What are the guidelines for Group A Streptococcus (GAS) bacteremia?

From the Guidelines

Group A Streptococcus (GAS) bacteremia requires prompt treatment with intravenous antibiotics, and penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis. The treatment guidelines for GAS bacteremia prioritize the use of broad-spectrum antibiotics, such as vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, due to the potential for polymicrobial or monomicrobial infections 1.

Key Recommendations

• Prompt surgical consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene (strong, low) 1.
• Empiric antibiotic treatment should be broad, covering mixed aerobic-anaerobic microbes or monomicrobial infections, including group A streptococci and community-acquired MRSA (strong, low) 1.
• Penicillin plus clindamycin is the recommended treatment for documented group A streptococcal necrotizing fasciitis (strong, low) 1.

Treatment Considerations

• Treatment duration should be at least 10-14 days, with longer courses of 2-3 weeks recommended for complicated cases involving endocarditis, osteomyelitis, or other deep tissue infections.
• Blood cultures should be repeated to confirm clearance of bacteremia.
• For severe invasive infections like necrotizing fasciitis or streptococcal toxic shock syndrome, combination therapy with penicillin plus clindamycin is recommended, as clindamycin inhibits toxin production.
• Surgical consultation is essential for cases with deep tissue involvement, and source control through drainage of abscesses or debridement of necrotic tissue is crucial.
• Supportive care, including fluid resuscitation and vasopressors, may be necessary for patients with shock, and close monitoring for complications such as endocarditis, septic arthritis, or metastatic abscesses is important, with echocardiography recommended for persistent bacteremia or signs of cardiac involvement.

From the FDA Drug Label

Antibiotic therapy for Group A β-hemolytic streptococcal infections should be maintained for at least 10 days to reduce the risk of rheumatic fever.

The guidelines for Group A Streptococcus (GAS) bacteremia recommend antibiotic therapy for at least 10 days to reduce the risk of rheumatic fever. The specific dosage is not directly stated for GAS bacteremia, but for serious infections due to susceptible strains of streptococci, the dosage is 150,000 - 300,000 units/kg/day divided in equal doses every 4 to 6 hours. 2

From the Research

Guidelines for Group A Streptococcus (GAS) Bacteremia

• The use of clindamycin in combination with benzylpenicillin has been shown to be of benefit in the treatment of GAS bacteremia 3
• Penicillin remains the antibiotic of choice when treating invasive GAS infections, and clinicians should consider adding clindamycin to the beta-lactam antibiotic regimen when necrotizing fasciitis or myositis is present 4
• Treatment with clindamycin reduced extracellular DNase Sda1 and streptolysin O (SLO) activity in vivo, and it is recommended to administer clindamycin as soon as possible to patients with necrotizing fasciitis 5
• Therapy for necrotizing fasciitis consists of definitive excisional surgical debridement in conjunction with high-dose intravenous penicillin G and clindamycin 6
• Risk factors for mortality include advanced age, underlying illness, hypotension, and bacteremia, and overall mortality remains high (20% to 34% in larger series) 6

Management of Contacts

• Conflicting recommendations regarding antibiotic prophylaxis for contacts of patients with invasive group A streptococcal (GAS) infection exist, and a practical approach includes an educational campaign and targeted antibiotic treatment to close contacts who have been exposed to an index patient for > 24 hours/week before the initial disease onset 7
• The presence of GAS strains in close contacts can be determined by pharyngeal culture testing, and the same clone was present in the throat of 36% of close contacts who had exposure to the index patient for >24 hours/week 7