Streptococcal throat infection is very common. A 10-day course of penicillin is prescribed mainly to protect against the complication of acute rheumatic fever, which occurs approximately 20 days after streptococcal throat or scarlet fever, and causes damage to the heart valves. Cases of acute rheumatic fever have dropped dramatically in high-income countries, with an annual incidence amongst school-aged children of 0.5 cases per 100,000, compared to 100 to 200 cases per 100,000 in low-income countries. Newer antibiotics, taken for a shorter duration, may have a comparable effect to penicillin taken for 10 days.
We summarized the evidence in the medical literature regarding the effect of two to six days of oral antibiotics (short duration) in treating children with streptococcal throat infection, compared with 10 days of oral penicillin (standard duration).
We searched the literature from 1951 to November 2007. Twenty studies were included with a total of 13,102 cases of streptococcal throat infection. The most common antibiotic studied was azithromycin (n = 6). Compared to standard duration, the short duration treatment had a shorter period of fever (mean difference (MD) -0.30 days, 95% CI -0.45 to -0.14) and sore throat (MD -0.50, 95% CI -0.78 to -0.22), and lower risk of early clinical treatment failure (OR 0.80, 95% CI 0.67 to 0.94), but there was no significant difference in early bacteriological treatment failure (OR 1.08, 95% CI 0.97 to 1.20), or late clinical recurrence (OR 0.95, 95% CI 0.83 to 1.08). The overall risk of late bacteriological recurrence was worse in the short duration treatment (OR 1.31, 95% CI 1.16 to 1.48). However, no significant difference was found when eliminating studies of low-dose azithromycin (10 mg/kg) (OR 1.06, 95% CI 0.92 to 1.22).
The short duration treatment resulted in better compliance (non-compliance OR 0.21, 95% CI 0.16 to 0.29), but more side effects (OR 1.85, 95% CI 1.55 to 2.21). All side effects were self-limiting: mostly mild to moderate diarrhea, vomiting, and abdominal pain. Three studies reported the rate of long duration complications with no statistically significant difference (OR 0.53, 95% CI 0.17 to 1.64).
Three to six days of oral antibiotics for children with streptococcal (strep) throat infection is a safe treatment with a comparable effect to the standard duration of 10 days of penicillin. However, our results must be interpreted with caution in low-income countries where acute rheumatic fever is still a problem.