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Epidemiology of Invasive Streptococcus pyogenes Infections in France in 2007


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Invasive group A streptococcal (GAS) infections cause significant morbidity and mortality. A national survey was initiated to assess the burden of invasive GAS infections in France, describe their clinical characteristics, and assess the molecular characteristics of GAS strains responsible for these infections. The survey was conducted in 194 hospitals, accounting for 51% of acute care hospital admissions in France. Clinical data, predisposing factors, and demographic data were obtained, and all GAS isolates were emm sequence typed. We identified 664 cases of invasive GAS infections, with an annual incidence of 3.1 per 100,000 population. The case-fatality ratio was 14% and rose to 43% in the case of streptococcal toxic shock syndrome. Bacteremia without identified focus (22%) and skin/soft tissue infections (30%) were the most frequent clinical presentations. Necrotizing fasciitis was frequent in adults (18%) and uncommon in children (3%). The 3 predominant emm types were emm1, emm89, and emm28, accounting for 33%, 16%, and 10% of GAS isolates, respectively. The emm1 type was associated with fatal outcomes and was more frequent in children than in adults. Six clusters of cases were identified, with each cluster involving 2 invasive cases due to GAS strains which shared identical GAS emm sequence types. Four clusters of cases involved eight postpartum infections, one family cluster involved a mother and child, and one cluster involved two patients in a nursing home. Invasive GAS infection is one of the most severe bacterial diseases in France, particularly in persons aged ≥50 years or when associated with toxic shock syndrome.
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JOURNAL OF CLINICAL MICROBIOLOGY, Dec. 2011, p. 4094–4100 Vol. 49, No. 12
0095-1137/11/$12.00 doi:10.1128/JCM.00070-11
Copyright © 2011, American Society for Microbiology. All Rights Reserved.
Epidemiology of Invasive Streptococcus pyogenes Infections
in France in 2007
A. Lepoutre,
* A. Doloy,
P. Bidet,
A. Leblond,
A. Perrocheau,
E. Bingen,
P. Trieu-Cuot,
A. Bouvet,
C. Poyart,
D. Le´vy-Bruhl,
and the Microbiologists of the Epibac Network†
French Institute for Public Health Surveillance, Saint Maurice, France
; Assistance Publique Hoˆpitaux de Paris, Service de
Bacte´riologie, Centre National de Re´fe´rence des Streptocoques, Hoˆpital Cochin, Paris, France
; Universite´ Paris Descartes,
Paris, France
; INSERM, U567, Paris, France
; Assistance Publique Hoˆpitaux de Paris, Service de Bacte´riologie,
Hoˆpital Robert Debre´, Paris, France
; Universite´ Paris Diderot, Paris, France
; and Institut Pasteur,
Unite´ de Biologie des Bacte´ries Pathoge`nes a` Gram Positif,
URA CNRS 2172, Paris, France
Received 13 January 2011/Returned for modification 16 March 2011/Accepted 27 September 2011
Invasive group A streptococcal (GAS) infections cause significant morbidity and mortality. A national survey
was initiated to assess the burden of invasive GAS infections in France, describe their clinical characteristics,
and assess the molecular characteristics of GAS strains responsible for these infections. The survey was
conducted in 194 hospitals, accounting for 51% of acute care hospital admissions in France. Clinical data,
predisposing factors, and demographic data were obtained, and all GAS isolates were emm sequence typed. We
identified 664 cases of invasive GAS infections, with an annual incidence of 3.1 per 100,000 population. The
case-fatality ratio was 14% and rose to 43% in the case of streptococcal toxic shock syndrome. Bacteremia
without identified focus (22%) and skin/soft tissue infections (30%) were the most frequent clinical presenta-
tions. Necrotizing fasciitis was frequent in adults (18%) and uncommon in children (3%). The 3 predominant
emm types were emm1, emm89, and emm28, accounting for 33%, 16%, and 10% of GAS isolates, respectively. The
emm1 type was associated with fatal outcomes and was more frequent in children than in adults. Six clusters
of cases were identified, with each cluster involving 2 invasive cases due to GAS strains which shared identical
GAS emm sequence types. Four clusters of cases involved eight postpartum infections, one family cluster
involved a mother and child, and one cluster involved two patients in a nursing home. Invasive GAS infection
is one of the most severe bacterial diseases in France, particularly in persons aged >50 years or when
associated with toxic shock syndrome.
Streptococcus pyogenes (group A streptococcus [GAS])
causes a wide variety of diseases ranging from mild pharyngitis
and impetigo to severe invasive infections, including strepto-
coccal toxic shock syndrome (TSS) and necrotizing fasciitis.
The lethality of severe GAS infections remains high, ranging
from 14% to 19% in high-income countries (8, 11, 12, 16, 22,
29). In addition, outbreaks of invasive GAS infections have
been described in the community, in nursing homes, and in
hospitals (7, 13, 17, 24, 26). Although rarely reported, second-
ary transmission occurs among household contacts (9, 18, 25).
In France, invasive GAS infection surveillance relies on the
Epibac national hospital-based laboratory network and on the
characterization of GAS strains sent to the French National
Reference Center for Streptococci. Since 1987, the Epibac
network has been collecting data from participating hospital
laboratories on bacteremic infections and meningitis due to 6
bacterial species, including GAS. These infections are defined
as the isolation of the bacterium from blood (bacteremia) or
cerebrospinal fluid (CSF; meningitis). The participating hospitals
account for more than 75% of French acute care admissions, as
described at
The French National Reference Center for Streptococci has
been collecting GAS strains isolated from invasive and nonin-
vasive GAS infections since 1995 (28).
According to Epibac data, between 2000 and 2006, the inci-
dence of GAS bacteremia and meningitis increased by 32% in
France, from 1.5 to 2.0 cases per 100,000 population (French
Institute for Public Health Surveillance, unpublished data).
National guidelines for the prevention of secondary cases of
invasive GAS infection in the community and hospitals were
issued in 2005 and 2006, respectively (5, 6). Antibiotic prophy-
laxis is recommended for all household contacts of a patient
with invasive GAS infection when one of them presents with a
predisposing factor to invasive GAS infection.
In order to better characterize the epidemiology of invasive
GAS infections, we conducted a national prospective survey of
invasive GAS infections in metropolitan France. The main
goals were to (i) estimate the burden of invasive GAS infec-
tions with or without a positive blood culture, (ii) characterize
the clinical presentations, (iii) assess predisposing factors and
outcomes, (iv) describe the molecular characteristics and an-
tibiotic susceptibility of GAS strains isolated from invasive
infections, and (v) assess the level of implementation of the
recommendations on antibiotic prophylaxis among household
contacts (6).
* Corresponding author. Mailing address: Institut de Veille Sani-
taire, 12 rue du Val d’Osne, 94415 Saint-Maurice Cedex, France.
Phone: 331 41 79 68 91. Fax: 331 41 79 68 72. E-mail: a.lepoutre@invs
† A list of the microbiologists of the Epibac network is available at
Published ahead of print on 5 October 2011.
Design. We conducted a cross-sectional survey over a 1-year period from
November 2006 to November 2007. Among the 332 hospital laboratories eligible
for Epibac surveillance, 194 laboratories located throughout the 22 French ad-
ministrative regions participated on a voluntary basis. The participating hospitals
accounted for 51% of French acute care inpatient admissions in 2007.
Case definition. GAS invasive infection was defined as the isolation of the
bacterium from a usually sterile site (e.g., blood, cerebrospinal fluid, joint, bone,
or synovial fluid) or from samples obtained from deep-body-site aspirates, in-
traoperative specimens, or a nonsterile site in association with one of the fol-
lowing clinical conditions: necrotizing fasciitis, clinically ascertained pneumonia,
endometritis, salpingitis, or TSS not attributable to any other cause and defined
according to the U.S. Working Group on Severe Streptococcal Infections defi-
nitions (31).
Invasive GAS infections identified during the hospital stay or within the 7 days
following the hospital discharge were presumed to be nosocomial if they oc-
curred at least 48 h after the time of admission or if the patient underwent a
surgical operation during the 7 days preceding the onset of GAS infection.
Postpartum infections were presumed to be nosocomial if they occurred during
the hospital stay or within 7 days after discharge.
A confirmed GAS infection in a case contact was defined as isolation of GAS
from the site of infection or, in case of acute pharyngitis, as a positive rapid
antigen detection test for GAS.
Data collection. Cases were identified by the local microbiologist, who com-
pleted a standardized questionnaire for each case meeting the case definition
with the support of the local infectious diseases specialist and of the attending
physician. Data collected included age, sex, clinical presentations, predisposing
factors, and outcomes at the time of discharge from hospital. Information re-
garding the occurrence of a GAS infection among close contacts 30 days before
or after the onset of disease of the identified case was also collected. Close
contacts were defined as individuals living in the same household or institution
as the case or having close and/or repeated contact during the 7 days preceding
the onset of the index case (5). In hospitals, close contacts were patients hospi-
talized in the same ward (6). Additional information regarding possible clusters
of nosocomial invasive GAS infection was retrieved from mandatory notifica-
tions of nosocomial invasive GAS infection and from available investigation
reports. The survey’s questionnaires were sent to the French Institute for Public
Health Surveillance staff, who reviewed the inclusion criteria and the complete-
ness of the data. The microbiologists were reminded to report cases by regular
phone calls and mailings.
