Streptococcus Group A Infections Treatment & Management

  • Author: Zartash Zafar Khan, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 12, 2012
 

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.[20]
  • 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.[21]
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Surgical Care

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

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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.
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Contributor Information and Disclosures
Author

Zartash Zafar Khan, MD  Infectious Disease Consultant

Zartash Zafar Khan, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and International Society for Infectious Diseases

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle R Salvaggio, MD, FACP  Assistant Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine; Medical Director of Infectious Diseases Institute, Director, Clinical Trials Unit, Director, Ryan White Programs, Department of Medicine, University of Oklahoma Health Sciences Center; Attending Physician, Infectious Diseases Consultation Service, Infectious Diseases Institute, OU Medical Center

Michelle R Salvaggio, MD, FACP 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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.

Additional Contributors

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

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Streptococcus group A infections. Necrotizing fasciitis rapidly progresses from erythema to bullae formation and necrosis of skin and subcutaneous tissue.
Streptococcus group A infections. Beta hemolysis is demonstrated on blood agar media.
Streptococcus group A infections. M protein.
Streptococcus group A infections. Erysipelas is a group A streptococcal infection of skin and subcutaneous tissue.
Streptococcus group A infections. White strawberry tongue observed in streptococcal pharyngitis. Image courtesy of J. Bashera, eMedicine, Inc.
Streptococcus group A infections. Streptococcal rash. Image courtesy of J. Bashera, eMedicine, Inc.
Group A Streptococcus on Gram stain of blood isolated from a patient who developed toxic shock syndrome.
Streptococcus group A infections. Necrotizing fasciitis of the left hand in a patient who had severe pain in the affected area.
Streptococcus group A infections. Patient who had had necrotizing fasciitis of the left hand and severe pain in the affected area (from Image 8). This photo was taken at a later date, and the wound is healing. The patient required skin grafting.
Streptococcus group A infections. Gangrenous streptococcal cellulitis in a patient with diabetes.
Erythema secondary to group A streptococcal cellulitis.
 
 
 
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