Streptococcal Infections

(Survival manual/6. Medical/b) Disease/Streptococcal infections) 

Overview of streptococcal infections

Group A streptococcal (strep) infections are caused by group A streptococcus, a bacterium responsible for a variety of health problems. These infections can range from a mild skin infection or sore throat to severe, life-threatening conditions such as toxic shock syndrome and necrotizing fasciitis, commonly known as flesh eating disease.
Most people are familiar with strep throat, which along with minor skin infection, is the most common form of the disease. Health experts estimate that more than 10 million mild infections (throat and skin) like these occur every year.

In addition to step throat and superficial skin infections, group A strep bacteria can cause infections in tissues (group of cells joined together to perform the same function) at specific body sites, including lungs, bones, spinal cord, and abdomen.

In 2004, 3,833 cases of severe group A streptococcal disease were reported to the Centers for Disease Control and Prevention. All severe group A strep infections may lead to shock, organ failure, and death. Health care providers must recognize and treat such infections quickly.

1.  Strep throat
Symptoms of strep throat
Your health care provider may call it acute streptococcal pharyngitis. If you have strep throat infection, you will have a red and painful sore throat and may have white patches on your tonsils. You also may have swollen lymph nodes in your neck, run a fever, and have a headache. Nausea, vomiting, and abdominal pain can occur but are more common in children than in adults.

People at the greatest risk of getting a severe strep infection are
•  Children with chickenpox
•  People with suppressed immune systems
•  Burn victims
•  Elderly people with cellulitis, diabetes, blood vessel disease, or cancer
•  People taking steroid treatments or chemotherapy
•  Intravenous drug users

Indicators that increase
or decrease the likelihood of strep throat

Increased likelihood

Decreased likelihood

Age 3-14 years Age 45 years or older
High fever (> 100.4 °F) Afebrile (no fever)
Absence of a cough Cough
Exudative pharyngitis or tonsillitis Stuffy, runny nose; conjunctivitis
Anterior cervical adenitis Hoarseness
Current group A strep epidemic Discrete oral ulcerative lesions
Recent close exposure to group A strep Diarrhea

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Severe strep infections
Some types of group A strep bacteria cause severe infections. These include
•  Bacteremia (blood stream infections)
•  Toxic shock syndrome (multi-organ infection)
•  Necrotizing fasciitis (flesh-eating disease)

Transmission of strep throat
You can get strep throat and other group A strep infections by direct contact with saliva or nasal discharge from an infected person. Most people do not get group A strep infections from casual contact with others, but a crowded environment like a dormitory, school, or an institutional setting such as a nursing home can make it easier for the bacteria to spread. There have also been reports of contaminated food, especially milk and milk products, causing infection. You can get sick within 3 days after being exposed to the germ. Once infected, you can pass the infection to others for up to 2 to 3 weeks even if you don’t have symptoms. After 24 hours of antibiotic treatment, you will no longer spread the germs to others.

Diagnosis of strep throat
Your health care provider will take a throat swab. This will be used for a culture (a type of laboratory test) or a rapid strep test, which only takes 10 to 20 minutes. If the result of the rapid test is negative, you may get a follow-up culture to confirm the results, which takes 24 to 48 hours. If the culture test is also negative, your health care provider may suspect you do not have strep, but rather another type of infection. The results of these throat cultures will affect what your health care provider decides to be the best treatment. Most sore throats are caused by viral infections, however, and antibiotics are useless against them.

Treatment for strep throat
If you have a strep infection, your health care provider will prescribe an antibiotic. This will help reduce symptoms, and after 24 hours of taking the medicine, you will no longer be able to spread the infection to others. Treatment will also reduce the chance of complications.

Health experts think penicillin is the best medicine for treating strep throat because it has been proven to be effective, safe, and inexpensive. Your health care provider may have you take pills for 10 days or give you a shot. If you are allergic to penicillin there are other antibiotics your health care provider can give you to clear up the illness.

