Current insights in invasive group A streptococcal infections in pediatrics

Ethical bioprospecting and microbial assessments for sustainable solutions to the AMR crisis

Antimicrobial resistance (AMR) has been declared one of the top 10 global public health challenges of our age by the World Health Organization, and the World Bank describes AMR as a crisis affecting the finance, health, and agriculture sectors and a major threat to the attainment of Sustainable Development Goals. But what is AMR? It is a phenotype that evolves in microbes exposed to antimicrobial molecules and causes dangerous infections. This suggests that scientists and healthcare workers should be on the frontline in the search for sustainable solutions to AMR. Yet AMR is also a societal problem to be understood by everyone. This review aims to explore the need to address the problem of AMR through a coherent, international strategy with buy-in from all sectors of society. As reviewed here, the sustainable solutions to AMR will be driven by better understanding of AMR biology but will require more than this alone to succeed. Some advances on the horizon, such as the use of bacteriophage (phage) to treat AMR infections. However, many of the new technologies and new therapeutics to address AMR require access to biodiversity, where the custodians of that biodiversity-and the traditional knowledge required to access it-are needed as key partners in the scientific, clinical, biotechnological, and international ventures that would treat the problem of AMR and ultimately prevent its further evolution. Many of these advances will be built on microbial assessments to understand the extent of AMR in our environments and bioprospecting to identify microbes that may have beneficial uses. Genuine partnerships for access to this biodiversity and sharing of benefits accrued require a consideration of ethical practice and behavior. Behavior change is needed across all sectors of culturally diverse societies so that rapid deployment of solutions can be implemented for maximum effect against the impacts of AMR.

Post-pandemic increase in invasive group A strep infections in New Zealand

BACKGROUND

Since October 2022, multiple high-income countries have reported an increase in invasive group A streptococcal (iGAS) infections. This study describes trends in iGAS infections in Aotearoa New Zealand (NZ) between 2017 and 2023, and examines associations of iGAS incidence, COVID-19 eras, and acute respiratory infections (ARI).

METHODS

Analyses include national-level surveillance data on iGAS and ARI. Multivariable Poisson regression was used to examine relationships between COVID-19 era and iGAS incidence, and Pearson pairwise correlations were calculated to examine trends between ARI and iGAS.

FINDINGS

A sharp increase in iGAS was observed in 2023, with notable increases among children aged under ten years. Indigenous Māori and Pacific peoples were disproportionately affected. emm1 and emm12 were commonly reported in 2022-2023. Compared to pre-pandemic, iGAS decreased significantly during the COVID-19 restrictions era and increased once COVID-19 restrictions were relaxed, after adjusting for ethnicity, sex, and age. ARI was moderately correlated with iGAS (r = 0∙55) in 2022-2023.

INTERPRETATION

Though delayed, NZ's recent iGAS trends mirror those seen in the 2022/2023 multi-country iGAS surge. These findings expand existing research, suggesting a link between the easing of COVID-19 measures, increased ARI circulation, and the rise in iGAS. Continued and improved iGAS surveillance, is needed to better understand iGAS epidemiology and support public health response. iGAS in NZ will become notifiable in late 2024, which should help improve iGAS monitoring and support public health response.

FUNDING

This research received no specific funding, though iGAS surveillance and typing in NZ is funded by the Ministry of Health, which was not involved in the analysis, interpretation, design, or any aspect of this study. No authors were paid to write this manuscript.

Acute Glomerulonephritis Following Systemic Scabies in Two Brothers

Scabies is a parasitic infestation of the skin with high prevalence in crowded spaces. In some instances, scabies becomes the underlying factor for complicated skin-borne opportunistic pathogens infections in both children and adults. Geographic area and socio-economic factors are determinants of the endemic pattern of this disease. Currently, the treatment of scabies has been under special attention. A combination of oral therapy with Ivermectin and sulfur-based ointments are the gold standard. However, caution is required in patients with kidney impairment. The renal involvement in children with scabies is mainly caused by acute glomerulonephritis. The severity of the nephritic syndrome can lead to other complications. Also, Ivermectin possesses a nephrotoxic effect. Severe hypertension can lead to neurological complications. The aim of our case report is to present two unusual complications in brothers with scabies. We report the cases of two brothers with scabies who presented with severe skin infection that developed acute post infectious glomerulonephritis (APIGN). In addition, one of the brothers presented with posterior reversible encephalopathy syndrome (PRES). The other one developed acute tubule-interstitial acute kidney injury following Ivermectin administration. The evolution of skin lesions was favorable, and kidney function returned to normal in both brothers.

