 353 children who had throat swabs positive for GABHS. Intervention Amoxicillin 1500 mg once daily (or 750 mg if bodyweight was ≤30 kg) orally or penicillin V 500 mg twice daily (or 250 mg if bodyweight was ≤20 kg) orally, each treatment for 10 days. Outcomes Eradication of GABHS, determined with follow-up throat cultures on days 3-6, 12-16, and 26-36. GABHS isolates were serotyped to distinguish bacteriologic treatment failures (and relapses) from new acquisitions. Main Results The upper 95% confidence limit for the differences in positive cultures between the antibiotics was 4.9% at days 3-6, 6.5% at days 12-16, and 8.5% at days 26-36. Treatment failures (including relapses) occurred at each visit in 5.8%, 12.7% and 10.7% of amoxicillin recipients and 6.2%, 11.9% and 11.3% of penicillin V recipients, respectively. No significant differences in resolution of symptoms were noted between treatment groups. One case of unsubstantiated acute rheumatic fever occurred after 7 days of amoxicillin. Conclusions In this adequately powered study, once-daily oral amoxicillin is not inferior to twice-daily penicillin V for the treatment and eradication of GABHS in children with pharyngitis. Commentary One of the problems facing care for populations at high risk of acute rheumatic fever is that of adherence to antibiotics—which we know have to be given for a relatively long period (roughly twice as long as most antibiotic courses) to be effective at reducing this important secondary nonsuppurative complication by two-thirds. Use of amoxicillin—although broader spectrum than oral penicillin—has the advantage of its longer half-life, rendering once-daily treatment possible, and lack of absorption problems with food, which probably therefore increases adherence. This study made the comparison in a randomized trial among a group of children, who were >80% Pacific Island/Maori and at high risk of acute rheumatic fever, designed to test equivalence. Unfortunately it was not blinded (which would have required a placebo second dose for the amoxicillin group), and the outcome measure was the proxy of the bacteriologic profile (checking for persistence of the original Group A beta-hemolytic Streptococcus strain) rather than acute rheumatic fever itself. But the risk of bias remains low (it is hard to see how the lack of blinding could have affected the bacteriology much). It adds to the literature suggesting that amoxicillin is equivalent to oral penicillin for this purpose—and much easier to use. Clinical Research Abstracts for PediatriciansThe Journal of PediatricsVol. 153Issue 5PreviewEDITOR'S NOTE: Journals reviewed for this issue: Archives of Disease in Childhood, Archives of Pediatrics and Adolescent Medicine, British Medical Journal, Journal of the American Medical Association, Journal of Pediatrics, The Lancet, New England Journal of Medicine, Pediatric Infectious Diseases Journal, and Pediatrics. Gurpreet K. Rana, BSc, MLIS, Taubman Medical Library, University of Michigan, contributed to the review and selection of this month's abstracts. Full-Text PDF

Acute hypocomplementemic post-infectious glomerulonephritis as a complication of sinus-related orbital cellulitis: case report

Group A beta-hemolytic streptococcus is the most common agent implicated in post-infectious acute glomerulonephritis. We report a case of acute poststreptococcal glomerulonephritis associated with sinus-related orbital abscess in an 11-year-old boy treated with surgical drainage and intravenous ceftriaxone and clindamycin. Twelve days after supportive measures, renal function was normalized. We also discuss this potentially severe nonsuppurative complication of orbital cellulitis caused by group A beta-hemolytic streptococcus.

Group A Streptococcal Isolates Temporally Associated with Acute Rheumatic Fever in Hawaii: Differences from the Continental United States

