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Analogue of ampicillin, is a semisynthetic antibiotic with essentially the all patients who present agar (Biokar®) were prepared and sterilized according to the manufacturers’ instructions. Another drug and may not reflect the rates.

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However, a peritonsillar abscess may yield mixed flora as well.

Needle aspiration or surgical drainage of the abscess as well as


are usually required.

Indications for needle aspiration include severe pain and trismus, difficulty swallowing, and poor response to antimicrobials alone.

Patients can be treated orally for 10 days with either a first generation cephalosporin such as cephalexin , clindamycin , or amoxicillin-clavulanic acid, if they appear nontoxic and can maintain adequate hydration. Some patients may require initial treatment with a parenteral antibiotic and be discharged to home on oral antibiotics to complete a 10 day course. Tonsillectomy at the time of surgical incision and drainage can provide improved drainage, prevent recurrences, and permit earlier discharge. Patients with a known allergy to cephalosporins can be treated with clindamycin. P eritonsillar Cellulitis: Occasionally, peritonsillar cellulitis occurs without development of a localized abscess. Like peritonsillar abscesses, peritonsillar cellulitis results from direct extension of an acute tonsillopharyngitis and may result solely from group A streptococcus but can include mixed oral flora as well. Patients with mild symptoms who can maintain adequate hydration can be treated orally with a first or second generation cephalosporin such as cephalexin or cefazolin . Patients with a known allergy to cephalosporins can be treated with clindamycin . Patients with severe trismus or inadequate hydration can be treated parenterally with clindamycin or a first generation cephalosporin such as cefazolin.

Tonsillectomy can ensure complete recovery and prevent recurrences.

R etropharyngeal Abscess: Retropharyngeal abscess also occurs from direct extension of an acute pharyngitis.

Causative organisms include both aerobes and anaerobes. Therapy consists of parenterally administered antimicrobials such as a first generation cephalosporin or clindamycin .

Patients who do not respond to antimicrobial therapy or who have impaired respiratory function may require surgical incision and drainage under general anesthesia. O titis Media and Sinusitis: Otitis media and sinusitis due to group A streptococcus normally are secondary to direct extension from a streptococcal infection occurring in


upper respiratory tract. With persistent infection, an appropriate alternative would be amoxicillin/clavulanate .

In patients allergic to amoxicillin, erythromycin or clindamycin is an acceptable alternative.

Oral cephalosporins can be effective as well in patients who have not had immediate hypersensitivity reactions to penicillin . U vulitis : Uvulitis can occur alone or in association with acute pharyngitis or



influenzae type b infection, recent immunization strategies have greatly decreased its incidence. However, uvulitis can occur secondary to group A streptococcus, usually as a complication of an acute pharyngitis (50). Parenteral therapy should be used, directed against both group A streptococcus and H. Patients can be discharged on an oral antibiotic to complete a 10 day course of therapy. C ervical Lymphadenitis: Cervical lymphadenitis secondary to group A streptococcus infection can result from direct extension from an acute pharyngitis or direct inoculation.

Since the etiologic agent is not always known, therapy is initially directed against the most common organisms, which include S.

Therefore, a first generation cephalosporin, such as cephalexin , or a ?-lactamase-resistant penicillin should be given enterally for 10 days.

If the infection persists or the patient develops signs of systemic toxicity, parenteral antibiotics should generally be used.

First generation cephalosporins such as cefazolin , nafcillin , or clindamycin are also appropriate choices. M eningitis and Brain Abscess: Meningitis and brain abscesses are rare complications of group A streptococcus that can occur either from direct extension of acute pharyngitis or sinusitis or from bacteremic spread. Penicillin is still the drug of choice for treatment of known group A streptococcal meningitis or brain abscess (12). Antimicrobial therapy should be given parenterally for 10 to 14 days (12). Patients allergic to penicillin can be treated with a third generation cephalosporin such as ceftriaxone or cefotaxime (12).

A rthritis: Post-streptococcal reactive arthritis (PSRA) is a recognized complication of group A streptococcal infections. Antibiotic therapy aimed at the underlying focus of infection is generally all that is required. However, anti-inflammatory drugs may aid patient comfort.