Surveillance of noninvasive group A Streptococcus infections in French ambulatory pediatrics before and during the COVID-19 pandemic: a prospective multicenter study from 2018-2022

OBJECTIVES

We evaluated the burden of noninvasive group A Streptococcus (GAS) infections in ambulatory pediatrics before and during the COVID-19 pandemic in France.

METHODS

We analyzed data from a national network of ambulatory pediatricians between 2018 and 2022. Clinicians evaluating children ≤15 years old for tonsillopharyngitis, perianal infections, paronychia/blistering dactylitis, and scarlet fever were invited to perform a rapid antigen detection test (RADT) for GAS. Monthly incidence of noninvasive GAS infections per 10,000 visits was modeled using time series analysis, considering two breakpoints: March 2020 (first national lockdown) and March 2022 (end of mandatory mask-wearing in schools).

RESULTS

Over the study period, 125 pediatricians recorded 271,084 infectious episodes. GAS-related illnesses represented 4.3% of all infections. In March 2020, the incidence of GAS diseases decreased by 84.5% (P <0.001), with no significant trend until March 2022. After March 2022, the incidence significantly increased (+23.8% per month, P <0.001), with similar patterns across all monitored GAS-related diseases.

CONCLUSION

By using routine clinical data and RADTs, we have monitored changes in the incidence of noninvasive GAS infections in ambulatory pediatrics. COVID-19 mitigation measures have had a major impact on the epidemiology of noninvasive GAS infections, but their relaxation was followed by a surge above baseline levels.

Group A streptococcal disease in paediatric inpatients: a European perspective

Group A streptococcal (GAS) disease shows increasing incidence worldwide. We characterised children admitted with GAS infection to European hospitals and studied risk factors for severity and disability. This is a prospective, multicentre, cohort study (embedded in EUCLIDS and the Swiss Pediatric Sepsis Study) including 320 children, aged 1 month to 18 years, admitted with GAS infection to 41 hospitals in 6 European countries from 2012 to 2016. Demographic, clinical, microbiological and outcome data were collected. A total of 195 (61%) patients had sepsis. Two hundred thirty-six (74%) patients had GAS detected from a normally sterile site. The most common infection sites were the lower respiratory tract (LRTI) (22%), skin and soft tissue (SSTI) (23%) and bone and joint (19%). Compared to patients not admitted to PICU, patients admitted to PICU more commonly had LRTI (39 vs 8%), infection without a focus (22 vs 8%) and intracranial infection (9 vs 3%); less commonly had SSTI and bone and joint infections (p < 0.001); and were younger (median 40 (IQR 21-83) vs 56 (IQR 36-85) months, p = 0.01). Six PICU patients (2%) died. Sequelae at discharge from hospital were largely limited to patients admitted to PICU (29 vs 3%, p < 0.001; 12% overall) and included neurodisability, amputation, skin grafts, hearing loss and need for surgery. More patients were recruited in winter and spring (p < 0.001).

CONCLUSION

In an era of observed marked reduction in vaccine-preventable infections, GAS infection requiring hospital admission is still associated with significant severe disease in younger children, and short- and long-term morbidity. Further advances are required in the prevention and early recognition of GAS disease.

WHAT IS KNOWN

• Despite temporal and geographical variability, there is an increase of incidence of infection with group A streptococci. However, data on the epidemiology of group A streptococcal infections in European children is limited.

WHAT IS NEW

• In a large, prospective cohort of children with community-acquired bacterial infection requiring hospitalisation in Europe, GAS was the most frequent pathogen, with 12% disability at discharge, and 2% mortality in patients with GAS infection. • In children with GAS sepsis, IVIG was used in only 4.6% of patients and clindamycin in 29% of patients.

Outcome of Severe Bacterial Pneumonia in the Era of Pneumococcal Vaccination

Introduction: After the introduction of pneumococcal conjugate vaccines, community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae has decreased whereas Staphylococcus aureus and Streptococcus pyogenes could be increasing. These bacteria have been associated with high rates of complications. Aims: (1) To describe the characteristics of pediatric bacterial CAP requiring hospitalization. (2) To compare outcomes according to causative microorganisms. (3) To analyze changes in bacterial CAP rate and etiology over time. Patients and Methods: Retrospective single-center study of inpatients aged 1 month-16 years with culture-confirmed bacterial CAP in 2010-2018 in Madrid, Spain. Results: We included 64 cases (42 S. pneumoniae, 13 S. pyogenes and 9 S. aureus). Culture-confirmed CAP represented 1.48-2.33/1,000 all-cause pediatric hospital admissions, and its rate did not vary over time. However, there was a significant decrease in pneumococcal CAP in the last 3 years of the study (78% of CAP in 2010-2015 vs. 48% in 2016-18, p = 0.017). Median hospital stay was 10.5 days (interquartile range 5-19.5), 38 patients (59%) developed complications and 28 (44%) were admitted to the intensive care unit. Outcomes were similar among children with S. pneumoniae and S. aureus CAP, whereas S. pyogenes was associated with a higher risk for complications (OR 8 [95%CI 1.1-57.2]) and ICU admission (OR 7.1 [95%CI 1.7-29.1]) compared with pneumococcal CAP. Conclusion: In a setting with high PCV coverage, culture-confirmed bacterial CAP did not decrease over time and there was a relative increase of S. pyogenes and S. aureus. Children with CAP caused by S. pyogenes were more likely to develop complications.