The annual incidence of acute rheumatic fever (ARF) in Hawaii has remained several times higher than that in the continental United States, particularly among ethnic Polynesians. The emm types of Streptococcus pyogenes that are associated with this nonsuppurative complication have, to our knowledge, not been previously reported in Hawaii. Patients with ARF were identified through an active surveillance system at Kapiolani Medical Center (Honolulu, HI), the only pediatric tertiary care referral hospital in Hawaii. Specimens were obtained by throat culture from patients who met the Jones criteria for ARF at the time of presentation (63 patients), prior to penicillin treatment, and from consenting family contacts (10 individuals). Eight patients and 2 close family contacts with positive throat culture results were identified from February 2000 through December 2005. Group A streptococci isolates were characterized by emm sequence typing. Unusual emm types were temporally associated with the onset of ARF. Emm types 65/69 (from 2 patients), 71, 92, 93, 98, 103, and 122 were isolated from the 8 patients with ARF, and emm types 52 and 101 were isolated from the 2 household contacts. So-called rheumatogenic emm types and/or serotypes, which were previously associated with ARF in the continental United States, were not found in this study. Instead, emm types that are not commonly included among group A streptococci isolates in the continental United States and that are seldom, if ever, temporally associated with ARF were identified. These findings suggest that unusual group A streptococci emm types play a significant role in the epidemiology of ARF in Hawaii.

Once-a-day Amoxicillin Therapy of Streptococcal Pharyngitis: Good, Better and, Future, Best?

Source: Clegg HW, Ryan AG, Dallas SD, et al. Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin. Pediatr Infect Dis J. 2006;25:761–767; doi:10.1097/01.inf.0000235678.46805.92Investigators from several Charlotte, NC institutions and the University of Minnesota, Minneapolis conducted a prospective, randomized, blinded, non-inferiority trial comparing once-daily (1xd) with twice-daily (2xd) amoxicillin for the treatment of group A ß-hemolytic streptococcal (GABHS) pharyngitis. Patients with a positive rapid GABHS test were stratified by weight and then randomly assigned to receive either 1xd amoxicillin (750 mg if <40 kg, 1000mg if ≥40 mg) or 2xd amoxicillin (375 mg 2xd if <40 kg, 500 mg 2xd if ≥40 mg) for 10 days. Of 652 patients enrolled and randomized, 590 (90%) were evaluable: 294 in the 1xd and 296 in the 2xd group. Of the 62 patients not evaluated, 45 were excluded because they did not follow up, 11 for negative cultures following a positive rapid streptococcal test, 3 because they did not take medication, and 3 who were enrolled twice and only had their first enrollment included.At visit 2 (14 to 21 days post-therapy), bacteriologic failure rates were similar between the 1xd treatment group (20.1%) and the 2xd group (15.5%, difference non-significant). The clinical recurrence rate was also comparable for the 2 treatment groups at visit 2 (9.2% 1xd vs 7.1% 2xd). At visit 3 (28 to 35 days post-therapy) the bacteriologic failure rate was significantly higher in the 2xd group (7.1% vs 2.8%). There were no significant differences in adverse events between the 2 treatment groups (gastrointestinal symptoms being most common). This study, along with previous studies,1,2 shows that 1xd amoxicillin is not inferior to 2xd amoxicillin for the treatment of GABHS pharyngitis despite the failure rate observed.Dr. Rathore has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of a commercial product/device. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The purpose of antimicrobial therapy for GABHS pharyngitis is both for the treatment of the acute illness and for prevention of non-suppurative post-streptococcal complications.3 Dependable rapid diagnosis has made immediate treatment of GABHS pharyngitis easier, but adherence to the antibiotic regimen may be problematic. Treatment with injectable depot penicillin is the best option to assure adherence and the only one shown to decrease non-suppurative complications of GABHS pharyngitis.4 However, the intramuscular route is frequently not acceptable to patients, parents, or physicians. Oral treatment regimens for GABHS pharyngitis have improved with time. Over the years we have decreased the frequency of daily antibiotic administration from 4 times a day to twice a day for treatment of GABHS pharyngitis.5Our ability to generalize the results of this study is limited because the patients were overwhelmingly white. Despite this limitation, the findings of this preliminary study will be welcome news for many pediatricians and parents. The next steps will be to replicate the study in other population groups and then go on to test the dogma that 10 days of antibiotic therapy are necessary for treatment of GABHS. Previous investigations have shown that the pharynx is sterile within 24 hours of antibiotic treatment for GABHS pharyngitis.6 It may be that a 5- or 7-day treatment course, or perhaps an even shorter one, would be just as effective as a 10-day course. While 1xd amoxicillin should increase adherence to treatment, a shorter course of therapy, if effective, would improve adherence even more, and a single oral dose would be best of all.