Invasive streptococcal infections in the era before the acquired immune deficiency syndrome: a 10 years' compilation of patients with streptococcal bacteraemia in North Yorkshire

Group A Streptococcus Infection in Neonatal Population: A Systematic Review of The Literature

(1) Background: The importance of group A streptococcus (GAS) infection severity has been recognized in children and adults. However, to our knowledge, there have been no systematic reviews or pooled assessments of the incidence and outcome of invasive GAS (iGAS) disease in neonates, a potentially high-risk population. Therefore, we performed a systematic review of available data regarding the risk factors, clinical presentation, and outcome of GAS infection in neonates. (2) Methods: An electronic search of the existing literature was carried out during the period July 2023-September 2023 in the PubMed and Scopus databases, considering studies referring to GAS infection in the neonatal population. (3) Results: Overall, 39 studies met all the inclusion criteria and were included in this review, evaluating data from 194 neonates. Unfortunately, there were a lot of missing data among the retrieved studies. Our systematic review highlighted the presence of differences with regards to clinical presentation, infection sites, and outcome of GAS invasive disease between neonates with early-onset (EOS) or late-onset sepsis (LOS). Common characteristics of EOS included respiratory distress, rapid deterioration, and high mortality rate irrespective of the infection site, while rash, gastrointestinal tract symptoms, and fever appeared to be the most frequent symptoms/clinical signs and manifestations of LOS disease. The management of severe invasive iGAS disease consists mainly of specific antimicrobial treatment as well as supportive care with fluids and electrolyte supplementation, minimizing or counteracting the effects of toxins. Furthermore, a mortality rate of approximately 14% was recorded for iGAS disease in the total of all studies' neonates. (4) Conclusions: Although iGAS is a rare entity of neonatal infections, the potential severity of the disease and the rapid deterioration requires the development of quick analysis methods for the detection of GAS allowing the prompt diagnosis and administration of the indicated antibiotic treatment. Furthermore, given the exceptional risk for both the pregnant woman and the neonate, it is very important to raise awareness and create easily accessible guidelines that could facilitate the prevention and management of maternal as well as the subsequent neonatal severe iGAS disease.

Burden of invasive group B Streptococcus disease in non-pregnant adults: A systematic review and meta-analysis

Background

Streptococcus agalactiae or group B Streptococcus (GBS) has emerged as an important cause of invasive disease in adults, particularly among the elderly and those with underlying comorbidities. Traditionally, it was recognised as an opportunistic pathogen colonising and causing disease in pregnant women, neonates, and young infants. Reasons for the upsurge of invasive GBS (iGBS) among the elderly remain unclear, although it has been related to risk factors such as underlying chronic diseases, immunosenescence, impaired inflammatory response, and spread of virulent clones. Antibiotics are successfully as treatment or prophylaxis against iGBS. Several candidate vaccines against iGBS are under development.

Objectives

To conduct a systematic review of the current literature on invasive GBS in order to determine disease incidence and case fatality ratio (CFR) among non-pregnant adults. Additionally, information on risk factors, clinical presentation, serotype distribution, and antimicrobial resistance was also retrieved.

Methods

Between January and June 2020, electronic searches were conducted in relevant databases: MEDLINE, EMBASE, Global Health, and SCOPUS. Studies were included in the systematic review if they met the inclusion/exclusion criteria. The authors assessed the selected studies for relevance, risk of bias, outcome measures, and heterogeneity. Meta-analyses on incidence and CFR were conducted after evaluating the quality of methods for assessment of exposure and outcomes.

Results

Pooled estimates of iGBS incidence in non-pregnant adults 15 years and older were 2.86 cases per 100.000 population (95% CI, 1.68–4.34). Incidence rates in older adults were substantially higher, 9.13 (95%CI, 3.53–17.22) and 19.40 (95%CI, 16.26–22.81) per 100.000 population ≥50 and ≥ 65 years old, respectively. Incidence rates ranged from 0.40 (95% CI, 0.30–0.60) in Africa to 5.90 cases per 100.000 population (95% CI, 4.30–7.70) in North America. The overall CFR was and 9.98% (95% CI, 8.47–11.58). CFR was highest in Africa at 22.09% (95% CI, 12.31–33.57). Serotype V was the most prevalent serotype globally and in North America accounting for 43.48% (n = 12926) and 46,72% (n = 12184) of cases, respectively. Serotype Ia was the second and serotype III was more prevalent in Europe (25.0%) and Asia (29.5%). Comorbidities were frequent among non-pregnant adult iGBS cases. Antimicrobial resistance against different antibiotics (i.e., penicillin, erythromycin) is increasing over time.