Skin infections in Australian Aboriginal children: a narrative review

Impetigo, scabies, cellulitis and abscesses are common in Australian Aboriginal children. These conditions adversely affect wellbeing and are associated with serious long term sequelae, including invasive infection and post-infectious complications, such as acute post-streptococcal glomerulonephritis and acute rheumatic fever, which occurs at the highest documented rates in the world in remote Aboriginal communities. Observational research in remote communities in northern Australia has demonstrated a high concurrent burden of scabies and impetigo and their post-infectious complications. Few data are available for other Australian states, especially for urban Aboriginal children; however, nationwide hospital data indicate that the disparity between Aboriginal and non-Aboriginal children in skin infection prevalence also exists in urban settings. The Australian National Healthy Skin Guideline summarises evidence-based treatment of impetigo, scabies and fungal infections in high burden settings such as remote Aboriginal communities. It recommends systemic antibiotics for children with impetigo, and either topical permethrin or oral ivermectin (second line) for the individual and their contacts as equally efficacious treatments for scabies. β-Lactams are the treatment of choice and trimethoprim-sulfamethoxazole and clindamycin are effective alternatives for treatment of paediatric cellulitis. Abscesses require incision and drainage and a 5-day course of trimethoprim-sulfamethoxazole or clindamycin. Addressing normalisation of skin infections and the social determinants of skin health are key challenges for the clinician. Research is underway on community-wide skin health programs and the role for mass drug administration which will guide future management of these common, treatable diseases.

Molecular Characterization of Streptococcus pyogenes Causing Invasive Disease in Pediatric Population in Spain A 12-year Study

OBJECTIVES

To perform a comprehensive description of the epidemiology of Streptococcus pyogenes invasive disease in the pediatric population in 2 regions of Spain (Catalonia and Gipuzkoa) through 12 years.

METHODS

All S. pyogenes isolates causing invasive disease in pediatric patients between 2005 and 2016 were included. The emm-type and the presence of 13 exotoxin genes (speA, speB, speC, speF, speG, speH, speI, speJ, speK, speL, speM, smeZ, ssa and slo) were determined in all 93 available isolates and the Multi Locus Sequece Typing in 10% of isolates of each different emm-type.

RESULTS

Overall, 103 cases of S. pyogenes invasive infections were detected: 77 in Catalonia and 26 in Gipuzkoa, being 50.5% females. The incidence rate per 100,000 children was 2.5 for Gipuzkoa and 2.6 for Catalonia, with no significant temporal trends. The median age was 30 months. The most frequent clinical presentations were: pneumonia (26.2%), bacteremia/sepsis (23.3%), septic arthritis/osteomyelitis (22.3%), cellulitis/mastoiditis (12.6%) and meningitis (6.8%). Eight children developed streptococcal toxic shock syndrome. Nine cases were preceded by varicella infection. The associated mortality rate was 3.9%. Three isolates were resistant to erythromycin, being one of them also resistant to clindamycin and 4 isolates were resistant to levofloxacine. Forteen different emm-types were detected being emm1/ST28 (40.9%) the most frequent clone in both regions followed by emm12/ST36-ST242, emm6/ST382, emm3/ST15, emm75/ST150 and emm4/ST38-39. speA gene was only detected in emm1 and emm3 isolates. Eight exotoxins were enough to assign an emm-type with a very high degree of accuracy (95%). The 30-valent vaccine would include 96.8% of isolates.

[Invasive disease due to Streptococcus pyogenes: Changes in incidence and prognostic factors]

INTRODUCTION

Invasive group A streptococcal disease (iGASD) is a serious infection in children. Several studies have shown an increased incidence in the past years.

OBJECTIVE

To evaluate the characteristics and outcome of iGASD in children, and to determine changes in incidence or severity.

