eMedicine Specialties > Infectious Diseases > Bacterial Infections

Streptococcus Group A Infections: Follow-up

Author: Zartash Zafar Khan, MD, Fellow in Infectious Diseases, University of Oklahoma Health Science Center
Coauthor(s): Michelle R Salvaggio, MD, Assistant Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine; Medical Director of Infectious Diseases Institute, University of Oklahoma Health Sciences Center; Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital; Godfrey Harding, MD, FRCP(C), Program Director of Medical Microbiology, Professor, Department of Medicine, Section of Infectious Diseases and Microbiology, St Boniface Hospital, University of Manitoba, Canada
Contributor Information and Disclosures

Updated: Sep 23, 2009

Follow-up

Further Outpatient Care

Routine throat culture is unnecessary in asymptomatic patients who have completed a course of antibiotic therapy, except in special circumstances. Symptoms that persist after a treatment course may have several explanations.

  • Persistent carriage in the face of intercurrent viral infection
  • Noncompliance with the prescribed antimicrobial regimen
  • A new group A streptococci (GAS) infection acquired from family, the classroom, or community contacts
  • A recurrent episode of pharyngitis caused by the original infecting strain of GAS (ie, treatment failure)

Streptococcus carriers are unlikely to spread the organism to their close contacts and are at very low risk, if any, for developing suppurative complications or nonsuppurative complications (eg, acute rheumatic fever [ARF]). Continuous antimicrobial prophylaxis is not recommended except to prevent the recurrence of rheumatic fever in patients who have experienced a previous episode of rheumatic fever.

Follow-up culture of throat swabs is not routinely indicated in asymptomatic patients who have received a complete course of therapy for GAS pharyngitis (A-II), except in those with a history of rheumatic fever. Follow-up throat culture should also be considered in patients who develop acute pharyngitis during outbreaks of ARF or acute poststreptococcal glomerulonephritis (PSGN), during outbreaks of GAS pharyngitis in closed or partially closed communities, and when "ping-pong" spread of GAS infection has been occurring within a family (B-III).2

Deterrence/Prevention

Uncertainty remains about the risk of secondary cases of invasive GAS disease developing among close contacts of an index case of GAS infection. The currently available evidence does not justify routine chemoprophylaxis in close contacts. All household contacts of a patient with invasive GAS disease should be informed of the clinical manifestations of invasive disease and counseled to seek immediate medical attention upon development of such symptoms.

Complications

  • Potential complications of GAS tonsillopharyngitis include peritonsillar abscess, otitis media, and sinusitis. Inferior intrathoracic spread may lead to necrotizing mediastinitis.22 Contiguous intracranial invasion may result in fatal meningitis.23
  • Necrotizing fasciitis carries high morbidity and mortality rates and can result in TSS with multiorgan failure.
  • Puerperal sepsis follows abortion or delivery when streptococci that colonize the genital tract invade the endometrium and enters the blood stream. Pelvic cellulitis, septic pelvic thrombophlebitis, pelvic abscess, and septicemia can occur. Peripartum genital tract infections with group B streptococci are relatively more common, but fatal peripartum GAS infections have been reported.24
  • Empyema develops in 30%-40% of pneumonia cases. Other complications of pneumonia include mediastinitis, pericarditis, pneumothorax, and bronchiectasis.
  • The nonsuppurative complications of GAS tonsillopharyngitis include ARF, rheumatic heart disease, and acute glomerulonephritis.

Prognosis

  • Acute proliferative PSGN carries a good prognosis, as more than 95% of patients recover spontaneously within 3-4 weeks with no long-term sequelae.
  • With appropriate treatment, pharyngitis and skin infections carry a good prognosis.
  • Invasive GAS disease carries an overall mortality rate of 10%-15%. TSS and necrotizing fasciitis carry higher morbidity and mortality rates.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The index of suspicion for GAS infection should be very high in cases of acute pharyngitis and skin infections including impetigo, cellulitis, erysipelas, wound infection, and gangrene.
  • GAS infection can result in two nonsuppurative sequelae, acute rheumatic fever (ARF) and acute poststreptococcal glomerulonephritis (PSGN).
  • GAS are important organisms that cause necrotizing fasciitis and STSS. Both of these conditions are associated with high mortality rates unless treated promptly and aggressively.

