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For further information, see CMDT Part 33-01: Streptococcal Infections

Key Features

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

Clinical Findings

  • 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

  • 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

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