eMedicine Specialties > Infectious Diseases > Bacterial Infections

Streptococcus Group A Infections: Treatment & Medication

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

Treatment

Medical Care

  • Therapy for streptococcal pharyngitis is primarily aimed at preventing nonsuppurative and suppurative complications and decreasing infectivity. A 10-day course of penicillin V 250 mg bid in children and 500 mg bid or 250 mg qid in adults is very effective. A single intramuscular injection of 1.2 million U of penicillin G benzathine can be administered in patients who weigh more than 27 kg; 600,000 U is used in patients who weigh less than 27 kg. Amoxicillin is equally effective and may be better tolerated in children.
  • A meta-analysis compared bacterial and clinical cure rates in patients with group A streptococcal (GAS) tonsillopharyngitis treated with oral beta-lactam or macrolide antibiotics for 4-5 days versus 10-days. Twenty-two trials that involved 7470 patients were included in 4 separate analyses. Short-course cephalosporin treatment was superior to 10 days of penicillin for bacterial cure rate, short-course penicillin therapy was inferior to 10 days of penicillin, and clinical cure rates were similar to bacteriologic cure rates.17
  • In patients who are allergic to penicillin, erythromycin or the newer macrolides (eg, azithromycin, clarithromycin) appear to be effective. Oral cephalosporins are also highly effective in the treatment of streptococcal pharyngitis. Although eradication rates conferred by cephalosporins may be superior to those achieved with penicillin, the latter is the recommended drug of choice by the American Heart Association and the Infectious Diseases Society of America.2
  • Treatment failures are uncommon but may occur. If symptoms recur, the throat should be recultured and another course of treatment should be prescribed, preferably with an oral cephalosporin. An asymptomatic carrier state, as evidenced by positive throat culture results obtained on a weekly basis, is not treated with antibiotics.
  • Streptococcal pyoderma is treated with oral antibiotics (eg, penicillin or erythromycin) for 10 days. However, because concomitant S aureus infection may occur, therapy with cloxacillin, cephalexin, or cefaclor is suggested. Treatment of pyoderma may not prevent nephritis if the patient is infected with a nephritogenic strain.
  • Treatment of necrotizing fasciitis consists of antibiotic therapy, supportive therapy for associated shock, and prompt surgical intervention. GAS remain susceptible to beta-lactam antibiotics; clinical failures of penicillin therapy for streptococcal infections may occur. The failure rates in patients with invasive infections are higher because of the larger number of organisms. Clindamycin may be more effective in invasive infections. Unlike with penicillin, the efficacy of clindamycin is unaffected by the size of the inoculum and the stage of bacterial growth. In addition, clindamycin inhibits the production of toxin by streptococci.
  • Intravenous polyspecific immunoglobulin G (IVIG) has been reported to be efficacious as adjunctive therapy in patients with GAS TSS. GAS can also cause necrotizing fasciitis, for which early and extensive surgical intervention is currently advocated. A medical regimen including IVIG may allow an initial nonoperative or minimally invasive management approach, thus limiting the need for extensive debridement and amputation.18

Surgical Care

Consultation with a surgeon should be obtained early to assess the need for debridement in patients with necrotizing fasciitis.

Consultations

  • Complicated pharyngeal infections with peripharyngeal extension, abscess, or Ludwig angina should be evaluated by an ENT specialist.
  • Consultation with a surgeon should be obtained in cases of necrotizing fasciitis.
  • Consultation with an infectious diseases specialist should be considered.

Medication

To date, S pyogenes has remained universally susceptible to the first-line treatment of choice, penicillin. European surveillance in Italy identified that 32% of group A streptococcal (GAS) isolates exhibited resistance to macrolides. France has reported a steady escalation of erythromycin resistance, reaching 23% to date. Portugal identified 11% of GAS isolates as resistant to macrolides. Resistance in other European countries during the 1990s fell between 1% and 7%.19

Invasive GAS isolates were tested for fluoroquinolone susceptibility from 1992-1993 and in 2003 in Ontario, Canada. All isolates were susceptible to levofloxacin. Two of 153 (1.3%) in 1992-1993 and 7 of 160 (4.4%) in 2003 had a levofloxacin minimal inhibitory concentration (MIC) of 2 µg/mL; all 9 had parC mutations, and 8 were serotype M6.

Between October 2003 and September 2006, 482 GAS strains were collected from 45 medical institutions in various parts of Japan. Susceptibility of GAS strains to 8 beta-lactam agents was excellent, with MICs of 0.0005–0.063 µg/mL–1. Macrolide-resistant strains accounted for 16.2% of all strains. Although no strains with high resistance to levofloxacin were found, strains with an MIC of 2–4 µg/mL–1 (17.4%) with intermediate susceptibility were observed.20

In 2006, of 50 GAS isolates examined with antibiotic susceptibility tests, 100% were found to be susceptible to penicillin, ampicillin, cefotaxime, cefazolin, and vancomycin. Eight isolates (16%) exhibited some level of antibiotic resistance. Six were resistant to erythromycin alone, and two were resistant to erythromycin and clindamycin (the first clindamycin-resistant isolates reported since 1999).21

Antibiotics

Therapy should cover all likely pathogens in the context of clinical settings. Antibiotic selection should be guided by blood culture sensitivity, whenever feasible.

