Streptococcal, Group A Infections

Arthritis, pneumonia, empyema, endocarditis, and necrotizing fasciitis are relatively uncommon infections that may be caused by group A beta-hemolytic streptococci

Arthritis generally occurs in association with cellulitis

Pneumonia and empyema often are characterized by

• Extensive tissue destruction

• Aggressive, rapidly progressive clinical course

Endocarditis (rare)

• Should be suspected when bacteremia accompanies pneumonia, particularly if the patient uses injection drugs

• Tricuspid valve is most commonly involved

Necrotizing fasciitis

• Rapidly spreading infection involving the fascia of deep muscle

• Clinical findings at presentation range from severe cellulitis to systemic toxicity and severe pain

Any streptococcal infection, especially necrotizing fasciitis, can be associated with streptococcal toxic shock syndrome, characterized by invasion of skin or soft tissues, acute respiratory distress syndrome, and kidney failure

Culture of affected site or blood

Arthritis

• Penicillin G aqueous, 2 million units every 4 hours intravenously

• Frequent percutaneous needle aspiration

Pneumonia/empyema

• Penicillin G aqueous, 4 million units every 4 hours intravenously

• Chest tube drainage for treatment of the empyema

Endocarditis

• Penicillin G aqueous, 4 million units every 4 hours intravenously for 4 weeks

• Vancomycin, 1 g intravenously every 12 hours, is recommended for persons allergic to penicillin

Necrotizing fasciitis: early, extensive débridement is essential for survival

Toxic shock syndrome

• Penicillin G aqueous 4 million units every 4 hours intravenously

• Consider the addition of clindamycin, 600 mg every 8 hours intravenously, to halt toxin production, and intravenous immune globulin, 0.5 g/kg once daily for 5–6 days or a single dose of 2 g/kg with a repeat dose at 48 hours if the patient remains unstable