Initial therapy for complicated Streptococcus pyogenes (group A streptococcus) bloodstream infections, including toxic shock syndrome

Australian Commission on Safety and Quality in Health Care (ACSQHC), 2023

Patients have complicated Streptococcus pyogenes bloodstream infection if they have sepsis, septic shock, toxic shock syndrome, pneumonia, meningitis or necrotising fasciitis.

For adults and children with complicated S. pyogenes bloodstream infection, use:

benzylpenicillin 2.4 g (child 60 mg/kg up to 2.4 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment. See advice on continuation therapy benzylpenicillin benzylpenicillin benzylpenicillin

PLUS

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly for a minimum of 72 hours and until organ function has significantly improved¹. See advice on continuation therapy clindamycin clindamycin clindamycin

PLUS for toxic shock syndrome or necrotising fasciitis

intravenous immunoglobulin (IVIg) (adult and child) 2 g/kg intravenously, as a single dose as soon as possible but not later than 72 hours. It is reasonable to give the dose in divided doses if it is not possible to give a single dose. intravenous immunoglobulin (IVIg) intravenous immunoglobulin (IVIg) intravenous immunoglobulin (IVIg)

Despite limited clinical evidence, clindamycin is recommended to reduce bacterial toxin production.

The majority of observational studies, strongly support the use of intravenous immunoglobulin (IVIg) to treat S. pyogenes necrotising fasciitisBruun, 2021 Carapetis, 2014 Linner, 2014; however, not all studies have demonstrated benefitKadri, 2017. It is the consensus view of the Antibiotic Expert Group that intravenous immunoglobulin (IVIg) should be used when available.

For adults and children who have had a nonsevere (immediate or delayed) or a severe (immediate)² hypersensitivity reaction to a penicillin, replace benzylpenicillin in the above regimens with cefazolin. Use:

cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For patients with septic shock or requiring intensive care support, use a 6-hourly cefazolin dosing interval³. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. See advice on continuation therapy. cefazolin cefazolin cefazolin

For adults and children who have had a⁴ severe delayed hypersensitivity reaction to a penicillin, replace benzylpenicillin in the above regimens with vancomycin. Use:

vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children. Loading doses are recommended for critically ill adults. See advice on continuation therapy. vancomycin vancomycin vancomycin

¹ There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ Pharmacokinetics may be altered in patients who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure for patients with septic shock or requiring intensive care support, a modified dosage of cefazolin is recommended. Once the critical illness has resolved, consider switching to the standard dosage. If the isolate is not reported to have dose-dependent susceptibility to cefazolin (ie susceptible dose dependent [SDD] or susceptible increased exposure [I or SIE]), it may also be appropriate to switch to the standard dosage – seek expert advice.Return

⁴ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return