Microbiological methods. GAS isolates were confirmed to be S. pyogenes by
beta-hemolysis on sheep blood agar, presence of Lancefield group A antigen, and
production of pyrrolydonyl arylamidase (20). Susceptibility to penicillin, amoxi-
cillin, vancomycin, erythromycin, tetracycline, and clindamycin was determined
according to the French Society for Microbiology guidelines described at http:
// All available isolates were also screened for streptococcal
pyrogenic exotoxin speA,speB, and speC genes and ssa genes by multiplex PCR
assay. When identical isolates on these markers were obtained from any given
patient, only the first invasive isolate was further characterized by molecular
typing. The emm gene sequencing was performed as described by Beall et al. (1)
with the modifications described at
Data analysis. The incidence of invasive GAS infections in France was esti-
mated by applying a correcting factor yielded by the survey to the incidence of
GAS bacteremic infections and meningitis in 2007 ascertained by Epibac sur-
veillance (IncEPI). IncEPI is calculated by dividing the number of reported cases
by the population covered by Epibac surveillance, corrected for the rates of
underreporting of cases, which is evaluated by 3 sources of capture-recapture
analysis (2, 3, 10, 14, 23). The population coverage was assessed to be 78% in
2007, and a 20% underreporting rate was assumed.
Invasive GAS incidence was therefore computed as IncEPI/(1 k), where kis
the correcting factor corresponding to the proportion of invasive GAS infections
in the survey where GAS has not been isolated from blood or cerebrospinal fluid,
and IncEPI is the incidence estimated through Epibac. Age-specific incidence
rates for invasive GAS infections were estimated by applying to the specific age
groups considered the same methodology described above for the all-age inva-
sive GAS infection incidence rate.
A cluster of invasive GAS infections was defined as the occurrence of 2
invasive GAS infection cases in close contacts within 30 days for community-
acquired invasive GAS infections and within 6 months for institutionalized in-
vasive GAS infection cases. Clusters were confirmed if the related invasive GAS
infection cases were due to GAS strains of identical emm sequence types.
Associations between outcomes, clinical presentations, predisposing factors,
and strain characteristics were tested using Fisher’s exact test for binomial data.
Associations between each specific clinical presentation or predisposing factor
with death were tested irrespective of the presence of other clinical presentations
or predisposing factors. Death predictors were evaluated using logistic regression
modeling. Statistical analysis was performed using Stata (version 9.2) software
(Stata Corporation, College Station, TX).
Number of cases, demographic characteristics, and inci-
dence. We identified 664 invasive GAS infections meeting the
case definition. GAS strains were isolated from blood cultures
alone (n345, 52%), blood cultures and other sterile sites
(n47, 7%), blood cultures and nonsterile sites (n75,
11%), sterile sites other than blood (n127, 19%), and
nonsterile sites (n70, 11%); cases where strains were iso-
lated from nonsterile sites were included on the basis of the
presence of at least one of the following clinical manifesta-
tions: toxic shock syndrome (n21), necrotizing fasciitis (n
22), endometritis (n23), salpingitis (n2), or pneumonia
The median age of the patients was 55 years (range, 28 days
to 103 years). The male-to-female ratio was 0.9.
The estimates of invasive GAS infection incidence in 2007 by
age group are presented in Fig. 1. On the basis of Epibac
surveillance, the incidence of GAS bacteremic infections and
meningitis was 2.2 cases per 100,000 population in 2007. More-
over, GAS invasive infections where GAS was not isolated
from blood or cerebrospinal fluid accounted for 29% (n193)
of the total invasive GAS infections reported in the survey.
Therefore, the overall incidence of invasive GAS infections in
France was estimated to be 3.1 (95% confidence interval [CI],
2.9 to 3.2) cases per 100,000 population in 2007. The highest
incidence occurred in children 5 years of age (5.7 per
100,000) and in adults 70 years of age (8.4 per 100,000).
Incidence rates were similar for men and women except in
those aged 50 to 69 years, where the incidence was higher in
men than in women (3.5 versus 2.2 per 100,000; P0.001).
Clinical presentations. Among the 664 invasive GAS infec-
tions included, various clinical presentations were reported
(Table 1). Nonnecrotic skin or soft tissue infections were the
most frequent, accounting for 30% of the cases; blood cultures
were positive in 82% of these cases. Necrotizing fasciitis was
reported in 16% of cases, pleuropulmonary infection in 11%,
septic arthritis in 9%, and postpartum sepsis in 5%. Other
FIG. 1. Age-specific rates and case-fatality ratios of invasive group
A streptococcal infections in France in 2007.
clinical presentations, such as intra-abdominal infections, os-
teomyelitis, and gynecological infections, were reported in less
than 5% of cases. No identified focus of invasive GAS infection
was reported in 22% of cases, although the portal of entry was
clinically suspected in 71% (n105) to be the skin in 60%, the
respiratory tract in 30%, or other sites in 10%.
Septic arthritis, osteomyelitis, and pleural infection were
observed more frequently in children (age, 15 years; n109)
than in adults (age, 15 years; n554), being reported in
20%, 15%, and 12% of children, respectively, and in 7%, 1%,
and 2% of adults, respectively (P0.001 each). Necrotizing
fasciitis was mostly observed in adults and uncommon in chil-
dren (18% versus 3%; P0.001). Postpartum cases accounted
for 32% (32/100) of cases in women of childbearing age (15 to
49 years).
A TSS was associated in 20% of cases (Table 2). It was 3-
and 1.9-fold more frequent in the presence of necrotizing fas-
ciitis and pulmonary infection, respectively (P0.001 and P
0.01), than in other clinical presentations. TSS was reported in
children (15%) and in adults (21%), but it was more frequent
in persons aged 50 to 69 years than in other age groups (31%
versus 17%; P0.001) (Table 2).
Predisposing factors. Predisposing factors were ascertained
for 657 (99%) cases; 507 (77%) presented at least one predis-
posing factor for invasive GAS infection (Table 3). A cutane-
ous pathology (e.g., burns, varicella, skin disease, and wounds)
was reported in 247 (38%) cases and in 114 (52%) of those
aged 70 years. A chronic medical condition such as diabetes,
malignancy, or liver or cardiac chronic disease was reported in
234 (36%) cases. Among children (age, 15 years), 55 (51%)
presented a predisposing factor; varicella was reported in 20
(19%), primarily in those under 5 years of age (19/20), and some
other lesion or disease of the skin was reported in 19 (18%). Only
6 (6%) children presented with a chronic medical condition.
Ninety-six cases (15%) were considered nosocomial; among
them, 32 (5%) were postpartum infection cases.
emm sequence typing and antimicrobial susceptibility.
Among the 664 cases, at least one GAS strain for 623 cases
(94%) was sent to the National Reference Center for Strep-
tococci, which analyzed only one representative strain per case.
A total of 48 different emm types were identified, and 3 types,
emm1(n203, 33%), emm89 (n100, 16%), and emm28
(n65, 10%), accounted for 59% of isolates, followed by
emm4(n34, 5%) and emm12 (n33, 5%) (Fig. 2). No
association between the distribution of emm types and geo-
graphical location was observed. emm1, emm3, and emm12
types were more frequently identified in children than in adults
(45% versus 30% [P0.05], 7% versus 2% [P0.05], and
12% versus 4% [P0.01], respectively), while the emm89 type
was less frequently identified in children than in adults (9%
versus 18% [P0.05]).
The speA,speB,speC, and ssa genes were detected in 37%,
100%, 49%, and 12% of strains, respectively. The speA gene
was carried by 97% of emm1 strains (196/203) and 100% of
emm3 strains (18/18), whereas it was carried by only 4% (16/
399) of strains of other emm types.
The emm1 type was associated with a higher frequency of
TSS (P0.001) and fatal outcomes (P0.001) than other
emm types in univariate analysis. The presence of the speA
gene was also associated with a higher frequency of TSS (P
0.001) and fatal outcomes (P0.001).
All GAS strains were susceptible to penicillin, amoxicillin,
and vancomycin; 8% were resistant to erythromycin, 13% to
tetracycline, and 6% to clindamycin. Among GAS isolates
from children (n105), 4%, 3%, and 1% were resistant to
erythromycin, tetracycline, and clindamycin, respectively. A
TABLE 1. Clinical presentations, incidence of positive blood
cultures, and outcomes among 664 invasive group
A streptococcal infection cases
Clinical presentation
No. (%) of cases No. of cases
with fatal
total no.
With positive
with a
Bacteremia without
identified focus
147 (22) 147 (100) 24 (16) 32/144 (22)
Skin or soft tissue
196 (30) 160 (82) 29 (15) 17/193 (9)
Necrotizing fasciitis 104 (16) 49 (47) 45 (43) 22/102 (22)
71 (11) 44 (62) 24 (34) 15/68 (22)
32 (5) 12 (38) 0 (0) 0/32 (0)
24 (4) 11 (46) 5 (21) 3/23 (13)
Septic arthritis 59 (9) 22 (37) 7 (12) 2/54 (4)
Osteomyelitis 22 (3) 13 (59) 0 (0) 0/22 (0)
Other clinical
48 (7) 30 (63) 10 (21) 5/45 (11)
The total number does not add up to 664, as certain patients presented with
more than one clinical presentation; percentages are given with respect to the
664 cases.