During treatment, you may start to feel better within 4 days. This can happen even without treatment. Still, it is very important to finish all your medicine to prevent complications. Children with strep throat are usually treated with amoxicillin.

Treatments and drugs
A number of medications are available to cure strep throat, relieve its symptoms and prevent its spread.
If you or your child has strep throat, your doctor will likely prescribe an oral antibiotic such as:
__A.  Penicillin. This drug may be given by injection in some cases — such as if you have a young child who is having a hard time swallowing or is vomiting from strep throat.
Penicillin V (Penicillin VK)
Since its introduction in the 1940s, penicillin has been the “gold standard” treatment for strep throat and still remains the drug of choice in many cases of strep throat. The ability of penicillin and other penicillin antibiotics (e.g., amoxicillin) to kill group A streptococci has not changed in more than 50 years. There has never been a group A streptococcus grown from a person that has been resistant to penicillin. Penicillin has proven efficacy and safety. It is a narrow-spectrum agent that does not promote antimicrobial resistance.
Penicillin V dosage:
•  Children: 250 mg two or three times daily for 10 days
•  Adults: 500 mg two or three times for daily 10 days
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__B.  Amoxicillin. This drug is in the same family as penicillin, but is often a preferred option for children because it tastes better and is available as a chewable tablet.
Amoxicillin, a broader spectrum penicillin, may have some advantages because of higher blood levels, longer plasma half-life, and lower protein binding activity. Suspensions of this drug taste better than penicillin V suspensions, and chewable tablets are available. However, gastrointestinal side effects and skin rash may be more common with amoxicillin.

Amoxicillin has no microbiologic advantage over the less expensive penicillin. Some studies show that amoxicillin given just once a day may work as well as penicillin V given more often.
Amoxicillin dosage:
•  Children: 40 mg/kg per day in three divided doses for 10 days
•  Adults: 500 mg three times daily for 10 days
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Symptom relievers
In addition to antibiotics, your doctor may suggest over-the-counter medications to relieve throat pain and reduce fever, such as:

•  Ibuprofen (Advil, Motrin, others)
•  Acetaminophen (Tylenol, others)

Because of the risk of Reye’s syndrome, a potentially life-threatening illness, don’t give aspirin to young children and teenagers. Be careful with acetaminophen, too.
Taken in large doses, it can cause liver problems. Read and follow label directions. Talk to your doctor or pharmacist if you have questions.
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Complications of strep throat
Untreated group A strep infection can result in rheumatic fever and post-streptococcal lomerulonephritis (PSGN).
Rheumatic fever develops about 18 days after a bout of strep throat and causes joint pain and heart disease. It can be followed months later by Sydenham’s chorea, a disorder where the muscles of the torso and arms and legs are marked with dancing and jerky movements. PSGN is an inflammation of the kidneys that may follow an untreated strep throat but more often comes after a strep skin
infection. Both disorders are rarely seen in the United States because of prompt and effective treatment of most cases of strep throat.

2.  Skin infections: Impetigo, Cellulitis, Erysipelas
a)  Impetigo
Impetigo is an infection of the top layers of the skin and is most common among children ages 2 to 6 years. It usually starts when the bacteria get into a cut, scratch, or insect bite. Impetigo is usually caused by staphylococcus (staph), a different bacterium, but can be caused by group A streptococcus. Skin infections are usually caused by different types (strains) of strep bacteria than those that cause strep throat. Therefore, the types of strep germs that cause impetigo are usually different from those that cause strep throat.
Symptoms of impetigo
Symptoms start with red or pimple-like lesions (sores) surrounded by reddened skin. These lesions can be anywhere on your body, but mostly on your face, arms, and legs. Lesions fill with pus, then break open after a few days and form a thick crust. Itching is common. Your health care provider can diagnose the infection by looking at the skin lesions.
Transmission of impetigo
The infection is spread by direct contact with wounds or sores or nasal discharge from an infected person. Scratching may spread the lesions. From the time of infection until you show symptoms is usually 1 to 3 days. If your skin doesn’t have breaks in it, you can’t be infected by dried streptococci in the air.
Treatment for impetigo
Impetigo can be treated with a topical ointment or oral antibiotic. Mupirocin is a typical ointment that may be prescribed by your doctor. Oral antibiotics such as penicillins or cephalosporins are used for more severe infections. To prevent the spread of the infection to other parts of the body, avoid scratching the blisters or sores. Because impetigo is commonly seen in children, it may be helpful to cut the fingernails and cover the affected areas of the body with bandages or gauze. It also is important to prevent the spread of infection to other individuals in close contact by not sharing things such as blankets, linens, toys, or clothing.

