Spectrum: Local Antimicrobial Stewardship, for Prisma Health Children’s Hospital-Midlands

Streptococcus pyogenes / Group A Strep

Precautions

See 'Additional Information'
See 'Additional Information'

Susceptibilities

Susceptibilities

General Susceptibilities

General Information

First Line Treatment

First Line Treatment

General

  • Penicillin G or Amoxicillin

Pharyngitis

  • Amoxicillin or Penicillin G x 10 days

Erysipelas/Cellulitis

  • Penicillin G or amoxicillin

Toxic Shock Syndrome (TSS) or Necrotizing Fasciitis

  • Clindamycin + Penicillin G

  • Stop clindamycin once clinically improved for TSS

  • Continue clindamycin for entire treatment duration if necrotizing fasciitis

Bacteremia

  • Clindamycin + Penicillin G

  • Stop clindamycin once blood is cleared

Pneumonia

  • Penicillin G or Amoxicillin

Alternate Treatment

Alternate Treatment

General

  • Beta-lactam allergy: Clindamycin

Pharyngitis

  • Penicillin G benzathine IM x 1 dose - If can't ensure adherence to PO

  • Cephalexin - If amoxicillin within 4 weeks (recurrent disease)

  • Cefdinir or cefuroxime - If allergy to amoxicillin or cephalexin

  • Clindamycin - If unspecified beta-lactam allergy

Erysipelas/Cellulitis

  • Cefazolin - If allergy to Penicillin

  • Clindamycin - If unspecified beta-lactam allergy

Toxic Shock Syndrome

  • Clindamycin + Ceftriaxone - If allergy to penicillin

Pneumonia

  • Cefazolin - If allergy to Penicillin

  • Clindamycin - If unspecified beta-lactam allergy

Pathogen information

Pathogen information

  • Gram positive cocci in chains, beta-hemolytic

  • Pyrogenic exotoxin producing strains

Associated syndromes

Associated syndromes

Respiratory Infections

  • Tonsillopharyngitis (“Strep Throat”): most common in children >3 years old

    • Incubation period: 2-5 days

  • Scarlet fever: in associated w/ pharyngitis, erythematous sandpaper-like rash caused by GAS produced exotoxins

  • Purulent complications: otitis media, sinusitis, peritonsillar and retropharyngeal abscesses, suppurative cervical adenitis

Skin Infections

  • Impetigo: Incubation period 7-10 days

    • Characteristic honeycomb-like crusts after pustular lesions break vs S. aureus paper-like crusts
    • Not associated w/ fever

  • Cellulitis (erysipelas): bright red appearance of skin, demarcation from normal surrounding skin

    • Associated w/ fever

  • Necrotizing fasciitis: infection via trauma to tissue or via bowel flora

Invasive infections

Entry site is skin or mucous membranes

  • Pneumonia and empyema

  • Bacteremia

  • Endocarditis

  • Pericarditis

  • Septic arthritis

  • Osteomyelitis

  • Myositis

  • Surgical site infection

  • Streptococcal toxic shock syndrome (STSS): toxin-producing GAS strains and manifests in acute illness

  • Fever, erythroderma, rapid-onset hypotension, signs of multiorgan involvement

Postinfectious Syndromes

  • Acute rheumatic fever (ARF)

  • Poststreptococcal glomerulonephritis (PSGN)

Additional Information

Additional Information

Precautions

  • School pharyngitis outbreaks due to contact with respiratory secretions

  • Droplet precautions: GAS pharyngitis and pneumonia until 24 hours after appropriate antimicrobial therapy

  • Contact precautions: Burns with secondary GAS infection and extensive draining/cutaneous infection that is not covered or contained by dressings; for 24 hours after appropriate antimicrobial therapy

Treatment Notes

  • Adding Clindamycin for toxic shock syndrome/sepsis: Inhibits protein synthesis to suppress toxin production

  • Linezolid is an alternative to clindamycin for toxin production inhibition

  • Not reasonable to treat colonization unless symptomatic pharyngitis

  • TMP/SMX (Bactrim) may be effective for mild cases of cellulitis if staph is still a concern in the outpatient setting