Invasive Group A Streptococcal Infection in Children, Florida, 1996-2000 December 7, 2005.
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Transcript of Invasive Group A Streptococcal Infection in Children, Florida, 1996-2000 December 7, 2005.
Zuber D. Mulla, Ph.D.Division of Epidemiology
UT Health Science Center at HoustonAnd
Dept. of OB/GYNTexas Tech University School of Medicine
El Paso, Texas
Sabiha S. Khadim, M.D.University of Miami School of Medicine
Introduction
Group A Streptococcus (GAS) or Streptococcus pyogenes
Very important human pathogen
Impetigo, scarlet fever, puerperal fever, pharyngitis, erysipelas
Descriptive Epidemiology
663,000 new cases
163,000 deaths
Carapetis J et al., Lancet Infectious Diseases, November 2005
Descriptive Epidemiology
>10 million noninvasive infections a year in the U.S.
10,000 cases of invasive GAS disease (U.S. annual incidence = 3.7 per 100,000)
4 times that of meningococcal disease
Biology
Group A streptococci are gram-positive, non-spore forming, facultative anaerobic bacteria
Pairs and chains
Beta-hemolytic: complete lysis of red blood cells surrounding the colony
Necrotizing fasciitis
Deep-seated infection of subcutaneous tissue
Rapidly progressive
Described in 1924 by Meleney
Risk Factors for Invasive Disease
Chickenpox
Old age
Immunosuppression
Diabetes (peripheral vascular disease soft tissue necrosis)
Risk Factors for Invasive Disease
Chronic pulmonary & heart disease
NSAIDs (?)
Skin lesions
Blacks and Native Americans
Southern Medical Journal, August 2003
Zuber D. Mulla, Ph.D.
Paul E. Leaverton, Ph.D.
Steven T. Wiersma, M.D., M.P.H.
Study Question
What are the clinical and epidemiologic features of children hospitalized for IGASI in Florida during a four-year period?
Surveillance Case Definition
Isolation of GAS from normally sterile site (e.g., blood, cerebrospinal fluid, joint fluid, pleural fluid, or pericardial fluid), and a clinically-compatible presentation.
The definition of a clinically-compatible presentation is as follows: Pneumonia, bacteremia in association with cutaneous infection (e.g., cellulitis, erysipelas, or infection of a surgical or nonsurgical wound), deep soft-tissue infection (e.g., myositis), meningitis, peritonitis, osteomyelitis, septic arthritis, postpartum sepsis, neonatal sepsis, and nonfocal bacteremia.
Surveillance Case Definition
The original study also included cases of necrotizing fasciitis if GAS was isolated from a nonsterile site.
CDC’s ABCs Program
Cases
Hospitalized throughout Florida
Admitted between August 1996 and August 2000
25 children: 0 to 17 years of age
Data Analysis
Line listing
Frequency distributions
Crude pediatric IGASI hospital mortality compared to crude adult IGASI rate using Fisher’s exact test
Figure 1. Reported Incidence of Invasive Group A Streptoccal Infection by Age, Florida, USA, 1997-2000
0
0.3
0.6
0.9
1.2
1.5
1.8
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 >79
Age (years)
Inci
denc
e pe
r 100
,000
Age Number0 to 6 weeks 3
7 weeks to 51 weeks 31 year to 3 years 44 years to 9 years 9
10 years to 14 years 415 years to 17 years 2
TOTAL 25
Age Distribution, 25 cases
ID Yr Age Sex Race Clinical Presentation Under-lying
Condi-tion
Out-come
1 96 4 w F Asian Primary bacteremia None Lived
2 97 13 y M Black Primary bacteremia NA Lived
3 97 2 m F White Low appetite, secondary bacteremia
None Lived
4 98 2 y M NA Pneumonia, pleural effusion, secondary bacteremia, streptococcal toxic shock syndrome
None Lived
ID Yr Age Sex Race Clinical Presentation Under-lying
Condi-tion
Out-come
5 98 4 y F Black Impetigo, secondary bacteremia
None Lived
6 98 7 y M Black Cellulitis, necrotizing fasciitis
None Lived
7 98 9 y F White Meningitis None Lived
8 98 16 y
F Black Pharyngitis, secondary bacteremia
Cancer NA
9 98 3 y M Black Septic arthritis, cellulitis, secondary bacteremia
None Lived
ID Yr Age Sex Race Clinical Presentation Under-lying
Condi-tion
Out-come
10 99 4 y M White Pneumonia, secondary bacteremia
None Lived
11 99 1 y M White Otitis media, pharyngitis, pneumonia, secondary bacteremia
Asthma Lived
12 99 8 m M Black Meningoencephalitis, cellulitis, secondary bacteremia
Varicella Lived
13 99 4 y F White Necrotizing fasciitis Varicella Lived
ID Yr Age Sex Race Clinical Presentation Under-lying
Condi-tion
Out-come
14 99 6 y M White Pneumonia, pleural effusion
None Lived
15 99 17 y M White Necrotizing fasciitis, gangrene, cellulitis
NA Lived
16 99 12 y F White Myositis, cellulitis, secondary bacteremia
NA Lived
17 99 3 y M White Osteomyelitis, myositis, secondary bacteremia
None Lived
18 99 4 y M White Cellulitis, septic arthritis
None Lived
ID Yr Age Sex Race Clinical Presentation Under-lying
Condi-tion
Out-come
19 99 6 y F White Pharyngitis, secondary bacteremia
None Died
20 99 5 y F White Infection of nonsurgical wound site
Nonsurgical wound
Lived
21 99 3 w M Black Primary bacteremia None Lived
22 99 10 y M White Osteomyelitis, secondary bacteremia
None Lived
ID Yr Age Sex Race Clinical Presentation Under-lying
Condi-tion
Out-come
23 00 4 w M White Upper respiratory tract infection, secondary bacteremia
None NA
24 00 8 m F Black Pneumonia, secondary bacteremia
NA Lived
25 00 14 y
F Black Primary bacteremia Sickle cell disease
Lived
Crude hospital mortality
Children: 4.4% (1/23)
Adult: 19.5% (40/205)
P (Fisher’s exact two-tailed) = 0.09
Conclusions and Strengths
Low case-fatality rate in children, similar to other pediatric IGASI case series
Current series larger than 11 other previous pediatric case series
Strengths
Davies et al. reported on 24 children ranging in age from 0.03 to 17 years who presented to their institution with IGASI.
One of these patients met definition for probable streptococcal toxic shock syndrome.
None of these cases died and 79% had bacteremia.
Strengths
We report 1 case of streptococcal toxic shock syndrome (Case 4).
Overall, 1 of our 23 cases with a known mortality status expired in hospital.
Approximately 72% of our cases had bacteremia.
Strengths
Data on recent varicella infection was available for 21 of our 25 cases.
2 of the 21 patients (9.5%) had a recent history of varicella infection.
Result is similar to one reported by Factor et al. Population-based case-control study of risk factors for pediatric IGASI.
8% (3/38) of their cases had varicella-zoster infection.
Limitations
Retrospective, so no cultures to study the molecular epidemiology
M protein serotyping PFGE PCR for toxin encoding genes
Public Health Implications
1. Varicella vaccination. Florida: 2001 – 2002 school year
2. Add clindamycin to pen regimen to protect against mortality in pts with NF
Interaction between Clindamycin and NF (N=195)
NF Present?
Total N
Adjusted OR (95% CI )
Yes 33 0.11 (0.01-0.89)
No 162 1.01 (0.31-3.33)