Toxic shock syndrome surveillance in UK children

Treatment of toxic shock in children

Toxic shock syndrome (TSS) is a life-threatening complication of infection typically caused by one of two bacterial species: Staphylococcus aureus and Streptococcus pyogenes The outcomes in children with TSS can be devastating. Careful consideration of TSS is required as a potential differential diagnosis of children presenting with sepsis or severe illness associated with fever and rash.

The Thousand Faces of Invasive Group A Streptococcal Infections: Update on Epidemiology, Symptoms, and Therapy

Invasive infections caused by Streptococcus pyogfenes (iGAS), commonly known as Group A Streptococcus, represent a significant public health concern due to their potential for rapid progression and life-threatening complications. Epidemiologically, invasive GAS infections exhibit a diverse global distribution, affecting individuals of all ages with varying predisposing factors. The pathogenesis of invasive GAS involves an array of virulence factors that contribute to tissue invasion, immune evasion, and systemic dissemination. In pediatrics, in the last few years, an increase in iGAS infections has been reported worldwide becoming a challenging disease to diagnose and treat promptly. This review highlights the current knowledge on pathogenesis, clinical presentations, and therapeutic approaches for iGAS in children.

High-dose intravenous immunoglobulin versus albumin 4% in paediatric toxic shock syndrome: a randomised controlled feasibility study

PURPOSE

Toxic shock syndrome (TSS) is a rare disease responsible for significant morbidity and mortality. Intravenous immunoglobulin (IG) therapy in paediatric TSS could improve shock and organ failure, but more consistent efficacy and safety data are needed. Our objective was to determine whether a randomised clinical trial (RCT) assessing intravenous IG in TSS in children is feasible.

METHODS

We performed a multicentre, feasibility, double-blind RCT assessing efficacy of high-dose intravenous IG versus albumin 4% (control group) within the first 12 hours of shock onset. Included patients were aged above 1 month and below 18 years with suspected TSS and septic shock. Feasibility was assessed by measuring inclusion rate, protocol compliance and missing data regarding death and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score. Other secondary clinical outcomes were evaluated during hospital stay, at 60 day and 1 year.

RESULTS

28 patients, admitted in 6 paediatric intensive care units during 36 consecutive months and followed for 1 year, received the allocated treatment: 13 in intravenous IG group, 15 in control group. The median age was 10.6 years and the sex ratio was 1. Inclusion rate was above 50%, protocol deviations were below 30% and missing data regarding death and PELOD-2 Score below 10%. No difference concerning secondary clinical outcomes between groups was observed, and more adverse events were reported in the control group.

CONCLUSION

It seems to be feasible to conduct an RCT assessing intravenous IG efficacy and safety in paediatric TSS but must be realised internationally, with choice of a clinically relevant endpoint and a specific design in order to be realistic.

TRIAL REGISTRATION NUMBER

NCT02219165.

Toxic Shock Syndrome: Eighteen Years of Experience in a Pediatric Intensive Care Unit

Introduction Toxic shock syndrome (TSS) is a life-threatening disease usually caused by a Staphylococcus aureus or group Aβ-hemolytic Streptococcus infection. Methods In this retrospective study, we included patients with TSS admitted to a tertiary hospital's pediatric intensive care unit (PICU) over the last 18 years. We compared the staphylococcal TSS (Staph-TSS) and streptococcal TSS (Strep-TSS) groups. Results We included 17 patients (64.7% male), with a median age of 6.1 years (3.0 years for streptococcal TSS versus 13.3 years for staphylococcal TSS, p = 0.040), a median of 3.0 days from symptom onset to diagnosis, and a median of 6.0 days of hospitalization. Ten patients met the Centers for Disease Control and Prevention (CDC) criteria for staphylococcal TSS (one menstrual-related) and seven met the criteria for streptococcal TSS (four of them occurring since the COVID-19 pandemic was declared). Fifteen patients had identified risk factors, primarily cutaneous lesions (29.4%). In 15 patients, at least three organs or systems were affected, with fever, rash, and hypotension as universal findings. Mucous membrane hyperemia was present in 16 patients, gastrointestinal symptoms in 14 patients, and desquamation in nine. Muscular involvement was present in seven patients, all with staphylococcal TSS (p = 0.010). All patients received two or more antibiotics, including a protein synthesis inhibitor (except for one), and required fluid resuscitation and vasoactive amines (median three days). Six patients needed invasive mechanical ventilation (median seven days). Albumin infusion was necessary in six patients, significantly more frequently in patients with streptococcal TSS (p = 0.035). Two patients with staphylococcal TSS died, while the seven patients with streptococcal TSS survived hospital discharge. There were no recurrent cases. Conclusions Our study revealed TSS severity and multiorgan involvement, emphasizing the importance of early diagnosis and intervention. Risk factors were prevalent, and we noted an increased frequency of group A streptococcal (GAS) TSS post-COVID-19 pandemic.

