Treatment of streptococcal infection with and without antibiotics

The use of antibacterial drugs will be most effective when drug therapy is targeted, that is, etiotropic: if the causative agent of the disease is streptococci, then antibiotics for streptococci should be used.

This requires a bacteriological study to isolate and identify a specific bacterium, confirming its belonging to the genus of gram-positive bacteria Streptococcus spp.

What antibiotics kill strep?

Bactericidal drugs that can not only overcome their virulence factors – enzyme antigens, cytotoxins (leading to β-hemolysis), surface adhesive proteins that allow streptococci to resist phagocytosis – but also ensure the eradication of the pathogen in vivo can be effective against streptococci. And in order for an antibiotic to eradicate bacteria, it must penetrate their outer membranes and affect the vulnerable structures of the microorganism’s cells.

The main names of antibacterial pharmacological agents that are considered the best antibiotics for streptococcus:

Antibiotics for hemolytic streptococci or antibiotics against group A streptococcus - β-hemolytic streptococcus group A strain Streptococcus pyogenes - also include antibiotics for streptococcus in the throat (since this strain causes streptococcal pharyngitis and tonsillitis): β-lactam carbapenems - Imipenem (other trade names - Imipenem with cilastatin, Tienam, Cilaspen), Meropenem (Mepenam, Merobocide, Inemplus, Doriprex, Sinerpen); lincosamide antibiotics Clindamycin (Clindacin, Klimycin, Klinimicin, Dalacin); Amoxiclav (Amoxil, A-Clav-Pharmex, Augmentin, Flemoklav Solutab).

Antibiotics for streptococcus pneumoniae - a nasopharyngeal colonizing commensal bacterium Streptococcus pneumoniae, often called pneumococcus - include all of the above drugs, as well as fourth-generation cephalosporin antibiotics Cefpirome (Keyten) or Cefepime.

Inflammation of the inner lining of the heart is most often a consequence of the pathogenic effect of viridans streptococcus - alpha-hemolytic type Streptococcus viridans. If it enters the heart with blood, it can cause subacute bacterial endocarditis (especially in people with damaged heart valves). Treatment of viridans streptococcus with antibiotics is carried out using Vancomycin (trade names - Vancocin, Vanmixan, Vancorus) - a glycopeptide antibiotic.

Sensitivity of streptococci to antibiotics is a factor in successful treatment

Before moving on to the characteristics of individual antibacterial agents used for streptococcal infections, it should be emphasized that the most important factor in the effectiveness of treatment is the sensitivity of streptococci to antibiotics, which determines the ability of drugs to destroy bacteria.

Often the effectiveness of antibiotic therapy is so low that the question arises: why didn’t the antibiotic kill the streptococcus? These bacteria – in particular, Streptococcus pneumoniae – have demonstrated a significant increase in resistance, that is, resistance to antibacterial drugs, over the past two decades: tetracycline and its derivatives do not affect them; almost a third of their strains are not affected by erythromycin and penicillin; resistance has developed to some drugs of the macrolide group. And fluoroquinolones are initially less effective against streptococcal infection.

Researchers associate the decrease in the sensitivity of streptococci to antibiotics with the transformation of individual strains as a result of genetic exchange between them, as well as with mutations and increased natural selection, one way or another provoked by the same antibiotics.

And we are not only talking about self-medication, which is condemned by doctors. The medicine prescribed by the doctor may also be powerless against streptococcal infection, since in most cases the antibacterial drug is prescribed without identifying a specific pathogen, so to speak, empirically.

In addition, the antibiotic does not have time to kill the streptococcus if the patient stops taking the drug prematurely, shortening the duration of the course of treatment.

Useful information is also in the material - Antibiotic resistance

Indications antibiotics for strep throat

The strains, serotypes and groups of streptococci are very numerous, as are the inflammatory diseases they cause, which spread from the mucous membrane of the pharynx to the membranes of the brain and heart.

The list of indications for the use of antibacterial agents includes: peritonitis, sepsis, septicemia and bacteremia (including neonatal); meningitis; scarlet fever; impetigo and erysipelas; streptoderma; lymphadenitis; sinusitis and acute otitis media; pneumococcal pharyngitis, tonsillitis, bronchitis, tracheitis, pleurisy, bronchopneumonia and pneumonia (including nosocomial); endocarditis. They are effective in infectious inflammations of soft and bone tissues (abscesses, phlegmon, fasciitis, osteomyelitis) and joint lesions of streptococcal origin with rheumatic fever in acute form.

These antibiotics are used in the treatment of pyelonephritis and acute glomerulonephritis; inflammation of the genitourinary organs; intra-abdominal infection; postpartum infectious inflammations, etc.

