What is the recommended treatment for a patient with strep throat and skin infections?

Treatment of Strep Throat with Concurrent Skin Infections

For patients with both strep throat and skin infections, the recommended treatment is penicillin or amoxicillin for strep throat plus an antibiotic with MRSA coverage (such as clindamycin, trimethoprim-sulfamethoxazole, or doxycycline) for skin infections. 1, 2

Strep Throat Treatment

First-line therapy:

• Penicillin V: 250 mg 2-3 times daily for children; 500 mg 2-3 times daily for adolescents/adults for 10 days 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 3
  • Often preferred over penicillin V due to better palatability, especially for children 1

For penicillin-allergic patients:

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 2
• Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days (if no immediate hypersensitivity to penicillin) 1, 4
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1

It is critical to complete the full 10-day course of antibiotics for strep throat to prevent treatment failure and reduce the risk of rheumatic fever 1

Skin Infection Treatment

For purulent skin infections (abscesses, furuncles, carbuncles):

1. Incision and drainage is the primary treatment 2
2. Antibiotic therapy should be added if:
   • Systemic symptoms are present (fever, extensive lesions)
   • Rapid progression
   • Associated cellulitis
   • Immunocompromised host 2

Recommended antibiotics for skin infections with MRSA coverage:

• Clindamycin: 300-450 mg orally three times daily for 7-14 days 2
• Trimethoprim-sulfamethoxazole: 1-2 DS tablets twice daily for 7-14 days 2
• Doxycycline: 100 mg twice daily for 7-14 days (not for children <8 years) 2

For non-purulent cellulitis:

• Beta-lactam antibiotics (e.g., cephalexin) are appropriate if MRSA is not suspected 2
• If no response to beta-lactams, switch to MRSA-active therapy 2

Combination Therapy Approach

When both strep throat and skin infections are present:

1. For strep throat: Use penicillin or amoxicillin for 10 days 2, 1

2. For skin infections:

   • If purulent: Incision and drainage plus MRSA coverage if indicated 2
   • If non-purulent: Beta-lactam antibiotics 2

3. When a single agent is preferred: Clindamycin is effective against both strep throat and MRSA skin infections 2

Special Considerations

• Children: Adjust dosing based on weight; avoid tetracyclines in children <8 years 2
• Recurrent infections: Consider decolonization strategies with intranasal mupirocin and chlorhexidine body washes 2
• Environmental measures: Clean high-touch surfaces, avoid sharing personal items 2

Monitoring and Follow-up

• Patients should show clinical improvement within 48-72 hours of appropriate therapy
• Continue antibiotics for at least 10 days for strep throat even if symptoms resolve quickly 1
• Consider patients non-contagious after 24 hours of appropriate antibiotic therapy 1

Prevention of Recurrence

For recurrent skin infections:

• Decolonization with intranasal mupirocin twice daily for 5-10 days
• Daily chlorhexidine body washes for 5-14 days
• Regular cleaning of personal items and high-touch surfaces 2

For recurrent strep throat:

• Evaluate for chronic carriage
• Consider tonsillectomy for patients meeting Paradise criteria (≥7 well-documented episodes in one year, ≥5 episodes per year for two years, or ≥3 episodes per year for three years) 1