Effectiveness of intravenous immunoglobulin therapy for invasive group A Streptococcus infection: A Japanese nationwide observational study

OBJECTIVES

Invasive group A Streptococcus infection (iGAS) is a rare but fatal condition. We aimed to evaluate the effectiveness of intravenous immunoglobulin (IVIG) in the treatment of iGAS.

METHODS

Patients' data were extracted from a Japanese nationwide database between April 2018 and March 2021. The primary outcome was in-hospital mortality rate, whereas the secondary outcomes were 30-day and 7-day mortality rates.

RESULTS

Overall, 481 patients (median age, 65 years; female, 49.7%) were included in the analysis. The overall mortality rate was 31.0%. After adjusting for background factors, we found that IVIG treatment had no effect on in-hospital mortality (adjusted odds ratio [OR]: 0.99, 95% confidence interval [CI]: 0.93-1.04, P = 0.92). Similar results were obtained after propensity score matching (OR: 1.00, 95% CI: 0.62-1.61, P >0.99). The 7-day and 30-day mortality rates were not associated with IVIG treatment.

CONCLUSION

IVIG administration had no survival benefit in iGAS patients. However, these overall findings should not be extrapolated to streptococcal toxic shock syndrome as the effect of IVIG therapy in this condition remains uncertain. Considering the rarity of iGAS, conducting a randomized controlled trial may be impractical. Therefore, an equivalent or more extensive observational study is warranted to validate these findings.

Staphylococcal toxic shock syndrome

Toxic Shock Syndrome (TSS) is a severe acute disease characterized by high fever, hypotension, rash, multiple organ dysfunction and desquamation during convalescence. TSS is caused by toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes. TSS remains a rare but severe disease. Early diagnosis is important because specific treatments with antitoxin effects must be started as soon as possible. This manuscript presents a set of images that illustrate the main findings in the peripheral blood film of a patient with TSS.

Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children: A 10-Year Single-Centre Experience from North India

OBJECTIVE

To describe the clinical and laboratory profile, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India.

METHODS

This retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011-December 2020) including children < 12 y with TSS (n = 63).

RESULTS

The median (interquartile range, IQR) age was 5 (2-9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12-17). The primary focus of infection was identified in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n = 11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fluid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n = 17). The duration of PICU and hopsital stay was 5 (4-10) and 7 (4-11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive-inotropic score.

CONCLUSION

TSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

Incidence and clinical and microbiological features of invasive and probable invasive streptococcal group A infections in children and adults in the Brussels-Capital Region, 2005-2020

Assess the incidence, risk factors, clinical and microbiological features, and outcome of both probable invasive and invasive group A Streptococcus (GAS) infections in children and adults in the BrusselsCapital Region between 2005 and 2020. A retrospective, multicentric study was performed in three university hospitals in Brussels. Patients were identified through the centralized laboratory information system. Epidemiological and clinical data were collected from patients' hospital records. A total of 467 cases were identified. Incidence has increased from 2.1 to 10.9/100,000 inhabitants between 2009 and 2019 in non-homeless adults while it was above 100/100,000 on homeless in years with available denominators. Most of GAS were isolated from blood (43.6%), and the most common clinical presentation was skin and soft tissue infections (42.8%). A third of all the patients needed surgery, a quarter was admitted to the intensive care unit, and 10% of the adult patients died. Wounds and chickenpox disease were the main risk factors for children. Tobacco, alcohol abuse, wounds or chronic skin lesion, being homeless, and diabetes were identified as major predisposing factors for adults. The most common emm clusters were D4, E4, and AC3; 64% of the isolates were theoretically covered by the 30-valent M-protein vaccine. The burden of invasive and probable invasive GAS infections is on the rise in the studied adult population. We identified potential interventions that could contribute to decrease this burden: appropriate care of wounds, specifically among homeless and patients with risk factors such as diabetes and systematic chickenpox vaccination for children.

Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis

OBJECTIVES

To quantify the prognostic effects of demographic and modifiable factors in streptococcal toxic shock syndrome (STSS).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE and CINAHL from inception to 19 September 2022, along with citations of included studies.

ELIGIBILITY CRITERIA

Pairs of reviewers independently screened potentially eligible studies of patients with Group A Streptococcus-induced STSS that quantified the association between at least one prognostic factor and outcome of interest.

