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Clinical Findings
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A Symptoms and Signs
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Impetigo is a focal, vesicular, pustular lesion with a thick, amber-colored crust with a stuck-on appearance Erysipelas is a painful superficial cellulitis that frequently involves the face It is well demarcated from the surrounding normal skin It affects skin with impaired lymphatic drainage, such as edematous lower extremities or wounds
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B Laboratory Findings
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Cultures obtained from a wound or pustule are likely to grow group A streptococci Blood cultures are occasionally positive
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Benzathine penicillin G, 12 million units intramuscularly as a single dose, is optimal therapy
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Treatment
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Parenteral antibiotics are indicated for patients with facial erysipelas or evidence of systemic infection Penicillin, 2 million units intravenously every 4 hours, is the drug of choice However, staphylococci infections may at times be difficult to differentiate from streptococcal infections In practice, initial therapy for patients with risk factors for Staphylococcus aureus (eg, injection drug use, diabetes, wound infection) should cover this organism Nafcillin, 15 g every 6 hours intravenously, and cefazolin, 1 g intravenously or intramuscularly every 8 hours, are reasonable choices In the patient with a serious penicillin allergy (ie, anaphylaxis), vancomycin, 1000 mg intravenously every 12 hours, should be used Patients who do not require parenteral therapy may be treated with amoxicillin, 750 mg twice daily for 7 10 days A first-generation oral cephalosporin, eg, cephalexin, 500 mg four times daily, or clindamycin, 300 mg orally three times daily, is an alternative to amoxicillin
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Penicillin VK, 500 mg orally four times a day (or amoxicillin, 750 mg orally twice daily), is effective, but compliance may be poor after the patient becomes asymptomatic in 2 4 days
C Macrolides
Erythromycin, 500 mg orally four times a day, or azithromycin, 500 mg orally once daily for 3 days, is an alternative for the penicillin-allergic patient Macrolides are less effective than penicillins and are considered second-line agents Macrolide-resistant strains almost always are susceptible to clindamycin, a suitable alternative to penicillins; a 10-day course of 300 mg orally twice daily is effective
Prevention of Recurrent Rheumatic Fever
Effectively controlling rheumatic fever depends on identification and treatment of primary streptococcal infection and secondary prevention of recurrences Patients who have had rheumatic fever should be treated with a continuous course of antimicrobial prophylaxis for at least 5 years Effective regimens are erythromycin, 250 mg orally twice daily, or penicillin G, 500 mg orally daily
Mahakit P et al Oral clindamycin 300 mg BID compared with oral amoxicillin/clavulanic acid 1 g BID in the outpatient treatment of acute recurrent pharyngotonsillitis caused by group a beta-hemolytic streptococci: an international, multicenter, randomized, investigator-blinded, prospective trial in patients between the ages of 12 and 60 years Clin Ther 2006 Jan;28(1):99 109 [PMID: 16490583] Smith A et al Invasive group A streptococcal disease: should close contacts routinely receive antibiotic prophylaxis Lancet Infect Dis 2005 Aug;5(8):494 500 [PMID: 16048718]
3 Other Group A Streptococcal Infections
Arthritis, pneumonia, empyema, endocarditis, and necrotizing fasciitis are relatively uncommon infections that may be caused by group A streptococci Toxic shock-like syndrome also occurs Arthritis generally occurs in association with cellulitis In addition to intravenous therapy with penicillin G, 2 million units every 4 hours (or cefazolin or vancomycin in doses recommended above for penicillin-allergic patients), frequent percutaneous needle aspiration should be performed to remove joint effusions Open surgical drainage may be necessary when the hip or shoulder is infected Pneumonia and empyema often are characterized by extensive tissue destruction and an aggressive, rapidly progressive clinical course associated with significant morbidity and mortality High-dose penicillin and chest tube drainage are indicated for treatment of empyema Vancomycin is an acceptable substitute in penicillin-allergic patients Group A streptococci can cause endocarditis Endocarditis should be treated with 4 million units of penicillin G intravenously every 4 hours for 4 6 weeks Vancomycin, 1 g intravenously every 12 hours, is recommended for persons allergic to penicillin
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