Special Concerns

  • Acute rheumatic fever
    • General description: ARF is a delayed nonsuppurative sequela of GAS tonsillopharyngitis. Following the pharyngitis, a latent period of 2-3 weeks passes before the signs or symptoms of ARF appear. The disease presents with various clinical manifestations, including arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum.
    • Epidemiology: A streptococcal strain capable of causing bacterial pharyngitis is capable of causing rheumatic fever, although some exceptions have been noted.
    • Pathogenesis: The pathogenic mechanisms that lead to the development of ARF remain incompletely understood. It is clearly associated with streptococcal pharyngitis, but genetic susceptibility may exist. The evidence is insufficient that toxins produced by the streptococci are important in pathogenesis.
    • Genetic susceptibility: Rheumatic fever might be the result of host genetic predisposition. The disease gene may be transmitted either in an autosomal-dominant fashion or in an autosomal-recessive fashion, with limited penetrance. The disease gene has not yet been identified.
 
Acknowledgments

This article was reviewed by Michelle R. Salvaggio, MD, FACP, Assistant Professor, Associate Fellowship Director of Infectious Diseases, University of Oklahoma Health Science Center.



More on Streptococcus Group A Infections

Overview: Streptococcus Group A Infections
Differential Diagnoses & Workup: Streptococcus Group A Infections
Treatment & Medication: Streptococcus Group A Infections
Follow-up: Streptococcus Group A Infections
Multimedia: Streptococcus Group A Infections
References
Further Reading
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Further Reading

  • Stevens DL, Kaplan EL, eds. Streptococcal Infections: Clinical Aspects, Microbiology, and Molecular Pathogenesis. 1st ed. Oxford University Press; 2000.

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Keywords

Streptococcus group A infections, group A Streptococcus, group A streptococci, group A streptococcal infection, GAS infection, group A strep, strep throat, streptococci, Streptococcus, Streptococcus pyogenes, S pyogenes, gram-positive cocci, wound infection, acute rheumatic fever, ARF, acute glomerulonephritis, scarlet fever, pharyngitis, impetigo, tonsillopharyngeal cellulitis, tonsillopharyngeal abscess, otitis media, sinusitis, necrotizing fasciitis, streptococcal bacteremia, meningitis, brain abscess, gangrene, toxic shock syndrome, flesh-eating bacteria

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Contributor Information and Disclosures

Author

Zartash Zafar Khan, MD, Fellow in Infectious Diseases, University of Oklahoma Health Science Center
Zartash Zafar Khan, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, and International Society for Infectious Diseases
Disclosure: Nothing to disclose.

Coauthor(s)

Michelle R Salvaggio, MD, Assistant Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine; Medical Director of Infectious Diseases Institute, University of Oklahoma Health Sciences Center
Michelle R Salvaggio, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Merck Honoraria Speaking and teaching

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Godfrey Harding, MD, FRCP(C), Program Director of Medical Microbiology, Professor, Department of Medicine, Section of Infectious Diseases and Microbiology, St Boniface Hospital, University of Manitoba, Canada
Godfrey Harding, MD, FRCP(C) is a member of the following medical societies: American College of Physicians, American Society for Microbiology, Canadian Infectious Disease Society, Canadian Medical Association, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Douglas A Drevets, MD, Assistant Professor, Department of Medicine, Section of Infectious Disease, Oklahoma University Health Sciences Center
Douglas A Drevets, MD is a member of the following medical societies: American Association of Immunologists, American Society for Microbiology, Central Society for Clinical Research, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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