What is the first line treatment for recurring peri-anal streptococcal (strep) infections in a toddler?

First-Line Treatment for Recurring Perianal Streptococcal Infections in Toddlers

For recurring perianal streptococcal infections in toddlers, oral clindamycin (20-30 mg/kg/day in 3 divided doses for 10 days) is the recommended first-line treatment. 1

Clinical Presentation and Diagnosis

• Perianal streptococcal infection typically presents with a sharply demarcated perianal erythema, often accompanied by pain, itching, rectal bleeding, and defecation disorders 2
• The condition predominantly affects children under 7 years of age, with boys affected more frequently than girls (80% of cases are boys) 2
• Diagnosis is often delayed, with 65% of cases taking ≥3 weeks to diagnose 2
• Obtain perianal swab culture specifically requesting testing for Group A beta-hemolytic streptococci (GABHS) or perform a rapid strep test of the perianal area 3
• In approximately 95% of patients with perianal streptococcal infection, concurrent pharyngeal cultures are also positive for Group A Streptococcus 4

Treatment Approach for Recurring Infections

First-Line Treatment

• Oral clindamycin at 20-30 mg/kg/day in 3 divided doses for 10 days is recommended for recurrent perianal streptococcal infections 1
• For adults and older children, clindamycin 600 mg/day in 2-4 equally divided doses for 10 days is appropriate 1

Alternative Options

• Amoxicillin-clavulanic acid at 40 mg/kg/day in 3 divided doses for 10 days for children 1
• For penicillin-allergic patients, consider clindamycin as the preferred alternative 1
• Treatment duration should be at least 14 days, or preferably 21 days, guided by both clinical and microbiological cure 3

Managing Recurrences

• Recurrence rate after amoxicillin treatment is approximately 12.4%, typically occurring within 3½ months of initial treatment 2, 4
• Risk factors for recurrence include longer duration of symptoms prior to diagnosis and having a sibling with perianal streptococcal infection 4
• For patients with multiple recurrences, consider the following additional measures:

Decolonization Strategies

• Nasal decolonization with mupirocin twice daily for 5-10 days 1
• Topical body decolonization with chlorhexidine skin antiseptic solution for 5-14 days 1
• Consider dilute bleach baths (1 teaspoon per gallon of water, 15 minutes twice weekly for 3 months) 1

Environmental Measures

• Focus cleaning efforts on high-touch surfaces that may contact bare skin 1
• Use commercially available cleaners according to label instructions 1
• Maintain good personal hygiene with regular bathing and hand cleaning 1
• Keep draining wounds covered with clean, dry bandages 1

Important Clinical Considerations

• Always complete the full course of antibiotics to prevent recurrence and complications 5
• Post-treatment cultures may be considered to confirm eradication 3
• Monitor for potential complications such as post-streptococcal glomerulonephritis 3
• Consider testing and treating household members if recurrences continue despite appropriate treatment 1
• Perineal streptococcal infections follow a similar seasonal pattern as streptococcal pharyngitis, with 65% occurring between October and March 4

Treatment Pitfalls to Avoid

• Avoid short courses of antibiotics; a full 10-21 day course is necessary to prevent recurrence 3, 6
• Don't rely solely on topical treatments, as systemic antibiotics are superior 2
• Don't overlook testing household contacts in cases of recurrent infection 1
• Avoid tetracyclines in children under 8 years of age 1
• Don't miss concurrent pharyngeal colonization, which occurs in approximately 95% of cases 4