Dear Editor,

We read with interest the once-daily amoxicillin versus twice-daily penicillin V in group A b-haemolytic streptococcal pharyngitis recently issued by the Archives of Disease in Childhood (1).

The universal sensitivity of GABHS isolates to penicillin makes this an effective therapeutic option when the entire 10-day course of treatment is given; however, the arduous dosing regimen is often a barrier to compliance, particularly in children (2). The use of intramuscular benzathine penicillin for secondary prophylaxis has the greatest and most cost-effective impact on rheumatic fever recurrence (3). However, intramuscular benzathine penicillin (Single dose > 30 kg: 1.2 MU, < 30 kg: 600 000 MU) may be also used in primary prevention of rheumatic fever (4).

We think that rheumatic fever is stil a major problem in some developing countries, in especially Turkey. Ozer et al studied cross- sectionally to verify the clinical profile and were followed during the acute period for childhood acute rheumatic fever (5). Their study indicates that acute rheumatic fever is still a significant problem in Turkey. In their study by Uysal et al throat cultures have been performed on 297 children suspected of tonsillopharyngitis on clinical findings (6). GABHS has been isolated from 86 patients (41 males/45 females) aged 6-15 years. They were randomly allocated to receive oral cefuroxime axetil for 10 days (group 1) or one dose of intramuscular benzathine penicillin (group 2) and responses were evaluated 2 weeks later. Clinical cure was observed in 95% of group 1 and 96% of group 2 and bacteriological cure in 86 and 84% of groups 1 and 2, respectively. Their study showed that intramuscular benzathine penicilin remains an effective treatment for GABHS and that oral cefuroxime axetil is also effective.

Yildirim et al have evaluated the effect of clarithromycin, amoxicillin/clavulanate, cefprozil and benzathine penicillin G on the bacteriological cure, beta-lactamase production, pharyngeal microflora and alpha hemolytic streptococci when used in the treatment of pediatric GABHS tonsillopharyngitis (7). Intramuscular benzathine penicillin G and oral clarithromycin, amoxicillin/clavulanate and cefprozil have been administered to 70 patients who were between 2-16 years of age. Isolation rates of GABHS have been 97.1% and 77.9% in clarithromycin group, 100% and 83.8% in amoxicillin/clavulanate group, 97.2% and 98.6% in cefprozil group and 100% and 83.8% in the benzathine Pen G group before and after treatment, respectively. The most prominent inhibitory effect on GABHS has been observed with amoxicillin/clavulanate, while cefprozil had the least effect. In their study, cefprozil seems to be advantageous in GABHS eradication by having less inhibitory effect on GABHS. As seen in the literature, many different agents are being used as alternative options in the treatment of pediatric GABHS tonsillopharyngitis. We think that intramuscular benzathine penicillin is a cheap therapy method for primary and secondary prevention of rheumatic fever in childhood, especially in developing countries. Thus, in children aged 5–15 years who have a problem for compliance of oral penicilin V or amoxicillin and have no hypersensitivity to penicillin, using of intramuscular benzathine penicillin may be also appropriate for primary prevention of rheumatic fever.

References

1. Lennon DR, Farrell E, Martin DR, Stewart JM. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child 2008;93(6):474-478. 2. Bisno AL, Gerber MA, Gwaltney JM Jr, et al. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis 2002;35:113–125. 3. Strasser T. Cost-effective control of rheumatic fever in the community. Health Policy 1985;5:159–64. 4. Mayosi BM. Protocols for antibiotic use in primary and secondary prevention of rheumatic fever.S Afr Med J 2006;96(2):240. 5. Ozer S, Hallioðlu O, Ozkutlu S, Celiker A, Alehan D, Karagöz T. Childhood acute rheumatic fever in Ankara, Turkey. Turk J Pediatr 2005;47(2):120-124. 6. Uysal S, Sancak R, Sunbul M. A comparison of the efficacy of cefuroxime axetil and intramuscular benzathine penicillin for treating streptococcal tonsillopharyngitis. Ann Trop Paediatr. 2000;20(3):199-202. 7. Yildirim I, Ceyhan M, Gür D, Kaymakoðlu I. Comparison of the effect of benzathine penicillin G, clarithromycin, cefprozil and amoxicillin/clavulanate on the bacteriological response and throat flora in group A beta hemolytic streptococcal tonsillopharyngitis. Turk J Pediatr. 2008;50(2):120-125.

Dear Editor,

We read with interest the once-daily amoxicillin versus twice-daily penicillin V in group A b-haemolytic streptococcal pharyngitis recently issued by the Archives of Disease in Childhood (1).

