The survey covers 266 patients with febrile mucocutaneous syndromes. A brief account of the highly varied clinical picture is given. The syndromes constitute an allergic reaction which in most drug‐provoked cases appeared as a late immunological reaction of serum disease type; for the rest sensitization had probably often taken place. An allergic disposition could be traced in 34% of the cases. Infections and drugs were the causative factor in 235 cases (88.3%). Infections accounted for 25.2%, drugs for 36.1% and both together for 27.1%. An account is given of the provocative bacterial and viral infections and of the role of drugs in cases with and without infection. Among the remaining 31 cases an infection and/or drug may have been the provocative agent in 16 (6%) whereas 15 (5.6%) may have been due to alimentary and other factors.
Penicillin V is extremely efficacious against infections caused by haemolytic streptococci. A comparison with the broad-spectrum penicillin, ampicillin, is justified since this drug, too, has a highly effective bactericidal action on pyogenic streptococci. On the basis of a small series of cases in France ampicillin has even been considered "l'antibiotique de choix" for the treatment of scarlet fever (1). On the other hand a fairly high incidence of side-effects is reported from the use of ampicillin. especially in the form of exanthem (3, 4, 5, 6), which may be a restraining factor. An aetiologically and clinically uniform disease such as scarlet fever should be a suitable object for the study of the antibacterial and clinical efficacy of ampicillin as well as of its side-effects in comparison with penicillin V, our hitherto best per oral penicillin for scarlet fever therapy.
MATERIAL AND METHODSThe study covers the period 1962-64. The patients were treated in the same department. As from the morning of the second day in hospital alternate cases of scarlet fever were put on ampicillin (Doctacil1in)-dose 125 mg x 3 for ages 1-4 years and 250 mg Y 3 for ages 5-13 yearsand penicillin V (Meropenin)-dose 100,000 IU (60 mg) \I 3 and 200,000 IU (120 mg) x 3 for the two age groups. The treatment lasted for 10 days. Daily tests for haemolytic streptococci were made during the 10 days in hospital and thereafter at follow-ups one and three weeks after discharge. The antistreptolysin titre of children above 4 years of age was determined on admission, after one week and at the second follow-up, i.e. about 2'/? weeks after discharge. Each series consisted of 110 cases.
RESULTS
Clinical effect.The results were satisfactory with both drugs. No complications occurred, either purulent or of toxic-allergic origin in the form of myocarditis or nephritis.The duration of the fever as from the onset of the disease was for the penicillin V series 4.2+ 0.16 days and for the ampicillin series 4.6k0.23 days, and during the period in hospital 1.920.10 and 2.3 0.19 days respectively-thus a rather shorter duration for the penicillin V patients, but not statistically significant.The sedimeniation rate on admission to hospital and one week later was for the penicillin V series 28.92 1.4 and 1 1 . 6 2 0.7 mm/hr, respectively, and for the ampicillin series 28.3 5 1.3 and 11.4 & 0.7 mm/hr, thus practically no difference.Bacteriological effect. This is illustrated in Fig. 1, which includes only those patients who had a positive test on the first day (98 in the ampicillin, 93 in the penicillin V series). All of the penicillin V series were negative on the third day. In the ampicillin series two patients did not become free from bacteria until the fourth day, and one not until the fifth. Streptococcal recurrence occurred rather more often in the ampicillin patients at the check-up after one week (15.4% against 9.1 % ). The difference is not significant. During the follow-up period pharyngeal symptoms accompanied by fever were noted in 12 ampicillin...
Summary
The effect of penicillin on immunity following scarlatina has been investigated. Comparative studies were made of the incidence of second attacks in Stockholm during the pre‐penicillin period 1938–46 and during the penicillin period 1947–51. Parallel series in addition comprised treated and untreated cases.
Early second attacks, or relapses, in hospital diminished considerably due to the lesser risk of cross‐infections. The frequency of early second attacks within the first three months of recovery was, however, as great as previously. Apart from the possibility of impaired immunologic conditions during this first period, the factors governing the recurrence of attack at this stage are nowadays the risk of infection from the home environment and also, to some degree, the lack of intensity in treatment. A reduction in the early second attacks should be obtainable as a result of effective treatment and after‐control of the patients and of eradication of bacteria from the environment.
As regards the late second attacks (after three months) the frequency was many times higher in 0–14 year‐old children who had been treated with penicillin than in the untreated. With increase in age, moreover, the relative frequency of second attacks rose still more. The interval between attacks was much shorter than in the pre‐penicillin period. There was thus a marked deterioration in immunity, which was all the more pronounced as the children grew older.
It proved probable that the risk of a new attack of scarlatina could be diminished by postponement of treatment. This is in agreement with the observation that second attacks among penicillin‐treated desquamation cases are very much less numerous than among treated cases of scarlatina.
The value of penicillin in the treatment of scarlatina is so great that its use should be continued. The tendency to second attacks, even recurring attacks, is on the other hand so considerable, at least in built‐up areas, that a modification in the treatment should be introduced. Postponed treatment can be adopted in all cases in children except those exhibiting markedly toxic symptoms or purulent complications.
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