Antimicrobial regimens for the treatment of <em>Streptococcus anginosus</em> group infections
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Antimicrobial regimens for the treatment of Streptococcus anginosus group infections
Initial antimicrobial regimen*
Preferred regimens
PLUS
Alternative regimens
(for patients who
cannot tolerate or
have
contraindications to
preferred regimens)
Oral step-down regimens for select cases §
Preferred regimens
PLUS
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Adult dosing
Ceftriaxone 2 g IV every 24 hours, or
Penicillin G 2 to 4 million units IV every 4 to 6
hours
Metronidazole 500 mg orally or IV every 8
PLUS
hours
Ampicillin-sulbactam ¶ 3 g IV every 6 hours
For patients who require anti-anaerobic
therapy:
Ertapenem 1 g IV every 24 hours
For patients with endovascular infections
without associated abscess:
Δ
Vancomycin IV or
Linezolid 600 mg orally or IV every 12 hours
Amoxicillin-clavulanate 875 mg/125 mg orally 2
to 3 times daily
Cefuroxime 500 mg orally twice daily
Metronidazole 500 mg orally 3 times daily, or
PLUS
Clindamycin 300 mg orally 4 times daily or 300
to 450 mg orally 3 times daily
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Pediatric dosing
Ceftriaxone 50 to 100 mg/kg/dose IV every 24
hours (maximum: 1000 mg/dose), or
Penicillin G 100,000 to 300,000 units/kg/day IV
divided every 4 to 6 hours (maximum dose: 24
million units/day)
Metronidazole 30 to 40 mg/kg/day orally or IV
in 3 divided doses (maximum: 500 mg/dose)
Ampicillin-sulbactam ¶ 100 to 200 mg
ampicillin/kg/day IV divided every 6 hours
(maximum: 2000 mg ampicillin/dose)
For patients who require anti-anaerobic
therapy:
Ertapenem
Children ≥3 months to <13 years: 15
mg/kg/dose IV every 12 hours
(maximum: 500 mg/dose)
Children ≥13 years: 1 g IV every 24
hours
For patients with endovascular infections
without associated abscess:
Vancomycin IV ◊ or
Linezolid
Children <12 years: 10 mg/kg/dose
orally or IV every 8 hours (maximum:
600 mg/dose)
Children ≥12 years: 600 mg orally or IV
every 12 hours
Amoxicillin-clavulanate ¥ 45 mg
amoxicillin/kg/day orally in 2 divided doses
(maximum: 1750 mg/day)
Cefuroxime 20 to 30 mg/kg/day orally in 2
divided doses (mild to moderate infection,
maximum: 500 mg/dose)
Metronidazole 30 to 40 mg/kg/day orally in 3
divided doses (maximum: 500 mg/dose), or
Clindamycin 10 to 25 mg/kg/day orally in 3
divided doses (maximum: 1800 mg/day)
Antimicrobial regimens for the treatment of <em>Streptococcus anginosus</em> group infections

Alternative regimens Linezolid 600 mg orally twice daily Linezolid

(for patients who
cannot tolerate or
have
contraindications to
preferred regimens)
PLUS
Ciprofloxacin 500 mg orally twice daily
PLUS
Metronidazole 500 mg orally every 8 hours, or
Clindamycin 300 mg orally 4 times daily or 300
to 450 mg orally 3 times daily
Children <12 years: 10 mg/kg/dose orally
every 8 hours (maximum: 600 mg/dose)
Children ≥12 years: 600 mg orally twice
daily
PLUS
Ciprofloxacin 10 to 15 mg/kg/dose orally twice
daily (maximum: 500 mg/dose) ‡

PLUS

Metronidazole 30 to 40 mg/kg/day orally in 3

divided doses (maximum: 500 mg/dose), or
Clindamycin 10 to 25 mg/kg/day orally in 3
divided doses (maximum: 1800 mg/day)

Selected antimicrobial regimens are listed here. Other regimens with the same spectrum of activity are also appropriate. The
doses recommended in this table are intended for patients with normal kidney and liver function. Pediatric dosing is intended
for patients >28 days of age, unless otherwise noted. Refer to Lexicomp drug monographs and the UpToDate clinical topic
review of S. anginosus group infections for additional information.

IV: intravenously.

* Dosing of certain antimicrobials (eg, ceftriaxone, penicillin G, ampicillin, clindamycin) for treatment of severe infections (eg,
central nervous system infections, endocarditis) differs from the doses listed in this table. Refer to Lexicomp drug monographs.

¶ Ampicillin-sulbactam is a combination product formulated in a 2:1 ratio (eg, each vial contains 2 g of ampicillin and 1 g of
sulbactam). Adult dosing is provided as total grams of ampicillin and sulbactam. Pediatric dosing is expressed as mg of
ampicillin component.

Δ For severely ill patients, a vancomycin loading dose (20 to 35 mg/kg) is appropriate; within this range, we use a higher dose
for critically ill patients. The loading dose is based on actual body weight, rounded to the nearest 250 mg increment and not
exceeding 3000 mg. The initial maintenance dose and interval are determined by nomogram (typically 15 to 20 mg/kg every 8 to
12 hours for most patients with normal kidney function). Subsequent dose and interval adjustments are based on area under
the curve (AUC)-guided or trough-guided serum concentration monitoring. Refer to the UpToDate topic on vancomycin dosing
for sample nomogram and discussion of vancomycin monitoring.

◊ The approach to pediatric vancomycin dosing is generally determined at the institutional level. A typical dose is 15
mg/kg/dose IV every 6 to 8 hours (use every 6-hour interval for serious infections; maximum dose: 4 g/day), however other
dosing strategies (eg, AUC-guided approach) may be used. Refer to UpToDate content on invasive staphylococcal infections in
children for details of trough-guided and AUC-guided vancomycin dosing.

§ Oral step-down therapy is appropriate for certain clinical syndromes (eg, abscess in the absence of bacteremia). However, we
favor continuing initial intravenous therapy for endovascular infections (eg, bacteremia, endocarditis) as well as other severe or
difficult to treat syndromes.

¥ Dosing is based on the amoxicillin component for the amoxicillin:clavulanate 7:1 formulations (eg, amoxicillin-clavulanate 200
mg/28.5 mg, 400 mg/57 mg, or 875 mg/125 mg). Not all products are interchangeable; using a product with the incorrect
amoxicillin:clavulanate ratio could result in subtherapeutic clavulanic acid concentrations or adverse effects (eg, severe
diarrhea). For dosing for other amoxicillin-clavulanate formulations, refer to the Lexicomp drug monograph.

‡ Although ciprofloxacin is not routinely used in children, it is a reasonable alternative when no other oral options are available.

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