Conclusions

This systematic review revealed that iGBS in non-pregnant adults has risen in the last few years and has become a serious public health threat especially in older adults with underlying conditions. Given the current serotype distribution, vaccines including serotypes predominant among non-pregnant adults (i.e., serotypes V, Ia, II, and III) in their formulation are needed to provide breadth of protection. Continued surveillance monitoring potential changes in serotype distribution and antimicrobial resistance patterns are warranted to inform public health interventions.

Early intravenous immunoglobulin therapy for group A β-haemolytic streptococcal meningitis with toxic shock syndrome

A woman in her forties was transferred to a Sydney (Australia)-based tertiary hospital, following presentation to a regional hospital with group A Streptococcus (GAS) otomastoiditis; complicated by meningitis, venous sinus thrombosis, haemorrhagic cerebral infarction and subdural empyema. She rapidly deteriorated with profound cardiovascular collapse. Despite initiation of high dose vasoactive therapy, she remained shocked and developed multiorgan dysfunction syndrome. Early intravenous immunoglobulin therapy (140 g in two doses) was initiated as an adjunct to antimicrobial, surgical and supportive care for refractory streptococcal toxic shock syndrome. Over the course of a twelve-day intensive care unit stay she made good progress with de-escalation of her vasoactive supportive care and reversal of her organ injuries. She was subsequently discharged to ward-based care. At her three-month follow-up appointment she had significantly reduced neurological deficit. Five months following her presentation to hospital she had returned to full-time work.

Streptococcal toxic shock syndrome with fatal outcome: Report on four forensic autopsy cases

Streptococcal toxic shock syndrome (STSS) is a severe infection most commonly caused by group A streptococcus. It is clinically characterized by rapidly progressive multiple organ failure and septic shock. This report presents four fatal cases associated with STSS. In two cases (cases 2 and 3), the portals of entry may be ulcer and mucosa at the surgical site; the initial symptoms in these cases included fever. In the other cases, the portal of entry was unknown; the initial symptom was pain. In two cases (cases 1 and 3), malpractice was suspected before autopsy. At autopsy, blood culture was positive for group A streptococcus in all of the present cases. Although C-reactive protein levels were increased, procalcitonin levels were not markedly elevated. This is the first report of autopsy cases associated with STSS in which postmortem computed tomography was performed; the swelling of muscles and increased concentrations of peripheral subcutaneous tissue without gas may be characteristic findings. Histology revealed extensive bacterial colonies and necrosis with mild neutrophilic reaction in two cases (cases 3 and 4), and hemophagocytosis in two cases (cases 1 and 4). It is essential to perform appropriate examinations and make a proper diagnosis because STSS still has a high fatality rate and medical malpractice is often suspected. In addition, it is important to evaluate STSS again for the reduction of the fatal cases associated with STSS.

Hospital-acquired invasive group a streptococcal infections in Ontario, Canada, 1992-2000

BACKGROUND

A significant proportion of invasive group A streptococcal infections are hospital acquired. No large, prospective studies have characterized this subgroup of cases and evaluated the risk of transmission in hospitals.

METHODS

We conducted prospective, population-based surveillance of invasive group A streptococcal infections in Ontario, Canada, from 1992 to 2000. Epidemiologic and microbiologic investigations were conducted to identify cross-transmission.

RESULTS

We identified 291 hospital-acquired cases (12.4%) among 2351 cases of invasive group A streptococcal disease. Hospital-acquired invasive group A streptococcal infections are heterogeneous, including surgical site (96 cases), postpartum (86 cases), and nonsurgical, nonobstetrical infections (109 cases). Surgical site infections affected 1 of 100,000 surgical procedures and involved all organ systems. Postpartum infections occurred at a rate of 0.7 cases per 10,000 live births and exhibited an excellent prognosis. Nonsurgical, nonobstetrical infections encompassed a broad range of infectious syndromes (case-fatality rate, 37%). Nine percent of cases were associated with in-hospital transmission. Transmission occurred from 3 of 142 patients with community-acquired cases of necrotizing fasciitis requiring intensive care unit (ICU) admission, compared with 1 of 367 patients with community-acquired cases without necrotizing fasciitis admitted to the ICU and 1 of 1551 patients with other cases (P<.001). Fifteen outbreaks were identified; 9 (60%) involved only 2 cases. Hospital staff were infected in 1 of 15 outbreaks, but colonized staff were identified in 6 (60%) of 10 investigations in which staff were screened.

