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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 streptococci

  • Toxic shock-like syndrome also occurs

Clinical Findings

  • Arthritis generally occurs in association with cellulitis

  • Pneumonia and empyema often are characterized by

    • Extensive tissue destruction

    • Aggressive, rapidly progressive clinical course associated with significant morbidity and mortality

  • Endocarditis (rare)

  • Any streptococcal infection, especially necrotizing fasciitis, can be associated with streptococcal toxic shock syndrome

  • Streptococcal toxic shock syndrome

    • Characterized by

      • Invasion of skin or soft tissues

      • Acute respiratory distress syndrome

      • Kidney failure

    • Persons who are very young, older adults, 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%


  • Culture of affected site or blood


  • Arthritis

    • Penicillin G aqueous, 2 million units intravenously every 4 hours (or cefazolin or vancomycin)

    • Frequent percutaneous needle aspiration to remove joint effusions

    • Open surgical drainage may be necessary in many cases

    • Treatment duration is usually 2–4 weeks

  • Pneumonia/empyema

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

    • Chest tube drainage for treatment of the empyema

    • Vancomycin is an acceptable substitute in penicillin-allergic patients

    • Duration of therapy is guided by clinical improvement, with a minimum of 5 days for pneumonia

    • Adequate drainage is key for the management of empyema, and serial imaging is usually necessary to assess for resolution

  • Endocarditis

    • Penicillin G aqueous, 4 million units intravenously every 4 hours for 4–6 weeks

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

  • Necrotizing fasciitis: early, extensive debridement is essential for survival (see Necrotizing Fasciitis)

  • Streptococcal toxic shock syndrome

    • Penicillin G aqueous, 4 million units intravenously every 4 hours, plus clindamycin, 900 mg intravenously every 8 hours, especially in the presence of shock

    • Intravenous immune globulin can be added: 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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