Diagnosis and treatment of invasive group A streptococcal infections

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.

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.

A Red Blood Cell Membrane-Camouflaged Nanoparticle Counteracts Streptolysin O-Mediated Virulence Phenotypes of Invasive Group A Streptococcus

Group A Streptococcus (GAS), an important human-specific Gram-positive bacterial pathogen, is associated with a broad spectrum of disease, ranging from mild superficial infections such as pharyngitis and impetigo, to serious invasive infections including necrotizing fasciitis and streptococcal toxic shock syndrome. The GAS pore-forming streptolysin O (SLO) is a well characterized virulence factor produced by nearly all GAS clinical isolates. High level expression of SLO is epidemiologically linked to intercontinental dissemination of hypervirulent clonotypes and poor clinical outcomes. SLO can trigger macrophage and neutrophil cell death and/or the inactivation of immune cell functions, and promotes tissue injury and bacterial survival in animal models of infection. In the present work, we describe how the pharmacological presentation of red blood cell (RBC) derived biomimetic nanoparticles ("nanosponges") can sequester SLO and block the ability of GAS to damage host cells, thereby preserving innate immune function and increasing bacterial clearance in vitro and in vivo. Nanosponge administration protected human neutrophils, macrophages, and keratinocytes against SLO-mediated cytotoxicity. This therapeutic intervention prevented SLO-induced macrophage apoptosis and increased neutrophil extracellular trap formation, allowing increased GAS killing by the respective phagocytic cell types. In a murine model of GAS necrotizing skin infection, local administration of the biomimetic nanosponges was associated with decreased lesion size and reduced bacterial colony-forming unit recovery. Utilization of a toxin decoy and capture platform that inactivates the secreted SLO before it contacts the host cell membrane, presents a novel virulence factor targeted strategy that could be a powerful adjunctive therapy in severe GAS infections where morbidity and mortality are high despite antibiotic treatment.

Clinical and microbial characteristics of invasive Streptococcus pyogenes disease in New Caledonia, a region in Oceania with a high incidence of acute rheumatic fever

New Caledonia is an archipelago in the South Pacific with a high prevalence of acute rheumatic fever and rheumatic heart disease. Conducted in 2006, this study aimed at characterizing clinical manifestations and microbial features of isolates obtained from invasive Streptococcus pyogenes disease. Clinical and demographic data were collected prospectively. Isolates were biotyped, T typed, emm sequenced, and tested for antibiotic susceptibility. Detection of the speA, speB, speC, and ssa genes was also carried out. The estimated annual incidence of invasive S. pyogenes disease in 2006 was high at 38 cases/100,000 inhabitants in New Caledonia. Invasive isolates were obtained from 90 patients with necrotizing fasciitis (41 cases), bacteremia with no identified focus (12 cases), myositis (10 cases), septic arthritis (9 cases), erysipelas (8 cases), postpartum infection (4 cases), myelitis and osteomyelitis (3 cases), severe pneumonia (2 cases), and endocarditis (1 case). The most frequent associated comorbidities were skin lesions (71%) and obesity (29%). Thirty-one different emm types were identified, and the following six accounted for 54% of the isolates: emm15 (15.5%), emm92 (12.2%), emm106 (8.9%), emm74 (6.7%), emm89 (5.6%), and emm109 (5.6%). The speA, speC, and ssa genes were expressed at different frequencies in the various emm types. The first epidemiological study of invasive S. pyogenes disease in New Caledonia highlights that emm type distribution is particular and should be taken into account in the development of an appropriate vaccine. These findings support the prevention of pyoderma and other cutaneous lesions in order to limit the development of both invasive disease and poststreptococcal sequelae in the South Pacific.

Prospective surveillance of invasive group a streptococcal disease, Fiji, 2005-2007

We undertook a prospective active surveillance study of invasive group A streptococcal (GAS) disease in Fiji over a 23-month period, 2005-2007. We identified 64 cases of invasive GAS disease, which represents an average annualized all-ages incidence of 9.9 cases/100,000 population per year (95% confidence interval [CI] 7.6-12.6). Rates were highest in those >65 years of age and in those <5 years, particularly in infants, for whom the incidence was 44.9/100,000 (95% CI 18.1-92.5). The case-fatality rate was 32% and was associated with increasing age and underlying coexisting disease, including diabetes and renal disease. Fifty-five of the GAS isolates underwent emm sequence typing; the types were highly diverse, with 38 different emm subtypes and no particular dominant type. Our data support the view that invasive GAS disease is common in developing countries and deserves increased public health attention.