Abstract
The fulminant nature of group A streptococcal sepsis poses impressive challenges from diagnostic and therapeutic perspectives. Most patients are seen early in the course of infection by primary care providers or emergency department physicians and sent home, only to return in 12 to 24 hours with fully developed group A streptococcal sepsis. Early diagnosis is imperative, but the clinician must have a high index of suspicion. Often, the diagnosis is established only after aggressive interventional management has begun. This review emphasizes salient clinical features and provides general recommendations for critical care management.
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References and Recommended Reading
The Working Group on Severe Streptococcal Infections: Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition. JAMA 1993, 269:390–391.
Schwartz B, Facklam RR, Brieman RF: Changing epidemiology of group A streptococcal infection in the USA. Lancet 1990, 336:1167–1171.
Cockerill FR, MacDonald KL, Thompson RL, et al.: An outbreak of invasive group A streptococcal disease associated with high carriage rates of the invasive clone among school-aged children. JAMA 1997, 277:38–43.
Outbreak of group A streptococcal pneumonia among Marine Corps recruits--California, November 1-December 20, 2002. MMWR Morb Mortal Wkly Rep 2003, 52:106–109.
Chaussee MS, Liu J, Stevens DL, Ferretti JJ: Genetic and phenotypic diversity among isolates of Streptococcus pyogenes from invasive infections. J Infect Dis 1996, 173:901–908.
Gamba MA, Martinelli M, Schaad HJ, et al.: Familial transmission of a serious disease-producing group A streptococcus clone: case reports and review. Clin Infect Dis 1997, 24:1118–1121.
Dipersio JR, File TM, Stevens DL, et al.: Spread of serious disease-producing M3 clones of group A streptococcus among family members and health care workers. Clin Infect Dis 1996, 22:490–495.
Ichiyama S, Nakashima K, Shimokata K, et al.: Transmission of Streptococcus pyogenes causing toxic shock-like syndrome among family members and confirmation by DNA macrorestriction analysis. J Infect Dis 1997, 175:7231–7236.
Gamba MA, Martinelli M, Schaad HJ, et al.: Familial transmission of a serious disease-producing group A streptococcus clone: case reports and review. Clin Infect Dis 1997, 24:1118–1121.
Dipersio JR, File TM, Stevens DL, et al.: Spread of serious disease-producing M3 clones of group A streptococcus among family members and health care workers. Clin Infect Dis 1996, 22:490–495.
Auerbach SB, Schwartz B, Williams D, et al.: Outbreak of invasive group A streptococcal infections in a nursing home. Lessons on prevention and control. Arch Intern Med 1992, 152:1017–1022.
Hohenboken JJ, Anderson F, Kaplan EL: Invasive group A streptococcal (GAS) serotype M-1 outbreak in a long-term care facility (LTCF) with mortality. In Program & Abstracts of the Interscience Conference on Antimicrobial Agents and Chemotherapy, Orlando, FL. 1994:Abstract J189.
Nosocomial group A streptococcal infections associated with asymptomatic health-care workers--Maryland and California, 1997. MMWR Morb Mortal Wkly Rep 1999, 48:163–166.
Stevens DL, Tanner MH, Winship J, et al.: Reappearance of scarlet fever toxin A among streptococci in the Rocky Mountain West: severe group A streptococcal infections associated with a toxic shock-like syndrome. N Eng J Med 1989, 321:1–7.
Bisno AL, Stevens DL: Streptococcal infections in skin and soft tissues. N Engl J Med 1996, 334:240–245.
Demers B, Simor AE, Vellend H, et al.: Severe invasive group A streptococcal infections in Ontario, Canada: 1987–1991. Clin Infect Dis 1993, 16:792–800.
Stegmayr B, Bjorck S, Holm S, et al.: Septic shock induced by group A streptococcal infections: clinical and therapeutic aspects. Scand J Infect Dis 1992, 24:589–597.
Kim KS, Kaplan EL: Association of penicillin tolerance with failure to eradicate group A streptococci from patients with pharyngitis. J Pediatr 1985, 107:681–684.
Gatanaduy AS, Kaplan EL, Huwe BB, et al.: Failure of penicillin to eradicate group A streptococci during an outbreak of pharyngitis. Lancet 1980, 2:498–502.
Brook I: Role of beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococci. Pediatr Infect Dis 1985, 4:491–495.
Adams EM, Gudmundsson S, Yocum DE, et al.: Streptococcal myositis. Arch Intern Med 1985, 145:1020–1023.
Stevens DL: Invasive group A streptococcus infections. Clin Infect Dis 1992, 14:2–13.
Martin PR, Hoiby EA: Streptococcal serogroup A epidemic in Norway 1987–1988. Scand J Infect Dis 1990, 22:421–429.
Kohler W: Streptococcal toxic shock syndrome. Zentralbl Bakteriol 1990, 272:257–264.
Hribalova V: Streptococcus pyogenes and the toxic shock syndrome. Ann Intern Med 1988, 108:772.
Gaworzewska ET, Coleman G: Correspondence: group A streptococcal infections and a toxic shock-like syndrome. N Engl J Med 1989, 321:1546.
Eagle H: Experimental approach to the problem of treatment failure with penicillin. I. Group A streptococcal infection in mice. Am J Med 1952, 13:389–399.
Stevens DL, Bryant-Gibbons AE, Bergstrom R, Winn V: The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis 1988, 158:23–28.
Stevens DL, Bryant AE, Yan S: Invasive group A streptococcal infection: new concepts in antibiotic treatment. Int J Antimicrob Agents 1994, 4:297–301.