Read also – Streptococcal infection

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Release form

The antibiotics Imipenem, Meropenem, Cefpirome and Vancomycin are available in the form of sterile powder in vials, intended for the preparation of a solution that is administered parenterally.

Amoxiclav is available in three forms: tablets for oral use (125, 250, 500 mg), powder for preparation of oral suspension and powder for preparation of injection solution.

Clindamycin is available in the form of capsules, granules (for making syrup), solution in ampoules and 2% cream.

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Pharmacodynamics

The beta-lactam antibiotics Imipenem and Meropenem, which belong to the carbapenems (a class of organic compounds known as thienamycins), penetrate bacterial cells and interfere with the synthesis of vital components of their cell walls, which leads to the destruction and death of bacteria. These substances differ slightly from penicillins in structure; in addition, Imipenem contains sodium cilastatin, which inhibits its hydrolysis by renal dehydropeptidase, which prolongs the effect of the drug and increases its effectiveness.

Amoxiclav, a combination drug with the aminopenicillin amoxicillin and clavulanic acid, which is a specific β-lactamase inhibitor, has a similar principle of action.

The pharmacodynamics of Clindamycin is based on binding to the 50 S subunit of bacterial cell ribosomes and inhibition of protein synthesis and growth of the RNA complex.

The fourth-generation cephalosporin antibiotic Cefpirome also disrupts the production of heteropolymer peptide glycans (mureins) of the bacterial wall framework, leading to the destruction of peptide glycan chains and lysis of bacteria. And the mechanism of action of Vancomycin lies both in the inhibition of murein synthesis and in the disruption of RNA synthesis in Streptococcus spp. The advantage of this antibiotic is that, not having a β-lactam ring in its structure, it is not affected by the protective enzymes of bacteria - β-lactamases.

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Pharmacokinetics

Meropenem penetrates into tissues and biological fluids, but binding to plasma proteins does not exceed 2%. It is broken down to form one inactive metabolite. Two-thirds of the drug is eliminated in its original form; with intravenous administration, the half-life is 60 minutes, with intramuscular injection - about one and a half hours. It is excreted from the body by the kidneys on average after 12 hours.

The pharmacokinetic characteristics of Clindamycin note its 90% bioavailability and high degree of binding to blood albumins (up to 93%). After oral administration, the maximum concentration of the drug in the blood is reached in about 60 minutes, after intravenous administration - in 180 minutes. Biotransformation occurs in the liver, some metabolites are therapeutically active. Excretion from the body lasts about four days (through the kidneys and intestines).

Cefpirome is administered by infusion, and although the drug binds to plasma proteins by less than 10%, the therapeutic concentration in tissues is maintained for 12 hours, and bioavailability is 90%. This drug is not broken down in the body and is excreted by the kidneys.

After oral administration of Amoxiclav, amoxicillin and clavulanic acid enter the bloodstream in about an hour and are excreted twice as long; binding to blood proteins is 20-30%. At the same time, accumulation of the drug is noted in the sinuses of the maxilla, lungs, pleural and cerebrospinal fluids, in the middle ear, abdominal cavity and pelvic organs. Amoxicillin is almost not broken down and is excreted by the kidneys; metabolites of clavulanic acid are excreted through the lungs, kidneys and intestines.

Vancomycin pharmacokinetics are characterized by binding to plasma proteins at a level of 55% and penetration into all biological fluids of the body and through the placenta. Biotransformation of the drug is insignificant, and the half-life is on average five hours. Two-thirds of the substance is excreted by the kidneys.

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Dosing and administration

The method of administration of drugs depends on their form of release: tablets are taken orally, solutions for injection are administered parenterally.

Imipenem can be administered intravenously (slowly, over 30-40 minutes) and intramuscularly, but intravenous administration is more common. A single dose for adults is 0.25-0.5 g (depending on the disease), the number of injections is three to four per day. Doses for children are determined by body weight - 15 mg per kilogram. The maximum daily dose for adults is 4 g, for children - 2 g.

Meropenem is administered intravenously - by jet or drip: every 8 hours at 0.5-1 g (for meningitis - 2 g). For children under 12 years of age, the dosage is calculated at 10-12 mg per kilogram of body weight.

Capsulated Clindamycin is taken orally - 150-450 mg four times a day for ten days. Syrup is more suitable for children: up to one year - half a teaspoon three times a day, after one year - a teaspoon. Clindamycin injections - intravenous drip and intramuscular - are prescribed in a daily dose of 120 to 480 mg (divided into three administrations); the duration of parenteral use is 4-5 days with a transition to taking capsules until the end of the course of treatment, the total duration of which is 10-14 days. Clindamycin in the form of a vaginal cream is used once a day for a week.

