by Carla Kemp • Senior Editor Health Briefs ©Copyright 2012 AAP News Volume 33 • Number 4 April 2012 www.aapnews.org ◆ Logan LK, et al. Pediatrics. 2012;129:e798-e802. Physicians from two Chicago hospitals report on two cases of macrolide resistance and/or treatment failure that resulted in the development of acute rheumatic fever in patients with group A Streptococcus (GAS). In addition, a review of studies from 2000 to 2011 showed that macrolide resistance is increas- ing worldwide. GAS is among the most common pathogenic bacteria in children, accounting for about 30% of episodes of acute bacterial pharyngitis. Treatment of GAS pharyngitis is important to pre- vent complications such as acute rheumatic fever and rheumatic heart disease. The first case involved a previously healthy 11-year-old boy with fever, sore throat, ear pain and rash. His brother had been diagnosed with GAS pharyngitis. The patient, who had a sig- nificant penicillin allergy, was treated with azithromycin and diphenhydramine for 10 days. He tested positive for GAS after developing fever, ankle pain and swelling while still taking azithromycin. Twenty-one days after symptoms began, he presented to the hospital with a rash, pain, and swelling of his left ankle and bilateral second to fourth metacarpal phalangeal joints. A throat culture showed an erythromycin-resistant, clin- damycin-sensitive strain of GAS. After treatment with clin- damycin and aspirin, the rash and arthritis resolved. The second case was a 13-year-old girl with Best disease who had been diagnosed with GAS pharyngitis and received a 10-day course of azithromycin. She was not allergic to penicillin. She presented to the hospital with pain and swelling in her left ankle and a small tender nodule on her right first digit. Echocardiogram showed mild tricuspid and trivial mitral valve regurgitation. She was treated with prednisone as well as penicillin VK for acute rheumatic fever treatment and secondary prophylaxis. A year later, an echocardiogram was unchanged. The authors’ review of published studies on macrolide resistance in children showed rates ranging from 1.1% in Cyprus to 48% in the United States and 97.9% in China. They concluded that health care professionals should use macrolide antibiotics to treat GAS infections only if the patient has had an anaphylactic reaction to penicillin. Macrolide treatment failure leads to rheumatic fever

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by Carla Kemp • Senior Editor

Health Briefs

Volume 33 • Number 4April 2012www.aapnews.org

◆ Logan LK, et al. Pediatrics. 2012;129:e798-e802.

Physicians from two Chicago hospitals report on two casesof macrolide resistance and/or treatment failure that resultedin the development of acute rheumatic fever in patients withgroup A Streptococcus (GAS). In addition, a review of studiesfrom 2000 to 2011 showed that macrolide resistance is increas-ing worldwide.

GAS is among the most common pathogenic bacteria inchildren, accounting for about 30% of episodes of acute bacterialpharyngitis. Treatment of GAS pharyngitis is important to pre-vent complications such as acute rheumatic fever and rheumaticheart disease.

The first case involved a previously healthy 11-year-old boywith fever, sore throat, ear pain and rash. His brother had beendiagnosed with GAS pharyngitis. The patient, who had a sig-nificant penicillin allergy, was treated with azithromycin anddiphenhydramine for 10 days. He tested positive for GAS afterdeveloping fever, ankle pain and swelling while still takingazithromycin.

Twenty-one days after symptoms began, he presented to

the hospital with a rash, pain, and swelling of his left ankleand bilateral second to fourth metacarpal phalangeal joints.A throat culture showed an erythromycin-resistant, clin-damycin-sensitive strain of GAS. After treatment with clin-damycin and aspirin, the rash and arthritis resolved.

The second case was a 13-year-old girl with Best diseasewho had been diagnosed with GAS pharyngitis and receiveda 10-day course of azithromycin. She was not allergic to peni-cillin. She presented to the hospital with pain and swelling inher left ankle and a small tender nodule on her right first digit.Echocardiogram showed mild tricuspid and trivial mitral valveregurgitation. She was treated with prednisone as well as peni-cillin VK for acute rheumatic fever treatment and secondaryprophylaxis. A year later, an echocardiogram was unchanged.

The authors’ review of published studies on macrolide resist-ance in children showed rates ranging from 1.1% in Cyprusto 48% in the United States and 97.9% in China.

They concluded that health care professionals should usemacrolide antibiotics to treat GAS infections only if the patienthas had an anaphylactic reaction to penicillin.

Macrolide treatment failure leads to rheumatic fever