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Mercadante S, Ficari A, Romani L, De Luca M, Tripiciano C, Chiurchiù S, Calo Carducci FI, Cursi L, Di Giuseppe M, Krzysztofiak A, Bernardi S, Lancella L. The Thousand Faces of Invasive Group A Streptococcal Infections: Update on Epidemiology, Symptoms, and Therapy. CHILDREN (BASEL, SWITZERLAND) 2024; 11:383. [PMID: 38671600 PMCID: PMC11048970 DOI: 10.3390/children11040383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
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.
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Affiliation(s)
- Stefania Mercadante
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Andrea Ficari
- Residency School of Pediatrics, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Lorenza Romani
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Maia De Luca
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Costanza Tripiciano
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Sara Chiurchiù
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Francesca Ippolita Calo Carducci
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Laura Cursi
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Martina Di Giuseppe
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Andrzej Krzysztofiak
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Stefania Bernardi
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Laura Lancella
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
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Bartoszko JJ, Elias Z, Rudziak P, Lo CKL, Thabane L, Mertz D, Loeb M. Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis. BMJ Open 2022; 12:e063023. [PMID: 36456018 PMCID: PMC9716873 DOI: 10.1136/bmjopen-2022-063023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Jessica J Bartoszko
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Zeyad Elias
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paulina Rudziak
- Department of Biology, Western University, London, Ontario, Canada
| | - Carson K L Lo
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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Amari K, Tago M, Katsuki NE, Yamashita SI. Diverse disease processes of group A Streptococcus infection including severe invasive infections among members of a family. BMJ Case Rep 2021; 14:14/4/e241339. [PMID: 33858899 PMCID: PMC8054054 DOI: 10.1136/bcr-2020-241339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We herein report three cases of group A Streptococcus (GAS) infection in a family. Patient 1, a 50-year-old woman, was transferred to our hospital in shock with acute respiratory distress syndrome, swelling in the right neck and erythemata on both lower extremities. She required intubation because of laryngeal oedema. At the same time, patient 2, a 48-year-old man, was admitted because of septic shock, pneumonia and a pulmonary abscess. Five days later, patient 3, a 91-year-old woman, visited our clinic with bloody stool. All three patients were cured by antibiotics, and GAS was detected by specimen cultures. During these patients' clinical course, an 84-year-old woman was found dead at home after having been diagnosed with type A influenza. All four patients lived in the same apartment. The GAS genotypes detected in the first three patients were identical. When treating patients with GAS, appropriate management of close contacts is mandatory.
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Affiliation(s)
- Kaori Amari
- Department of General Medicine, Saga University Hospital, Saga, Japan.,Department of Emergency Medicine, Saga-Ken Medical Centre, Koseikan, Saga, Japan
| | - Masaki Tago
- Department of General Medicine, Saga University Hospital, Saga, Japan
| | - Naoko E Katsuki
- Department of General Medicine, Saga University Hospital, Saga, Japan
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de Almeida Torres RSL, dos Santos TZ, Torres RADA, Petrini LMCDM, Burger M, Steer AC, Smeesters PR. Management of Contacts of Patients With Severe Invasive Group A Streptococcal Infection. J Pediatric Infect Dis Soc 2016; 5:47-52. [PMID: 26908491 DOI: 10.1093/jpids/piu107] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 10/05/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Conflicting recommendations regarding antibiotic prophylaxis for contacts of patients with invasive group A streptococcal (GAS) infection exist. Close contacts of patients with such severe and rapidly progressive disease often strongly appeal to the treating clinicians for antimicrobial treatment to prevent additional cases. We aimed to use an approach based on pharyngeal culture testing of contacts and targeted antibiotic prophylaxis. METHODS A large throat swab survey including 105 contacts was undertaken after a fulminant and fatal case of GAS necrotizing fasciitis. GAS strains were characterized by emm typing and antimicrobial susceptibility to 7 antibiotics. The presence of 30 virulence determinants was determined by polymerase chain reaction and sequencing. RESULTS The GAS isolate recovered from the index patient was an M1T1 GAS clone susceptible to all antimicrobial agents tested. The same clone was present in the throat of 36% of close contacts who had exposure to the index patient (family households and classroom contacts) for >24 hours/week, whereas the strain was present in only 2% of the other contacts. CONCLUSIONS Although the study does not allow firm conclusions to be drawn as to whether antibiotic prophylaxis is effective, we describe a practical approach, including an educational campaign and targeted antibiotic treatment to close contacts who have been exposed to an index patient for > 24 hours/week before the initial disease onset.
