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. 2003;5(5):379–386. doi: 10.1007/s11908-003-0017-7

Group A streptococcal sepsis

Dennis L Stevens 1
PMCID: PMC7101722  PMID: 13678567

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.

Keywords: Clindamycin, Necrotizing Fasciitis, Streptococcal Infection, Scarlet Fever, Invasive Group

References and Recommended Reading

  • 1.The Working Group on Severe Streptococcal Infections Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition. JAMA. 1993;269:390–391. doi: 10.1001/jama.269.3.390. [DOI] [PubMed] [Google Scholar]
  • 2.Schwartz B, Facklam RR, Brieman RF. Changing epidemiology of group A streptococcal infection in the USA. Lancet. 1990;336:1167–1171. doi: 10.1016/0140-6736(90)92777-F. [DOI] [PubMed] [Google Scholar]
  • 3.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. doi: 10.1001/jama.277.1.38. [DOI] [PubMed] [Google Scholar]
  • 4.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. [PubMed]
  • 5.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. doi: 10.1093/infdis/173.4.901. [DOI] [PubMed] [Google Scholar]
  • 6.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. doi: 10.1086/513636. [DOI] [PubMed] [Google Scholar]
  • 7.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. doi: 10.1093/clinids/22.3.490. [DOI] [PubMed] [Google Scholar]
  • 8.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. doi: 10.1093/infdis/175.3.723. [DOI] [PubMed] [Google Scholar]
  • 9.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. doi: 10.1086/513636. [DOI] [PubMed] [Google Scholar]
  • 10.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. doi: 10.1093/clinids/22.3.490. [DOI] [PubMed] [Google Scholar]
  • 11.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. doi: 10.1001/archinte.152.5.1017. [DOI] [PubMed] [Google Scholar]
  • 12.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.
  • 13.Nosocomial group A streptococcal infections associated with asymptomatic health-care workers--Maryland and California, 1997. MMWR Morb Mortal Wkly Rep 1999, 48:163–166. [PubMed]
  • 14.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. doi: 10.1056/NEJM198907063210101. [DOI] [PubMed] [Google Scholar]
  • 15.Bisno AL, Stevens DL. Streptococcal infections in skin and soft tissues. N Engl J Med. 1996;334:240–245. doi: 10.1056/NEJM199601253340407. [DOI] [PubMed] [Google Scholar]
  • 16.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. doi: 10.1093/clind/16.6.792. [DOI] [PubMed] [Google Scholar]
  • 17.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. doi: 10.3109/00365549209054644. [DOI] [PubMed] [Google Scholar]
  • 18.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. doi: 10.1016/S0022-3476(85)80392-9. [DOI] [PubMed] [Google Scholar]
  • 19.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. doi: 10.1016/S0140-6736(80)91832-2. [DOI] [PubMed] [Google Scholar]
  • 20.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. doi: 10.1097/00006454-198509000-00010. [DOI] [PubMed] [Google Scholar]
  • 21.Adams EM, Gudmundsson S, Yocum DE, et al. Streptococcal myositis. Arch Intern Med. 1985;145:1020–1023. doi: 10.1001/archinte.145.6.1020. [DOI] [PubMed] [Google Scholar]
  • 22.Stevens DL. Invasive group A streptococcus infections. Clin Infect Dis. 1992;14:2–13. doi: 10.1093/clinids/14.1.2. [DOI] [PubMed] [Google Scholar]
  • 23.Martin PR, Hoiby EA. Streptococcal serogroup A epidemic in Norway 1987–1988. Scand J Infect Dis. 1990;22:421–429. doi: 10.3109/00365549009027073. [DOI] [PubMed] [Google Scholar]
  • 24.Kohler W. Streptococcal toxic shock syndrome. Zentralbl Bakteriol. 1990;272:257–264. doi: 10.1016/s0934-8840(11)80026-5. [DOI] [PubMed] [Google Scholar]
  • 25.Hribalova V. Streptococcus pyogenes and the toxic shock syndrome. Ann Intern Med. 1988;108:772–772. doi: 10.7326/0003-4819-108-5-772_2. [DOI] [PubMed] [Google Scholar]
  • 26.Gaworzewska ET, Coleman G. Correspondence: group A streptococcal infections and a toxic shock-like syndrome. N Engl J Med. 1989;321:1546–1546. [Google Scholar]