DATA EXTRACTION AND SYNTHESIS

We performed random-effects meta-analysis after duplicate data extraction and risk of bias assessments. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

One randomised trial and 40 observational studies were eligible (n=1918 patients). We found a statistically significant association between clindamycin treatment and mortality (n=144; OR 0.14, 95% CI 0.06 to 0.37), but the certainty of evidence was low. Within clindamycin-treated STSS patients, we found a statistically significant association between intravenous Ig treatment and mortality (n=188; OR 0.34, 95% CI 0.15 to 0.75), but the certainty of evidence was also low. The odds of mortality may increase in patients ≥65 years when compared with patients 18-64 years (n=396; OR 2.37, 95% CI 1.47 to 3.84), but the certainty of evidence was low. We are uncertain whether non-steroidal anti-inflammatory drugs increase the odds of mortality (n=50; OR 4.14, 95% CI 1.13 to 15.14; very low certainty). Results failed to show a significant association between any other prognostic factor and outcome combination (very low to low certainty evidence) and no studies quantified the association between a prognostic factor and morbidity post-infection in STSS survivors.

CONCLUSIONS

Treatment with clindamycin and within clindamycin-treated patients, IVIG, was each significantly associated with mortality, but the certainty of evidence was low. Future research should focus on morbidity post-infection in STSS survivors.

PROSPERO REGISTRATION NUMBER

CRD42020166961.

Medication and Fluid Management of Pediatric Sepsis and Septic Shock

Sepsis is a life-threatening response to infection that contributes significantly to neonatal and pediatric morbidity and mortality worldwide. The key tenets of care include early recognition of potential sepsis, rapid intervention with appropriate fluids to restore adequate tissue perfusion, and empiric antibiotics to cover likely pathogens. Vasoactive/inotropic agents are recommended if tissue perfusion and hemodynamics are inadequate following initial fluid resuscitation. Several adjunctive therapies have been suggested with theoretical benefit, though definitive recommendations are not yet supported by research reports. This review focuses on the recommendations for medication and fluid management of pediatric sepsis and septic shock, highlighting issues related to antibiotic choices and antimicrobial stewardship, selection of intravenous fluids for resuscitation, and selection and use of vasoactive/inotropic medications. Controversy remains regarding resuscitation fluid volume and type, antibiotic choices depending upon infectious risks in the patient's community, and adjunctive therapies such as vitamin C, corticosteroids, intravenous immunoglobulin, and methylene blue. We include best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices.

Haemofiltration in the Management of Severe Paediatric Burns - Experience in a UK Burns Centre and Systematic Review

Paediatric burns are life-threatening injuries due to the acute injury and secondary complications. In acute phase burns, hypovolaemia and vasoconstriction cause renal impairment. Sepsis and multi-organ failure compound the problem resulting in morbidity and mortality. This paper outlines 5 years' experience using haemofiltration in major paediatric burns, and a review of the current literature.Retrospective patient data collection was undertaken identifying relevant paediatric burns undergoing Continuous Veno-Venous Haemofiltration. Data were analysed to identify demographics, indication, duration of therapy, and outcomes. A systematic review was also performed using PRISMA principles. PubMed, Science Direct and OVID databases were explored and relevant papers were included.From January 2015-December 2019, haemofiltration was utilised in 5 cases. Age range 3-15 years (mean: 12), 4 males / 1 female, mean weight 56kg (12-125kg). TBSA 21-61% (mean: 37.6%), mechanism of injury was scald-60%, flame-40%. Overall survival was 100%. 3 patients were filtered for a brief period during the first 24 hours to correct metabolic acidosis and control temperature. 2 patients required prolonged therapy. All patients recovered without further long term renal support. A total of 3814 papers were identified for systematic review. 3 were considered relevant for inclusion.This paper reflects the benefits of haemofiltration in the management of severe paediatric burns. Renal replacement therapy is useful in managing metabolic acidosis, temperature control and renal failure. The current literature supports judicious use on a patient-by-patient basis. Given the lack of evidence in the literature, further studies are required to establish guidelines for the use of haemofiltration in paediatric burns.

Invasive Group A Streptococcal Infections: Benefit of Clindamycin, Intravenous Immunoglobulins and Secondary Prophylaxis

Introduction: Mortality associated with invasive group A streptococcal infections (iGAS) remains high among adults, with lower mortality in children. The added value of both clindamycin and immunoglobulins in such treatment is still controversial, as is the need for antibiotic secondary prophylaxis. It is unlikely that conclusive randomized clinical studies will ever definitively end these controversies. Materials and Methods: A clinical and experimental literature review was conducted in Pubmed, Cochrane, and lay literature to determine the benefit of adding clindamycin and immunoglobulins to β-lactams in the management of iGAS, as well as the need for secondary prophylaxis measures in close contacts. Results: This review includes two meta-analyses, two randomized controlled trials, four prospective studies, five retrospective studies, and microbiological studies. To reduce mortality and morbidity, it appears useful to add clindamycin to β-lactams in severe clinical presentations, including necrotizing fasciitis or streptococcal toxic shock syndrome, and immunoglobulins for the latter two presentations. The high risk of secondary infection in household contacts justifies the need of taking preventive measures. Conclusions: Both clinical studies and available experimental evidence suggest that adding clindamycin and immunoglobulins as adjunctive therapies in the management of invasive group A streptococcal infections may reduce mortality. Household contacts should be warned about the increased risk of secondary infection, and chemoprophylaxis may be considered in certain situations.