The antibiotic for streptococci, Cefpirome, is administered only intravenously, and the dose depends on the pathology caused by the streptococcus - 1-2 g twice a day (every 12 hours); the maximum permissible dose is 4 g per day.

Amoxiclav is administered intravenously to adults and children over 12 years of age four times a day at 1.2 g; to children under 12 years of age – 30 mg per kilogram of body weight. The course of treatment is 14 days with a possible transition (depending on the condition) to taking tablets. Amoxiclav tablets are taken during meals at 125-250 mg or 500 mg two or three times a day for 5-14 days.

A single dose of Vancomycin, which requires very slow intravenous administration, for adults is 500 mg (every six hours). For children, the dose is calculated as follows: 10 mg per kilogram of the child's weight.

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Use antibiotics for strep throat during pregnancy

The safety of carbapenem antibiotics (Imipenem and Meropenem) in pregnant women has not been established by manufacturers, so their use during pregnancy is permitted only if the benefits to the expectant mother significantly outweigh the potential negative impact on the fetus.

The same principle applies to the use of Clindamycin and Amoxiclav by pregnant and lactating women.

During pregnancy, Cefpirome is prohibited. The ban on the use of Vancomycin applies to the first trimester of pregnancy, and at later stages, its use is allowed only in extreme cases - if there is a threat to life.

Contraindications

Main contraindications for use:

Imipenem and Meropenem – presence of allergies and hypersensitivity to drugs, children under three months of age;

Clindamycin - intestinal inflammation, liver or kidney failure, children under one year of age;

Cefpirome – penicillin intolerance, pregnancy and lactation, patients under 12 years of age;

Amoxiclav - hypersensitivity to penicillin and its derivatives, bile stasis, hepatitis;

Vancomycin - hearing impairment and cochlear neuritis, renal failure, first trimester of gestation, lactation period.

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Side effects antibiotics for strep throat

The most likely side effects of Imipenem, Meropenem, and Cefpirome include:

Pain at the injection site, nausea, vomiting, diarrhea, skin rashes with itching and hyperemia, decreased white blood cell count and increased urea levels in the blood. There may also be hyperthermia, headache, respiratory and heart rhythm disturbances, convulsions, and intestinal microflora disturbances.

In addition to those already listed, side effects of Clindamycin may include a metallic taste in the mouth, hepatitis and cholestatic jaundice, increased levels of bilirubin in the blood, and pain in the epigastric region.

The use of Amoxiclav may be accompanied by nausea, vomiting and diarrhea, acute inflammation of the intestine (pseudomembranous colitis) due to the activation of an opportunistic infection - clostridia, as well as exudative erythema of the skin and the development of toxic necrosis of the epidermis.

Similar side effects may occur when treating viridans streptococcus with glycopeptide antibiotics (Vancomycin). In addition, this antibiotic may negatively affect hearing.

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Overdose

The official instructions for the drugs Imipenem and Meropenem indicate that an overdose is unlikely.

Exceeding the dose of the other antibiotics considered in this review is manifested by an increase in their side effects, which are treated symptomatically.

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Interactions with other drugs

The following drug interactions occur with the listed antibiotics for streptococci:

Imipenem and Meropenem should not be used simultaneously with drugs that can damage the liver or impair kidney function.

Clindamycin is incompatible with aminoglycoside antibiotics, sleeping pills and sedatives, calcium gluconate and magnesium sulfate, as well as with vitamins B6, B9, B12.

The activity of the drug Cefpirome is potentiated by the simultaneous use of antibiotics of other groups (aminoglycosides, fluoroquinolones, etc.). Its combination with antitumor agents, immunosuppressants, drugs for the treatment of tuberculosis, loop diuretics should also be avoided.

Amoxiclav reduces blood clotting and the reliability of hormonal contraceptives.

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Storage conditions

Sealed vials of Imipenem, Meropenem, Cefpirome should be stored in a place protected from light at t <+25°C; prepared solutions – at t < +5°C (no more than two days).

Vancomycin – at t <+10°C.

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Shelf life

The expiration date of the drugs is indicated on their packaging.

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Treatment of streptococcus without antibiotics

As doctors note, treating streptococcus without antibiotics is impossible, because strengthening the immune system with vitamin infusions of rose hips or decoctions of echinacea, cranberry juice or tea with ginger can reduce the inflammatory reaction, but does not kill its cause - bacteria.

Garlic, honey, goat's milk, gargling with eucalyptus leaf infusion, propolis or turmeric solution are auxiliary means against streptococcus in the throat. And septicemia, meningitis, scarlet fever or acute glomerulonephritis can only be cured with antibiotics against streptococci.