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Treatment for Streptococcal pharyngitis
Each strain of streptococcus requires different forms of treatment and antibiotics. Streptococcal pharyngitis, also known as strep throat, is an infection with group A beta-hemolytic streptococcus bacteria (GABHS). Other forms of strep include group B streptococcus and streptococcus pneumonia, which present different symptoms and are not to be confused with the species streptococcal pharyngitis. For over five decades, penicillin has been the choice treatment for this infection. Despite concern over increasing antimicrobial resistance to penicillin, GABHS has not been documented to show any resistance to penicillin. Penicillin beats out other antibiotics such as cephalosporin due to its narrow antimicrobial spectrum of activity, meaning decreased chance of resistance, low costs, effectiveness, and low chance of extreme adverse risks or side effects. Penicillin works best on those who are not carriers of the infection; in the cases of those who are carriers with intercurrent viral pharyngitis, cephalosporin work better at eradicating the infection. Amoxicillin is also effective, and because of its taste, is often prescribed to children. Erythromycin and first-generation cephalosporins are often administered to those with a penicillin allergy or carriers of strep. Those who are chronic carriers are at a lower risk of developing the invasive version of GABHS infections. Therefore, penicillin remains the most prescribed and standard therapeutic care for strep throat. Adults are suggested to take 250 mg of penicillin three to four times per day, or 500 mg two times per day, while children are suggested to take 250 mg two to three times per day.

There has also been controversy over when to begin the antibiotic course. Some scientists argued that the relationship between the recurrences rates of GABHS and the timing of treatment is insignificant. A 48 hour delay in the initiation of penicillin therapy apparently did not reduce recurrence rates; only 6 out of fifty patients who immediately began treatment had homologous serotypes. Previous studies suggested that a delay in penicillin treatment allowed immunity to build up. The reasoning is that waiting gives time for the "host generate a type-specific antibody response to the M protein in the streptococcal cell wall, thereby providing immunity to infection with homologous but not heterologous M types of streptococci". In other words, this theory that the host can build up immunity to repetition of the infection is supported by other scientists. It was found that immediate treatment of penicillin can reduce risk of transmission in the future and remains the recommended course of action. In this study, out of 260 children, only a very small percentage of the patients who were administered antibiotics failed to show clinical improvement after a 24 hour check in appointment, leading the team to recommend immediate therapy when the patient has a positive rapid strep test. The risks of waiting include acute rheumatic fever, a complication of strep throat, and reducing duration of illness. Other scientists acknowledge that while the excessive prescription of antibiotics can present further complications and is not ideal, short-course treatment can limit the time of discomfort and can treat the patient symptomatically. Furthermore, reducing the duration of an antibiotic course such as penicillin can reduce the risk of adverse effects such as anaphylaxis. Some recommend that the best course of action is two to six days of oral antibiotics rather than 10 days of oral penicillin, which helps reduce fever and sore throat for those patients with acute streptococcal pharyngitis. Further improvement was seen with the incorporation of systemic corticosteroids and anti-inflammatory drugs such as acetaminophen. The standard penicillin therapy includes a ten day course of oral therapy of penicillin, or one injection of intramuscular benzathine penicillin.

There is also debate over what treatment to use. Although penicillin is by far the most common standard of care, some scientists have argued that its tendency to lead to antimicrobial resistance outweighs the benefits of minimizing symptoms. One study found that penicillin only provided a 20% improvement over anti-inflammatory therapy of aspirin and acetaminophen, specifically in regard to sore throat complaints. Penicillin provided relief in more than half of the patients concerning a sore throat within 24 hours of use, but this was the only recorded improvement in therapy. For severely affected patients, penicillin only provided a 23% improvement within 24 hours. The team recommended therapy that included aspirin and acetaminophen with non-medicated pain relief measures. Penicillin did little in reducing greater symptoms of fever, malaise, exudate, odynophagia, adentitis, or pharyngitis. Furthermore, strep-throat is often self-remitting meaning that it does not usually come back after the body has fought it off, and could therefore be treated symptomatically.

Out of all the antibiotics however, penicillin works best, with the only significant caution of resistance. One discrepancy between all the studies in whether to use penicillin derives from uncertainty over type-specific infections, failure to exclude patients from studies who may be streptococcal carriers, and overlooking evidence that salivary levels of secretory antibodies can protect against recurrence, versus serum antibodies alone. Alternatives include macrocodes, oral cephalosporin, and other beta-lactam agents that are especially useful for those that are allergic to penicillin. Those who have suffered an attack of rheumatic fever will most likely have recurrences of the infection, in which penicillin is the choice treatment for secondary prophylaxis.

The diagnosis of strep throat includes a clinical screening that includes a rapid antigen test, and throat cultures when investigating breakouts of GABHS disease. In all cases of acute pharyngitis, strep is a causal agent in 10% of adult cases. Antibiotics should only be prescribed when the rapid antigen test comes out positive, and the development and spread of antibiotic resistance should always be monitored, as pharyngitis is a self-limited illness that requires usually only symptomatic, supportive care.