CONCLUSIONS

Presentation of hospital-associated invasive group A streptococcal infections is diverse. Cross-transmission is common; illness occurs in patients but rarely in staff. Isolation of new cases of necrotizing fasciitis and intervention after a single nosocomial case may also prevent transmission.

Relationship between oral motor dysfunction and oral bacteria in bedridden elderly

OBJECTIVE

The purpose of this study was to analyze the relationship between oral bacterial colonization and oral motor dysfunction.

STUDY DESIGN

Oral motor dysfunction (swallowing and speech disorders) and detection of oral bacterial species from dental plaque in 55 elderly persons who had remained hospitalized for more than 3 months were investigated and statistically analyzed.

RESULTS

The detection rates of methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Streptococcus agalactiae, and Stenotrophomonas maltophilia were significantly higher in subjects with than in those without a swallowing disorder. A similar result was found with regard to the presence of a speech disorder. About half of subjects who had oral motor dysfunction and hypoalbuminemia had colonization by MRSA and/or Pseudomonas aeruginosa.

CONCLUSION

These results suggest that the combination of oral motor dysfunction and hypoalbminemia elevated the risk of opportunistic microorganisms colonization in the oral cavity of elderly patients hospitalized over the long term.

Serum cytokine level during continuous venovenous hemofiltration in toxic shock-like syndrome due to group G beta Streptococcus bacteremia in a patient with idiopathic thrombocytopenic purpura

We report a case of toxic shock-like syndrome due to a rare infection of group G Streptococcus bacteremia in a patient with idiopathic thrombocytopenic purpura and its successful treatment with continuous venovenous hemofiltration (CVVH). As the result of sepsis treatment with CVVH, in addition to administration of vasopressors and antibiotics, serum levels of interleukin-1beta, interleukin-10 and tumor necrosis factor-a fell and shock was controlled.

Necrotizing fasciitis: reports of three fatal cases simulating and resulting from assaults

Necrotizing fasciitis is a progressive, potentially fatal, rapid, necrotizing infection of the subcutaneous tissues and fascia often caused by a mixture of organisms or by infection with group A Streptococcus pyogenes with or without Staphylococcus aureus. Three cases are presented that have been encountered in forensic pathologic practice. Two cases presented after assaults, and the third simulated an assault and burglary. The history, scene, and pathologic findings are presented with a brief review of the literature.

Bacterial arthritis due to beta-hemolytic streptococci of serogroups A, B, C, F, and G. Analysis of 23 cases and a review of the literature

The clinical features, essential laboratory findings, management, and outcome of all 23 cases of septic arthritis caused by different serogroups of beta-hemolytic streptococcus (BHS) seen at the Stanford Medical Center, Stanford, CA, from July 1, 1985, through October 31, 1996, were reviewed and compared to those found in the literature. Group A streptococci (GAS) accounted for 9 (40%) of our cases; group B (GBS), for 7 (30%); and Group G (GGS), for 7 (30%). No cases were caused by Group C (GCS) or F (GFS) during this period. During the same period, GAS accounted for 66 (33%) of 200 cases of bacteremia due to BHS, GBS, for 98 (49%); GCS, for 12 (6%); GFS, for 4 (2%); and GGS, for 20 (10%). A review of potential risk factors revealed that, with the exception of GGS, male and female patients were almost equally distributed among each of the serogroups. Patients aged 50 years and older comprised 56%-77% of each group. Associated conditions and risk factors were present among most patients (19/23, 83%); autoimmune diseases and a chronic skin wound or trauma were notably present among patients with GAS, while diabetes mellitus and malignancy were more common among patients with GBS. Infected prosthetic implants were present in 7 patients, including 4/7 patients with GGS. All patients had positive cultures of synovial fluid, and 11/23 (49%) had positive blood cultures (GAS, 5/9; GBS, 6/7; and GGS, 0/7). The clinical presentation and hospital course of patients infected with the different serogroups varied. Patients infected with GAS had the most severe disease and those with GGS the least severe. Necrotizing fascitis, shock, DIC, and admission to the intensive care unit were found only among patients infected with GAS. Despite aggressive management with antimicrobial therapy and surgery, 4/23 patients died (3 patients with GAS; 1 with GBS). The isolates from our patients were not available for study; investigations by others of the biology of BHS suggest that the production of 1 or more of the streptococcal pyrogenic exotoxins by isolates of GAS may account for the differences in the severity of disease among our patients with septic arthritis caused by different serogroups of BHS. Although septic arthritis due to BHS is uncommon, such patients provide a valuable model to study features of the host-parasite interaction that may contribute to the observed differences in severity of disease.

