. 2012 Nov 28:391–401. doi: 10.1016/B978-1-4160-4390-4.00036-9

TABLE 36-4.

Antibiotic Treatment Guidelines for Selected Group A Streptococcus Infections

Rationale	Medication	Evidence^*	Dose	Comments
Group A Streptococcus pharyngitis

• Prevention of acute rheumatic fever in moderate-to-high endemic settings • Prevention of suppurative complications • Alleviation of symptoms • Prevent secondary cases	Oral phenoxymethylpenicillin (penicillin V)	1	10 mg/kg up to 500 mg BD for 10 days	Treatment may be primarily for symptom alleviation unless the risk of sequelae is high

	Oral amoxicillin	1	≤30 kg: 750 mg daily for 10 days >30 kg: 1500 mg daily for 10 days	Not proven to prevent acute rheumatic fever

IM benzathine penicillin G	1	3–6kg: 225 mg 6–10kg: 337.5 mg 10–15kg: 450 mg 15–20kg: 675 mg 20+ kg: 900 mg as a single dose	Preferred where risk of rheumatic fever is high and adherence to oral therapy not assured

Oral roxithromycin^†	1	20 mg/kg up to 500 mg daily for 3 days	If hypersensitive to penicillin

Impetigo

• Alleviate symptoms • Prevent secondary cases • Possibly prevent invasive complications	Topical mupirocin 2% ointment	1	8-hourly for 7 days	Preferred for mild disease, but not proven in high-endemic settings. Use saline, soap water or 0.1% potassium permanganate to remove crusts prior to applying. Strains of Staphylococcus aureus may be resistant or may acquire resistance to topical antibiotics

	Oral di/flucloxacillin	1	12.5 mg/kg up to 500 mg q 6-hourly for 10 days	First-line treatment if multiple lesions and S. aureus is likely

IM benzathine penicillin G	1	3–6kg: 225 mg 6–10kg: 337.5 mg 10–15kg: 450 mg 15–20kg: 675 mg 20+ kg: 900 mg as a single dose	Preferred in endemic settings where risk of acute post-streptococcal glomerulonephritis is high and/or adherence to oral therapy not assured. Exclude S. aureus infection if refractory to treatment

Oral erythromycin	1	12.5 mg/kg up to 500 mg TDS for 10 days	If hypersensitive to penicillin

Erysipelas and cellulitis mild/early

• Alleviate symptoms • Prevent progression • Prevent complications	Oral di/flucloxacillin	1	12.5 mg/kg up to 500 mg q 6-hourly for 7–10 days	Switch to IV therapy if failure to respond and consider resistant pathogens, e.g. methicillin-resistant Staphylococcus aureus (MRSA)
	Oral phenoxymethylpenicillin (penicillin V)	2	10 mg/kg up to 500 mg BD for 10 days	If S. aureus is unlikely (e.g. early erysipelas or perianal cellulitis) or if Group A Streptococcus confirmed on culture. Exclude S. aureus infection if refractory to treatment

	Oral cephalexin	1	12.5 mg/kg up to 500 mg q 8hourly for 7–10 days	If non-immediate type hypersensitivity to penicillins

Oral clindamycin	1	10 mg/kg up to 450 mg q 8-hourly for 7–10days	If immediate type hypersensitivity to penicillin or infection with clindamycin-sensitive MRSA likely
Erysipelas and cellulitis moderate-to-severe

• Alleviate symptoms • Prevent complications	IV di/flucloxacillin	1	50 mg/kg up to 2 g q 6-hourly	Preferred treatment unless MRSA is likely

	IV cephalothin	2	50 mg/kg up to 2 g q 6-hourly	If non-immediate type hypersensitivity to penicillin

IV/Oral clindamycin	1	10 mg/kg up to 450 mg q 8-hourly for 7–10 days	If immediate type hypersensitivity to penicillin or infection with clindamycin sensitive MRSA likely. Bioavailability of clindamycin is high so oral clindamycin can be considered except in infants