Natural penicillins have good activity against S pyogenes. Various forms of natural penicillins are used for various diseases caused by GAS. The recommendation for S pyogenes pharyngitis in adults is a single IM dose of benzathine penicillin G 1.2 million U or penicillin V 500 mg qid PO for 10 days. For S pyogenes necrotizing fasciitis in adults, IV penicillin G (up to 24 million U/d in divided doses q4-6h) is recommended.


Clindamycin (Cleocin)

Lincosamide with activity against anaerobic organisms (resistance being seen with Bacteroides fragilis) and most gram-positive cocci (except enterococci and hospital-acquired MRSA). It is bacteriostatic and acts by binding to 23S portion of 50S ribosome and inhibiting elongation of peptide chain by inhibiting transpeptidase reaction.

Adult

600 mg IV q8h or 300-450 mg PO q6h

Pediatric

25-40 mg/kg/d IV divided tid/qid

Increases duration of neuromuscular blockage induced by tubocurarine and pancuronium; erythromycin may antagonize effects (in vitro); antidiarrheals (kaolin-pectin) may delay absorption, while loperamide may increase risk of diarrhea and Clostridium difficile –associated colitis

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis


Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Adult

2-4 million U IV q4h

Pediatric

150,000 U/kg/d IV divided q4h

Probenecid increases serum concentration of PCN; coadministration of tetracyclines can decrease effects

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function; rare side effects include hemolytic anemia, thrombocytopenia, leucopenia, interstitial nephritis, hepatitis; in very rare cases, seizures may occur with higher doses in patients with renal failure


Vancomycin (Lyphocin, Vancocin, Vancoled)

Vancomycin acts by inhibiting proper cell wall synthesis in gram-positive bacteria. Indicated for treatment of serious infections caused by beta-lactam–resistant organisms and in patients who have serious allergies to beta-lactam antimicrobials.

Adult

15 mg/kg IV q12h (dose based on actual body weight); consider 22.5 mg/kg q12h for CNS infections

Pediatric

40 mg/kg/d IV divided tid/qid for 7-10 d

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; when taken concurrently with aminoglycosides, risk of nephrotoxicity may increase; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure; side effects may include thrombocytopenia, neutropenia, eosinophilia, and ototoxicity; red man syndrome is caused by rapid IV infusion (characterized by flushing and pruritus with or without hypotension) and can be avoided by slow infusion (over >1 h)


Telavancin (Vibativ)

Lipoglycopeptide antibiotic that is a synthetic derivative of vancomycin. Inhibits bacterial cell wall synthesis by interfering with polymerization and cross-linking of peptidoglycan. Unlike vancomycin, telavancin also depolarizes the bacterial cell membrane and disrupts its functional integrity. Indicated for complicated skin and skin structure infections caused by susceptible gram-positive bacteria, including Staphylococcus aureus (both methicillin-resistant and methicillin-susceptible strains), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus anginosus group, and Enterococcus faecalis (vancomycin-susceptible isolates only).

Adult

10 mg/kg IV q24h for 7-14 d; infuse over 1 h
CrCl 30-50 mL/min: 7.5 mg/kg/d
CrCl 10-29 mL/min: 10 mg/kg q48h

Pediatric

Not established

Data limited; coadministration with other drugs that prolong QTc interval (eg, phenothiazine, TCAs, macrolide antibiotics, class I and III antiarrhythmic agents) may increase risk for life-threatening arrhythmias

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include taste disturbance, nausea, vomiting, and foamy urine; new-onset or worsening renal impairment has been reported (monitor renal function); efficacy decreased with moderate-to-severe baseline renal impairment (ie, CrCl <50 mL/min); administer over at least 1 h to minimize infusion-related adverse reactions; Clostridium difficile –associated diarrhea may occur; may prolong QTc interval; interferes with coagulation test results, including PT, INR, and aPTT, but does not interfere with coagulation


Penicillin VK (Beepen-VK, Betapen-VK, Pen-Vee K, Robicillin VK, V-Cillin K, Veetids)

Inhibits cell wall biosynthesis.

Adult

500 mg PO bid, tid, or qid for 10 d

Pediatric

250 mg PO bid or tid for 10 d

Tetracyclines decrease the therapeutic effect of PCN; probenecid increases serum PCN level; PCN may increase serum methotrexate level

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with renal impairment; high level of PCN may cause seizure; monitor for neutropenia, hemolytic anemia, and interstitial nephritis

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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References

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  36. Norrby-Teglund A, Muller MP, Mcgeer A, Gan BS, Guru V, Bohnen J, et al. Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis. 2005;37(3):166-72. [Medline].

  37. Pichichero ME. Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment. Ann Emerg Med. Mar 1995;25(3):390-403. [Medline].

  38. Pichichero ME, Disney FA, Talpey WB, et al. Adverse and beneficial effects of immediate treatment of Group A beta- hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J. Jul 1987;6(7):635-43. [Medline].

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  41. Smith A, Lamagni TL, Oliver I. Invasive group A streptococcal disease: should close contacts routinely receive antibiotic prophylaxis?. Lancet Infect Dis. Aug 2005;5(8):494-500. [Medline].

  42. Stevens DL. Invasive group A streptococcus infections. Clin Infect Dis. Jan 1992;14(1):2-11. [Medline].

  43. Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infections associated with a toxic shock- like syndrome and scarlet fever toxin A. N Engl J Med. Jul 6 1989;321(1):1-7. [Medline].

  44. Wilson P, Tierney L. Lemierre syndrome caused by Streptococcus pyogenes. Clin Infect Dis. Oct 15 2005;41(8):1208-9. [Medline].

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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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