Utility of MolecuLight i:X for Managing Bacterial Burden in Pediatric Burns

Pediatric burn injuries are vulnerable to severe complications, most often infection, making prompt and precise diagnosis of bacterial bioburden vital to preventing detrimental consequences and optimizing patients' outcomes. Currently, burn wounds are assessed for infection via examining the clinical signs and symptoms of infection, which can be confirmed by swab culture analysis. While the former approach is subjective and experience-dependant, the latter technique is susceptible to missing subsurface, biofilm-associated colonization, and any peripheral bacterial burden, and also delays confirmation by up to 5 days. The MolecuLight i:X is a handheld, noncontact fluorescence imaging device, which can reveal real-time information about clinically significant levels of bacteria and their biodistribution in surface and subsurface burn wound tissues. We conducted a single-center observational study to assess the device efficacy in identifying critical bacterial levels in pediatric burn wounds and to test the children's compliance and the overall feasibility of the device integration into the current diagnostic practice. Ten patients with 16 wounds were recruited and assessed for the presence or absence of clinical signs and symptoms of infection and the presence or absence of bacterial fluorescence on images, with swabs taken to confirm findings. Results demonstrate the device's ability to visualize clinically significant bacterial burden and to localize distribution of pathogens. All clinicians agreed on the high compliance with the device and high feasibility of incorporating the device into routine wound assessments. The results of this study may pave the way toward including bacterial fluorescence imaging into the standard diagnostic algorithm for pediatric burn population.

Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010-20171

Data are limited on the incidence and management of streptococcal toxic shock syndrome (TSS) and nonstreptococcal TSS in children. We aimed to define the clinical patterns of TSS at Nationwide Children's Hospital in Ohio as they relate to published criteria, diagnostic decisions, and treatment options. Through retrospective chart reviews, we identified 58 patients with TSS (27 streptococcal, 31 nonstreptococcal) during January 2010-September 2017. We observed clinical and laboratory findings that are not part of TSS criteria, such as pyuria in streptococcal TSS (50% of patients) and pulmonary involvement (85%) and coagulopathy (92%) in nonstreptococcal TSS patients. Recommended treatment with clindamycin and intravenous immunoglobulin was delayed in streptococcal TSS patients without rash (3.37 days vs. 0.87 days in patients with rash), leading to prolonged hospitalization and complications. Incorporation of additional TSS signs and symptoms would be helpful in TSS diagnosis and management.

Staphylococcus aureus Infections in the Paediatric Intensive Care Unit: Illustrated Cases

Staphylococcus aureus is known to be one of the most common gram-positive microorganisms and an important pathogen associated with sepsis and toxic shock. We present four anonymized consecutive cases in a paediatric intensive care unit (PICU) to illustrate the different clinical manifestations of staphylococcal infections, including local infection versus systemic infection, toxic shock versus septic shock, and osteomyelitis. Eczema, short gut syndrome, and scald injury may be associated. Haematologic and coagulopathic abnormalities may be present. Prompt diagnosis and use of appropriate antimicrobial treatments is essential to reducing mortality and morbidity associated with staphylococcal infections.

Genital Tract GAS Infection ISIDOG Guidelines

There has been an increasing worldwide incidence of invasive group A streptococcal (GAS) disease in pregnancy and in the puerperal period over the past 30 years. Postpartum Group A streptococci infection, and in particular streptococcal toxic shock syndrome (TSS) and necrotizing fasciitis, can be life threatening and difficult to treat. Despite antibiotics and supportive therapy, and in some cases advanced extensive surgery, mortality associated with invasive group A streptococcal postpartum endometritis, necrotizing fasciitis, and toxic shock syndrome remains high, up to 40% of postpartum septic deaths. It now accounts for more than 75,000 deaths worldwide every year. Postpartum women have a 20-fold increased incidence of GAS disease compared to non-pregnant women. Despite the high incidence, many invasive GAS infections are not diagnosed in a timely manner, resulting in potentially preventable maternal and neonatal deaths. In this paper the specific characteristics of GAS infection in the field of Ob/Gyn are brought to our attention, resulting in guidelines to improve our awareness, early recognition and timely treatment of the disease. New European prevalence data of vaginal GAS colonization are presented, alongside two original case histories. Additionally, aerobic vaginitis is proposed as a supplementary risk factor for invasive GAS diseases.

