Streptococcal Infections

GABHS are the most common cause of acute-onset bacterial pharyngitis. Other bacterial causes include groups C and G streptococci and Fusobacterium necrophorum. Most patients with GABHS pharyngitis are children between 3 years and 14 years of age who present with acute onset of sore throat, fever, beefy-red pharynx, and purulent tonsillar exudate. GABHS pharyngitis is rare in children younger than 3 years of age.

The cervical and submaxillary nodes may enlarge and become tender. Streptococcal pharyngitis can lead to peritonsillar abscess Peritonsillar Abscess and Cellulitis Peritonsillar abscess and cellulitis are acute pharyngeal infections most common among adolescents and young adults. Symptoms are severe sore throat, trismus, "hot potato" voice, and uvular... read more . Cough, laryngitis, and stuffy nose are not characteristic of streptococcal pharyngeal infection; their presence suggests another cause (usually viral or allergic).

Humans are the primary reservoir for group A streptococci, which spread person-to-person via saliva or nasal secretions from an infected person. An asymptomatic carrier state may exist in as many as 20% of people.

Scarlet fever, a predominantly childhood disease, usually follows a pharyngeal streptococcal infection; less commonly, it follows streptococcal infections at other sites (eg, the skin). Scarlet fever is caused by group A streptococcal strains that produce an erythrogenic toxin, leading to a diffuse pink-red cutaneous flush that blanches with pressure.

The rash is seen best on the abdomen or lateral chest and as dark red lines in skinfolds (Pastia lines) or as circumoral pallor. The rash consists of characteristic numerous small (1- to 2-mm) papular elevations, giving a sandpaper quality to the skin. The upper layer of the previously reddened skin often desquamates after fever subsides. The rash usually lasts 2 to 5 days.

Transmission of scarlet fever is enhanced in environments that result in close contact among people (eg, in schools or day care centers).

Scarlet fever is not as common as it was in the past, but in recent years there have been a number of significant outbreaks in the United States, Europe, and China. For example, since 2014 there has been an unprecedented and persistent increase in scarlet fever in England with the highest incidence for nearly 50 years. Over a century ago, scarlet fever was feared as a potentially lethal disease. Its mortality and morbidity waned, however, well before antibiotics became available. Since the advent of antibiotic therapy, the mortality rate of treated scarlet fever is < 1% (1 Scarlet fever reference Streptococci are gram-positive aerobic organisms that cause many disorders, including pharyngitis, pneumonia, wound and skin infections, sepsis, and endocarditis. Symptoms vary with the organ... read more ).

A strawberry tongue (inflamed papillae protruding through a bright red coating) also occurs and must be differentiated from that seen in toxic shock syndrome Toxic Shock Syndrome (TSS) Toxic shock syndrome is caused by staphylococcal or streptococcal exotoxins. Manifestations include high fever, hypotension, diffuse erythematous rash, and multiple organ dysfunction, which... read more and Kawasaki disease Kawasaki Disease Kawasaki disease is a vasculitis, sometimes involving the coronary arteries, that tends to occur in infants and children between the ages of 1 year and 8 years. It is characterized by prolonged... read more .

Other symptoms are similar to those in streptococcal pharyngitis, and the course and management of scarlet fever are the same as those of other group A infections.

Skin infections include

Impetigo is a superficial skin infection that causes crusting or bullae.

Erysipelas Erysipelas Erysipelas is a type of superficial cellulitis with dermal lymphatic involvement. Diagnosis is clinical. Treatment is with oral or parenteral antibiotics. (See also Overview of Bacterial Skin... read more is a superficial cellulitis that also involves the lymphatics. Patients have shiny, red, raised, indurated lesions with distinct margins. It is most often caused by GABHS, but other streptococcal and nonstreptococcal organisms are sometimes involved.

Cellulitis Cellulitis Cellulitis is acute bacterial infection of the skin and subcutaneous tissue most often caused by streptococci or staphylococci. Symptoms and signs are pain, warmth, rapidly spreading erythema... read more involves the deeper layers of skin and may spread rapidly because of the numerous lytic enzymes and toxins produced mainly by group A streptococci.