  • 27.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. doi: 10.1016/0002-9343(52)90293-3. [DOI] [PubMed] [Google Scholar]
  • 28.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. doi: 10.1093/infdis/158.1.23. [DOI] [PubMed] [Google Scholar]
  • 29.Stevens DL, Bryant AE, Yan S. Invasive group A streptococcal infection: new concepts in antibiotic treatment. Int J Antimicrob Agents. 1994;4:297–301. doi: 10.1016/0924-8579(94)90029-9. [DOI] [PubMed] [Google Scholar]
  • 30.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. doi: 10.1093/infdis/167.6.1401. [DOI] [PubMed] [Google Scholar]
  • 31.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. doi: 10.1111/j.1574-6968.1993.tb06341.x. [DOI] [PubMed] [Google Scholar]
  • 32.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. doi: 10.1093/infdis/170.3.609. [DOI] [PubMed] [Google Scholar]
  • 33.Stevens DL, Maier KA, Mitten JE. Effect of antibiotics on toxin production and viability of Clostridium perfringens. Antimicrob Agents Chemother. 1987;31:213–218. doi: 10.1128/aac.31.2.213. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.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. doi: 10.1172/JCI110152. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Stevens DL, Bryant AE, Hackett SP. Antibiotic effects on bacterial viability, toxin production, and host response. Clin Infect Dis. 1995;20:S154–S157. doi: 10.1093/clinids/20.supplement_2.s154. [DOI] [PubMed] [Google Scholar]
  • 36.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. doi: 10.1097/00006454-199912000-00014. [DOI] [PubMed] [Google Scholar]
  • 37.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. doi: 10.1128/aac.42.5.1266. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Cruz K, Hollenberg S. Update on septic shock: the latest approaches to treatment. J Crit Illn. 2003;18:162–168. [Google Scholar]
  • 39.Fisher CJ, Horowitz BZ, Albertson TE. Cardiorespiratory failure in toxic shock syndrome: effect of dobutamine. Crit Care Med. 1985;13:160–165. doi: 10.1097/00003246-198503000-00004. [DOI] [PubMed] [Google Scholar]
  • 40.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. doi: 10.1086/515199. [DOI] [PubMed] [Google Scholar]
  • 41.Barry W, Hudgins L, Donta S, Pesanti E. Intravenous immunoglobulin therapy for toxic shock syndrome. JAMA. 1992;267:3315–3316. doi: 10.1001/jama.267.24.3315. [DOI] [PubMed] [Google Scholar]
  • 42.Yong JM. Necrotising fasciitis. Lancet. 1994;343:1427–1427. doi: 10.1016/S0140-6736(94)92548-8. [DOI] [PubMed] [Google Scholar]
  • 43.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. doi: 10.1093/infdis/173.6.1399. [DOI] [PubMed] [Google Scholar]
  • 44.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. doi: 10.1016/S1201-9712(03)90038-5. [DOI] [PubMed] [Google Scholar]
  • 45.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. doi: 10.1093/infdis/173.3.619. [DOI] [PubMed] [Google Scholar]
  • 46.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. doi: 10.1093/clinids/15.2.277. [DOI] [PubMed] [Google Scholar]
  • 47.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. doi: 10.1016/S0196-0644(05)81129-1. [DOI] [PubMed] [Google Scholar]
  • 48.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. doi: 10.1093/infdis/138.3.287. [DOI] [PubMed] [Google Scholar]
  • 49.Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal infections in Ontario, Canada. N Engl J Med. 1996;335:547–554. doi: 10.1056/NEJM199608223350803. [DOI] [PubMed] [Google Scholar]
  • 50.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. [PubMed]
  • 51.Liu VC, Stevenson JG, Smith AL. Group A streptococcus mural endocarditis. Pediatr Infect Dis J. 1992;11:1060–1062. doi: 10.1097/00006454-199211120-00016. [DOI] [PubMed] [Google Scholar]
  • 52.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. doi: 10.1086/374800. [DOI] [PubMed] [Google Scholar]
  • 53.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. doi: 10.1086/314655. [DOI] [PubMed] [Google Scholar]

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