Percentages are of cases presenting with the clinical presentation.
Outcomes were available for a total of 646 cases. The total number of cases
does not add up to 646, as certain patients presented with more than one clinical
Cases presenting a pleuropulmonary infection (n71) included 48 cases
presenting with pneumonia, 12 cases presenting with a primary pleural infection,
and 11 cases presenting with pneumonia and pleural infection.
Other clinical presentations included 48 patients presenting 51 clinical pre-
sentations: meningitis (n7), salpingitis/endometritis (n14), endocarditis
(n7), other upper respiratory tract infection (n10), brain abscess (n3),
renal abscess/pyelonephritis (n4), vascular catheter infection (n2), urinary
catheter infection (n2), hip prosthesis infection (n1), and bacteremia from
digestive tract infection (n1).
P0.05 for a positive association between the presence of the specific
clinical presentation and death (Fisher exact test for binary data).
P0.05 for a negative association between the presence of the specific
clinical presentation and death (Fisher exact test for binary data).
TABLE 2. Ages and outcomes among 664 invasive group A
streptococcal infection cases
Age group
No. (%) of cases No. of cases with
fatal outcome/
total no. (%)
Total Presenting with
0–14 109 (17) 16 (15) 4/105 (4)
15–49 188 (28) 27 (14) 12/184 (7)
50–69 142 (21) 44 (31) 35/138 (25)
70 224 (34) 44 (20) 40/218 (18)
All ages
664 (100) 131 (20) 91/646 (14)
Outcomes were available for 646 cases.
P0.05 for the test of a difference in the frequency of death compared with
that for the 0- to 14-year-old age group, used as the reference group (Fisher exact
test for binary data).
Includes one patient without age information.
higher prevalence of resistance was observed among GAS isolates
from adults (n518), with 9%, 15%, and 7% being resistant to
erythromycin, tetracycline, and clindamycin, respectively.
Outcomes. Overall, 31% (n209) of cases required inten-
sive care unit admission and 28% (n183) underwent sur-
gery. The outcome at the time of discharge from hospital was
available for 646 cases (Table 2). The overall in-hospital le-
thality was 14% (95% CI, 11% to 17%), reaching 43% (56/129)
in patients who presented with TSS. More than two-thirds of
the deaths (62/91, 68%) occurred within the 4 days following
the onset of infection.
Among 104 necrotizing fasciitis cases, 64% required inten-
sive care unit admission and 69% underwent surgery, 22%
(22/102) died, and 31% (32/102) had a permanent complica-
tion at the time of discharge from hospital, such as an ampu-
tation (11%) or skin or soft tissue or muscular defects (14%)
due to necrosis. Overall, only 46% (47/102) of the patients who
presented with a case of necrotizing fasciitis recovered without
Bacteremia without an identified focus, necrotizing fasciitis,
pneumonia, and TSS were all associated with a higher risk of
death in univariate analysis (P0.01, P0.05, P0.05, and
P0.001, respectively).
Death was associated with the presence of a predisposing
factor (16% versus 9%, P0.05). Among predisposing fac-
tors, chemotherapy, diabetes, malignancy, and hepatic disease
were all associated with death in univariate analysis (P0.01,
P0.01, P0.05, and P0.01, respectively).
According to the results of multivariate logistic regression
analysis, age 50 years, hepatic disease, TSS, bacteremia with-
out an identified focus, and emm1 type were all independently
associated with an increased risk of a fatal outcome (Table 4).
Antibiotic prophylaxis and cluster of GAS infections in close
contacts. Information on the prescription of an antibiotic pro-
phylaxis to household contacts was available for 451 (68%)
cases. Among them, 50 (11%) reported having one or more of
their household contacts who presented with a predisposing
factor for invasive GAS infection; 266 (59%) cases did not
report such a factor among their contacts, and 135 (30%) lived
alone. In following French recommendations, an antibiotic
prophylaxis was to be prescribed to each member of these 50
households (i.e., 103 household contacts); the recommenda-
tions were actually fully respected for all the household con-
tacts in only 7 households (including 11 household contacts)
and partially realized in 1 household (1 antibiotic was pre-
scribed to 1 child with varicella, while the 5 other household
contacts did not receive any). No prophylaxis at all was con-
ducted in 42 households (including 86 household contacts).
Despite a poor compliance with the recommendations, no sub-
TABLE 3. Predisposing factors and outcomes among invasive GAS
infection cases
Predisposing factor
No. (%) of cases No. of cases with
fatal outcome/
total no. (%)
Presenting with
Immunosuppression 49 (7) 9 (18) 9/47 (19)
Steroid use 30 (5) 8 (27) 6/28 (21)
Chemotherapy 18 (3) 6 (33) 7/16 (44)
Injection drug use 9 (1) 1 (11) 1/9 (11)
Skin disease or wound
247 (38) 48 (19) 33/242 (14)
Varicella 20 (3) 3 (15) 1/20 (5)
Skin wound 193 (29) 41 (21) 27/188 (14)
Skin disease 46 (7) 8 (17) 6/46 (13)
Burn 3 (0) 0 (0) 0/3 (0)
Chronic medical
234 (36) 56 (24) 56/226 (25)
Diabetes 88 (13) 22 (25) 21/86 (24)
Malignancy 42 (6) 12 (29) 11/39 (28)
Hepatic disease 28 (4) 6 (21) 10/28 (36)
Renal impairment 25 (4) 6 (24) 7/25 (28)
Heart disease 44 (7) 10 (23) 10/43 (23)
Other chronic medical
31 (5) 8 (26) 6/29 (21)
Alcoholism 34 (5) 14 (41) 7/33 (21)
Surgery 8 days earlier 18 (3) 4 (22) 2/16 (13)
Childbirth 4 wk earlier 32 (5) 0 (0) 0/32 (0)
No predisposing factor
150 (23) 28 (19) 13/149 (9)
Information on the presence of a predisposing factor was available for 657 patients.
Patients may have more than one predisposing factor; percentages are cal-
culated using the 657 cases as the denominator.
Percentages are calculated using the number of cases presenting the specific
predisposing factor as the denominator.
Outcomes were available for 646 cases. The total number of cases does not
add up to 646, as certain patients presented more than one predisposing factor.
The total of the subcategories does not add up to 247, as certain patients
presented more than one type of skin disease or wound.
The total of the subcategories does not add up to 234, as certain patients
presented more than one chronic medical condition.
P0.05 for a positive association between the presence of the specific
predisposing factor and death (Fisher exact test for binary data).
P0.05 for a negative association between the presence of the specific
predisposing factor and death (Fisher exact test for binary data).
FIG. 2. Distribution of emm types among 623 GAS strains responsible for invasive infections in children and adults.
sequent case of invasive GAS infection was reported in the 103
household contacts of these 50 households.
Information concerning the occurrence of a GAS infection
in close contacts of the case was available for 518 (78%) cases.
A noninvasive GAS infection was confirmed in a close contact
of 11 (2%) cases; the contact case was a member of the house-
hold (8 cases), shared the same hospital room (1 case), or was
a resident of the same nursing home (2 cases).
Subsequent invasive GAS infection cases were identified in
the 30 days following the onset of a case among the close
contacts of 7 (1%) cases; for 5 of these cases, GAS strains were
of identical emm type, and for 2 they were of different emm
types. In addition to these 5 clusters, a cluster of 3 cases of
GAS infection (2 invasive cases and 1 noninvasive case) which
shared identical emm89 GAS strains was identified with a delay
of 77 days in 3 residents of the same nursing home.
Overall, 6 clusters involving 12 invasive GAS infections cases
were confirmed on the basis of epidemiological links and iso-
lation of GAS strains of identical emm types (Table 5). One
family cluster due to an emm1 strain (cluster 1) occurred in a
34-year-old mother and her 3-year-old daughter, both of whom
were previously healthy; the mother died and the young girl
recovered. One cluster of two invasive infections and one non-
invasive infection due to an emm89 strain (cluster 2) occurred
in three chronically disabled residents of a nursing home. Four
postpartum clusters involved two women each who shared the
same emm4, emm11, emm28, or emm89 strain. Investigation
reports were available for 3 clusters; the suspected route of
contamination was direct transmission in the members of the
family in cluster 1, indirect transmission from one resident to
another during skin wound care in cluster 2, and intrahospital
patient-to-patient contamination during the postdelivery pe-
riod in cluster 5 (Table 5).
This nationwide prospective survey enables the determina-
tion of the incidence of invasive GAS infections in France. It
indicates that cases not captured by routine surveillance of
bacteremia and meningitis account for a substantial part (29%)
of invasive GAS infections. Given this result, the estimated
rate in 2007 was 3.1 cases per 100,000 population, a rate com-
parable to the 2.2 to 3.8 recently reported from surveys in
Europe, the United States, and Canada (11, 22, 27).