Necrotizing fasciitis Necrotizing Soft-Tissue Infection Necrotizing soft-tissue infection is typically caused by a mixture of aerobic and anaerobic organisms that cause necrosis of subcutaneous tissue, usually including the fascia. This infection... read more due to S. pyogenes is a severe dermal (and sometimes muscle) infection that spreads along fascial planes. Inoculation originates through the skin or bowel.

Necrotizing fasciitis is prevalent among people who use injection drugs.

Formerly known as streptococcal gangrene and popularized as the flesh-eating bacteria, the same syndrome may also be polymicrobial, involving a host of aerobic and anaerobic flora, including Clostridium perfringens. Polymicrobial infection is likely when the source is the bowel (eg, after intestinal surgery, bowel perforation, diverticulitis, or appendicitis).

Symptoms of necrotizing fasciitis begin with fever and exquisite localized pain out of proportion to physical findings; pain increases rapidly over time and is often the first (and sometimes only) manifestation. Diffuse or local erythema may be present. Thrombosis of the microvasculature causes ischemic necrosis, leading to rapid spread and disproportionally severe toxicity. In 20 to 40% of patients, adjacent muscles are invaded. Shock and renal dysfunction are common. Mortality is high, even with treatment.

Streptococcal toxic shock syndrome Streptococcal toxic shock Toxic shock syndrome is caused by staphylococcal or streptococcal exotoxins. Manifestations include high fever, hypotension, diffuse erythematous rash, and multiple organ dysfunction, which... read more (TSS), similar to that caused by S. aureus, may result from toxin-producing strains of GABHS and occasionally from other streptococci.

Patients are usually otherwise healthy children or adults with skin and soft-tissue infections. Predisposing risk factors for TSS in patients infected with these toxin-producing strains include diabetes, alcohol use disorder, penetrating and nonpenetrating trauma, surgical procedures, and varicella infection.

An initial influenza-like prodrome is followed by high fever, tachycardia, tachypnea, and severe pain. Tissue necrosis, shock, disseminated coagulation, and multisystem organ failure follow.

The mechanism by which certain strains of GABHS cause delayed complications is unclear but may involve cross-reactivity of streptococcal antibodies against host tissue.

Rheumatic fever Rheumatic Fever Rheumatic fever is a nonsuppurative, acute inflammatory complication of group A streptococcal pharyngeal infection, causing combinations of arthritis, carditis, subcutaneous nodules, erythema... read more , an inflammatory disorder, occurs in < 3% of patients in the weeks after untreated GABHS pharyngitis. It has become much less common in developed countries, but incidence is still high in resource-limited regions.

Diagnosis of a first episode is based on a combination of arthritis, carditis, chorea, specific cutaneous manifestations, and laboratory test results (Jones criteria—see table ).

One of the most important reasons for treating GABHS pharyngitis (strep throat) is to prevent rheumatic fever.

Poststreptococcal acute glomerulonephritis Postinfectious Glomerulonephritis (PIGN) Postinfectious glomerulonephritis occurs after infection, usually with a nephritogenic strain of group A beta-hemolytic streptococcus. Diagnosis is suggested by history and urinalysis and confirmed... read more is an acute nephritic syndrome following pharyngitis or skin infection due to a certain limited number of nephritogenic strains of GABHS (eg, M protein serotypes 12 and 49). After a throat or skin infection with one of these strains, about 10 to 15% of patients develop acute glomerulonephritis. It is most common among children, occurring 1 to 3 weeks after infection. Nearly all children, but somewhat fewer adults, recover without permanent renal damage. Antibiotic treatment of GABHS infection has little effect on the development of glomerulonephritis.

PANDAS syndrome (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections) refers to a subset of obsessive disorders in children Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents Obsessive-compulsive disorder is characterized by obsessions, compulsions, or both. Obsessions are irresistible, persistent ideas, images, or impulses to do something. Compulsions are pathologic... read more or tic disorders in children Tic Disorders and Tourette Syndrome in Children and Adolescents Tics are defined as repeated, sudden, rapid, nonrhythmic muscle movements including sounds or vocalizations. Tourette syndrome is diagnosed when people have had both motor and vocal tics for... read more that is thought to be exacerbated by GABHS infection.