MATERIAL AND METHODS

A retrospective study was conducted on children≤16 years evaluated in a tertiary paediatric hospital in Madrid, and diagnosed with iGASD (June 2005-July 2013). An analysis was made of the demographics, symptomatology, microbiology, and treatment. The changes throughout the period studied were evaluated, as well as parameters associated with disease severity.

RESULTS

The study included a total of 55 children with iGASD, with 33 (60%) females, and a median age of 48.5 (20.5-88.9) months. The most frequent clinical syndromes were cellulitis/subcutaneous abscess (21.8%), ENT abscess (20%), pneumonia (16.4%), osteoarticular infection (16.4%), and mastoiditis (12.7%). The incidence of iGASD (cases/10⁵ emergencies/year) increased from 5.6 (4.2-7.2) between June 2005-May 2009 to 18.9 (15.1-26) between June 2009-May 2013; P=.057. Surgery and admission to PICU was required by 35 (63.6%) and 10 (18.2%) patients, respectively. Children in PICU were younger (26.5 vs 52.6 months, P=.116), had a higher C-reactive protein (24.5 vs 10.7mg/dl, P<.001) and higher frequency of pneumonia (60 vs 7%, P<.001). In the multivariate analysis, only C-reactive protein was a risk factor for admission to PICU (OR: 1.14 [1.004-1.286], P=.04). There were no sequelae.

CONCLUSIONS

An increased incidence of iGASD was observed in the children in this study. Lower age, pneumonia, and higher C-reactive protein were associated with disease severity in this series.

Acidic stress enhances CovR/S-dependent gene repression through activation of the covR/S promoter in emm1-type group A Streptococcus

Streptococcus pyogenes (group A Streptococcus) is a clinically important gram-positive bacterium that causes severe diseases with high mortality. Spontaneous mutations in genes encoding the CovR/CovS two-component regulatory system have been shown to derepress expression of virulence factors and are significantly associated with invasiveness of infections. Sensor kinase CovS senses environmental signals and then regulates the levels of phosphorylated CovR. In addition, CovS is responsible for survival of group A Streptococcus under acidic stress. How this system regulates the expression of CovR-controlled genes under acidic stress is not clear. This study shows that the expression of CovR-controlled genes, including hasA, ska, and slo, is repressed under acidic conditions by a CovS-dependent mechanism. Inactivation of CovS kinase activity or CovR protein phosphorylation derepresses the transcription of these genes under acidic conditions, suggesting that the phosphorylation of CovR is required for the repression of the CovR-controlled genes. Furthermore, the promoter activity of the covR/covS operon (pcov) was upregulated after 15min of incubation under acidic conditions. Replacement of pcov with a constitutively activated promoter abrogated the acidic-stress-dependent repression of the genes, indicating that the pH-dependent pcov activity is directly involved in the repression of CovR-controlled genes. In summary, the present study shows that inactivation of CovS not only derepresses CovR-controlled genes but also abrogates the acidic-stress-dependent repression of the genes; these phenomena may significantly increase bacterial virulence during infection.

[Streptococcus pyogenes infection in paediatrics: from pharyngotonsillitis to invasive infections]

BACKGROUND

Streptococcus pyogenes or Group A Streptococci (GAS) cause many infections in infancy. Changes in its epidemiology have been described in recent years, including an increase in invasive infections (iGAS).

METHODS

A retrospective-descriptive study was conducted on children less than 15 years old, with GAS infections, in particular iGAS, and their complications from February 2004-April 2014.

RESULTS

A total of 2,192 positive cultures were obtained of which 92.7% were pharyngeal cultures. Twenty-nine patients were admitted to hospital: 4 with suppurative complications, 7 post-infective, 14 iGAS, and 4 probable iGAS cases. There were no differences in the frequency of GAS isolations/year. Non-invasive isolates were more frequent in winter and spring (P<.001), and 68.3% were in patients younger than 5 years. The incidence of iGAS was 2.1/100,000 children/year. There was no seasonality, and it was more frequent in younger children (P=.039). The most common diagnosis was pneumonia (6/14). Eight patients required intensive care. They were treated empirically with second or third-generation cephalosporin or with intravenous penicillin, and pneumonia required longer treatment times (P=.016). All GAS isolates were sensitive to penicillin, and 10.6% were resistant to erythromycin. The time spent in hospital was longer for iGAS than other cases (P=.028). No patients died.

CONCLUSIONS

Pharyngotonsillitis caused by GAS is common in childhood, and its incidence is increasing in children younger than 5 years. At the moment, post-infectious complications are rare. Invasive infections are the most severe forms of presentation, and are more common in younger children.