The highest risks of invasive GAS infections were identified
in young children and elderly patients, as previously reported
(11, 27). This study also highlights the high severity of invasive
GAS infections, with a case-fatality ratio of 14%, which is also
in agreement with the ratios reported in the United States
(14%) (22), Sweden (14.5%) (8), and Denmark (16%) (16).
This survey allowed a comprehensive assessment of the ep-
idemiology of invasive GAS infections in France, since predis-
TABLE 4. Results of multivariate logistic regression analysis of
factors associated with death in invasive GAS infection
Variable Odds ratio
(95% CI) Pvalue
Age 50 yr Reference
Age 50 yr 2.9 (1.5–5.6) 0.01
Toxic shock syndrome 9.9 (5.6–17.5) 0.001
Bacteremia without
identified focus
2.5 (1.4–4.7) 0.01
Chemotherapy 3.9 (0.9–16.2) 0.06
Diabetes 1.8 (0.9–3.6) 0.10
Liver disease 3.7 (1.3–10.5) 0.02
emm1 type 2.2 (1.2–3.8) 0.01
Data are for 600 cases. Clinical presentations, predisposing factors, emm
types, and patient characteristics were entered in the model if associated with an
increased or a decreased frequency of death on univariate analysis (P0.20)
and retained in the model if associated with death (P0.10). Finally, factors
were considered to be independently associated with death if associated with a P
value of 0.05 or less (Wald test). Patients with missing data (n64) were
excluded from the analysis. Two-way interactions were evaluated.
TABLE 5. Confirmed clusters
of invasive GAS infections
no. Setting
No. of cases (clinical presentation) Duration
emm type(s)
(no. of
no. of strains)
Suspected mode of transmission
Invasive Noninvasive
1 Household 2 (1 pneumonia with empyema,
1 pneumonia and TSS)
1 (pharyngitis) 7 emm1 (3/3) Intrafamilial
2 Nursing home 2 (2 bacteremic skin infections) 1 (lower genital tract
77 emm89 (3/3) Indirect transmission from patient to
patient during the care of skin
wounds of the 3 patients by hand-
borne transmission or by
transmission from a carrier among
health care staff (not screened)
3 Postnatal ward A 3 (1 wound infection from
cesarean delivery and
endometritis, 2 endometritis)
20 emm11 (2/3),
emm1 (1/3)
4 Postnatal ward B 2 (1 bacteremic endometritis, 1
3emm89 (2/2) Unknown
5 Postnatal ward C 2 (1 bacteremic endometritis, 1
2emm4 (2/2) Patient to patient in the postdelivery
period, where the 2nd case shared
the same room as the index case
6 Postnatal ward D 2 (1 bacteremic endometritis, 1
3emm28 (2/2) Unknown
A confirmed cluster was defined as the occurrence in 30 days (in the community) or 6 months (in institutional settings) of 2 invasive GAS cases due to GAS strains
sharing identical emm sequence types.
The mode of transmission was suspected on the basis of the results of investigations of the infection control staff.
posing factors, outcomes, and GAS isolates were obtained
from more than 90% of the cases.
Regarding the representativeness of the survey, although the
survey was conducted on a voluntary basis, the participating
hospitals accounted for 51% of French acute care admissions
in 2007 and were distributed in all French regions. Regarding
case characteristics, the age and sex distribution of bacteremic
invasive GAS cases included did not differ from those of bac-
teremic cases identified in Epibac surveillance in 2007, suggest-
ing no significant bias in the recruitment of cases. Regarding
the estimation of invasive GAS infection incidence, as Epibac
results are regularly validated through 3 sources of capture-
recapture analysis, we consider that in our survey our estima-
tion of global invasive GAS infection incidence based on the
Epibac rates for bacteremia or meningitis, corrected by the
proportion of invasive GAS infections where the GAS has not
been isolated from blood or CSF, provides the best incidence
Inclusion of cases with GAS isolates obtained from a non-
sterile site (i.e., 23 cases of endometritis, 2 cases of salpingitis,
and 2 cases of pneumonia), accounting for 4% of the total
cases, may hamper comparison of the results with those of
surveys which include only cases with GAS isolates from nor-
mally sterile sites (8, 16, 22). However, the design of our survey
led to a more comprehensive ascertainment of the burden of
invasive GAS infections in our country.
The results emphasize the severity of invasive GAS infec-
tions in adults over 50 years of age, who accounted for the
majority (82%) of fatal invasive GAS infections. This may in
part be explained by the high frequency of TSS and preexisting
chronic medical conditions in this age group. On the contrary,
children and women with postpartum endometritis were less
likely to present severe clinical manifestations, such as necro-
tizing fasciitis, TSS, or a fatal outcome. The highest risk of fatal
outcome was associated with pneumonia, necrotizing fasciitis,
and bacteremia without an identified focus.
emm1 was the main emm type associated with a higher risk
of a fatal outcome, after adjusting for other predisposing fac-
tors, as previously reported in Europe and the United States
(15, 22). Most of the emm1 strains carried the speA gene, which
was also associated with severe infections and outcomes. How-
ever, as the presence of the speA gene was highly correlated
with emm1 type, the role of the speA gene in the occurrence of
TSS or a fatal outcome could not be distinguished from that of
emm1 type. Moreover, emm1 strains were more frequent in
patients without chronic medical conditions (36% versus 27%,
P0.02) and in children. These results confirm the high
virulence potential of emm1 strains circulating in France and
other countries. The second most frequent emm types included
emm89 and emm28, which were also frequent in the United
States, Denmark, and Sweden (8, 16, 22). On the contrary, the
emm3 type, which was identified to be preponderant and highly
virulent in the United States and other European countries
(15, 21, 22), accounted for only 3% of the strains isolated from
invasive infections in our survey.
Skin diseases or cutaneous lesions were the most common
predisposing factor, especially in elderly and younger patients.
Skin conditions were reported in more than half of the elderly
(52%), and varicella was reported in one-fifth of children un-
der the age of 15 years. This observation highlights the impor-
tance of skin breaches as portals of entry for GAS infection, as
also noticed in previous reports (12, 29, 30).
Six clusters of 12 GAS invasive infections with identical emm
types were identified; 4 of them involved 8 postpartum cases
accounting for 25% (8/32) of postpartum cases. This suggests
that a substantial proportion of postpartum GAS infections is
preventable. In addition, 10% (64/632) of nonpostpartum in-
vasive GAS infections were suspected to have been acquired in
hospital. The significant number of postpartum cases reported
in the survey could partially be related to the mandatory re-
porting of nosocomial infections since 2001 and the incentive
to investigate postpartum and postsurgery GAS infections, as
recommended in guidelines issued in 2006 (5). Sequencing of
the emm gene was very important in the investigation of clus-
ters of cases to confirm the links between epidemiologically
related cases.
The prescription of antibiotic prophylaxis in household
members of GAS-infected patients when one of them presents
with a predisposing factor has been recommended since 2005
(5, 6). This survey suggests that these recommendations were
inconsistently applied and strengthens the need to reinforce
their implementation in community settings.
In France, as in other developed countries, invasive GAS
infections are among the most severe bacterial infections.
Overall, we estimated that 1,900 cases of these infections oc-
curred in France in 2007. Assuming that the cases included in
the survey were representative of invasive GAS infections in
France, we estimated that 270 patients died from such infec-
tions in 2007.
Current strategies to prevent GAS invasive diseases still rely
on early detection of GAS infections, rapid and effective med-
ical care, and reinforcement of outbreak investigation and con-
trol, particularly in health care settings. However, identifica-
tion of factors associated with mortality can guide disease
prevention efforts. It was estimated that a 26-valent vaccine
candidate, which has reached phase II trials in adults, could
potentially prevent 40% to 50% of cases and 50% to 60% of
deaths due to invasive GAS infections among children and the
elderly (4, 19). In this context, the follow-up of GAS strains
involved in severe GAS infections is important to adapt cur-
rent vaccine development strategies.
We thank the members of the survey’s scientific committee, Cathe-
rine Chirouze, Julien Loubinoux, Alain Lortat Jacob, Jean Pierre Be-
dos, Fre´de´ric Laurent, Marc Lecuit, and Claude Bernet, for their
assistance in the preparation of the survey’s protocol and question-
naire and their advice for the implementation of the survey; Jean
Claude Desenclos for his helpful reading and comments on the man-
uscript; all the clinicians and microbiologists from the participating
hospitals who collected the data; and Gisle`ne Collobert and Ge´rald
Touak for excellent technical assistance.
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... Existen hipótesis acerca de los factores que lo vuelven dominante. Podría vincularse a una mayor prevalencia en la población, como consecuencia de una mayor adaptación a la colonización humana con respecto a otras variantes 38 . Su presentación clínica más frecuente fue neumonía/EI grave. ...
... Su presentación clínica más frecuente fue neumonía/EI grave. Lepoutre y cols., vincularon a las cepas emm1 con población pediátrica sana y mayor riesgo de resultados fatales 38 . ...
