What hemolytic complication can occur with Group A Streptococcus (Streptococcus pyogenes) and what is the appropriate first‑line management?

Group A Streptococcal Hemolytic Complications and Management

Primary Hemolytic Complication

Acute post-streptococcal glomerulonephritis (APSGN) is the key hemolytic complication of Group A Streptococcus pharyngitis, occurring after a latency period of a few weeks following the initial infection. 1

Non-Suppurative Complications

The non-suppurative complications of Group A β-hemolytic streptococcal pharyngitis include:

• Acute post-streptococcal glomerulonephritis – develops weeks after pharyngitis and represents a rare but serious immune-mediated consequence 1
• Acute rheumatic fever – another immune-mediated complication that has become very rare in Europe and developed countries, though prevention remains important for high-risk patients (those with prior rheumatic fever) 1

Suppurative Complications

For completeness, suppurative complications that may occur include peritonsillar abscess (quinsy), acute otitis media, cervical lymphadenitis, mastoiditis, and acute sinusitis. 1

First-Line Management Strategy

Primary Prevention Through Appropriate Antibiotic Treatment

Penicillin V 500 mg orally twice daily for a full 10 days remains the drug of choice for confirmed Group A streptococcal pharyngitis and is the cornerstone of preventing both suppurative and non-suppurative complications including glomerulonephritis. 1, 2

Key Management Principles:

• Complete the full 10-day course – shortening therapy by even a few days significantly increases treatment failure rates and complication risk 1, 2
• Confirm diagnosis before treatment – use throat culture or rapid antigen detection test (RADT) to avoid unnecessary antibiotic exposure 1, 2
• Clinical improvement expected within 24-48 hours of initiating appropriate therapy, with fever resolution within 48 hours in uncomplicated cases 3, 2

Alternative Regimens

For penicillin-allergic patients without anaphylactic reactions:

• First- or second-generation cephalosporins for 10 days 1, 2
• Erythromycin as an acceptable alternative 2

For patients with anaphylactic penicillin allergy:

• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days, though macrolides should be avoided in areas with high resistance rates 3, 2

For compliance concerns:

• Single intramuscular dose of benzathine penicillin G provides effective alternative when oral adherence is doubtful 1, 2

Management of Acute Post-Streptococcal Glomerulonephritis

When APSGN develops despite appropriate treatment or in untreated cases:

• Supportive care is the mainstay – there is no specific antimicrobial therapy that alters the course of established glomerulonephritis 1
• Antibiotic treatment at the time of glomerulonephritis diagnosis may still be warranted to eradicate persistent streptococcal carriage, though it does not reverse the immune-mediated kidney injury 1
• Monitor for complications including hypertension, fluid overload, and acute kidney injury requiring nephrology consultation 1

Critical Clinical Caveats

High-Risk Populations Requiring Vigilance

Patients at increased risk of complications who warrant more aggressive management include those with: 1

• History of rheumatic fever (highest priority for prevention)
• Valvular heart disease
• Immunosuppression
• Risk of severe infections

Common Pitfalls to Avoid

• Do not routinely test asymptomatic patients after completing therapy – this leads to unnecessary retreatment of carriers who develop intercurrent viral infections 1, 3, 2
• Do not use tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, or older fluoroquinolones – these are ineffective against Group A Streptococcus 3
• Do not shorten the antibiotic course – even minor reductions in treatment duration compromise efficacy 1, 2
• Distinguish carriers from active infection – up to 20% of school-aged children are asymptomatic carriers during winter/spring who have extremely low complication risk 1, 3

When to Consider Retreatment

For persistent symptoms after completing initial therapy: 3

• Perform throat culture to confirm persistent infection rather than assuming treatment failure
• Consider alternative antibiotics (clindamycin, amoxicillin-clavulanate, or narrow-spectrum cephalosporin) if reinfection confirmed
• Evaluate for macrolide resistance if azithromycin was used initially, particularly after multiple macrolide courses
• Assess for carrier state with concurrent viral infection – symptoms like cough, congestion, ear pain, and sinus drainage suggest viral etiology rather than streptococcal reinfection