Cotrimoxazole and clindamycin in skin and soft tissue infections

PURPOSE OF REVIEW

The aim of this study was to present recent microbiological, experimental, clinical and tolerance data for cotrimoxazole and clindamycin in the specific field of skin and soft tissue infections (SSTIs).

RECENT FINDINGS

Staphylococcus aureus and streptococci remain the leading cause of SSTIs. Cotrimoxazole is a good anti-Gram-positive agent with preserved activity against methicillin-susceptible and methicillin-resistant S. aureus (MRSA) and streptococci. Although clindamycin has good methicillin-susceptible S. aureus activity, a growing number of resistant MRSA and streptococci have been reported. Strong experimental data support the antitoxin activity of clindamycin, but clinical observations remain scarce. Several recent randomized trials involving cotrimoxazole and/or clindamycin demonstrate the efficacy and tolerance of both drugs. The oral formulation of both drugs may facilitate the implementation of early switch and early discharge protocols in clinical practice.

SUMMARY

Recent publications demonstrate that cotrimoxazole and clindamycin remain reliable and realistic therapeutic approaches for SSTIs.

Toxic Shock Syndrome in Patients Younger than 21 Years of Age, United States, 2006-2018

We examined the incidence of toxic shock syndrome in the United States during 2006-2018 among persons <21 years old with commercial or Medicaid-insurance using administrative data. There were 1008 commercially-insured and 481 Medicaid-insured toxic shock syndrome cases. The annual rate was 1 per 100,000 and stable over time. Rates were even lower in children <5 years old and stable over time.

Clinical Description and Outcomes of Australian Children With Invasive Group A Streptococcal Disease

BACKGROUND

Invasive group A streptococcal disease is a severe infection with a high case fatality rate, estimated to cause more than 150,000 deaths per year worldwide. The clinical presentation of this infection is variable, and early diagnosis can be challenging. There are few data on its short- and longer-term outcomes, especially in children. The aim of this study was to assess the clinical presentation, management and short- and longer-term outcomes of invasive group A streptococcal disease in children in Australia.

METHODS

We undertook a prospective surveillance study of children with laboratory-confirmed invasive group A streptococcus disease admitted to 7 sentinel tertiary and quaternary pediatric hospitals in Australia between July 2016 and June 2018. We collected demographic and clinical data and contacted patients 6 months after discharge to assess longer-term outcomes.

RESULTS

We enrolled 181 children, 7 days to 16 years of age. The principal site of invasive infection was blood (126 children, 69.6%), and the most frequent clinical presentation was pneumonia in 46 children (25.4%). Twenty-six children developed streptococcal toxic shock syndrome (14.4%), and 74 had severe disease (40.9%), including 71 admitted to the intensive care unit. Five children died (2.8%). At discharge and 6 months, 29.3% and 15.2% of the children had persisting health problems, respectively.

CONCLUSIONS

Invasive group A streptococcal infection in Australian children is frequently severe and has a high long-term morbidity burden, highlighting the need for strengthened clinical care pathways, epidemiologic surveillance and prevention strategies.

Toxic Shock Syndrome: Still a Timely Diagnosis

BACKGROUND

Toxic shock syndrome (TSS) is an acute, severe, toxin-mediated disease, characterized by fever, hypotension, and multiorgan system involvement. Toxic shock syndrome has made headlines because of its high associated morbidity and mortality rate in previously healthy young females. Incidence peaked in the early 1980s owing to increased usage of ultra-absorbent tampons. After improved patient education and tampon labeling, the incidence of menstrual TSS has declined.

CASE

A previously healthy 14-year-old girl presented to an urgent care center with a 2-day history of fever, erythematous maculopapular rash, vomiting, diarrhea, and malaise. She was found to be tachycardic and hypotensive. Investigations revealed thrombocytopenia, an elevated white count and lactate, and acute kidney injury, consistent with septic shock. Recent tampon usage with menstruation was reported, and a pelvic examination revealed purulent vaginal discharge. The patient was transferred to a pediatric intensive care unit for antibiotic and vasopressor therapy. Vaginal swabs later tested positive for Staphylococcus aureus and TSS toxin-1.

CONCLUSIONS

Although the incidence of TSS has decreased in recent years, it is crucial that clinicians rapidly recognize and treat this life-threatening condition. Emergency physicians should always have a high index of suspicion for TSS in young females presenting without another obvious cause of shock. A pelvic examination should always be completed in these cases.

