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Invasive Group A Strep Infections Are Increasing

February 20, 2023

Written by Gabby Leonard

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We have witnessed a seasonally uncharacteristic increase in invasive infections and scarlet fever due to group A strep (GAS). Early recognition and low threshold for antibiotics should be used to prevent severe disease.

Why does this matter?
GAS typically rises in the spring; however, data from September 2022 to January 2023 showed a significant rise in invasive infection due to GAS, with a case fatality rate of 8.2%. Pediatricians should be aware of this trend and have a lower threshold to prescribe antibiotics when patients present with GAS that may be masked by co-infection with viral URI.

Bicillin x1 or amoxicillin x10, pick your poison!
Theories around this wave of GAS leading to more invasive disease include genetic mutation of the M virulence protein, higher transmission, and more toxigenic strains. Authors also considered that the COVID-19 pandemic (with masking, social distancing, etc.) reduced overall rates of GAS exposure and infection at a younger age, as well as re-exposure, decreasing overall innate immunity in school age children.

Currently pediatric hospitals are seeing a rise in co-infections with viral URIs and concomitant GAS. Other patients at higher risk for invasive GAS infections include neonates, pregnant or postpartum women, and adults >75yo. UK Health & Security agency advises a lower threshold to prescribe antibiotics in patients presenting with GAS infection to prevent severe infection or scarlet fever.

Pleural empyema is now the most common complication of severe GAS infection. Pleural empyema was largely secondary to pneumococcus in the past but now is infrequent due to widespread pneumococcal vaccination. While invasive GAS cases are rising higher than anticipated, mortality has not changed yet.

Editor’s note: There has been some debate about the benefit vs harm of GAS treatment. At present, it’s probably best to err on the side of treatment. ~Clay Smith

Resurgence of group A streptococcal disease in children. BMJ. 2023 Jan 10;380:p43. doi: 10.1136/bmj.p43.

What are your thoughts?