Group A streptococcal bacteremia. A 10-year prospective study

In this paper we present a prospective evaluation of 100 patients with Group A Streptococcal (GAS) bacteremia evaluated in our hospital over a 10-year period. Sixty-two patients were intravenous drug users (IVDU); all but 1 of these had an obvious cutaneous portal of entry related to the injection of illicit drugs. Twenty-seven patients had infectious metastasis, and the presence of septic pulmonary embolism was associated with suppurative phlebitis. Four of these patients had endocarditis. In the non-IVDU group, 24 patients had an underlying disease, and 12 were immunosuppressed. In 14 cases the infection was of hospital acquisition; in 35% infection was related to medical manipulations. Comparing the IVDU and non-IVDU groups, GAS bacteremia in IVDU patients is associated with a more benign outcome, a longer time of evolution before diagnosis, and a lower frequency of septic shock and mortality than in non-IVDU patients. Although in the univariate analysis GAS bacteremia was associated with several variables, in the multivariate analysis only the presence of shock and nosocomial acquisition of the infection were independently associated with a fatal outcome. Fifty-two patients were infected with human immunodeficiency virus (HIV); 5 of these were in the non-IVDU group. During the last 5 years of study, GAS bacteremia in our hospital was 39 times more frequent in HIV-infected patients than in patients without HIV. Nine patients presented clinical criteria corresponding to Streptococcal toxic shock syndrome (STSS), although its incidence was lower in the IVDU group. In the non-IVDU group, STSS was more frequent in patients with a necrotizing portal of entry, an age between 20 and 40 years, women, and when the origin of the infection was the skin or soft tissue. Six patients with STSS died, and death was associated with the presence of necrotizing lesions and lower counts of white cells, platelets, or hemoglobin.

Prospective study of Streptococcus milleri bacteremia

In a prospective study of bacteremia caused by organisms of the Streptococcus milleri group a total of 32 adult patients were observed over a seven-year period. These patients accounted for 1.6% of all patients diagnosed as having significant bacteremia and 17% of all cases of streptococcal (nonpneumococcal) bacteremia diagnosed during the study period. Only five patients had polymicrobic bacteremia. In 31 cases, a presumed origin of infection was identified, generally oral or gastrointestinal disease. There were only six cases of nosocomial acquisition. The most common presenting symptom was prolonged fever. The following forms of presentation were documented: bacteremia with local suppurative infection (56%), bacteremia without local suppurative infection (25%), and endocarditis (19%). An associated focus of infection was found in the abdominal cavity in 20 cases (62%). The mortality rate was 12.5%. All isolates were susceptible to penicillin. Caution is necessary in interpreting a blood culture positive for Streptococcus milleri group organisms, since, unlike other viridans streptococci, they are rarely contaminants. For this reason patients with suppurative processes and/or digestive tract disease must be carefully investigated.

Group B streptococcal bacteremia in adults. Five years' experience and a review of the literature

The importance of group B streptococcus (GBS) as a cause of serious infectious disease among adults is not widely appreciated. In adults, the modes of acquisition and transmission are unknown. Since most hospital-based studies of GBS bacteremia in adults consist of small numbers of patients, the clinical spectrum of disease is not well described. Our retrospective study reviews the clinical features, antimicrobial therapy, and risk factors for mortality of 32 adult patients (18 women and 14 men) with GBS bacteremia and compares the proportion of isolates from the different beta-hemolytic streptococci sero-groups. We found that 39% of isolates from adult blood cultures were group B, a frequency nearly identical to that of group A streptococcal bacteremia. Most (66%) adult patients were more than 50 years old. Primary bacteremia was the most frequent clinical diagnosis, occurring in 7 (22%) of 32 patients. Nonhematologic cancer was the most frequently associated condition (25%). Nineteen percent of the patients had diabetes mellitus. The overall mortality rate was 31% and was significantly associated with increasing age. Our results are compared to those obtained by a review of all 5 previous comparable studies and demonstrate that GBS bacteremia is a serious infection in adults with increased mortality related to advancing age.

Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new concepts in treatment

Since the 1980s there has been a marked increase in the recognition and reporting of highly invasive group A streptococcal infections with or without necrotizing fasciitis associated with shock and organ failure. Such dramatic cases have been defined as streptococcal toxic-shock syndrome. Strains of group A streptococci isolated from patients with invasive disease have been predominantly M types 1 and 3 that produce pyrogenic exotoxin A or B or both. In this paper, the clinical and demographic features of streptococcal bacteremia, myositis, and necrotizing fasciitis are presented and compared to those of streptococcal toxic-shock syndrome. Current concepts in the pathogenesis of invasive streptococcal infection are also presented, with emphasis on the interaction between group A Streptococcus virulence factors and host defense mechanisms. Finally, new concepts in the treatment of streptococcal toxic-shock syndrome are discussed.

Severe community acquired pneumonia associated with a desquamating rash due to group A beta-haemolytic streptococcus

In recent years frequent and severe infections due to group A beta-haemolytic streptococci have been recognised with increasing frequency. Group A streptococcal pneumonia remains a rare disease occurring sporadically in contrast to epidemics in the past. The association between group A streptococcal pneumonia and a desquamating skin rash typical of scarlet fever has rarely been reported.

Bacteraemia due to different groups of beta-haemolytic streptococci: a two-year survey and presentation of a case of recurring infection due to Streptococcus "equisimilis"

We present a 2-year survey of bacteraemic episodes due to beta-haemolytic streptococci and a case of recurring infection due to group C streptococcus, Streptococcus "equisimilis". We found 53 episodes of bacteraemia with beta-haemolytic streptococci. Group A was the most common, followed by groups B, G and C. The proportion of nosocomial cases was the same in all four groups i.e. 24% (neonatal cases excluded). The clinical picture presented by groups C and G streptococcal cases was indistinguishable from that caused by group A streptococci, but patients with group G bacteraemia were older than patients with group A bacteraemia. Obvious clinical foci were more common in group A than group G cases. Disregarding neonatal cases, most patients had predisposing conditions. There was no difference in foci of bacteraemia, predisposing factors, treatment and outcome of disease. The overall mortality was 25%.

Beta haemolytic streptococci and musculoskeletal sepsis in adults

Lancefield group A streptococci (GAS) account for 3-17% cases of septic arthritis, but other beta haemolytic streptococci (BHS) (groups B, C, and G) are being increasingly implicated. Epidemiological evidence suggests that the increase of BHS sepsis in adults is a true increase and not simply a reflection of better reporting. While underlying predisposing disease and old age are common concomitants of BHS sepsis, some subjects with devastating disease have been young and healthy. This is particularly the case for highly virulent M1 serotypes of GAS, where a toxic shock-like syndrome has led to a number of deaths in young adults in the United Kingdom and elsewhere. Musculoskeletal features, such as myalgias, painful swollen limbs, myositis, and fasciitis, are important features of this condition, so that rheumatologists may be involved in management. Group C and G musculoskeletal sepsis remains uncommon, with a high prevalence of underlying predisposing disease, or pre-existing arthritis in the septic joint. Group B BHS septic disease appears to be increasing in incidence. Musculoskeletal sepsis with these organisms usually takes place in subjects with other diseases, but healthy subjects have not been spared. Multiple septic foci and a rapidly destructive arthritis are not uncommon, and a recently described extra-articular feature is potentially blinding metastatic endophthalmitis. Clinicians need to be aware of an apparently increasing incidence of BHS musculoskeletal sepsis in adults so that early identification can lead to aggressive management in these potentially fatal infections.

