Treating serious STREP infections

Continue to use oral penicillin or amoxicillin for strep throat. Or consider benzathine penicillin G IM x 1, if PO adherence is a concern....

Overview

As a clinical pharmacist, The uptick in severe cases will raise questions about how to treat Group A strep. We generally think of this bug causing strep throat, or skin infections. Most cases are mild, or some patients are asymptomatic carriers. But there’s a rise in serious infections, such as necrotizing fasciitis and toxic shock syndrome. The increase may be due to getting back to normal after COVID-19 with less social distancing, etc, on top of surges in flu and RSV. Viral illness can set patients up for bacterial infections.

Management

ED patients

Continue to use oral penicillin or amoxicillin for strep throat. Or consider benzathine penicillin G IM x 1, if PO adherence is a concern. For mild cellulitis or other nonpurulent skin infections, use oral antibiotics (penicillin, cephalexin, etc).

Reinforce to finish the 10-day course for strep throat, to possibly limit progression to invasive infections or complications (rheumatic fever, etc).

But 5 days is often enough for skin infections.

Use amoxicillin/clavulanate if needed due to shortages. Or think of cephalexin for a nonsevere penicillin allergy (non-itchy rash).
For more severe penicillin allergies (hives, anaphylaxis), use clindamycin, or 5 days of azithromycin for strep throat.

Hospitalized patients

In many severe cases, be ready to manage sepsis using fluids, pressors, etc. For Group A strep necrotizing fasciitis OR toxic shock syndrome, generally give penicillin G IV every 4 to 6 hours plus clindamycin IV every 6 to 8 hours to decrease toxin production. For a mild penicillin allergy, generally turn to cefazolin plus clindamycin. Work with the physician to determine the best regimen for more severe allergies. Expect patients to need lengthy antibiotic courses, often 14 days or more. Reinforce IV-to-po switches as patients improve. Help ensure isolates of severe Group A strep in patients under age 18, or clusters of cases in any age, are submitted to CDC.

References

emergency.cdc.gov. (2022). HAN Archive - 00484 | Health Alert Network (HAN). [online] Available at: https://emergency.cdc.gov/han/2022/han00484.asp.
Anon (2019). Group A Strep. [online] Available at: https://www.cdc.gov/groupastrep/index.html
Sanford Guide Web Edition. (2023). Sanford Guide Web Edition. [online] Available at: https://webedition.sanfordguide.com/en/sanford-guide-online/disease-clinical-condition/streptococcus-pyogenes-streptococcus-beta-hemolytic.
Shulman ST, Bisno AL, et al. Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov 15;55(10):e86-102.