What is the recommended treatment for a streptococci group A skin infection?

Treatment of Group A Streptococcal Skin Infections

For Group A streptococcal skin infections, penicillin is the drug of choice, with amoxicillin being preferred in young children due to better taste acceptance at a dosage of 40-50 mg/kg/day divided into 3 doses for 10 days. 1

First-line Treatment Options

For Non-Allergic Patients:

• Oral therapy:

  • Children: Amoxicillin 40-50 mg/kg/day divided into 3 doses for 10 days (maximum 1,000 mg/day) 1, 2
  • Adolescents and adults: Penicillin V 250 mg 3-4 times daily or 500 mg twice daily for 10 days 3

• Parenteral therapy (for severe infections or patients unable to take oral medications):

  • Benzathine penicillin G: 1.2 million units as a single intramuscular dose 3
  • Penicillin G: 2-4 million units every 4-6 hours IV for serious infections 4

For Penicillin-Allergic Patients:

• Erythromycin estolate: 20-40 mg/kg/day divided 2-3 times daily for 10 days 3, 5
• Erythromycin ethylsuccinate: 40 mg/kg/day divided 2-3 times daily for 10 days 3, 5
• Clindamycin: 600-900 mg every 8 hours (for adults) 3

Treatment Considerations

Infection Severity

1. Mild to moderate infections:

   • Oral therapy is generally sufficient
   • Complete the full 10-day course even if symptoms resolve earlier 1

2. Severe infections:

   • Consider parenteral therapy, especially for:
     • Extensive skin involvement
     • Systemic symptoms
     • Inability to take oral medications
     • Poor compliance concerns

Special Populations

• Young children: Amoxicillin is preferred over penicillin V due to better taste acceptance 1
• Immunocompromised patients: Consider broader coverage or higher doses

Duration of Therapy

• A full 10-day course is recommended to eradicate the organism and prevent complications, even if symptoms resolve earlier 3, 1
• Exception: Azithromycin can be given for 5 days if used as an alternative 1

Adjunctive Measures

• Analgesics/antipyretics for moderate to severe symptoms or high fever 1
• Wound care for open lesions
• Avoid corticosteroids as adjunctive therapy 1

Treatment Failures and Recurrences

• Recurrences occur in approximately 20% of cases 1
• For treatment failures:
  1. Consider compliance issues
  2. Evaluate for penicillin-resistant organisms (particularly coexisting Staphylococcus)
  3. Consider switching to a broader-spectrum agent like clindamycin 3

Important Clinical Pearls

1. Recent studies have shown erythromycin may be superior to penicillin for streptococcal skin infections, possibly due to increasing numbers of penicillin-resistant staphylococci found in these lesions 5

2. Testing or treating asymptomatic household contacts is not routinely recommended 1

3. For mixed infections with both streptococci and staphylococci, consider broader coverage with agents effective against both pathogens, such as amoxicillin-clavulanate or clindamycin 6

4. In areas with high prevalence of methicillin-resistant Staphylococcus aureus (MRSA), empiric coverage may need to include agents active against MRSA if there is concern for mixed infection 3

5. Topical antibiotics may be useful in preventing streptococcal pyoderma, especially in children known to be at increased risk for such infection 7