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April 2010
Patient Care and Science
EIN Update: Invasive Group A Streptococcal (GAS) Infections

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds the EIN. The reader assumes all risks in using this information. 

Two recent EIN discussions featured widespread comments from members in a number of states and a Canadian province about invasive streptococcal infections, including cases requiring hospitalization.

“Has anyone seen clusters of invasive group A streptococcal (GAS) infections recently?” an EIN member from Virginia asked. “We have had four severe cases in the last two weeks.” None of the patients were contacts with one another, and appropriate infection control measures were used. Two patents died in the emergency room, one with bacteremia and sepsis, the other with sepsis and a facial wound. “We have been in discussion with our local and state health departments about this,” the member wrote.

A respondent in South Carolina reported three cases of invasive GAS skin and soft tissue infections in the last month, including two involving toxic shock syndrome. “Fortunately, they have all done well,” the respondent noted. “Again, they were all from the community with no recent health care exposure. No common contacts.”

Members in New York, Michigan, and Tennessee shared reports of cases as well. A California respondent highlighted an excerpt from a recent editorial in The Journal of Infectious Diseases, which attributed the “resurgence of invasive disease by GAS” partly to “the emergence and global spread of a new strain of M-type 1 (M1) organisms over the past 20–30 years.” The editorial refers to an accompanying article.

The California member also shared a comment from a physician with the Centers for Disease Control and Prevention (CDC), who wrote that “clusters of severe GAS infections are often part of a community-wide temporal increase in cases, often related to influx of a strain to which the community at large does not have much immunity. They are rarely point source and, unfortunately, cannot be easily prevented.” Clusters may also occur “because of an increase in the underlying at risk population,” such as accompanying some virus outbreak, like influenza, the CDC physician added.

A 1997 article in the Journal of the American Medical Association may be relevant, according to an Illinois respondent. The article describes the migration of virulent GAS strains and dissemination through school-age children.

A Florida EIN member, meanwhile, asked if others were seeing a recent increase in hospitalizations related to invasive GAS infections. The question generated responses from 10 states and a Canadian province, including several reporting specific recent cases.

A respondent in Oregon noted three cases within the last six to eight weeks: a 17- year-old boy from a youth camp who started with untreated pharyngitis and progressed to bilateral pneumonia and empyemas, requiring two decortications and three weeks in the hospital; a severely handicapped 14-year-old boy with primary pneumonia, sepsis, respiratory failure, and prolonged assisted ventilation; and a 60-year-old man with mitral valve (MV) endocarditis.

“All survived but were critically ill,” the respondent wrote. “We usually get one or two cases a year like this, so I would consider this a bit of a ‘cluster.’ ”

Another member in Florida asked if any isolates from this cluster had been typed. “The apparent increase in occurrence of invasive GAS cases could be due to the introduction of a particularly virulent GAS strain—likely M1 or M3—into your community. Admittedly, this information won't have immediate clinical relevance to you, but it may confirm a true cluster and further alert local docs to be on the lookout for such cases.”

Several members reported invasive GAS disease from somewhat unusual sterile sites, including a case of jugular venous thrombosis combined with transverse sinus thrombosis, one case of mycotic aneurysm, and another of mitral valve endocarditis. There were also two cases of otomastoiditis and three cases of empyema reported.

The ability to search electronic medical records or discharge diagnostic codes to look for past trends in GAS disease over time may be useful, noted a respondent in Washington state who reported no suspected increases in GAS disease locally. 

An Illinois respondent also cited a recent report about transmission of GAS infection in the operating room setting presented at the Fifth Decennial International Conference on Healthcare-Associated Infections in March. Two surgeons became ill, one with pharyngitis and one with a severe and ultimately fatal case of fasciitis, after performing extensive debridement on a patient with severe necrotizing fasciitis caused by GAS.

“The latter case [was] related, apparently, to contamination of [the surgeon’s] socks in surgery,” the respondent wrote. The surgeon had athlete's foot, which may have served as a portal of entry for the infection, and he didn't change his socks after the surgery.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public-health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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