What is the recommended treatment for a female patient with a vaginal open sore that tested positive for streptococcal (strep) infection?

Treatment of Vaginal Streptococcal Infection

For a vaginal open sore that tested positive for streptococcus, you should treat with oral antibiotics—specifically amoxicillin 500 mg every 8 hours or 875 mg every 12 hours for 7-10 days—because topical therapy alone is inadequate for invasive streptococcal skin and soft tissue infections involving open wounds. 1, 2

Why Oral (Systemic) Treatment is Required

• Streptococcal infections involving open sores or ulcerated tissue require systemic antibiotic therapy because these represent deeper soft tissue infections beyond superficial colonization 1
• The IDSA guidelines for skin and soft tissue infections (SSTIs) specifically recommend systemic antibiotics for infections in difficult-to-drain areas including the genitalia, particularly when there is tissue breakdown 1
• Topical antimicrobials may be used for superficial vaginal bacterial colonization, but they are insufficient for invasive streptococcal infections with tissue ulceration 3, 4

Recommended Oral Antibiotic Regimens

First-Line Treatment (Beta-Hemolytic Streptococci)

• Amoxicillin 500 mg every 8 hours OR 875 mg every 12 hours for 7-10 days is the preferred treatment for streptococcal genital skin infections 2
• Amoxicillin is FDA-approved for skin and skin structure infections due to susceptible Streptococcus species (α- and β-hemolytic isolates) 2
• Treatment duration should be 7-10 days but may require extension if clinical response is slow 1

Alternative Options for Penicillin Allergy

• Clindamycin 300-450 mg orally three times daily provides excellent coverage for streptococcal infections and has activity against both aerobic and anaerobic organisms 1
• Cephalexin 500 mg four times daily can be used for patients with non-severe penicillin allergy 1
• Avoid macrolides (erythromycin, azithromycin) as monotherapy due to increasing streptococcal resistance 5

Why Topical Treatment Alone is Inadequate

• Research shows that women with genital streptococcal infections treated with topical erythromycin failed to improve symptomatically 5
• Topical antibiotics do not achieve adequate tissue penetration for invasive infections with ulceration or open wounds 1, 3
• The presence of an open sore indicates tissue invasion requiring systemic therapy to prevent progression to deeper infection 1

Important Clinical Considerations

Rule Out Concurrent Infections

• Obtain cultures for Candida species, as 27-43% of women with vaginal streptococcal infections have concurrent candidiasis requiring antifungal therapy 5
• Consider testing for other sexually transmitted infections if clinically indicated, though streptococcal vulvovaginitis is not typically sexually transmitted 1
• Evaluate for underlying dermatologic conditions (lichen sclerosus, lichen planus) that may predispose to secondary streptococcal infection 5

Special Pregnancy Considerations

• If the patient is pregnant, the same oral antibiotic regimens apply (amoxicillin or clindamycin), as these are safe in pregnancy 2
• However, if Group B Streptococcus (GBS) is identified at any concentration during pregnancy, document this carefully as it mandates intrapartum IV antibiotic prophylaxis during labor regardless of treatment now 6
• Treating GBS colonization or infection during pregnancy does NOT eliminate the need for intrapartum prophylaxis 6

When to Consider Hospitalization

• Severe or rapidly progressive infection with systemic signs (fever, malaise) 1
• Extensive tissue involvement or abscess formation requiring surgical drainage 1
• Immunocompromised patients or those with diabetes 1
• Failed outpatient therapy after 48-72 hours 1

Common Pitfalls to Avoid

• Do not rely on topical therapy alone for open sores or ulcerated lesions—this represents invasive infection requiring systemic antibiotics 1, 5
• Do not assume streptococcus is the sole pathogen—check for concurrent Candida infection which occurs in 27-43% of cases 5
• Do not use erythromycin as monotherapy—clinical studies show poor response rates for genital streptococcal infections 5
• If pregnant, do not assume treating the infection now eliminates the need for intrapartum GBS prophylaxis—these are separate requirements 6

Follow-Up Recommendations

• Reassess in 48-72 hours to ensure clinical improvement (reduced pain, decreased erythema, healing of ulceration) 1
• If no improvement by 72 hours, consider culture and sensitivity testing to guide alternative therapy 1
• Complete the full antibiotic course even if symptoms resolve earlier to prevent recurrence 2
• If symptoms recur within 2 months, re-evaluate for alternative diagnoses including desquamative inflammatory vaginitis, atrophic vaginitis, or resistant organisms 1, 4