Stevens DL, Yan S, Bryant AE: Penicillin binding protein expression at different growth stages determines penicillin efficacy in vitro and in vivo: an explanation for the inoculum effect. J Infect Dis 1993, 167:1401–1405.
Yan S, Mendelman PM, Stevens DL: The in vitro antibacterial activity of ceftriaxone against Streptococcus pyogenes is unrelated to penicillin-binding protein 4. FEMS Microbiol Lett 1993, 110:313–318.
Yan S, Bohach GA, Stevens DL: Persistent acylation of highmolecular weight penicillin binding proteins by penicillin induces the post antibiotic effect in Streptococcus pyogenes. J Infect Dis 1994, 170:609–614.
Stevens DL, Maier KA, Mitten JE: Effect of antibiotics on toxin production and viability of Clostridium perfringens. Antimicrob Agents Chemother 1987, 31:213–218.
Gemmell CG, Peterson PK, Schmeling D, et al.: Potentiation of opsonization and phagocytosis of Streptococcus pyogenes following growth in the presence of clindamycin. J Clin Invest 1981, 67:1249–1256.
Stevens DL, Bryant AE, Hackett SP: Antibiotic effects on bacterial viability, toxin production, and host response. Clin Infect Dis 1995, 20:S154-S157.
Zimbelman J, Palmer A, Todd J: Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr Infect Dis J 1999, 18:1096–1100.
Stevens DL, Madaras-Kelly KJ, Richards DM: In vitro antimicrobial effects of various combinations of penicillin and clindamycin against four strains of Streptococcus pyogenes. Antimicrob Agents Chemother 1998, 42:1266–1268.
Cruz K, Hollenberg S: Update on septic shock: the latest approaches to treatment. J Crit Illn 2003, 18:162–168. This is a current, concise review regarding the management of septic shock in patients in the intensive care unit.
Fisher CJ, Horowitz BZ, Albertson TE: Cardiorespiratory failure in toxic shock syndrome: effect of dobutamine. Crit Care Med 1985, 13:160–165.
Kaul R, McGeer A, Norrby-Teglund A, et al.: Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome--a comparative observational study. Clin Infect Dis 1999, 28:800–807.
Barry W, Hudgins L, Donta S, Pesanti E: Intravenous immunoglobulin therapy for toxic shock syndrome. JAMA 1992, 267:3315–3316.
Yong JM: Necrotising fasciitis. Lancet 1994, 343:1427.
Sriskandan S, Moyes D, Buttery LK, et al.: Streptococcal pyrogenic exotoxin A release, distribution, and role in a murine model of fasciitis and multiorgan failure due to Streptococcus pyogenes. J Infect Dis 1996, 173:1399–1407.
Miwa K, Fukuyama M, Ida N, et al.: Preparation of a superantigen-adsorbing device and its superantigen removal efficacies in vitro and in vivo. Int J Infect Dis 2003, 7:21–28. The authors of this paper developed a polystyrene-based device that absorbed more than 70% of staphylococcal and streptococcal superantigens from human plasma and reduced the available levels of TNF-_ and interleukin-8 from superantigen-stimulated whole blood. Extracorporeal blood purification through this device in superantigen-treated animals resulted in significant improvement in survival.
Stevens DL, Bryant AE, Hackett SP, et al.: Group A streptococcal bacteremia: the role of tumor necrosis factor in shock and organ failure. J Infect Dis 1996, 173:619–626.
Schwartz B, Elliot JA, Butler JC, et al.: Clusters of invasive group A streptococcal infections in family, hospital, and nursing home settings. Clin Infect Dis 1992, 15:277–284.
Valenzuela TD, Hooton TM, Kaplan EL, Schlievert PM: Transmission of ’toxic strep’ syndrome from an infected child to a firefighter during CPR. Ann Emerg Med 1991, 20:90–92.
Stamm WE, Feeley JC, Facklam RR: Wound infections due to group A streptococcus traced to a vaginal carrier. J Infect Dis 1978, 138:287–292.
Davies HD, McGeer A, Schwartz B, et al.: Invasive group A streptococcal infections in Ontario, Canada. N Engl J Med 1996, 335:547–554.
Prevention of invasive group A streptococcal diseases among household contacts of case-patients: is prophylaxis warranted? The Working Group on Prevention of Invasive Group A Streptococcal Infections. JAMA 1998, 279:1206–1210.
Liu VC, Stevenson JG, Smith AL: Group A streptococcus mural endocarditis. Pediatr Infect Dis J 1992, 11:1060–1062.
Batzloff MR, Hayman WA, Davies MR, et al.: Protection against group A streptococcus by immunization with J8-diphtheria toxoid: contribution of J8- and diphtheria toxoid-specific antibodies to protection. J Infect Dis 2003, 187:1598–1608. This paper represents a novel approach to vaccine development. A 12-amino acid peptide from the C-repeat (ie, conserved) region of M protein was conjugated to diphtheria toxin. Active immunization elicited opsonic antibody against several different M-types and was protective against challenge with an M-6 strain of GAS.
Guzman CA, Talay SR, Molinari G, et al.: Protective immune response against Streptococcus pyogenes in mice after intranasal vaccination with the fibronectin-binding protein SfbI. J Infect Dis 1999, 179:901–906.
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Stevens, D.L. Group A streptococcal sepsis. Curr Infect Dis Rep 5, 379–386 (2003). https://doi.org/10.1007/s11908-003-0017-7
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DOI: https://doi.org/10.1007/s11908-003-0017-7