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Group A -hemolytic streptococci are not normal skin flora Streptococcal skin infections result from colonization of nor-
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Necrotizing fasciitis is a rapidly spreading infection involving the fascia of deep muscle The clinical findings at presentation may be those of severe cellulitis, but the presence of systemic toxicity and severe pain, which may be followed by anesthesia of the involved area due to destruction of nerves as infection advances through the fascial planes, is a clue to the diagnosis Surgical exploration is mandatory when the diagnosis is suspected Early and extensive debridement is essential for survival Any streptococcal infection and necrotizing fasciitis in particular can be associated with streptococcal toxic shock syndrome, typified by invasion of skin or soft tissues, acute respiratory distress syndrome, and renal failure The very young, the elderly, and those with underlying medical conditions are at particularly high risk for invasive disease Bacteremia occurs in most cases Skin rash and desquamation may not be present Mortality rates can be up to 80% The syndrome is due to elaboration of pyrogenic erythrotoxin (which also causes scarlet fever), a superantigen that stimulates massive release of inflammatory cytokines believed to mediate the shock A -lactam remains the drug of choice for treatment of serious streptococcal infections, but clindamycin, which is a potent inhibitor of toxin production, should also be administered at a dose of 600 mg every 8 hours intravenously for invasive disease, especially in the presence of shock Intravenous immune globulin has also been recommended for streptococcal toxic shock syndrome for presumed, although unproven, therapeutic benefit from specific antibody to streptococcal exotoxins in immune globulin preparations Two dosage regimens have been used: 450 mg/kg once daily for 5 days or a single dose of 2 g/kg with a repeat dose at 48 hours if the patient remains unstable Outbreaks of invasive disease have been associated with colonization by invasive clones that can be transmitted to close contacts who, though asymptomatic, may be a reservoir for disease Tracing contacts of patients with invasive disease is controversial
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Stevens DL et al; Infectious Diseases Society of America Practice guidelines for the diagnosis and management of skin and soft-tissue infections Clin Infect Dis 2005 Nov 15;41(10): 1373 406 [PMID: 16231249] Vinh DC et al Rapidly progressive soft tissue infections Lancet Infect Dis 2005 Aug;5(8):501 13 [PMID: 16048719]
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recommend the addition of low-dose gentamicin, 1 mg/kg every 8 hours Viridans streptococci, which are nonhemolytic or hemolytic (ie, producing a green zone of hemolysis on blood agar), are part of the normal oral flora Although these strains may produce focal pyogenic infection, they are most notable as the leading cause of native valve endocarditis (see below) Group D streptococci include Streptococcus bovis and the enterococci S bovis is a cause of endocarditis in association with bowel neoplasia or cirrhosis and is treated like viridans streptococci
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Edwards MS et al Group B streptococcal infections in elderly adults Clin Infect Dis 2005 Sep 15;41(6):839 47 [PMID: 16107984]
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ENTEROCOCCAL INFECTIONS
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Two species, Enterococcus faecalis and Enterococcus faecium, are responsible for most human enterococcal infections Enterococci cause wound infections, urinary tract infections, bacteremia, and endocarditis Infections caused by penicillinsusceptible strains should be treated with penicillin 3 4 million units every 4 hours; ampicillin 3 g every 6 hours; or if the patient is penicillin-allergic, vancomycin 15 mg/kg every 12 hours intravenously If the patient has endocarditis, meningitis, or osteomyelitis, gentamicin 1 mg/kg every 8 hours intravenously should be added to the regimen in order to achieve the bactericidal activity that is required to cure these infections Resistance to vancomycin, penicillin, and gentamicin is common among enterococcal isolates, especially E faecium; it is essential to determine antimicrobial susceptibility of isolates Infection control measures that may be indicated to limit their spread include isolation, barrier precautions, and avoidance of overuse of vancomycin and gentamicin Consultation with an infectious diseases specialist is strongly advised when treating infections caused by resistant strains of enterococci Quinupristin/dalfopristin and linezolid are approved by the US Food and Drug Administration (FDA) for treatment of infections caused by vancomycin-resistant strains of enterococci Quinupristin/dalfopristin is not active against strains of E faecalis and should be used only for infections caused by E faecium The dose is 75 mg/kg intravenously every 8 12 hours Phlebitis and irritation at the infusion site (often requiring a central line) and an arthralgia-myalgia syndrome are relatively common side effects Quinupristin/ dalfopristin is an inhibitor of cytochrome P450 enzyme 3A4 and has numerous, important drug interactions Linezolid, an oxazolidinone, is active against both E faecalis and E faecium The dose is 600 mg twice daily, and both intravenous and oral preparations are available Its two principal side effects are thrombocytopenia and bone marrow suppression Emergence of resistance has occurred during therapy with either quinupristin/dalfopristin or linezolid
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McDonald JR et al Enterococcal endocarditis: 107 cases from the international collaboration on endocarditis merged database Am J Med 2005 Jul;118(7):759 66 [PMID: 15989910] Rice LB Antimicrobial resistance in gram-positive bacteria Am J Med 2006 Jun;119(6 Suppl 1):S11 19 [PMID: 16735146]
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