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Introducción: Streptococcuspyogenes (EGA) es agente de enfermedad invasora (EI); su alta morbimortalidad exige vigilancia epidemiológica. Objetivo: Describir características clínicas y epidemiológicas de niños hospitalizados con EI por EGA en un centro de referencia de Uruguay del 1/1/2014 al 31/12/2020 incluyendo el estudio de los factores de virulencia encontrados en las cepas aisladas. Materiales y Métodos: Descriptivo y retrospectivo. Definición de caso: aislamiento de EGA. en sitios estériles. Variables: epidemiológicas, clínicas, laboratorio, tratamiento y evolución. Se tipificó por secuenciación del gen emm. Se obtuvieron perfiles cromosómicos por digestión del ADN con la enzima SmaI. Presencia de los genes que codifican SpeB, SpeA, SpeC y Ssa, y susceptibilidad a antimicrobianos. Resultados: Tasa de admisiones: 3,98/10.000. Se incluyeron 22 pacientes; infección osteoarticular (n = 11), infección pleuropulmonar (n = 6), absceso no cutáneo (n = 4) y aislamiento en sangre (n = 1). Media de edad: 44 meses; 8 fueron graves, siendo su media de edad menor (16 meses) Todas los casos con neumonías fueron graves y un paciente falleció. Se secuenciaron 12 cepas: 5 emm1 (4 emm 1.29 y 1 emm 1) y 1 de cada uno de los siguientes: emm 6.4, emm 81, emm12, emm28, emm 22, emm 87, emm 11. Todas eran SpeB+. Perfiles de toxinas: SpeA+SpeC-Ssa-(5), SpeA-SpeC+Ssa-(4) SpeA-SpeC-Ssa-(2) y SpeA-SpeC+Ssa+ (2). Conclusiones: Este estudio permite dar continuidad a un estudio previo. Se logró mayor tipificación de EGA. que puede contribuir a su conocimiento clínico molecular. No hubo registro de pacientes con diagnóstico de SST ni de fascitis necrosante, a diferencia de la serie anterior.
... Thus, it is an important epidemiological risk factor for death and severe complications [1]. Scarlet fever is a common infectious disease with a characteristic morphology; however, according to existing data, its diagnosis is often delayed or not considered at all in groups of children over five years of age due to its similarity to streptococcal pharyngitis [2,3]. Distinguishing between viral and bacterial etiologies of acute pharyngitis can be problematic when attempting to make a correct diagnosis. ...
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Introduction: Scarlet fever is usually a mild childhood disease caused by type A streptococci. This disease is spread by droplets, mainly through direct contact with an infected person or the objects they have used. In pediatrics, these are significant risk factors for the transmission of infectious diseases. However, it is important to remember the possibility of serious complications in the course of scarlet fever. Aim: This paper provides a discussion of two pediatric cases in order to determine the possibilities of diagnosis, differentiation, and treatment of patients with severe, non-obvious courses of scarlet fever. Methods: The case reports of two patients hospitalized in a pediatric department due to Streptococcus pyogenes infection were examined. Results: The patients were admitted to the emergency room with symptoms not directly indicative of type A streptococcal infection, which required further diagnosis. Both patients complained of weakness at the time of presentation. They had an elevated temperature, were dehydrated during the course of gastroenteritis, and passed liquid stools without pathological admixtures. Further stages of diagnosis and treatment required hospitalization in the pediatric department. Therapeutic benefit from the implemented treatment was obtained, and the patients were discharged in good general condition with further recommendations. Conclusions: Medical history, which is often very detailed, can be the key to making the final diagnosis and can supplement the data collected on the basis of laboratory tests. Scarlet fever does not always occur with a mild course, and sometimes its course can be quite non-specific and may require a thorough diagnosis.
... However, it has increased in Spain between 1996 and 2006 [12]. Clindamycin resistance is reported in 6-7% of the tested isolates across different settings over the past 15 years [13,14]. ...
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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.
... It can cause mild illnesses such as pharyngitis and impetigo and trigger severe manifestations, including necrotizing fasciitis and streptococcal toxic shock syndrome (STSS). STSS is characterized by high fever, rash, hypotension, and multiorgan failure (1), with mortality ranging from 15-50%, although it often affects healthy people (2)(3)(4). ...
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Background Streptococcal toxic shock syndrome (STSS) is a rare but potentially fatal condition. Intravenous immunoglobulin (IVIG) treatment appears to reduce mortality; however, the clinical evidence remains controversial. Therefore, this study aimed to evaluate the effect of IVIG using a nationwide database by considering and adjusting for all background factors. Methods The treatment efficacy of IVIG in patients with STSS was investigated. Patient data were extracted from a Japanese nationwide database between April 2015 and March 2018. In-hospital mortality was considered the primary outcome, and 30-day and 7-day mortalities were considered secondary outcomes. Background adjustments were made using multivariate logistic analysis. For the sensitivity analysis, propensity score matching, time dependence of IVIG administration, and dose-response relationship were also assessed. Results Overall, 102 patients were included for the analysis. Their characteristics were as follows: median age, 62 years; female sex, 33.0% (34/102); overall mortality, 30.4% (31/102); necrotizing fasciitis patients, 57.8% (59/102); and IVIG-treated patients, 35.3% (36/102). After adjustment using multivariate logistic regression, no effect of IVIG treatment was observed on in-hospital mortality (adjusted odds ratio, [95% confidence interval (CI)]: 0.99 [0.90–1.08], p=0.88). This result was consistent with that after propensity score matching (odds ratio [95% CI]: 1.00 [0.34–2.92], p>0.99). Furthermore, IVIG treatment did not change the 30-day and 7-day mortalities. Neither the timing of IVIG administration nor IVIG dose had an effect on in-hospital mortality. Conclusions The administration of IVIG did not show any survival benefits.An equivalent or a more extensive observational study is warranted to confirm these findings.
... Our multicenter study including severely ill patients with high-grade of organ dysfunction secondary to bacteremic invasive GAS confirms that this infection has a significant morbidity and a high mortality rate. Importantly, clindamycin as part of the antimicrobial therapy significantly reduced mortality after controlling for confounders while we could not non-critically ill patients with a mortality rate much lower than ours (14%) [19]. ...
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Objective: Mortality of patients requiring Intensive Care Unit (ICU) admission for an invasive group A streptococcal (GAS) infection continues being high. In critically ill patients with bacteremic GAS infection we aimed at determining risk factors for mortality. Methods: Retrospective multicentre study carried out in nine ICU in Southern Spain. All adult patients admitted to the participant ICUs from January 2014 to June 2019 with one positive blood culture for S. pyogenes were included in this study. Patient characteristics, infection-related variables, therapeutic interventions, failure of organs, and outcomes were registered. Risk factors independently associated with ICU and in-hospital mortalities were determined by multivariate regression analyses. Results: Fifty-seven patients were included: median age was 63 (45-73) years, median SOFA score at admission was 11 (7-13). The most frequent source was skin and soft tissue infection (n=32) followed by unknown origin of bacteremia (n=12). In the multivariate analysis, age (OR 1.079; 95% CI 1.016-1.145), SOFA score (OR 2.129; 95% CI 1.339-3.383) were the risk factors for ICU mortality and the use of clindamycin was identified as a protective factor (OR 0.049; 95% CI 0.003-0.737). Age and SOFA were the independent factors associated with hospital mortality however the use of clindamycin showed a strong trend but without reaching statistical significance (OR 0.085; 95% CI 0.007-1.095). Conclusions: In this cohort of critically ill patients the use of intravenous immunoglobulin was not identified as a protective factor for ICU or hospital mortality treatment with clindamycin significantly reduced mortality after controlling for confounders.
... S. pyogenes is a species of Gram-positive bacteria that causes respiratory tract infections with mild to modest disease (tonsillitis and pharyngitis) and invasive and potentially life-threatening diseases (cellulitis, necrotizing fasciitis, and toxic shock syndromes) [3,4]. Mortality from lethal S. pyogenes remains high in developed and developing countries [5]. In addition, there are reports of S. pyogenes outbreaks in communities and hospitals [6]. ...
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Phosphorylcholine (PC) is a structural component of various pathogens and is involved in bacterial adhesion via the platelet-activating factor receptor (PAF-R). In this study, we investigated how PC expression affects cell adhesion and invasion of Streptococcus pyogenes (S. pyogenes). Eight clinical strains of S. pyogenes were cultured, and PC expression was measured using fluorescence-activated cell sorting. Bacterial adherence and invasion were examined using Detroit 562 cells. An anti-PC-specific monoclonal antibody (TEPC-15) was used to inhibit bacterial PC, and a PAF-R antagonist (ABT-491) was used to inhibit cellular PAF-R. The emm gene was amplified by the polymerase chain reaction with the standard primers. The level of PC expressed on the S. pyogenes surfaces differed in each strain and differed even in the same emm genotype. Adherence assay experiments showed a significant negative correlation between TEPC-15 and ABT-491 inhibitory effects and PC expression in S. pyogenes. Similarly, intracellular invasion assay experiments showed a significant negative correlation between TEPC-15 and ABT-491 inhibitory effects and PC expression in S. pyogenes. This study suggests that S. pyogenes is involved in cell adhesion and invasion by PC.