Invasive group A Streptococcus disease in Australian children: 2016 to 2018 - a descriptive cohort study

Objectives

Invasive group A Streptococcus (iGAS) disease is serious and sometimes life-threatening. The Paediatric Active Enhanced Disease Surveillance (PAEDS) Network collects voluntary notifications from seven major Australian paediatric hospitals on patients with certain conditions, including iGAS disease. Our aims were to: 1) Describe the epidemiological distribution of paediatric iGAS disease in Australia and correlate this with influenza notifications, 2) Identify GAS strains commonly associated with invasive disease in children.

Methods

IGAS and influenza notification data were obtained (from the PAEDS Network and the Australian Institute of Health and Welfare, respectively, for the period 1 July 2016 to 30 June 2018). Included iGAS patients had GAS isolated from a normally sterile body site. Data were described according to selected clinical and demographic characteristics, including by age group and Australian State, with proportions and minimum incidence rates estimated.

Results

A total of 181 patients were identified, with most (115, 63.5%) <5 years old. The mean annual minimum incidence rate was 1.6 (95% confidence interval: 1.1–2.3) per 100,000 children across the study period. An epidemiological correlation with the seasonal burden of influenza was noted. Contact prophylaxis was not consistently offered. Of 96 patients with emm-typing results available, 72.9% showed emm-1, −4 or − 12.

Conclusions

Robust surveillance systems and cohesive patient management guidelines are needed. Making iGAS disease nationally notifiable would help facilitate this. Influenza vaccination may contribute to reducing seasonal increases in iGAS incidence. The burden of disease emphasises the need for ongoing progress in GAS vaccine development.

Prospective Surveillance of Pediatric Invasive Group A Streptococcus Infection

BACKGROUND

Invasive group A Streptococcus (GAS) disease has an incidence in high-income countries of 3 to 5 per 100000 per annum and a case-fatality ratio of 10% to 15%. Although these rates are comparable to those of invasive meningococcal disease in Australia before vaccine introduction, invasive GAS disease currently requires reporting in only 2 jurisdictions.

METHODS

Data were collected prospectively through active surveillance at the Royal Children's Hospital, Melbourne (October 2014 to September 2016). Isolation of GAS from a sterile site was required for inclusion. Comprehensive demographic and clinical data were collected, and emm typing was performed on all isolates. Disease was considered severe if the patient required inotropic support or mechanical ventilation.

RESULTS

We recruited 28 patients. The median age of the patients was 3.5 years (range, 4 days to 11 years). Ten (36%) patients had severe disease. Fifteen (54%) children had presented to a medical practitioner for review in the 48 hours before their eventual admission, including 7 of the 10 patients with severe GAS infection. Complications 6 months after discharge persisted in 21% of the patients. emm1 was the most common emm type (29%).

CONCLUSION

We found considerable short- and longer-term morbidity associated with pediatric invasive GAS disease in our study. Disease manifestations were frequently severe, and more than one-third of the patients required cardiorespiratory support. More than one-half of the patients attended a medical practitioner for assessment but were discharged in the 48-hour period before admission, which suggests that there might have been a window for earlier diagnosis. Our methodology was easy to implement as a surveillance system.

Clinical and Molecular Epidemiology of Staphylococcal Toxic Shock Syndrome in the United Kingdom

Staphylococcal toxic shock syndrome (TSS) was originally described in menstruating women and linked to TSS toxin 1 (TSST-1)-producing Staphylococcus aureus. Using UK national surveillance data, we ascertained clinical, molecular and superantigenic characteristics of TSS cases. Average annual TSS incidence was 0.07/100,000 population. Patients with nonmenstrual TSS were younger than those with menstrual TSS but had the same mortality rate. Children <16 years of age accounted for 39% of TSS cases, most caused by burns and skin and soft tissue infections. Nonmenstrual TSS is now more common than menstrual TSS in the UK, although both types are strongly associated with the tst+ clonal complex (CC) 30 methicillin-sensitive S. aureus lineage, which accounted for 49.4% of all TSS and produced more TSST-1 and superantigen bioactivity than did tst+ CC30 methicillin-resistant S. aureus strains. Better understanding of this MSSA lineage and infections in children could focus interventions to prevent TSS in the future.

Epidemiology and Clinical Relevance of Toxic Shock Syndrome in US Children

INTRODUCTION

It is important for clinicians to recognize the contribution of toxic shock syndrome (TSS) to the overall burden of pediatric septic shock because the clinical features, optimal therapy and prognosis differ from non-TSS septic shock.