The universal sensitivity of GABHS isolates to penicillin makes this an effective therapeutic option when the entire 10-day course of treatment is given; however, the arduous dosing regimen is often a barrier to compliance, particularly in children (2). The use of intramuscular benzathine penicillin for secondary prophylaxis has the greatest and most cost-effective impact on rheumatic fever recurrence (3). However, intramuscular benzathine penicillin (Single dose > 30 kg: 1.2 MU, < 30 kg: 600 000 MU) may be also used in primary prevention of rheumatic fever (4).

We think that rheumatic fever is stil a major problem in some developing countries, in especially Turkey. Ozer et al studied cross- sectionally to verify the clinical profile and were followed during the acute period for childhood acute rheumatic fever (5). Their study indicates that acute rheumatic fever is still a significant problem in Turkey. In their study by Uysal et al throat cultures have been performed on 297 children suspected of tonsillopharyngitis on clinical findings (6). GABHS has been isolated from 86 patients (41 males/45 females) aged 6-15 years. They were randomly allocated to receive oral cefuroxime axetil for 10 days (group 1) or one dose of intramuscular benzathine penicillin (group 2) and responses were evaluated 2 weeks later. Clinical cure was observed in 95% of group 1 and 96% of group 2 and bacteriological cure in 86 and 84% of groups 1 and 2, respectively. Their study showed that intramuscular benzathine penicilin remains an effective treatment for GABHS and that oral cefuroxime axetil is also effective.

Yildirim et al have evaluated the effect of clarithromycin, amoxicillin/clavulanate, cefprozil and benzathine penicillin G on the bacteriological cure, beta-lactamase production, pharyngeal microflora and alpha hemolytic streptococci when used in the treatment of pediatric GABHS tonsillopharyngitis (7). Intramuscular benzathine penicillin G and oral clarithromycin, amoxicillin/clavulanate and cefprozil have been administered to 70 patients who were between 2-16 years of age. Isolation rates of GABHS have been 97.1% and 77.9% in clarithromycin group, 100% and 83.8% in amoxicillin/clavulanate group, 97.2% and 98.6% in cefprozil group and 100% and 83.8% in the benzathine Pen G group before and after treatment, respectively. The most prominent inhibitory effect on GABHS has been observed with amoxicillin/clavulanate, while cefprozil had the least effect. In their study, cefprozil seems to be advantageous in GABHS eradication by having less inhibitory effect on GABHS. As seen in the literature, many different agents are being used as alternative options in the treatment of pediatric GABHS tonsillopharyngitis. We think that intramuscular benzathine penicillin is a cheap therapy method for primary and secondary prevention of rheumatic fever in childhood, especially in developing countries. Thus, in children aged 5–15 years who have a problem for compliance of oral penicilin V or amoxicillin and have no hypersensitivity to penicillin, using of intramuscular benzathine penicillin may be also appropriate for primary prevention of rheumatic fever.

References

1. Lennon DR, Farrell E, Martin DR, Stewart JM. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child 2008;93(6):474-478. 2. Bisno AL, Gerber MA, Gwaltney JM Jr, et al. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis 2002;35:113–125. 3. Strasser T. Cost-effective control of rheumatic fever in the community. Health Policy 1985;5:159–64. 4. Mayosi BM. Protocols for antibiotic use in primary and secondary prevention of rheumatic fever.S Afr Med J 2006;96(2):240. 5. Ozer S, Hallioðlu O, Ozkutlu S, Celiker A, Alehan D, Karagöz T. Childhood acute rheumatic fever in Ankara, Turkey. Turk J Pediatr 2005;47(2):120-124. 6. Uysal S, Sancak R, Sunbul M. A comparison of the efficacy of cefuroxime axetil and intramuscular benzathine penicillin for treating streptococcal tonsillopharyngitis. Ann Trop Paediatr. 2000;20(3):199-202. 7. Yildirim I, Ceyhan M, Gür D, Kaymakoðlu I. Comparison of the effect of benzathine penicillin G, clarithromycin, cefprozil and amoxicillin/clavulanate on the bacteriological response and throat flora in group A beta hemolytic streptococcal tonsillopharyngitis. Turk J Pediatr. 2008;50(2):120-125.

ANOTHER ERROR NOTED. AS REFERENCE TO THE ARTICLE IT SHOULD BE PENICILLIN 500 MGM BID NOT QD.

Dear Sirs,

There is a mistake: Children were randomised to oral amoxicillin 1500mg BID. Should be QD.

Regards, Andrzej Kania, MD