Certain forms of psoriasis Psoriasis Psoriasis is an inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with silvery scales. Multiple factors contribute, including... read more (eg, guttate) may also be related to beta-hemolytic streptococcal infections.

(See also the Infectious Diseases Society of America’s 2012 Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis and the American Heart Association's 2020 Contemporary Diagnosis and Management of Rheumatic Heart Disease statement.)

Ordinarily, pharyngeal GABHS infections, including scarlet fever, are self-limited. Antibiotics shorten the course in young children, especially those with scarlet fever, but have only modest effect on symptoms in adolescents and adults. However, antibiotics help prevent local suppurative complications (eg, peritonsillar abscess), otitis media, and rheumatic fever.

Penicillin is the drug of choice for pharyngeal GABHS infections. No isolate of GABHS has shown penicillin resistance clinically. However, some streptococcal strains appear to have in vitro tolerance to penicillin (ie, significantly decreased bactericidal effect of penicillin); the clinical significance of such strains is unclear.

A single injection of benzathine penicillin G 600,000 units IM for small children (< 27 kg) or 1.2 million units IM for children weighing ≥ 27 kg, adolescents, and adults usually suffices.

Oral medications may be used if the patient can be trusted to maintain the regimen for the required 10 days. Choices include

Oral narrow-spectrum cephalosporins (eg, cephalexin, cefadroxil) are also effective and can be used unless patients have an anaphylactic reaction to penicillin. Azithromycin can be used for a 5-day course of therapy, although macrolides are inactive against Fusobacterium necrophorum, a common cause of pharyngitis in adolescents and adults. Delaying treatment 1 to 2 days until laboratory confirmation increases neither the duration of disease nor the incidence of complications.

When penicillin and a beta-lactam are contraindicated, choices include

Because resistance of GABHS to macrolides has been detected, some authorities recommend in vitro confirmation of susceptibility if a macrolide is to be used and there is macrolide resistance in the community. Clindamycin 7 mg/kg orally every 8 hours is preferred in children who have relapses of chronic tonsillitis, possibly because of the following:

Amoxicillin/clavulanate is also effective.

Trimethoprim/sulfamethoxazole (TMP/SMX), some of the fluoroquinolones, and tetracyclines are unreliable for treating GABHS infection.

Sore throat, headache, and fever can be treated with analgesics or antipyretics. Aspirin should be avoided in children. Bed rest and isolation are unnecessary. Close contacts who are symptomatic or have a history of poststreptococcal complications should be examined for streptococci.

Cellulitis is often treated without doing a culture because isolating organisms can be difficult. Thus, regimens effective against both streptococci and staphylococci are used; for example, one of the following may be used:

Necrotizing fasciitis should be treated in an intensive care unit. Extensive (sometimes repeated) surgical debridement is required. A recommended initial antibiotic regimen is a broad-spectrum beta-lactam (eg, piperacillin/tazobactam) or a carbapenem (eg, meropenem, imipenem) (until etiology is confirmed by culture) plus clindamycin. Vancomycin should be added if infection with MRSA is suspected. Although streptococci remain susceptible to beta-lactam antibiotics, animal studies show that penicillin is not always effective against a large bacterial inoculum because the streptococci are not rapidly growing and may lack penicillin-binding proteins, which are the target of penicillin activity.

For treating groups B, C, and G infections, antibiotics of choice are

Cephalosporins or macrolides are usually effective, but susceptibility tests must guide therapy, especially in very ill, immunocompromised, or debilitated people and in people with foreign bodies at the infection site. Surgical wound drainage and debridement as adjuncts to antimicrobial therapy may be lifesaving.

S. gallolyticus (formerly S. bovis) is relatively susceptible to antibiotics. Although vancomycin-resistant S. gallolyticus isolates have been reported, the organism remains susceptible to penicillin and aminoglycosides.

Most viridans streptococci are susceptible to penicillin G and other beta-lactams. Resistance is growing, and therapy for such strains should be dictated by results of in vitro susceptibility tests.