Title : Invasive group A streptococcal infections in children: Current therapeutic challenges
Abstract:
Group A Streptococcus (GAS) is responsible for a broad spectrum of infections in children, ranging from common and usually self-limiting diseases to rapidly progressive and life-threatening invasive infections. Invasive GAS (iGAS) disease includes bacteremia, pneumonia, osteoarticular infections, deep soft-tissue infections, necrotizing fasciitis, sepsis, and streptococcal toxic shock syndrome (STSS). Since late 2022, a marked increase in pediatric iGAS infections has been reported across several European countries. Multiple factors may have contributed to this resurgence, including increased circulation of respiratory viruses following the COVID-19 pandemic, changes in population susceptibility and the emergence or expansion of particular GAS lineages. Viral infections, especially influenza and varicella, may facilitate invasive disease. Despite increasing clinical experience, several aspects of the management of pediatric iGAS remain supported by limited evidence.
iGAS may evolve rapidly, and early recognition of severe disease is critical. Clinical features suggesting a complicated course include hemodynamic instability, rapidly progressive soft-tissue infection, severe pain disproportionate to local findings, respiratory compromise, altered mental status, and evidence of multiorgan involvement. Microbiological confirmation should be actively pursued, but antimicrobial treatment should not be delayed in critically ill children. β-lactam antibiotics remain the mainstay of treatment because GAS remains predictably susceptible to penicillin. In severe invasive or toxin-mediated disease, an additional protein-synthesis inhibitor is recommended to reduce bacterial toxin production. Clindamycin has traditionally been used for this purpose, whereas linezolid represents an alternative in selected situations, particularly when clindamycin resistance is documented or suspected. Surgical evaluation and prompt source control are fundamental in necrotizing soft-tissue infection and other infections requiring drainage or debridement. Intravenous immunoglobulin may be considered in selected children with life-threatening toxin-mediated disease, especially STSS, although the quality of pediatric evidence remains limited. Evidence supporting corticosteroid treatment is currently insufficient. Management should also address the risk of secondary transmission. Close contacts should be assessed promptly, with chemoprophylaxis particularly indicated for individuals at increased risk of severe disease and considered more broadly in specific outbreak settings.
