Severe Invasive Group A Streptococcal Infections: A Subject Review

The course of severe invasive group A b-hemolytic streptococcal (GABHS) infections is often precipitous, requiring prompt diagnosis and rapid initiation of appropriate therapy. Therefore, physicians must have a high index of suspicion of this disease, particularly in patients at increased risk (eg, those with varicella or diabetes mellitus). Although a relationship between the use of nonsteroidal antiinflammatory drugs and severe invasive GABHS infections has been suggested, at present data on which to base a clinical decision about the use or restriction of nonsteroidal antiinflammatory drugs in children with varicella are insufficient. When necrotizing fasciitis is suspected, prompt surgical drainage, debridement, fasciotomy, or amputation often is necessary. Many experts recommend intravenously administered penicillin G and clindamycin for the treatment of invasive GABHS infections on the basis of animal studies. Some evidence exists that intravenous immunoglobulin given in addition to appropriate antimicrobial and surgical therapy may be beneficial. Although chemoprophylaxis for household contacts of persons with invasive GABHS infections has been considered by some experts, the limited available data indicate that the risk of secondary cases is low (2.9 per 1000) and data about the effectiveness of any drug are insufficient to make recommendations. Because of the low risk of secondary cases of invasive GABHS infections in schools or child care facilities, chemoprophylaxis is not indicated in these settings. Routine immunization of all healthy children against varicella is recommended and is an effective means to decrease the risk of invasive GABHS infections. ABBREVIATIONS. GABHS, group A b-hemolytic streptococcal; TSS, toxic shock syndrome; SPE, streptococcal pyrogenic exotoxin; NSAID, nonsteroidal antiinflammatory drug. In recent years, an increased incidence of severe invasive group A b-hemolytic streptococcal (GABHS) infections, including the group A streptococcal toxic shock syndrome (TSS) and necrotizing fasciitis, has been observed.1–4 Because invasive GABHS infections are associated with significant morbidity and mortality, it is important for pediatricians to be familiar with the diagnosis, management, and prevention of these infections.1–4 In addition, sensationalized reports in the lay literature have contained considerable misinformation about these infections, including the incidence, the relationship to acute pharyngitis, and the presence of antibiotic resistance among strains of GABHS. Pediatricians need accurate information to put these infections into proper perspective for patients and their families. Invasive GABHS disease is defined as an infection associated with the isolation of GABHS from a normally sterile body site and includes three overlapping clinical syndromes.4,5 The first is group A streptococcal TSS that is differentiated from other types of invasive GABHS infections by the occurrence of shock and multiorgan system failure early in the course of the infection. In 1993, the Centers for Disease Control and Prevention Working Group on Severe Streptococcal Infections developed a case definition for the streptococcal TSS (Table).5 The second group is GABHS necrotizing fasciitis characterized by extensive local necrosis of subcutaneous soft tissues and skin and the isolation of GABHS from a normally sterile body site. The third is a group of infections characterized by the isolation of GABHS from a normally sterile site in patients not meeting the criteria for streptococcal TSS or necrotizing fasciitis. Included in this group are bacteremia with no identified focus and focal infections (eg, meningitis, pneumonia, peritonitis, puerperal sepsis, osteomyelitis, septic arthritis, myositis, and surgical wound infections) with or without bacteremia. These severe invasive GABHS infections rarely occur after an episode of acute GABHS pharyngitis.4 HISTORICAL PERSPECTIVE Severe, invasive GABHS infections had become uncommon in the United States and western Europe during the second half of the 20th century.6 However, during the mid-1980s, reports began to appear of an increasing incidence of invasive disease, septicemia, and deaths attributable to GABHS infections in Great Britain and the United States.6 The reasons for this increase have not been identified clearly; however, history is replete with periodic epidemics of GABHS infections. During most of the 18th century, scarlet fever was considered by parents and physicians to be a benign disease of early childhood. However, during the early 19th century, this situation changed dramatically. In 1831, a lethal epidemic of scarlet fever was reported in Dublin, and the following year, an equally lethal epidemic was reported in Augusta, GA.6 At the same time, in several large cities in the United States and Europe, localized clusters of severe cases of scarlet fever with case fatality rates of $ 30% were reported. Scarlet fever continued to be an extremely severe disease for the next half century, and then suddenly in approximately 1885, the character of this disease in Europe and the United States changed again quite dramatically.6 Severe The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-