... The Dutch mortality rate of necrotizing fasciitis (23-29%) is slightly higher than the reported mortality rate of 18-21% in recent international literature from selected centers and is slightly lower than the pooled mortality rate from the three previous Dutch cohort studies (28%). The Dutch mortality rate for GAS necrotizing fasciitis (17%) is comparable to that found in other European studies on GAS necrotizing fasciitis (10-22%) [4,12,21,22]. In the current study a higher mortality rate was observed in non-GAS necrotizing fasciitis patients compared to GAS necrotizing fasciitis patients. ...
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Background Little is known about the exact incidence of necrotizing soft tissue infections. The few incidences reported in international literature are not directly relatable to the Netherlands, or other European countries, due to geographic heterogeneity in causative micro-organisms involved. This resulted in the aim of this study to map the incidence, mortality rate and hospital course of necrotizing fasciitis infections in the Netherlands to gain insight in the incidence of necrotizing fasciitis in the Netherlands and the associated mortality and health care burden. Methods This nationwide retrospective database study used three distinct data sources to map the incidence of necrotizing fasciitis in the Netherlands between 2014 and 2019, being data from the Dutch Hospital Data (DHD) foundation, data from Osiris-AIZ, which is a database of notifiable diseases managed by regional Public Health Services (GGD) and the National Institute for Public Health and the Environment (RIVM), and previously published studies on necrotizing fasciitis conducted in the Netherlands. Results The incidence of necrotizing fasciitis in the Netherlands is estimated to be approximately 1.1 to 1.4 cases per 100,000 person years, which corresponds to 193–238 patients per year. Of all necrotizing fasciitis infections, 34 to 42% are caused by the group A Streptococcus. Annually, 56 patients die as a result of a necrotizing fasciitis infection (mortality of 23–29%) and 26 patients undergo an amputation for source control (11–14%). Patients stay a mean of 6 to 7 days at the intensive care unit and have a mean hospital length of stay of 24 to 30 days. Conclusion The combination of nationwide databases provides reliable insight in the epidemiology of low-incidence and heterogenic diseases. In the Netherlands, necrotizing fasciitis is a rare disease with group A Streptococcus being the most common causative micro-organism of necrotizing fasciitis. The prior Dutch cohort studies on necrotizing fasciitis report slightly higher sample mortality rates, compared to the population mortality. However, necrotizing fasciitis remain associated with substantial morbidity and mortality, risk at amputation and health care burden characterized by prolonged ICU and hospital stay.
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Introduction: Group A streptococcus (Streptococcus pyogenes) is one of the most lethal bacterial pathogens of humans, with increased risk of progression to septic shock and multiorgan failure in the pregnant population. The objective of this study is to systematically review the outcomes and management strategies for pregnancy and puerperal group A streptococcus infections in an effort to provide further guidance for prevention and treatment of a rare but lethal infection worldwide. Material and methods: A comprehensive search using puerperium and streptococcus pyogenes terms was completed across several registered databases. A total of 902 articles investigating pregnancy and puerperal group A streptococcus infection were identified, with 40 studies fulfilling inclusion criteria of original research articles in humans published from 1990 onwards reporting four or more unique cases of group A streptococcus in pregnancy or postpartum. This study was registered in PROSPERO: CRD42020198983. Results: A total of 1160 patients with pregnancy and puerperal group A streptococcus infection were identified. Most infections occurred postpartum (91.9%), with 4.7% reported antepartum and 0.6% intrapartum. Bacteremia was present in 49.0% of patients and endometritis in 45.9%. Puerperal sepsis was described in 28.2% of cases and progressed to streptococcal toxic shock syndrome in one-third of such cases. Overall, the case fatality ratio was 2.0%, with one-third of the deaths from antenatal cases including 3/22 (13.6%) cases of septic abortion and 10/46 (21.7%) antenatal cases of group A streptococcus infection. Conclusions: Group A streptococcus infection remains an important contributor to pregnancy and puerperal morbidity and mortality. Early recognition, diagnosis and aggressive management are important for favorable outcomes given the serious risk of sepsis and streptococcal toxic shock syndrome.
Background Necrotising fasciitis (NF) represents a rare but often life-threatening condition. Early diagnosis and surgical treatment are of vital importance. The LRINEC score was developed to distinguish necrotising fasciitis from other soft tissue infections (STI) at initial evaluation using six laboratory values. In this retrospective study, we tried to determine the diagnostic and prognostic value of the LRINEC score. Methods A total of 125 patients, hospitalised in our clinic between 2003 and 2021 with a histologically confirmed diagnosis of necrotising fasciitis (NF group) and 319 patients with surgically treated soft tissue infections (STI group) were included in this study. Individual LRINEC scores were calculated and analysed retrospectively. Results The sensitivity of the LRINEC score at the cut-off point of ≥ 6 was 59%, whereas the specificity was 82%. The positive and negative predictive values were 57% and 84% respectively. The mean LRINEC score was significantly higher in the NF group than in the STI group (6.0 compared with 2.4 respectively). All clinical outcome parameters such as amputation and mortality rates (15% vs 1%) were found to be significantly higher in the NF group (p<0.001). Within the NF group, there was no statistically significant association between the LRINEC score and clinical outcomes except for the necessary number of operations. Conclusion In isolation we found the LRINEC score not to be a reliable enough diagnostic tool for the differentiation between NF and other soft tissue infections, due its low sensitivity. Although we cannot recommend it as a prognostic tool either, we do believe it can be a useful adjunct to the clinical suspicion of NF.
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Drug resistance among gram positive aerobic cocci poses a significant problem in management of patients with skin and soft tissue infections (SSTI's). S. aureus is the most common organism that causes mild skin and soft tissue infections to serious infections such as sepsis and toxic shock syndrome. Enterococcus and Streptococcus species have also emerged as a cause of skin and soft tissue infections and health care associated infections (HAI's). SSTI's is an inflammatory microbial invasion of epidermis, dermis and subcutaneous tissue. It is classified according to the layer of infection, severity of infection and microbiologic etiology. The practice guidelines of the Infectious Disease Society of America (IDSA) for the diagnosis and management of skin and soft tissue infection classifies SSTI's into five categories comprising superficial and complicated infections which include impetigo, erysipelas, cellulitis, necrotizing fasciitis, surgical site infection. Risk factors associated with development of SSTI's include poor hygiene, overcrowding, co- morbidities like diabetes, immunocompromised state, overuse of antibiotics, prolonged hospital stay, burn patients etc. Prompt recognition, timely surgical debridement or drainage with appropriate antibiotic therapy is the mainstay treatment for SSTI's. Empirical therapy includes penicillin, cephalosporins, clindamycin and cotrimoxazole. Multi-Drug resistance is of major concern commonly caused by MRSA (Methicillin resistant staphylococcus aureus) which includes CA-MRSA (Community acquired methicillin resistant Staphylococcus aureus), HA-MRSA (hospital acquired methicillin resistant Staphylococcus aureus), VRSA (vancomycin resistant staphylococcus aureus) & VRE (vancomycin resistant Enterococci). HA-MRSA is generally susceptible to clindamycin, vancomycin, Linezolid & trimethoprim- sulfamethoxazole. In contrast, CA-MRSA is usually sensitive to these former antibiotics as well as broader range of oral antimicrobial agents like clindamycin, linezolid, quinolones, daptomycin, tigecycline etc. These empirical therapeutic agents provide coverage for both S. aureus, Streptococcus species and Enterococcus species. Therefore, demographic knowledge of antimicrobial agents and their resistance pattern plays a significant role in management of SSTI's.
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Several reports suggest that the incidence of invasive group A streptococcal infections, including streptococcal toxic shock syndrome and necrotizing fasciitis, is increasing. During 1992 and 1993 we conducted prospective, population-based surveillance of invasive group A streptococcal disease in Ontario, Canada. We reviewed clinical and laboratory records, searched for secondary cases of invasive disease, and cultured specimens from household contacts. We identified 323 patients with invasive group A streptococcal infections, for an annual incidence of 1.5 cases per 100,000 population. The rates were highest in young children and the elderly. Fifty-six percent of the patients had underlying chronic illness. Risk factors for disease included infection with the human immunodeficiency virus, cancer, diabetes, alcohol abuse, and chickenpox. The most common clinical presentations were soft-tissue infection (48 percent), bacteremia with no septic focus (14 percent), and pneumonia (11 percent). Necrotizing fasciitis occurred in 6 percent of patients, and toxic shock in 13 percent. The mortality rate was 15 percent overall, but it was 29 percent among those over 64 years of age (P<0.001) and 81 percent among those with toxic shock (P<0.001). Fourteen percent of the cases were nosocomial, and 4 percent occurred in nursing home residents, often in association with disease outbreaks. Invasive disease occurred in 2 household contacts of patients with infection, for an estimated risk of 3.2 per 1000 household contacts (95 percent confidence interval, 0.39 to 12 per 1000). The elderly and those with underlying medical conditions are at greatest risk for invasive group A streptococcal disease, toxic shock, and necrotizing fasciitis. Invasive steptococcal infection is associated with a substantial risk of transmission in households and health care institutions.
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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.