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Affiliation(s)
| | | | | | | | - Marion Burger
- Secretaria Municipal de Curitiba Associação Hospitalar de Proteção a Infância Dr Raul Carneiro, Curitiba, Paraná, Brazil
| | - Andrew C Steer
- Centre for International Child Health, University of Melbourne Group A Streptococcal Research Group, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia
| | - Pierre R Smeesters
- Centre for International Child Health, University of Melbourne Group A Streptococcal Research Group, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia Laboratory of Bacterial Genetics and Physiology, IBMM, Faculté des Sciences, Université Libre de Bruxelles, Brussels, Belgium
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Lithgow A, Duke T, Steer A, Smeesters PR. Severe group A streptococcal infections in a paediatric intensive care unit. J Paediatr Child Health 2014; 50:687-92. [PMID: 24909187 DOI: 10.1111/jpc.12601] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2014] [Indexed: 11/30/2022]
Abstract
AIM To describe the clinical presentation, management and outcomes for children with invasive group A streptococcal (GAS) infection in a paediatric intensive care unit (PICU). METHODS We reviewed the clinical and laboratory records of patients admitted to a PICU in Melbourne with invasive GAS infection from April 2010 to April 2013. Outcomes recorded included survival, organ failure, need for extracorporeal support, renal replacement therapy and prolonged neuromuscular weakness. RESULTS Twelve cases of invasive GAS infection were identified. The most common clinical presentations were pneumonia (n=5), bacteraemia with no septic focus (n=4) and septic arthritis (n=3). Necrotising fasciitis occurred in one patient and another patient presented with ischaemic lower limbs requiring amputation. Of the eight isolates with available emm typing results, the most common emm type was emm1 (n=4) followed by emm4, 12 and 22. Nine patients had multi-organ failure. Ten patients required mechanical ventilation for a median duration of 8 days. Nine patients required inotropic and/or vasopressor support and four patients extracorporeal membrane oxygenation support. Eleven patients survived. A prolonged period of neuromuscular weakness following the initial severe illness was common (n=5), but most children returned to normal or near normal neurological function. CONCLUSIONS Invasive GAS disease in children may cause severe multi-organ failure with resultant prolonged intensive care stay and significant morbidity. However, a high rate of survival and return to normal functioning may be achieved with multi-system intensive care support and multi-disciplinary rehabilitation.
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Affiliation(s)
- Anna Lithgow
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
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Steer AC, Lamagni T, Curtis N, Carapetis JR. Invasive group a streptococcal disease: epidemiology, pathogenesis and management. Drugs 2012; 72:1213-27. [PMID: 22686614 PMCID: PMC7100837 DOI: 10.2165/11634180-000000000-00000] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Invasive group A streptococcal infections are uncommon, although serious, infections with high case fatality rates. Periodic resurgences in invasive group A streptococcal infections in industrialized countries have been reported from the 1980s onwards, with current estimates of incidence in these countries of approximately 3–4 per 100000 population. Infants, pregnant women and the elderly are at increased risk of invasive group A streptococcal infection. The group A streptococcus has an array of virulence factors that underpin its invasive capacity and, in approximately 10% of cases, super-antigen toxins produced by the bacteria stimulate a large proportion of T cells, leading to streptococcal toxic shock syndrome. Given the rapid clinical progression, effective management of invasive group A streptococcal infections hinges on early recognition of the disease and prompt initiation of supportive care (often intensive care) together with antibacterial therapy. In cases of toxic shock syndrome, it is often difficult to distinguish between streptococcal and staphylococcal infection before cultures become available and so antibacterial choice must include coverage of both of these organisms. In addition, clindamycin is an important adjunctive antibacterial because of its anti-toxin effects and excellent tissue penetration. Early institution of intravenous immunoglobulin therapy should be considered in cases of toxic shock syndrome and severe invasive infection, including necrotizing fasciitis. Early surgical debridement of necrotic tissue is also an important part of management in cases of necrotizing fasciitis.
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Affiliation(s)
- Andrew C Steer
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.