IV vancomycin	1	25 mg/kg (<12 yr use 30 mg/kg) up to 1g BD	If infection with clindamycin-resistant MRSA likely. Adjust dose on basis of trough blood levels

Necrotizing fasciitis^§

Prevent death Prevent complications Alleviate symptoms Minimize disfigurement	IV meropenem	5	25 mg/kg up to 1 g q 8-hourly	Broad-spectrum cover is recommended in addition to surgical debridement until Group A Streptococcus infection is confirmed, thereafter penicillin + clindamycin is recommended

	IV benzylpenicillin	2	45 mg/kg up to 1.8 g q 4-hourly	If Group A Streptococcus infection is confirmed. Use in addition to surgical debridement

IV cephalothin	5	50 mg/kg up to 2 g q 6-hourly	If GAS confirmed and non-immediate type hypersensitivity to penicillin. If there is a history of immediate-type hypersensitivity to ß-lactams, seek expert advice

+ IV clindamycin	2	15 mg/kg up to 600 mg q 8-hourly	Use as an adjunct to meropenem or penicillin if Group A Streptococcus infection is suspected or confirmed

Streptococcal toxic shock syndrome (STSS)^§

• Prevent death • Minimize complications	Intravenous immunoglobulin (IVIG)	4	2 g/kg as an immediate infusion, repeated once in 48–72 h if necessary	Use as an adjunct to penicillin and clindamycin therapy +/− debridement as recommended above for necrotizing fasciitis
Acute rheumatic fever treatment

• Alleviate symptoms • Prevent death from acute cardiac failure	Aspirin	1	80–100mg/kg/day (up to 4–8 g/day) in 4–5 divided doses	For the control of pain of acute rheumatic fever arthritis. Duration dependent on clinical response

	IM benzathine penicillin G	5	≤20 kg: 450 mg as a single dose >20 kg: 900 mg as a single dose	Preferred where adherence to oral therapy not assured. Treatment should focus on pain relief with salicylates and management of cardiac failure

	Oral phenoxymethylpenicillin (penicillin V)	5	250 mg BD for 10 days	An acceptable alternative to benzathine penicillin if adherence can be assured, e.g. in hospital

Oral prednisolone	5	1–2 mg/kg/day (up to 80 mg/day)	Not routinely recommended for carditis, but may be considered for severe carditis if surgery is not an option

Carbamazepine	3	7–10 mg/kg/day in 3 divided doses	Not routinely recommended for management of chorea, but may be considered in severe cases

Acute rheumatic fever prophylaxis

• Prevent further episodes of acute rheumatid fever • Prevent progressive carditis	IM benzathine penicillin G	1	<20 kg: 450 mg >20 kg: 900 mg every 3–4 weeks	Preferred regimen. Should be continued for at least 10 years and at least until patient is 21 years old. Patients with established valve disease may require longer duration. Four-weekly injections satisfactory if a good control programme is in place
	Oral phenoxymethylpenicillin (penicillin V)	1	250 mg BD	Associated with inferior adherence. Only where IM injections are refused or risk of progressive carditis very low

Oral erythromycin	5	250 mg BD	If hypersensitive to penicillin. Dose for erythromycin ethyl succinate is 400 mg BD

Level of evidence: 1=randomized controlled trial, 2=comparative clinical study > 20 patients, 3=comparative clinical study < 20 patients, 4=case series, 5=expert opinion on basis of in vitro data or animal studies.

^†

Roxithromycin, semi-synthetic macrolide not commercially available in the USA.

^§

Intravenous immune globulin (IVIG) 2 g/kg as a single infusion, repeated if necessary 24–48 hours later is also recommended for necrotizing fasciitis or other severe invasive Group A Streptococcus infections (e.g. impending STSS). If indicated, IVIG should be administered as early as possible.