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Diseases caused by the Lancefield group A streptococcus, Streptococcus pyogenes, are amongst the most challenging to clinicians and public health specialists alike. Although severe infections caused by S. pyogenes are relatively uncommon, affecting around 3 per 100,000 of the population per annum in developed countries, the case fatality is high relative to many other infections. Despite a long scientific tradition of studying their occurrence and characteristics, many aspects of their epidemiology remain poorly understood, and potential control measures undefined. Epidemiological studies can play an important role in identifying host, pathogen and environmental factors associated with risk of disease, manifestation of particular syndromes or poor survival. This can be of value in targeting prevention activities, as well directing further basic research, potentially paving the way for the identification of novel therapeutic targets. The formation of a European network, Strep-EURO, provided an opportunity to explore epidemiological patterns across Europe. Funded by the Fifth Framework Programme of the European Commission s Directorate-General for Research (QLK2.CT.2002.01398), the Strep-EURO network was launched in September 2002. Twelve participants across eleven countries took part, led by the University of Lund in Sweden. Cases were defined as patients with S. pyogenes isolated from a normally sterile site, or non-sterile site in combination with clinical signs of streptococcal toxic shock syndrome (STSS). All participating countries undertook prospective enhanced surveillance between 1st January 2003 and 31st December 2004 to identify cases diagnosed during this period. A standardised surveillance dataset was defined, comprising demographic, clinical and risk factor information collected through a questionnaire. Isolates were collected by the national reference laboratories and characterised according to their M protein using conventional serological and emm gene typing. Descriptive statistics and multivariable analyses were undertaken to compare characteristics of cases between countries and identify factors associated with increased risk of death or development of STSS. Crude and age-adjusted rates of infection were calculated for each country where a catchment population could be defined. The project succeeded in establishing the first European surveillance network for severe S. pyogenes infections, with 5522 cases identified over the two years. Analysis of data gathered in the eleven countries yielded important new information on the epidemiology of severe S. pyogenes infections in Europe during the 2000s. Comprehensive epidemiological data on these infections were obtained for the first time from France, Greece and Romania. Incidence estimates identified a general north-south gradient, from high to low. Remarkably similar age-standardised rates were observed among the three Nordic participants, between 2.2 and 2.3 per 100,000 population. Rates in the UK were higher still, 2.9/100,000, elevated by an upsurge in drug injectors. Rates from these northern countries were reasonably close to those observed in the USA and Australia during this period. In contrast, rates of reports in the more central and southern countries (Czech Republic, Romania, Cyprus and Italy) were substantially lower, 0.3 to 1.5 per 100,000 population, a likely reflection of poorer uptake of microbiological diagnostic methods within these countries. Analysis of project data brought some new insights into risk factors for severe S. pyogenes infection, especially the importance of injecting drug users in the UK, with infections in this group fundamentally reshaping the epidemiology of these infections during this period. Several novel findings arose through this work, including the high degree of congruence in seasonal patterns between countries and the seasonal changes in case fatality rates. Elderly patients, those with compromised immune systems, those who developed STSS and those infected with an emm/M78, emm/M5, emm/M3 or emm/M1 were found to be most likely to die as a result of their infection, whereas those diagnosed with cellulitis, septic arthritis, puerperal sepsis or with non-focal infection were associated with low risk of death, as were infections occurring during October. Analysis of augmented data from the UK found use of NSAIDs to be significantly associated with development of STSS, adding further fuel to the debate surrounding the role of NSAIDs in the development of severe disease. As a largely community-acquired infection, occurring sporadically and diffusely throughout the population, opportunities for control of severe infections caused by S. pyogenes remain limited, primarily involving contact chemoprophylaxis where clusters arise. Analysis of UK Strep-EURO data were used to quantify the risk to household contacts of cases, forming the basis of national guidance on the management of infection. Vaccines currently under development could offer a more effective control programme in future. Surveillance of invasive infections caused by S. pyogenes is of considerable public health importance as a means of identifying long and short-term trends in incidence, allowing the need for, or impact of, public health measures to be evaluated. As a dynamic pathogen co-existing among a dynamic population, new opportunities for exploitation of its human host are likely to arise periodically, and as such continued monitoring remains essential. Lancefield-ryhmän A streptokokin eli Streptococcus pyogenes-bakteerin aiheuttamat taudit ovat erittäin haasteellisia kliinikoille sekä kansanterveyden asiantuntijoille. Vaikka S. pyogenesin aiheuttamia vakavia infektioita esiintyy kehittyneissä maissa väestöpohjaisesti vain kolmella 100 000:sta vuosittain, on tapauskuolleisuus suuri verrattuna moniin muihin infektiotauteihin. Siitä huolimatta, että näiden infektioiden ominaisuuksia ja esiintymistä koskevalla tutkimuksella on pitkät perinteet, on niiden epidemiologia vielä useilta osin huonosti tunnettua ja mahdolliset torjuntakeinot määrittelemättä. Epidemiologisilla tutkimuksilla voi olla merkittävä rooli tautiriskiin, tiettyihin oireisiin tai huonoon selviytymiseen liittyvien isäntään, taudinaiheuttajaan ja ympäristötekijöihin liittyvien tekijöiden tunnistamisessa. Tämä voi osoittautua hyödylliseksi ehkäisytoimenpiteitä ja jatkotutkimuksia suunnitellessa, sekä toimia uraauurtavasti uusien hoidon kohteiden tunnistamisessa. Eurooppalaisen Strep-EURO- verkoston perustaminen mahdollisti epidemiologisten tekijöiden tutkimuksen ympäri Eurooppaa. Euroopan komission tutkimusdirektoraatin (QLK2.CT.2002.01398) viidennen puiteohjelman rahoittama Strep-EURO -verkosto perustettiin syyskuussa 2002. Hankkeeseen osallistui kaksitoista osanottajaa yhdestätoista maasta ruotsalaisen Lundin yliopiston johdolla. Tapauksiksi määriteltiin potilaat, joilta oli viljelty S. pyogenes joko normaalisti steriilistä tai epästeriilistä kohteesta yhdistettynä toksisen shokin taudinkuvaan (STSS). Prospektiivisen tehoseurantatutkimuksen avulla etsittiin kaikista osallistujamaista 1. tammikuuta 2003 ja 31. joulukuuta 2004 välisenä aikana diagnostisoituja potilastapauksia. Luotiin standardisoidu seurantatietokanta, joka sisälsi kyselylomakkeen avulla kerättyjä demografisia, kliinisiä ja riskitekijätietoja. Kansalliset asiantuntijalaboratoriot keräsivät bakteerilöydökset, ja tutkivat niiden M proteiineja perinteistä serologista ja emm -geenityypitystä hyödyntämällä. Deskriktiivinen tilasto- ja monimuuttuja-analyysi suoritettiin eri maiden välillä tautitapauksiin liittyvien ominaisuuksien sekä suurentuneeseen kuolemanriskiin tai STSS:n kehittymiseen liittyvien riskitekijöiden tunnistamiseksi. Infektioiden esiintymisluvut laskettiin sekä suoraan että ikäryhmiin mukautettuna kullekin maalle, jonka kohdeväestö oli määriteltävissä. Tunnistamalla 5522 tapausta kahden vuoden aikana, hanke onnistui luomaan ensimmäisen eurooppalaisen vakavien S. pyogenes infektioiden seurantaverkoston. Yhdessätoista maasta kerättyä materiaalia analysoimalla saatiin uutta, tärkeää tietoa vakavien S.pyogenes infektioiden epidemiologiasta Euroopassa 2000-luvulla. Kattavaa epidemiologista tietoa näistä infektioista oli saatavilla ensimmäistä kertaa Ranskasta, Kreikasta ja Romaniasta. Tapausten esiintymistiheys viittasi korkeasta alhaiseen kulkevaan pohjois-etelä gradienttiin. Kolmen pohjoismaalaisen osallistujan välillä oli nähtävissä huomattavan yhdenmukaiset ikävakioidut arvot, noin 2,2 -2,3 tapausta 100 000 asukasta kohti. Ruiskuhuumeita käyttävien äkillisesti nousseesta lukumäärästä johtuen olivat kyseiset luvut Iso-Britaniassa vielä korkeampia, noin 2,9/100 000. Näistä Pohjois-Euroopan maista saadut luvut vastasivat suunnilleen USA:sta ja Australiasta samalla aikavälillä saatuja arvoja. Euroopan keski- ja eteläosan maissa (Tsekin tasavalta, Romania, Kypros ja Italia) havaittiin sen sijaan huomattavasti vähemmän tapauksia ja kyseiset luvut vaihtelivat 0,3:n ja 1,5:n tapauksen välillä 100 000 asukasta kohti. Tämän voidaan mitä todennäköisimmin katsoa heijastuvan mikrobiologisten diagnostisten menetelmien vähemmästä käytöstä kyseisissä maissa. Projektitulosten analysointi toi joitakin uusia näkökulmia vakavien S. pyogenes tautien riskitekijöistä. Etenkin Iso-Britanniassa ruiskuhuumeiden käyttö ja näiden potilaiden infektiot muokkasivat merkittävästi tautiepidemiologiaa tänä ajanjaksona. Tutkimus tuotti paljon uusia tuloksia, kuten vuodenaikavaihtelun samankaltaisuuden kaikissa maissa, ja vuodenajan vaikutuksen tapauskuolleisuuteen. Iäkkäät ja puolustusrajoitteiset potilaat sekä henkilöt, joille oli kehittynyt STSS tai joilla oli emm/M78, emm/M5, emm/M3 tai emm/M1 tauti, kuolivat todennäköisimmin infektion seurauksena, kun taas selluliittia, septistä artriittia, puerperaalista sepsistä tai yleisinfektiota (ei elinfokusta) sairastavien potilaiden keskuudessa kuolemanriski oli alhainen. Kuolleisuus oli alhaisempaa myös, jos infektio esiintyi lokakuussa. Iso-Britannian laajennetun tietokeräysmateriaalin analyysissa NSAID lääkkeiden käyttö assosioitui tilastollisesti merkitsevästi STSS:n kehittymiseen. Tämä löydös saattaa osaltaan kiihdyttää keskustelua, jota käydään NSAID lääkkeiden roolista vakavan taudin kehittymiseen. Koska vakavat S.pyogenes infektiot ovat pitkälti avohoitoperäisiä, ja ajallisesti ja maantieteellisesti harvakseltaan esiintyviä tauteja, ovat torjuntakeinot vähäiset. Ne rajoittuvat lähinnä lähikontaktien lääkeprofylaksiaan, jos todetaan tautirypäitä. Iso-Britannian Strep-EURO tuloksia käytettiin arvioimaan samassa taloudessa asuvien henkilöiden tautiriskiä; tämä loi pohjaa kansallisen hoito-ohjeen luonnille. Kehitteillä olevat rokotteet voisivat tulevaisuudessa tarjota tehokkaamman torjuntaohjelman. Vakavien S. pyogenes infektioiden seuranta on kansanterveydellisesti tärkeää nimenomaan pitkän ja lyhyen ajanjakson esiintyvyydessä tapahtuvien muutosten tunnistamiseksi, sekä kansanterveydellisten toimenpiteiden tarpeen ja vaikutusten arvioimiseksi. S. pyogenes, joka on muuntautumiskykyinen taudinaiheuttaja, osaa väestössä ja isännässä tapahtuvien muutosten myötä etsiä aika ajoin uusia taudinaiheuttamismuotoja. Tämän takia jatkuva seuranta on tärkeää.