METHODS

We analyzed cases of pediatric septic shock reported to the Pediatric Health Information Systems database between 2009 and 2013 to define the clinical and demographic characteristics of pediatric TSS in the United States. Using a validated International Classification of Diseases, 9th revision, coding strategy, we identified patients with infectious shock among inpatients age 1-18 years and classified cases of staphylococcal and streptococcal TSS for comparison with non-TSS cases.

RESULTS

Of 8,226 cases of pediatric septic shock, 909 (11.1%) were classified as TSS and 562 (6.8%) were possible TSS cases. Staphylococcal TSS represented the majority (83%) of TSS cases and occurred more commonly in females and at an older age. Compared with non-TSS septic shock, TSS had significantly lower fatality rates, disease severity and length of hospital stay and was present more often at the time of admission (P < 0.001 for each). Streptococcal TSS was associated with poorer outcomes than staphylococcal TSS. Treatment for TSS differed from non-TSS septic shock in use of more clindamycin, vancomycin and Intravenous Immunoglobulin and less need for vasopressors.

CONCLUSIONS

Results demonstrate a significant contribution of TSS to the burden of pediatric septic shock in the United States. The findings emphasize the importance of inclusion of TSS diagnostic and therapeutic considerations in sepsis treatment protocols for children.

Polyspecific Intravenous Immunoglobulin in Clindamycin-treated Patients With Streptococcal Toxic Shock Syndrome: A Systematic Review and Meta-analysis

We evaluated the effect of intravenous immunoglobulin (IVIG) on mortality in clindamycin-treated streptococcal toxic shock syndrome using a meta-analysis. In association with IVIG, mortality fell from 33.7% to 15.7% with remarkable consistency across the single randomized and four nonrandomized studies.

Toxic shock syndrome - the seven Rs of management and treatment

Staphylococcal and streptococcal toxic shock syndrome (TSS) are associated with significant morbidity and mortality. There has been considerable progress in understanding the pathophysiology and delineating optimal management and treatment. This article reviews the management of TSS, outlining the 'Seven Rs of Managing and Treating TSS': Recognition, Resuscitation, Removal of source of infection, Rational choice of antibiotics, Role of adjunctive treatment (clindamycin and intravenous immunoglobulin), Review of progress and Reduce risk of secondary cases in close contacts.

Similarities and Differences Between Staphylococcal and Streptococcal Toxic Shock Syndromes in Children: Results From a 30-Case Cohort

Introduction: Toxic shock syndromes (TSS) are severe shocks due to staphylococcal or streptococcal infection that require specific treatments. The early recognition of these shocks is crucial to improve their outcomes. Objectives: The primary objective of this study was to compare characteristics and outcomes of staphylococcal and streptococcal TSS in children, in order to identify putative early clinical diagnostic criteria. Secondary objectives were to determine the toxin gene profiles of associated isolated strains and the relevance of measuring Vβ T-cell signatures to confirm the diagnosis. Study design: We performed a multicenter retrospective evaluation of clinical data, biological results, and treatment outcomes of children with a confirmed or probable case of staphylococcal or streptococcal TSS. Children were consecutively included if they were admitted to the pediatric intensive care units of Lyon (France), between January 2005 and July 2011. Results: Among the 30 analyzed children, 15 presented staphylococcal TSS and 15 streptococcal TSS. The most frequent origin of staphylococcal and streptococcal TSS was the lower respiratory tract (53%) and the genital tract (47%) respectively. Non-menstrual TSS syndrome cases presented more frequently with neurological alterations, and digestive signs were predominant in menstrual forms. Compared to Staphylococcal TSS, Streptococcal TSS presented with higher organ dysfunction scores (median Pediatric Index of Mortality 2 score 20.9 (4.1-100) vs. 1.7 (1.3-2.3), p = 0.001), required respiratory support more frequently (80 vs. 33%, p = 0.02), were intubated for a longer time (3 days (0.75-5) vs. 1 day (0-1.5), p = 0.006) and had a non-significant trend of higher, case-fatality rate (20 vs. 7%, p = 0.60). The lack of antitoxin therapy was associated with higher case-fatality rate (50 vs. 4%, p = 0.04). The Vβ repertoire measurements exhibited toxin dependent-alterations in accordance with the toxin gene profiles of isolated strains in both types of toxic shock syndromes. Regarding toxin gene profiles of isolated strains, 10/15 Staphylococcus aureus belonged to clonal complex (CC) 30 and 6/12 Streptococcus pyogenes were emm1 type suggesting clonal etiologies for both staphylococcal and streptococcal TSS. Conclusion: Despite the involvement of functionally similar toxins, staphylococcal and streptococcal TSS differed by their clinical signs, origin of infection and prognosis. The detection of Vβ profiles was useful to confirm the diagnosis of staphylococcal and streptococcal TSS and for the identification of involved toxins.

