Letters to the Editor

Treatment of Streptococcal Pharyngitis

TO THE EDITOR: There are three points I would like to make regarding the article¹ on streptococcal pharyngitis.

First, the authors attribute azithromycin's "once daily dosing" and "shorter treatment course" to its "extended spectrum." The duration of therapy and timing of doses are consequences of the pharmacokinetic properties of the compound, not the antimicrobial spectrum. Specifically, the half-life of azithromycin in many tissues is as long as two to four days, resulting in antimicrobial activity for five days or more after a typical five-day course.²

Second, I would take exception to the authors' inclusion of penicillin resistance among the theories for treatment failures. As Bromberg³ notes in the accompanying editorial, resistance to penicillin has not been documented in a clinical setting.^4,5

Third, in an era with increasing antibiotic resistance, I would support the authors' proposal of reserving cephalosporins and other, more broad-spectrum antibiotics for treatment failures. The authors cite a study showing a 92 percent bacteriologic cure rate with a cephalosporin compared to 84 percent with penicillin.¹ This 8 percent difference translates to needing to treat an average of 12.5 patients with cephalosporin to prevent one penicillin-associated treatment failure.

ANDREW M. MOHLER, M.D.
Good Samaritan Family Practice Residency
1300 North 12th St. #605
Phoenix, AZ 85006

REFERENCES

1. Hayes CS, Williamson H Jr. Management of group A beta-hemolytic streptococcal pharyngitis. Am Fam Physician 2001;63:1557-64,1565.
2. Steigbigel NH. Macrolides and clindamycin. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone, 2000:366-80.
3. Bromberg K. Group A beta-hemolytic streptococcal pharyngitis [Editorial]. Am Fam Physician 2001;63: 1485-93.
4. Pickering LK, ed. 2000 Red book: report of the Committee on Infectious Diseases, 25th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 2000:526-36.
5. Pichichero ME. Streptococcal pharyngitis: is penicillin still the right choice? Compr Ther 1996;22:782-7.

EDITOR'S NOTE: This letter was sent to the authors of "Management of Group A Beta-Hemolytic Streptococcal Pharyngitis," who did not reply.

Treatment of Hansen's Disease

TO THE EDITOR: I enjoyed the article about annular lesions.¹ Although Hansen's disease is an unusual problem for most physicians in the United States, it should be noted that the recommended treatment has been revised.

The World Health Organization recommends² that paucibacillary persons receive 600 mg of rifampin (Rifadin) monthly and 100 mg of dapsone daily for six months. For multibacillary persons, treatment is 600 mg of rifampin plus 300 mg of clofazimine (Lamprene) monthly, in addition to 100 mg of dapsone plus 50 mg of clofazimine daily--all to be taken for 12 months. Persons with single­skin-lesion, paucibacillary leprosy can be treated with a single dose of rifampin, ofloxacin (Floxin), and minacycline (Minocin).^3,4

In the United States, one recommended treatment for persons with paucibacillary disease is 100 mg of dapsone plus 600 mg of rifampin daily for 12 months. For multibacillary disease, treatment consists of 100 mg of dapsone, 600 mg of rifampin, and 50 mg of clofazimine daily for 24 months, or the standard WHO regimen.² Treatment is usually instituted by a physician experienced in the management of the complications of Hansen's disease.

WILLIAM A. ALTO, M.D.
4 Sheridan Drive.
Fairfield, ME 04330

REFERENCES

1. Hsu S, Le EH, Khoshevis MR. Differential diagnosis of annular lesions. Am Fam Physician 2001;64: 289-96.
2. Ooi WW, Moschella SL. Update on leprosy in immigrants in the United States: status in the year 2000. Clin Infect Dis 2001;32:930-7.
3. Jacobson RR, Krahenbuhl JL. Leprosy. Lancet 1999; 353:655-60.
4. Style A. Early diagnosis and treatment of leprosy in the United States. Am Fam Physician 1995;52:
   172-8.

IN REPLY: A discussion of the treatment of Hansen's disease was beyond the scope of the article. We thank Dr. Alto for his detailed update.

SYLVIA HSU, M.D.
Baylor College of Medicine
One Baylor Plaza, FB800
Houston, TX 77030

Corrections

The article "Management of Group A Beta-Hemolytic Streptococcal Pharyngitis" (April 15, 2001, page 1557) contained an error in the dosage of azithromycin in Table 4. The dosage of azithromycin for children with group A beta-hemolytic streptococcal pharyngitis is incorrectly given as 10 mg per kg on day 1 and 5 mg per kg on days 2 through 5; the correct dosage is 12 mg per kg for five days.

An article in "Practice Guidelines" entitled "AAP Issues Recommendations on the Prevention and Treatment of Lyme Disease" (June 1, 2000, page 3263) incorrectly referred to Lyme disease as an insect-borne illness. Ticks are arachnids rather than insects. The first sentence of the second paragraph of this item should read as follows: "Lyme disease, a disease transmitted by ticks carrying the spirochete Borrelia burgdorferi, is the most common vector-borne illness in the United States."

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.