Of concern, is the risk that a subset of patients with PSRA may develop rheumatic heart disease.

This has led some to suggest that patients with PSRA, like patients who have had ARF, may require antimicrobial prophylaxis to prevent the occurrence of rheumatic heart disease (20). It has been recommended that these patients receive prophylaxis for 1 year, and then if no evidence of rheumatic heart disease develops, prophylaxis could be discontinued (20). Septic arthritis secondary to group A streptococcal infection can result from direct inoculation or bacteremic spread.

Therapy consists of parenteral antibiotics given for 10 to 14 days.

Choices include a third generation cephalosporin, such as ceftriaxone and cefotaxime , or beta lactams such as nafcillin or penicillin . In addition, surgical drainage of purulent material from the joint space is required. E ndocarditis: Endocarditis due to group A streptococcus was relatively common during the preantibiotic era.

Therapy aimed at the most common organisms in endocarditis also provides coverage for group A streptococcus and should be continued for 4 to 6 weeks.

Patients with known GAS endocarditis have been treated successfully with 6 weeks of parenterally administered penicillin (53).

O steomyelitis : Like septic arthritis, osteomyelitis secondary to group A streptococcal infection is known, but rare. Therapy consists of appropriate antimicrobials given parenterally to control the infection. If group A streptococcus has been identified as the etiologic agent, penicillin can be used. Patients allergic to penicillin can be treated with clindamycin , vancomycin, or cefazolin . L iver Abscess: Liver abscesses secondary to group A streptococcal infection generally result from hematogenous spread.

Therapy consists of long term parenterally administered penicillin and surgical drainage. Initially, until an etiologic agent has been determined, a combination of a penicillinase-resistant penicillin, such as nafcillin , and an aminoglycoside should be used.

Treatment should consist of 2 to 4 weeks of parenterally administered antibiotics followed by oral antibiotics to complete a 4 week course.

Patients allergic to penicillin can be treated with clindamycin , vancomycin, or an appropriate first generation cephalosporin. A cute Rheumatic Fever: Treatment of patients with acute rheumatic fever is generally directed toward decreasing acute inflammation, decreasing fever and toxicity, controlling cardiac failure, preventing episodes of recurrent ARF after significant streptococcal upper respiratory tract infections, and preventing rheumatic heart disease.

The mainstays of treatment are salicylates and corticosteroids. Neither of these agents prevents or modifies the development of rheumatic heart disease.

Patients clinically diagnosed with ARF who have not received antimicrobial therapy for a recent episode of GAS pharyngitis should receive a 10 day course of penicillin .

Primary prevention of ARF depends on accurate diagnosis of an antecedent streptococcal infection as well as adequate therapy. Penicillin given orally for 10 days or intramuscularly one time will prevent rheumatic fever.

Erythromycin is considered the drug of choice f the treatment of GAS pharyngitis in penicillin-allergic patients, but it has not been shown to prevent ARF (17). Approximately one third of patients who develop ARF have streptococcal infections that are either subclinical or too mild to be brought to medical attention; as a result, they receive no antibiotic therapy for the infection. Recent reports have suggested that up to 75% of patients with ARF either had no history of a preceding streptococcal infection or had an infection that was so mild they did not seek medical attention.

In contrast, in the past, preceding streptococcal infections were noted to be severe (55).

Of even more concern are reports of patients who develop ARF despite receiving adequate therapy for GAS pharyngitis (21).

Possible explanations for this include poor patient compliance with antibiotic therapy, a shorter latency period, documented streptococcal infections were not the cause of the resultant episodes of ARF, or currently recommended therapies for GAS pharyngitis have become inadequate for prevention of ARF (15). Only one series of studies has ever documented prevention of ARF following antimicrobial therapy for GAS pharyngitis. These studies were conducted during the 1940s on army recruits at Fort Warren, Wyoming. Penicillin G suspended in oil, administered parenterally in a placebo-controlled study, decreased the incidence of ARF (90). Following these studies, researchers compared orally administered penicillin with parenterally administered penicillin and found equivalent bacteriologic effects.

