coccal and phenoxymethylpenicillin by mouth (or erythromycin/clarithromycin or an oral cephalosporin in the penicillin allergic) should be given to prevent these complications. Ideally, it should be continued for 10 days, but compliance is bad once the symptoms have subsided and 5 days should be the minimum objective. If there is a possibility that the pharyngitis is due to infectious mononucleosis, amoxicillin must not be used as the patient is very likely to develop a rash (see p. 220). In a closed community, chemoprophylaxis of unaffected people to stop an epidemic may be considered, for instance with phenoxymethylpenicillin 125 mg 12-hourly orally, for a period depending on the course of the epidemic.

In scarlet fever and erysipelas, the infection is invariably streptococcal (Group A) and benzyl-penicillin should be used even in mild cases, to prevent rheumatic fever and nephritis.


Chemoprophylaxis of streptococcal (Group A) infection with phenoxymethylpenicillin should be undertaken in patients who have had one attack of rheumatic fever. It is continued for at least 5 years, or until aged 20, whichever is the longer period (although some hold that it should continue for life, for histological study of atrial biopsies shows that the cardiac lesions may progress despite absence of clinical activity). Chemoprophylaxis should be continued for life after a second attack of rheumatic fever. A single attack of acute nephritis is not an indication for chemoprophylaxis but in the rare cases of nephritis in which recurrent haematuria occurs after sore throats, chemoprophylaxis should be used. Ideally, chemoprophylaxis should continue throughout the year but, if the patient is unwilling to submit to this, at least the colder months should be covered (see also p. 207).

Adverse effects are uncommon. Patients taking penicillin prophylaxis are liable to have penicillin-resistant viridans type streptococci in the mouth, so that during even minor dentistry, e.g. scaling, there is a risk of bacteraemia and thus of infective endocarditis with a penicillin-resistant organism in those with any residual rheumatic heart lesion. The same risk applies to urinary, abdominal and chest surg ery, and patients need special chemoprophylaxis (see Endocarditis). Patients taking penicillins are also liable to be carrying resistant staphylococci and pneumococci.

Other causes of pharyngitis

Vincent's infection (microbiologically complex, includes anaerobes, spirochaetes) responds readily to benzylpenicillin; a single i.m. dose of 600 mg is often enough except in a mouth needing dental treatment, when relapse may follow. Metronidazole 200 mg 8-hourly by mouth for 3 days is also effective.

Diphtheria (Corynebacterinm diphtheriae). Antitoxin 10 000-100 000 units i.v. in two divided doses 0.5-2 h apart is given to neutralise toxin already formed according to the severity of the disease. Erythromycin or benzylpenicillin is also used, to prevent the production of more toxin by destroying the bacteria.

Whooping-cough (Bordetella pertussis). Chemotherapy is needed in children who are weak, have damaged lungs or are under 3 years old. Erythromycin is usually recommended at the catarrhal stage and should be continued for 14 days (also as prophylaxis in cases of special need). It may curtail an attack if given early enough (before paroxysms have begun) but is not dramatically effective; it also reduces infectivity to others. A corticosteroid, salbutamol, and physiotherapy may be helpful for relief of symptoms, but reliable evidence of efficacy is lacking.

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