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In an attempt to compare the epidemiology of severe Streptococcus pyogenes infection within Europe, prospective data were collected through the Strep-EURO program. Surveillance for severe cases of S. pyogenes infection diagnosed during 2003 and 2004 was undertaken in 11 countries across Europe by using a standardized case definition and questionnaire. Patient data as well as bacterial isolates were collected and characterized by T and M/emm typing, and selected strains were analyzed for the presence of superantigen genes. Data were analyzed to compare the clinical and microbiological patterns of the infections across the participating countries. A total of 4,353 isolates were collected from 5,521 cases with severe S. pyogenes infections who were identified. A wide diversity of M/emm types (n = 104) was found among the S. pyogenes clinical isolates, but the M/emm type distribution varied broadly between participating countries. The 10 most predominant M/emm types were M/emm type 1 (M/emm1), M/emm28, M/emm3, M/emm89, M/emm87, M/emm12, M/emm4, M/emm83, M/emm81, and M/emm5, in descending order. A correlation was found between some specific disease manifestations, the age of the patients, and the emm types. Although streptococcal toxic shock syndrome and necrotizing fasciitis were caused by a large number of types, they were particularly associated with M/emm1 and M/emm3. The emm types included in the 26-valent vaccine under development were generally well represented in the present material; 16 of the vaccine types accounted for 69% of isolates. The Strep-EURO collaborative program has contributed to enhancement of the knowledge of the spread of invasive disease caused by S. pyogenes within Europe and encourages future surveillance by the notification of cases and the characterization of strains, which are important for vaccination strategies and other health care issues.
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Vaccination with the 7-valent pneumococcal conjugate vaccine (PCV) has been recommended in France since 2003 for children under the age of two years who are at risk due to medical or living conditions. From 2006, the recommendation has been extended to all children under two years. The impact of PCV introduction on the incidence of pneumococcal meningitis and bacteraemia and on the serotype distribution in French children and other age-groups was assessed using laboratory surveillance data. The coverage with three doses of PCV was 44% in children aged 6-12 months in 2006. From 2001/2002 to 2006, the incidence of pneumococcal meningitis decreased from 8.0 to 6.0 cases per 100,000, and the incidence of pneumococcal bacteraemia decreased from 21.8 to 17.5 cases per 100,000 in children under the age of two years. For the vaccine strains, the incidence of pneumococcal meningitis and bacteraemia decreased from 20,4 to 6.0 cases per 100,000, while the incidence of pneumococcal meningitis and bacteraemia due to non-vaccine strains increased from 9.4 to 17.5 cases per 100,000 in this time period. The incidence in older children and adults did not decrease. Further expansion of PCV coverage is expected to increase the impact of the vaccination in both children and adults. However, the fact that cases caused by vaccine serotypes have been partially substituted by cases of non-vaccine serotypes is likely to reduce the overall benefit of PCV in France, should this early observation be confirmed in the future.
Objective To identify factors contributing to a cluster of deaths from invasive group A streptococcus (GAS) infection in a nursing home facility and to prevent additional cases. Design Outbreak investigation. Setting A 146-bed nursing home facility in northern Nevada. Methods We defined a case as the isolation of GAS from a normally sterile site in a resident of nursing home A. To identify case patients, we reviewed resident records from nursing home A, the local hospital, and the hospital laboratory. We obtained oropharyngeal and skin lesion swabs from staff and residents to assess GAS colonization and performed emm typing on available isolates. To identify potential risk factors for transmission, we performed a cohort study and investigated concurrent illness among residents and surveyed staff regarding infection control practices. Results Six residents met the case patient definition; 3 (50%) of them died. Among invasive GAS isolates available for analysis, 2 distinct strains were identified: emm11 (3 isolates) and emm89 (2 isolates). The rate of GAS carriage was 6% among residents and 4% among staff; carriage isolates were emm89 (8 isolates), emm11 (2 isolates), and emm1 (1 isolate). Concurrently, 35 (24%) of the residents developed a respiratory illness of unknown etiology; 41% of these persons died. Twenty-one (30%) of the surveyed employees did not always wash their hands before patient contacts, and 27 (38%) did not always wash their hands between patient contacts. Conclusions Concurrent respiratory illness likely contributed to an outbreak of invasive GAS infection from 2 strains in a highly susceptible population. This outbreak highlights the importance of appropriate infection control measures, including respiratory hygiene practices, in nursing home facilities.
GROUP A streptococcus (Streptococcus pyogenes) may cause a variety of illnesses ranging from very common, usually clinically mild conditions such as pharyngitis and impetigo to less common severe infections including septicemia and pneumonia. In 1987, Cone et al1 described two patients with severe group A streptococcal infections having clinical features similar to the staphylococcal toxic shock syndrome. This syndrome, designated the "streptococcal toxic shock—like syndrome" or the "toxic streptococcal syndrome,"2 was further characterized by Stevens et al3 in a series of 20 patients. Most patients included in this series were less than 50 years old and otherwise healthy. All had invasive group A streptococcal infections characterized by signs including shock, multi—organ system involvement, and rapidly progressive, destructive soft-tissue infection (necrotizing fasciitis). The case-fatality rate was 30% even though most patients received appropriate antimicrobial therapy, supportive care, and, where necessary, surgical débridement. Ten available isolates were serotyped and
Clin Microbiol Infect 2010; 16: 293–295 Four cases of Streptococcus pyogenes infection due to an emm-type 11 strain, including one with a fatal outcome, occurred within a seven-member family. All strains shared biotype 5, pyrogenic exotoxin genes speB and speC, and resistance to kanamycin, tetracycline, macrolides and lincosamides. The identity of SmaI pulsed-field gel electrophoresis patterns confirmed their clonal origin. This highlights the ability of S. pyogenes to spread rapidly among family members. This first report of a family outbreak due to emm11 S. pyogenes reinforces the importance of surveillance of close family contacts of individuals with invasive streptococcal disease, and provides further support for antibiotic prophylaxis among the elderly.
During the late 1990s, increases in referrals to the national reference laboratory of Streptococcus pyogenes isolates from injecting drug users (IDUs) with severe soft tissue infection indicated an emerging problem in the UK, later confirmed during the 2003-2004 European enhanced surveillance (Strep-EURO) programme. In light of these findings, further analyses were undertaken in an attempt to understand the reasons behind this increase in referrals. Single and multivariable analyses were undertaken to compare clinical, microbiological and demographic characteristics of IDUs diagnosed with severe S. pyogenes infection during the 2003-2004 enhanced surveillance study with those of other cases arising during this same period. Temporal and spatial analyses were undertaken for IDUs to identify clustering, as a means of understanding the transmission dynamics underpinning this increase. Infections in IDUs were spread across the UK, with some concentration in northern England and London. IDUs presented with a wide range of clinical manifestations, including pneumonia, which was found to be significantly more common in IDUs (OR 3.00) than in other cases. Marked differences in type distributions were found between IDUs and other cases, in particular the concentration of emm/M83 (22% of IDUs, 2% of non-IDUs). These findings indicate that an epidemic of severe S. pyogenes infections in IDUs occurred in the UK, peaking in 2003. The explanation for this rise remains unclear.