Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50

1384 Streptococcal Infections

■Prompt evaluation for surgical exploration in cases of suspected

necrotizing fasciitis can be life-saving

General Measures

■General supportive care

specific therapy

Treatment Options

■The antibiotic of choice for serious streptococcal infections remains

penicillin, with some exceptions.

■For serious streptococcal skin infections, may need to treat as pos-

sible staphylococcal infection (Cefazolin 500 mg IV TID or with Naf-

cillin 1.5 g IV QID). Treat with parental antibiotics for facial erysi-

pelas: Penicillin 2 million units IV q4h. For patients with serious

penicillin allergy, Vancomycin1gIVq12h is used.

■In necrotizing fasciitis and other conditions that lead to strepto-

coccal toxic shock syndrome, some advocate the addition of clin-

damycin (may suppress exotoxin production by group A streptococ-

cus).

■For endocarditis caused by the viridans streptococci and S. bovis,

gentamicin is added for the duration of therapy at synergistic doses

(1 mg/kg IV q8h for 4–6 weeks)

■For S. pneumoniae, increasing penicillin-resistance (MIC > 0.1) may

necessitate high-dose penicillin therapy. High level resistance (MIC

> 2.0) should be treated with Ceftriaxone or a fluoroquinolone such

as levofloxacin.

■In meningitis, Vancomycin is now indicated as empiric therapy with

Ceftriaxone, given the increasing prevalence of penicillin-resistant

pneumococcus.

■In streptococcal pharyngitis, therapy has a minimal effect on reso-

lution of symptoms but prevent complications; consider treatment

if clinical suspicion high even before definitive diagnosis by culture;

benzathine penicillin G 1.2 million units IM X1 is preferred or peni-

cillin V potassium 500 mg po QID for 10 days

■Control of rheumatic fever involves both treatment of primary strep-

tococcal pharyngitis and secondary prevention of recurrent disease;

patients who have had rheumatic fever need prophylaxis for at least

5 years (1.2 million unit q 4 weeks IM or 250 mg po BID)

follow-up

■Routine follow-up depending on the disease