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Steer AC, Lamagni T, Curtis N, Carapetis JR. Invasive group a streptococcal disease: epidemiology, pathogenesis and management. Drugs 2012. [PMID: 22686614 DOI: 10.2165/11634180-000000000-00000)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Invasive group A streptococcal infections are uncommon, although serious, infections with high case fatality rates. Periodic resurgences in invasive group A streptococcal infections in industrialized countries have been reported from the 1980s onwards, with current estimates of incidence in these countries of approximately 3-4 per 100 000 population. Infants, pregnant women and the elderly are at increased risk of invasive group A streptococcal infection. The group A streptococcus has an array of virulence factors that underpin its invasive capacity and, in approximately 10% of cases, superantigen toxins produced by the bacteria stimulate a large proportion of T cells, leading to streptococcal toxic shock syndrome. Given the rapid clinical progression, effective management of invasive group A streptococcal infections hinges on early recognition of the disease and prompt initiation of supportive care (often intensive care) together with antibacterial therapy. In cases of toxic shock syndrome, it is often difficult to distinguish between streptococcal and staphylococcal infection before cultures become available and so antibacterial choice must include coverage of both of these organisms. In addition, clindamycin is an important adjunctive antibacterial because of its anti-toxin effects and excellent tissue penetration. Early institution of intravenous immunoglobulin therapy should be considered in cases of toxic shock syndrome and severe invasive infection, including necrotizing fasciitis. Early surgical debridement of necrotic tissue is also an important part of management in cases of necrotizing fasciitis.
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Affiliation(s)
- Andrew C Steer
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.
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Hsieh YC, Huang YC. Scarlet fever outbreak in Hong Kong, 2011. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 44:409-11. [DOI: 10.1016/j.jmii.2011.07.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Steer AC, Curtis N, Carapetis JR. Diagnosis and treatment of invasive group A streptococcal infections. ACTA ACUST UNITED AC 2008; 2:289-301. [DOI: 10.1517/17530059.2.3.289] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Costa Orvay JA, Caritg Bosch J, Morillo Palomo A, Noguera Julián T, Esteban Torne E, Palomeque Rico A. [Toxic shock syndrome: experience in a pediatric intensive care unit]. An Pediatr (Barc) 2007; 66:566-72. [PMID: 17583617 DOI: 10.1157/13107390] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To review patients with toxic shock syndrome (TSS) in a pediatric intensive care unit. METHODS We performed a retrospective study of patients with TSS admitted to the intensive care unit in the previous 15 years. The patients included were those that met the clinical and microbiological criteria for TSS proposed by the Centers for Disease Control and Prevention. RESULTS There were nine patients (four boys). The mean age was 7 years. The most frequent findings were fever (100 %), hypotension (100 %), erythroderma (100 %), multisystem organ failure [coagulopathy (100 %), lethargy (89 %), hypertransaminasemia (89 %), increased creatine phosphokinase levels (78 %), renal failure (66 %)] and cutaneous desquamation (100 %). Laboratory studies showed changes in the leukocyte count and C-reactive protein value in all patients. The etiology was as follows: Staphylococcus was detected in six patients (S. epidermidis in three and S. aureus in three) and Streptococcus was detected in two patients (S. pyogenes in one and S. pneumoniae in one); no microorganisms were detected in only one patient. The origin of the infection was identified in seven patients (cutaneous in six patients and tonsillar in one). All patients received life support and antibiotic treatment. Six patients received corticosteroid treatment and one received intravenous immunoglobulins. Patients with TSS secondary to Streptococcus showed the greatest severity, exhibiting renal failure and requiring greater respiratory and circulatory support. All patients recovered well from the infection, without serious long-term sequelae. CONCLUSION. TSS should be included in the differential diagnosis of patients with fever, exanthema and shock, since early diagnosis has been shown to improve outcomes. S. pneumoniae should be included among the microorganisms that cause TSS. Treatment is based on life support measures and antibiotic therapy.
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Affiliation(s)
- J A Costa Orvay
- Sección de UCIP, Servicio de Pediatría, Unidad Integrada, Hospital Sant Joan de Déu-Clínic, Universidad de Barcelona, España.