It was then assumed that bacterial eradication from the pharynx was the necessary step in prevention of ARF. As a result, penicillins as a class were assumed to be efficacious in preventing ARF.

No study has investigated the efficacy of other antibiotics in prevention of ARF. Patients who develop ARF require continuous prophylaxis to prevent intercurrent and recurrent streptococcal infections and recurrent episodes of ARF.



regimen consists of penicillin G benzathine, 1.2 million units given intramuscularly every 4 weeks (17).

The recurrence rate of ARF with this regimen was reported to be 0.4 cases per 100 patient years of observation (8). Alternative therapies include oral sulfadiazine (1 g/day for persons over 60 lb and 0.5 g/day for those weighing less than 60 lb) or penicillin V (250 mg, twice a day). Both of these regimens are considered less effective than penicillin G benzathine. This is thought to be due to lack of patient compliance with an oral regimen.

Patients who are allergic to penicillin can be treated with erythromycin stearate (250 mg, twice a day) (8). Considerable debate has arisen over the optimal duration of prophylaxis.

Some investigators previously recommended lifelong prophylaxis. However, the risk of recurrence of ARF decreases with patient age and the number of years since the last attack and increases with the presence of rheumatic heart disease or previous recurrences. The physician must take into account all factors when deciding when to discontinue prophylaxis.

In general, it is recommended that prophylaxis continue until patients are in their early twenties and at least 5 years have passed since the most recent episode of ARF.

In 1995, the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association, released a special statement on the treatment of GAS pharyngitis and prevention of rheumatic fever. The committee recommended that patients who had rheumatic fever without rheumatic carditis should receive prophylaxis until the age of 21 or until at least 5 years had passed since their last attack. Patients who had rheumatic fever with carditis but no valvular disease should receive prophylaxis until adulthood and until at least 10 years had passed since their last attack of ARF. Patients with valvular disease should receive prophylaxis until age 40 and until at least 10 years had passed since their last attack (20).

Patients with residual rheumatic valvular disease must receive antibiotic prophylaxis whenever they undergo a surgical or dental procedure that may potentially evoke bacteremia.

This is done to prevent the occurrence of bacterial endocarditis.

Antimicrobial regimens recommended for the prevention of bacterial endocarditis are entirely distinct from regimens used in the prevention of ARF (14).

Currently, investigators are attempting to develop a polyvalent M-protein vaccine for the prevention of streptococcal infection and ARF. A cute Glomerulonephritis: Unlike rheumatic fever, post-streptococcal acute glomerulonephritis (AGN) has shown no increase in incidence.

Indeed, nephritogenic strains (particularly serotype M type 12) have decreased in prevalence (54). Treatment strategies in the approach to post-streptococcal acute glomerulonephritis are directed toward management of acute problems. All patients should be treated with penicillin to eradicate the nephritogenic strain regardless of culture results of group A streptococci or immunologic



Paralleling the recent changes in the pathogenesis of ARF, a substantial number of patients who develop post-streptococcal AGN do not have a history of a preceding pharyngitis or soft tissue infection. Penicillin-allergic patients can be treated with erythromycin in doses adequate for


of streptococcal pharyngitis.

It is generally recommended that family members be cultured for group A streptococcus. Family members with positive cultures should be treated appropriately.

Treatment of patients with post-streptococcal AGN or of family contacts is for epidemiologic purposes only. Therapy will not alter pre-existent post-streptococcal AGN or prevent the disease in patients who are in the latent period. Some data suggest that antibiotic therapy may have a small effect on prevention of post-streptococcal AGN, but this has not been substantiated. However, antibiotic therapy is effective in epidemiologic efforts at eradicating nephritogenic strains of group A streptococcus.

In high risk settings during an acute epidemic of AGN, universal penicillin prophylaxis can be considered. Recurrent episodes of AGN are rare, and continuous anti-streptococcal prophylaxis is generally not recommended. Long-term prognosis is generally thought to be excellent, but some studies found that up to 20% of patients develop urinary abnormalities (13). In general, combination antimicrobial therapy offers no added benefit in the treatment of known GAS infections.

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