Acute encephalopathy with biphasic seizures and late reduced diffusion associated with staphylococcal toxic shock syndrome caused by burns

We report a case of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) associated with toxic shock syndrome caused by burns. A one-year-old girl was admitted to our hospital for treatment of severe burns. On day 3, she exhibited a fever, generalized rash and multiple organ failure. She was diagnosed with toxic shock syndrome after burns. She had seizures with fever twice on the same day, followed by secondary seizures on day 8 and transient deterioration of the gross motor functions involved in sitting alone and rolling over. On day 9, MRI diffusion-weighted images showed bright tree appearance (BTA). We conclude that she developed AESD.

Toxic shock syndrome in Australian children

BACKGROUND

There are limited data describing the epidemiology, management and outcomes of children with toxic shock syndrome (TSS), a potentially life-threatening illness. Here, we describe the incidence, clinical features, treatment and outcome of children with staphylococcal and streptococcal TSS in Victoria, Australia.

METHODS

Retrospective chart review of children admitted between 2003 and 2014 to two tertiary paediatric referral centres who fulfilled the Centers for Disease Control and Prevention case definition of TSS.

RESULTS

There were 62 cases over the 11-year period; 43 staphylococcal TSS and 19 streptococcal TSS. The majority (46 (74%)) of cases were admitted to an intensive care unit and 44 (71%) required inotropic support. Compared with those with staphylococcal TSS, patients with streptococcal TSS were younger, more unwell and more likely to have residual morbidity. Adjunctive therapy with intravenous immunoglobulin or clindamycin was used in 58 (94%) of cases and fresh frozen plasma was used in 15 (24%). Seven patients received extracorporeal membrane oxygenation. All patients survived.

CONCLUSIONS

This study highlights the importance of early recognition of TSS and supports rapid tertiary referral and intensive care management, which includes the use of adjunctive therapy with intravenous immunoglobulin and clindamycin.

The Management of Staphylococcal Toxic Shock Syndrome. A Case Report

Staphylococcal toxic shock syndrome (TSS) is most frequently produced by TSS toxin-1 (TSST-1) and Staphylococcal enterotoxin B (SEB), and only rarely by enterotoxins A, C, D, E, and H. Various clinical pictures can occur depending on severity, patient age and immune status of the host. Severe forms, complicated by sepsis, are associated with a death rate of 50-60%. The case of a Caucasian female infant, aged seven weeks, hospitalized with a diffuse skin rash, characterized as allergodermia, who initially developed TSS with axillary intertrigo, is reported. TSS was confirmed according to 2011 CDC criteria, and blood cultures positive for Methicillin-sensitive Staphylococcus aureus (MSSA). Severe development occurred initial, including acidosis, consumption coagulopathy, multiple organ failures (MOF), including impaired liver and kidney function. Central nervous system damage was manifest by seizures. Clinical management included medical supervision by a multidisciplinary team of infectious diseases specialist and intensive care specialist, as well as the initiation of a complex treatment plan to correct hydro electrolytic imbalances and acidosis. This treatment included antibiotic and antifungal therapy, diuretic therapy, immunoglobulins, and local treatment similar to a patient with burns to prevent superinfection of skin and mucous membranes lesions. There was a favourable response to the treatment with resolution of the illness.

Intrauterine device infection causing concomitant streptococcal toxic shock syndrome and pelvic abscess with Actinomyces odontolyticus bacteraemia

Intrauterine devices (IUDs) are rarely associated with serious infections. We report an unusual concomitant infection of group A Streptococcus (GAS) causing toxic shock syndrome and pelvic abscess with Actinomyces odontolyticus associated with an IUD in a healthy 50-year-old patient. The IUD was subsequently removed and the patient recovered on the appropriate antibiotics. This case highlights the importance of clinicians' high index of suspicion of an IUD infection and prompt removal of the infected foreign body to obtain source control.

Infectious Diseases and the Kidney in Children

The kidney is involved in a wide range of bacterial, viral, fungal, and parasitic diseases. In most systemic infections, renal involvement is a minor component of the illness, but in some, renal failure may be the presenting feature and the major problem in management. Although individual infectious processes may have a predilection to involve the renal vasculature, glomeruli, interstitium, or collecting systems, a purely anatomic approach to the classification of infectious diseases affecting the kidney is rarely helpful because most infections may involve several different aspects of renal function. In this chapter, a microbiological classification of the organisms affecting the kidney is adopted. Although they are important causes of renal dysfunction in infectious diseases, urinary tract infections and hemolytic uremic syndrome (HUS) are not discussed in detail because they are considered separately in chapters XX and XX, respectively.