When should clinicians suspect group A streptococcus empyema in children? A multicentre case-control study in French tertiary care centres

BACKGROUND

The incidence of invasive group A streptococcus (GAS) infections is increasing worldwide, whereas there has been a dramatic decrease in pneumococcal invasive diseases. Few data describing GAS pleural empyema in children are available.

OBJECTIVE

To describe the clinical and microbiological features, management and outcome of GAS pleural empyema in children and compare them with those of pneumococcal empyema.

DESIGN, SETTING AND PATIENTS

Fifty children admitted for GAS pleural empyema between January 2006 and May 2013 to 8 hospitals participating in a national pneumonia survey were included in a descriptive study and matched by age and centre with 50 children with pneumococcal empyema.

RESULTS

The median age of the children with GAS pleural empyema was 2 (range 0.1-7.6) years. Eighteen children (36%) had at least one risk factor for invasive GAS infection (corticosteroid use and/or current varicella). On admission, 37 patients (74%) had signs of circulatory failure, and 31 (62%) had a rash. GAS was isolated from 49/50 pleural fluid samples and from one blood culture. The commonest GAS genotype was emm1 (n=17/22). Two children died (4%). Children with GAS empyema presented more frequently with a rash (p<0.01), signs of circulatory failure (p=0.01) and respiratory disorders (p=0.02) and with low leucocyte levels (p=0.04) than children with pneumococcal empyema. Intensive care unit admissions (p<0.01), drainage procedures (p=0.04) and short-term complications (p=0.01) were also more frequent in patients with GAS empyema.

CONCLUSIONS

Pleural empyema following varicella or presenting with rash, signs of circulatory failure and leucopenia may be due to GAS. These features should prompt the addition to treatment of an antitoxin drug, such as clindamycin.

Scarlet fever: A not so typical exanthematous pharyngotonsillitis (based on 171 cases)

AIM

To describe the age, signs and clinical symptoms of children with scarlet fever at the present time, and to check whether they are equivalent to those with traditional streptococcal pharyngotonsillitis.

STUDY DESIGN

An observational, retrospective study was conducted on the clinical records of 5500 children aged from 0 to 15 years attending a primary health care center. A record was made of the percentage of the cases in which signs and symptoms appear and the Centor score was calculated. Microbiological diagnosis of the disease was made using the rapid antigen-detection test or traditional culture.

RESULTS

A total of 171 out of 252 scarlet fever diagnoses were microbiologically verified in 158 patients. The median age was 3.8 years (interquartile range: 2.91-4.78), with the majority (57%) under the age of 4 years. There was fever in 89% of the processes (95% CI: 84-94%), with a temperature of >38°C in 73% (95% CI: 65-80%), enlarged lymph nodes in 70% (95% CI: 58-82%), absence of cough in 73% (95% CI: 65-80%), and tonsillar exudate in only 24% (95% CI: 17-31%). The Centor score (n=105) was ≤2 points in 86% (95% CI: 79-92%). The only difference regarding age is that episodes in patients under the age of 4 years old have significantly higher fever (>38°C) than the older ones (80% versus 63%. OR 3.13; 95% CI: 1.46-6.71).

CONCLUSION

Scarlet fever pharyngotonsillitis differs from the traditional streptococcal pharyngotonsillitis, and its evaluation using clinical prediction rules such as Centor or McIsaac is questionable. The main diagnostic key must certainly be rash, regardless of patient age.

Pediatric invasive streptococcal infection in northern and eastern regions of Hokkaido, Japan from 2010 to 2012

BACKGROUND

The frequency of occurrence of pediatric invasive streptococcal infection in Japan has not been studied, therefore the aim of this study was to survey the northern and eastern regions of Hokkaido from 2010 to 2012.

METHOD

Survey sheets were sent to the pediatric departments at 17 facilities where children in the subject region can be hospitalized. Responses were obtained from all of the 17 facilities.

RESULTS

Seven patients developed group A streptococcal infection over the 3 years, and their ages ranged from 1 day after the birth to 15 years old. Sepsis was diagnosed in five children, and empyema and arthritis in the knee were found in one child each, respectively. The number of cases in children under 15 years old was six excluding the child who was 15 years old, and the incidence rate per 100,000 population was 1.00. Eight children developed group B streptococcal infection, and their ages ranged from 0 days to 2 months after birth. Two cases were the early onset type (age within 7 days) and six cases were the late onset type. Five children developed sepsis and three children developed meningitis. The frequency of occurrence was 0.24 per 1000 births; which was 0.06 per 1000 births for the early onset type and was 0.18 per 1000 births for the late onset type. No reports for group C or group G hemolytic streptococcal infection were obtained.

CONCLUSIONS

The incidence rates identified in the present survey are similar to those in other advanced countries, and appear to be valid.