Group A streptococcal fasciitis.
OBJECTIVE
To review the current understanding of group A streptococcal fasciitis; the different bacterial serotypes, the role of superantigens, antibiotic and other therapies, and transmission to house hold contacts and health care workers.


METHODS
Articles and published abstracts on the mechanisms and management of group A streptococcal fasciitis.


RESULTS
The development of streptococcal fasciitis depends on the inoculation of a susceptible individual (i.e. one who has not been previously exposed to that particular serotype or superantigen) with a virulent streptococcus that has the ability to produce superantigens. The superantigens produce an excessive stimulation of the immune system, with a subsequent outpouring of inflammatory cytokines causing the multiorgan failure that characterises both streptococcal necrotising fasciitis as well as streptococcal toxic shock syndrome. Effective management of streptococcal necrotising fasciitis requires an early diagnosis, appropriate surgery, administration of clindamycin (600 mg/70 kg i.v. 6-hourly), penicillin G (1.2 g/70 kg i.v. 2 to 4-hourly), and polyvalent immunoglobulin (0.2 - 0.4 g/kg/day i.v. for 3 - 5 days). Household and health workers in close contact with the patient need to be warned to present to medical care early if they develop any signs of an infection.


CONCLUSIONS
Necrotising fasciitis is a severe disorder which is commonly caused by group A streptococcus. Early diagnosis and effective management with surgery, antibiotics and polyvalent immunoglobulin will reduce mortality. Further studies concerning the risk of transmission of the organism to close contacts need to be performed.
Everest
E
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Department of Critical Care Medicine, Flinders Medical Centre, Adelaide, South Australia. Evan.Everest@health.sa.gov.au