b) Cellulitis and erysipelas
Cellulitis is inflammation of the skin and deep underlying tissues. Erysipelas is an inflammatory disease of the upper layers of the skin. Group A strep germs are the most common cause of both conditions.
Symptoms of cellulitis and erysipelas
Symptoms of cellulitis may include fever and chills and swollen “glands” or lymph nodes. Your skin will be painful, red, and tender. Your skin may blister and then scab over. You may also have perianal (around the anus) cellulitis may with itching and painful bowel movements.
With erysipelas, a fiery red rash with raised borders may occur on your face, arms, or legs. Your skin will be hot, red, and have sharply defined raised areas. The infection may come back, causing chronic swelling of your arms or legs (lymphedema).
Transmission of cellulitis or erysipelas
Both cellulitis and erysipelas begin with a minor incident, such as a bruise. They can also begin at the site of a burn, surgical cut, or wound, and usually affect your arm or leg. When the rash appears on your trunk, arms, or legs, however, it is usually at the site of a surgical cut or wound. Even if you have no symptoms, you carry the germs on your skin or in your nasal passages and can transmit the disease to others.
Treatment of  cellulitis and erysipelas
Oral antibiotics are used to treat mild cellulitis; more severe cases must be treated with intravenous antibiotics in a hospital. Antibiotics that may be used include cephalosporins, dicloxacillin,  clindamycin, or vancomycin. Swelling can be lessened by elevating the affected area, such as the legs or arms. To stop cellulitis from occurring again, it is important to keep applying lotion to the skin and to maintain good skin cleanliness.

3.  Scarlet Fever
Scarlet fever is another form of group A strep disease  that can follow strep throat. It is usually contagious and lasts for a specific length of time whether or not it is treated.

Symptoms of scarlet fever
In addition to the symptoms of strep throat, a red rash appears on the sides of your chest and abdomen. It may spread to cover most of your body. This rash appears as tiny, red pinpoints and has a rough texture like sandpaper. When pressed on, the rash loses color or turns white. There may also be dark red lines in the folds of skin. You may get a bright strawberry-red tongue and flushed (rosy) face, while the area around your mouth remains pale. The skin on the tips of your fingers and toes often peels after you get better. If you have a severe case, you may have a high fever, nausea, and vomiting. 

What are the signs and symptoms of scarlet fever?
Scarlet fever usually starts with a sudden fever associated with sore throat, swollen neck glands, headache, nausea, vomiting, loss of appetite, swollen and red strawberry tongue, abdominal pain, body aches, and malaise.

Symptoms of  Scarlet Fever
The rash is the most striking sign of scarlet fever. It usually begins looking like a bad sunburn with tiny bumps and it may itch. The rash usually appears first on the neck and face, often leaving a clear unaffected area around the mouth. It spreads to the chest and back, then to the rest of the body. In body creases, especially around the underarms and elbows, the rash forms classic red streaks. Areas of rash usually turn white when you press on them. By the sixth day of the infection the rash usually fades, but the affected skin may begin to peel.