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Kikuta H, Shibata M, Nakata S, Yamanaka T, Sakata H, Fujita K, Kobayashi K. Efficacy of antibiotic prophylaxis for intrafamilial transmission of group A beta-hemolytic streptococci. Pediatr Infect Dis J 2007; 26:139-41. [PMID: 17259876 DOI: 10.1097/01.inf.0000253060.72953.9d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The role of chemoprophylaxis for household contacts of patients with acute streptococcal disease is uncertain. METHODS The subjects were 1440 sibling contacts of 1181 index patients with group A beta-hemolytic streptococcal (GABHS) pharyngitis. Instances of subsequent GABHS pharyngitis in sibling contacts who received chemoprophylaxis and in a control group without prophylaxis were compared. RESULTS Of the 948 siblings in the prophylaxis group, 507 were treated with cephalosporins and 441 were treated with penicillins for 3 to 5 days. Subsequent GABHS pharyngitis occurred within 30 days in 28 (3.0%) of the 948 siblings in the prophylaxis group and in 26 (5.3%) of the 492 siblings in the control group. Among siblings in the prophylaxis group, subsequent GABHS pharyngitis occurred in 9 (1.8%) of the 507 siblings in the cephalosporin prophylaxis group and in 19 (4.3%) of the 441 siblings in the penicillin prophylaxis group. When these data were each compared with that in the control group (5.3%), a significant statistical difference was seen in the cephalosporin prophylaxis group (P = 0.003) but not in the penicillin prophylaxis group (P = 0.542). Only 5-day cephalosporin prophylaxis showed significant reduction in the rate of subsequent GABHS pharyngitis compared with that in the control group (P = 0.002). CONCLUSIONS In view of the low incidence of subsequent GABHS pharyngitis in the nonprophylaxis group, the usual self-limited nature of GABHS pharyngitis, the cost of prophylaxis and the risk for selecting resistant flora, routine chemoprophylaxis against GABHS pharyngitis for sibling contacts is not recommended.
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Smith A, Lamagni TL, Oliver I, Efstratiou A, George RC, Stuart JM. Invasive group A streptococcal disease: should close contacts routinely receive antibiotic prophylaxis? THE LANCET. INFECTIOUS DISEASES 2005; 5:494-500. [PMID: 16048718 DOI: 10.1016/s1473-3099(05)70190-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Group A streptococci (Streptococcus pyogenes) causes a wide range of illnesses from non-invasive disease--eg, pharyngitis--to more severe invasive infections--eg, necrotising fasciitis and toxic shock-like syndrome. There remains uncertainty about the risk of secondary cases of invasive disease occurring among close contacts of an index case and how best to manage that risk. We do not consider that currently available evidence justifies the routine administration of chemoprophylaxis to close contacts. We suggest that the appropriate response should be to routinely inform all household contacts of a patient with invasive group A streptococcal disease about the clinical manifestations of invasive disease and to seek immediate medical attention if they develop such symptoms.
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Affiliation(s)
- A Smith
- Health Protection Agency, Centre for Infections, London, UK.
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Abstract
Toxic shock syndrome (TSS) is an acute, toxin-mediated illness, like endotoxic shock, and is characterized by fever, rash, hypotension, multiorgan involvement, and desquamation. TSS reflects the most severe form of the disease caused by Staphylococcus aureus and Streptococcus pyogenes. A case definition for staphylococcal TSS was well established in the early 1980s and helped in defining the epidemiology. Since the late 1980s, a resurgence of highly invasive streptococcal infections, including a toxic shock-like syndrome, was noted worldwide and a consensus case definition for streptococcal TSS was subsequently proposed in 1993. Both TSS and the toxic shock-like syndrome occur at a lower incidence in children than in adults. Changes in the manufacturing and use of tampons led to a decline in staphylococcal TSS over the past decade, while the incidence of nonmenstrual staphylococcal TSS increased. Nonmenstrual TSS and menstrual TSS are now reported with almost equal frequency. The incidence of streptococcal TSS remains constant after its resurgence, but varies with geographic location. Streptococcal TSS occurs most commonly following varicella or during the use of NSAIDs. Sites of infection in streptococcal TSS are much deeper than in staphylococcal TSS, such as infection caused by blunt trauma, and necrotizing fasciitis. Bacteremia is more common in streptococcal TSS than in staphylococcal TSS. Mortality associated with streptococcal TSS is 5-10% in children, much lower than in adults (30-80%), and is 3-5% for staphylococcal TSS in children.TSS is thought to be a superantigen-mediated disease. Toxins produced by staphylococci and streptococci act as superantigens that can activate the immune system by bypassing the usual antigen-mediated immune-response sequence. The host-pathogen interaction, virulence factors, and the absence or presence of host immunity determines the epidemiology, clinical syndrome, and outcome. Early recognition of this disease is important, because the clinical course is fulminant and the outcome depends on the prompt institution of therapy. Management of a child with TSS includes hemodynamic stabilization and appropriate antimicrobial therapy to eradicate the bacteria. Supportive therapy, aggressive fluid resuscitation, and vasopressors remain the main elements. An adjuvant therapeutic strategy may include agents that can block superantigens, such as intravenous immunoglobulin that contains superantigen neutralizing antibodies.