Beta haemolytic streptococci and reactive arthritis in adults

There is an increasing occurrence of reactive group A beta haemolytic streptococci (BHS) phenomena. This review makes a case for considering BHS in the differential diagnosis of adult reactive arthritis. This is based on (a) published reports over the past 45 years describing first attacks of rheumatic fever in adults; (b) the longstanding observation that polyarthritis is the most commonly expressed Jones major criterion in adults; (c) the broad spectrum of clinical expression of disease following streptococcal infection, with the re-emergence of the term 'poststreptococcal reactive arthritis'. The arthritis in adult rheumatic fever is characterised by sequential involvement of large weightbearing joints. Recurrent, severe, prolonged arthritis has been a prominent feature of adult poststreptococcal reactive arthritis. Carditis has been reported in 33% of adult patients with rheumatic fever. Consequently long term antibiotic prophylaxis for adults with reactive BHS phenomena should be strongly considered, and guidelines are suggested for this in individual patients. Further areas for research are discussed, particularly the interrelations between bacteria and host in disease expression, and the possibility that BHS might play a part in chronic arthritides and vasculitides.

Streptococcal infection in general practice

The last 30 years have been changes in emphasis in the study of streptococci and streptococcal diseases. Earlier work concentrated mainly on the sources and methods of cross-infection and descriptive epidemiology of Streptococcus pyogenes in its major manifestations of respiratory, cutaneous and invasive infection and in the complications of rheumatic fever (RF), scarlet fever (SF) and post-streptococcal glomerulonephritis (PSGN).

Spectrum of disease in bacteraemic patients during a Streptococcus pyogenes serotype M-1 epidemic in Norway in 1988

All 87 known cases of bacteraemia due to Streptococcus pyogenes (beta-haemolytic group A streptococci) occurring during the peak of a nationwide outbreak in Norway (population 4.2 million) between January and June 1988 were reviewed. Clinical features varied widely and appeared largely to be dependent on the patients' age. The case fatality rate ranged from 11% in the age group under 30 years to 44% in patients over 60 years. Clinical complications such as shock, severe renal or respiratory failure or serious local infection occurred particularly in 30-to 59-year old individuals. Shock was manifest in 32% of the patients and carried a 68% case fatality rate. Chronic heart disease in the elderly and pneumonia seemed to be associated with a fatal outcome. In the 25 patients (29%) who died the disease showed a fulminant course, 80% dying within 48 hours after admission. However, 56% of the patients had experienced symptoms for more than two days before admission, suggesting that early diagnosis and treatment might possibly have prevented the development of a serious disease. This study revealed a wide spectrum of clinical manifestations in bacteraemia cases in a unique epidemiological situation caused largely by a single serotype of Streptococcus pyogenes; 89% of the 27 preserved bacteraemia strains carried the M-1 antigen. The observations call attention to the ability of these organisms to cause fulminant clinical illness, indicating a probable increase in both invasiveness and toxicity of group A streptococci responsible for the epidemic.

Increased number of sporadic nosocomial group A streptococcal bacteraemias during a community epidemic

An increased morbidity rate due to Lancefield group A streptococci (GAS) in the Scandinavian countries, beginning late in 1987, led to the present retrospective survey of bacteraemias with GAS in Denmark. Among 242 reported cases from January 1987-December 1989, 94 were found to have been nosocomially acquired, and their occurrence mirrored the pattern of the epidemic with T-type 1 and the seasonal variation of other serotypes in the community. The 27 nosocomial cases from 1988 were studied further. Eighty percent were associated with postoperative wound infection, erysipelas, puerperal or neonatal infection. Of the 52 community-acquired cases in 1988, 80% comprised erysipelas, respiratory tract infection, meningitis, gastrointestinal disease or arthritis. The bacteraemic patients were promptly treated with antibiotics, but the use of penicillin was in some cases delayed because the clinical signs of streptococcal infection were misinterpreted by the attending clinician. Ideally, the nosocomial infections should have been prevented by hygienic measures in the hospitals. When an epidemic situation of this type exists in the community, handwashing routines become vitally important. A warning for epidemics should be extended to the hospital.

Septicemia and endocarditis caused by group G streptococci in a Norwegian hospital

The clinical and bacteriological features of septicemia caused by group G streptococci were analyzed in nine patients seen during a period of 28 months. Four of these patients had acute endocarditis with a high rate of serious neurological complications. The clinical response to antibiotic treatment was slow in the endocarditis patients despite sensitivity of the organism in vitro. Group G streptococcal septicemia can be a very serious condition associated with endocarditis of a destructive nature. Comparison with previous reports suggests that group G streptococcal infections are of increasing importance. The virulence of group G streptococci may be changing, resulting in more serious infections and complications. This series stresses the importance of prompt recognition of this infection and the need for aggressive management of these patients.