Aside from the rash, there are usually other symptoms that help to confirm a diagnosis of scarlet fever, including a reddened sore throat, a fever above 101° Fahrenheit (38.3° Celsius), and swollen glands in the neck. The tonsils and back of the throat may be covered with a whitish coating, or appear red,
swollen, and dotted with whitish or yellowish specks of pus. Early in the  infection, the tongue may have a whitish or yellowish coating. A child with scarlet fever also may have chills, body aches, nausea, vomiting, and loss of appetite.

When scarlet fever occurs because of a throat infection, the fever typically stops within 3 to 5 days, and the sore  throat passes soon afterward. The scarlet fever rash usually fades on the sixth day after sore throat symptoms began, but skin that was covered by rash may begin to peel. This peeling may last 10 days. With antibiotic treatment, the infection itself is usually cured with a 10-day course of antibiotics, but it may take a few weeks for tonsils and swollen glands to return to normal.

Scarlet fever, synopsis
The characteristic rash appears 12-48 hours after the start of the fever. The rash usually starts below the ears, neck, chest, armpits and groin before spreading to the rest of the body over 24 hours.
Scarlet spots or blotches, giving a boiled lobster appearance, are often the first sign of rash.
As skin lesions progress and become more widespread, they start to look like sunburn with goose pimples. The skin may have a rough sandpaper-like feel.
In body folds, especially the armpits and elbows, fragile blood vessels (capillaries) can rupture and cause classic red streaks called Pastia lines. These may persist for 1-2 days after the generalised rash has
In the untreated patient, the fever peaks by the second day and gradually returns to normal in 5-7 days. When treated with appropriate antibiotics, the fever usually resolves within 12-24 hours.
By about the sixth day of the infection the rash starts to fade and peeling, similar to that of sunburned skin, occurs. Peeling of the skin is most prominent in the armpits, groin, and tips of the fingers and/or toes and may continue up to 6 weeks.
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Transmission of scarlet fever
You can get scarlet fever the same way as strep throat-through direct contact with throat mucus, nasal discharge, and saliva of an infected person.

Treatments and drugs
A number of medications are available to cure strep throat, relieve its symptoms and prevent its spread.
Scarlet fever is treated with antibiotics. The standard treatment is penicillin, but amoxicillin is usually
given instead. Amoxicillin is a derivative of penicillin and tastes better, which makes it easier to give it to children.
Although treatment for just five days may be enough to treat the infection, treatment is given for ten days in order to prevent future complications of rheumatic fever and rheumatic heart disease.
Ten days of treatment has been proven to prevent these complications.[3]

If a person is allergic to penicillin, then erythromycin, clindamycin, or azithromycin is used. Azithromycin (Zithromax) may be used instead of penicillin because fewer doses are needed. However, it has not yet been proven that this azithromycin definitely prevents rheumatic fever or rheumatic heart disease.

An intramuscular dose of penicillin G as a one-time shot is also effective and may be used instead, particularly where compliance may be difficult. Some parents of children with scarlet fever and some adults may prefer the one-time shot instead of the 10-day course of antibiotics.

There is no need to retest a person who has been treated for strep throat or scarlet fever, as the cure rate is virtually 100%.

Home comfort
•  Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin and others) to relieve pain and reduce fever
•  Soothing gargles to fight sore throat (in adults and older children who can gargle safely)
•  A cool-mist humidifier to soothe the breathing passages and throat
•  A liquid diet, including warm soups or cold milkshakes, if the patient’s sore throat makes it difficult to swallow solid foods

You Need To Know
•  The rash of scarlet fever is caused by streptococcal pyrogenic exotoxins produced by certain strains of the group A strep bacteria that causes strep throat. Since not all strains of strep produce this exotoxin, you don’t get scarlet fever every time you get strep throat.
•  The rash of scarlet fever usually lasts about 3 or 4 days.
•  Scarlet fever used to be a much more serious infection then it is today.
•  Children with scarlet fever are contagious until they have been on an antibiotic for at least 24 hours.
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