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Affiliation(s)
- Yu-Yu Chuang
- Department of Pediatrics, St. Mary's Hospital, LoTung, Taiwan.
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Roy S, Kaplan EL, Rodriguez B, Schreiber JR, Salata RA, Palavecino E, John CC. A family cluster of five cases of group A streptococcal pneumonia. Pediatrics 2003; 112:e61-5. [PMID: 12837907 DOI: 10.1542/peds.112.1.e61] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A cluster of 5 family members, a mother and 4 children, were hospitalized for severe group A Streptococcus (GAS) pneumonia. Three family members had complications: sepsis (1), empyema (2), and a sterile parapneumonic effusion (1). Two additional family members had symptoms of upper respiratory tract infection, and 1 was hospitalized for these symptoms. GAS was isolated from the blood of 1 patient, the pleural fluid of 2 patients, and the oropharynx of 6 patients. Pulsed field gel electrophoresis testing revealed an identical deoxyribonucleic acid pattern in all 7 isolates. Genotyping revealed the speA gene and serotyping the T-1, M-1 serotype in all isolates. This family cluster of invasive GAS disease is the largest reported to date, with an attack rate of 41.7% (5 of 12 family members). This report provides further support for antibiotic prophylaxis of close contacts of individuals with invasive GAS disease.
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MESH Headings
- Anti-Bacterial Agents
- Child
- Contact Tracing
- DNA, Bacterial/analysis
- Disease Outbreaks
- Disease Transmission, Infectious/prevention & control
- Drug Therapy, Combination/therapeutic use
- Electrophoresis, Gel, Pulsed-Field
- Empyema, Pleural/drug therapy
- Empyema, Pleural/microbiology
- Empyema, Pleural/surgery
- Family Health
- Female
- Genotype
- Humans
- Male
- Middle Aged
- Pharyngitis/microbiology
- Pneumonia, Bacterial/microbiology
- Serotyping
- Shock, Septic/microbiology
- Streptococcal Infections/drug therapy
- Streptococcal Infections/microbiology
- Streptococcal Infections/prevention & control
- Streptococcal Infections/surgery
- Streptococcal Infections/transmission
- Streptococcus pyogenes/classification
- Streptococcus pyogenes/genetics
- Streptococcus pyogenes/isolation & purification
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Affiliation(s)
- Sumita Roy
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
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Prevention of invasive group A streptococcal disease among household contacts of case patients and among postpartum and postsurgical patients: recommendations from the Centers for Disease Control and Prevention. Clin Infect Dis 2002; 35:950-9. [PMID: 12355382 DOI: 10.1086/342692] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2002] [Revised: 05/28/2002] [Indexed: 11/03/2022] Open
Abstract
The Centers for Disease Control and Prevention hosted a workshop to formulate recommendations for the control of invasive group A streptococcal (GAS) disease among household contacts of persons with invasive GAS infections and for responding to postpartum and postsurgical invasive GAS infections. Experts reviewed data on the risk of subsequent invasive GAS infection among household contacts of case patients, the effectiveness of chemoprophylactic regimens for eradicating GAS carriage, and the epidemiology of postpartum and postsurgical GAS infection clusters. For household contacts of index patients, routine screening for and chemoprophylaxis against GAS are not recommended. Providers and public health officials may choose to offer chemoprophylaxis to household contacts who are at an increased risk of sporadic disease or mortality due to GAS. One nosocomial postpartum or postsurgical invasive GAS infection should prompt enhanced surveillance and isolate storage, whereas > or =2 cases caused by the same strain should prompt an epidemiological investigation that includes the culture of specimens from epidemiologically linked health care workers.
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