From the Guidelines
Treatment of streptococcus bacteremia should be initiated with a 4-week regimen of intravenous aqueous crystalline penicillin G, as it achieves a high cure rate in those with highly penicillin-susceptible streptococcal infections. This approach is recommended by the American Heart Association 1 and is particularly useful in avoiding aminoglycoside-containing regimens for patients with impairment of renal function, concurrently administered nephrotoxic drugs, or eighth cranial nerve impairment.
Key Considerations
- For adult patients, 4 weeks of therapy with ceftriaxone given once daily is also a recommended approach 1.
- The decision to treat part of the antibiotic course at home requires careful selection of the appropriate candidate based on family accommodations and access to home healthcare providers 1.
- It is essential to identify and control the source of infection, which may require drainage of abscesses or removal of infected devices.
- Supportive care, including fluid resuscitation and vasopressors, may be necessary for patients with sepsis.
- Blood cultures should be repeated to ensure clearance of bacteremia.
Antibiotic Regimens
- Penicillin G: 2-4 million units every 4-6 hours for 10-14 days
- Ceftriaxone: 2g IV daily for 4 weeks
- Vancomycin: 15-20 mg/kg IV every 8-12 hours
- Clindamycin: 600-900 mg IV every 8 hours
Special Considerations
- For Streptococcus viridans or Streptococcus bovis, combination therapy with penicillin plus gentamicin may be necessary, especially if endocarditis is suspected.
- For Group A streptococcus (S. pyogenes), clindamycin may be added to penicillin to inhibit toxin production in cases of toxic shock syndrome or necrotizing fasciitis.
From the FDA Drug Label
Serious infections, such as pneumonia and endocarditis, due to susceptible strains of streptococci (including S pneumoniae) and meningococcus 150,000 - 300,000 units/kg/day divided in equal doses every 4 to 6 hours; duration depends on infecting organ-ism and type of infection For the treatment of streptococcus bacteremia, the recommended dosage of penicillin G (IV) is 150,000 - 300,000 units/kg/day divided in equal doses every 4 to 6 hours. The duration of treatment depends on the infecting organism and type of infection 2.
- Key considerations:
- Dosage adjustments may be required in cases of severe renal impairment.
- Treatment should be continued for at least 48 to 72 hours after the patient becomes asymptomatic.
- For Group A β-hemolytic streptococcal infections, treatment should be maintained for at least 10 days to reduce the risk of rheumatic fever.
From the Research
Treatment Options for Streptococcus Bacteremia
- Ceftriaxone is a commonly used antibiotic for treating bacteremia caused by Streptococcus spp. 3
- The optimal dose of ceftriaxone for treating bacteremia is not well established, with studies suggesting that 1 gram and 2 grams daily may have similar clinical outcomes 3
- Penicillin G is also considered a reasonable treatment option for viridans group streptococci bloodstream infections, with similar clinical outcomes to ceftriaxone 4
Oral Antibiotic Step-down Therapy
- Oral antibiotic step-down therapy may be an appropriate treatment option for uncomplicated streptococcal bacteremia, with consideration of factors such as patient comorbidities and clinical progress 5
- A study found that oral step-down therapy was associated with a shorter hospital length of stay and similar clinical outcomes compared to continued intravenous therapy 5
- Another study found that 5-10 day courses of antibiotics were non-inferior to 11-15 day courses for treating uncomplicated streptococcal bacteremia 6
Clinical Outcomes and Antibiotic Duration
- The duration and route of antibiotic treatment for streptococcal bloodstream infections are not well established, with varying practices across healthcare systems 6, 7
- A study found that the frequency of clinical failure was similar between patients who received oral step-down therapy and those who received continued intravenous therapy 5
- Another study found that the use of oral step-down therapy was common and associated with similar readmission and mortality rates compared to definitive intravenous therapy 7