TABLE 1.
Characteristics of included studies
| Study, year | Collection dates | Study design | Study setting | Primary objective(s) | Secondary objective(s) |
|---|---|---|---|---|---|
| Acosta, 2014 | June 1, 2011–May 31, 2012 | Prospective Case–Control | Obstetrician‐led maternity units, UK | Estimate the incidence, describe the causative organisms and sources of infection, and identify the risk factors for severe maternal sepsis in the UK | None |
| Alberts, 2018 | 2010–2014 | Retrospective case series | Swedish insurance company reports of injury in connection with care database | Study reported obstetric care injuries related to bacterial pathogenesis | None |
| Alexander, 2018 | February 2015–March 2016 | Retrospective case series | Large academic medical center, US | Rule out potential transmission by a health care worker of GAS following a series of cases identified in postpartum women | None |
| Anteby, 1999 | June 1987–December 1994 | Retrospective case–control | University hospital, Jerusalem | Identify factors characteristic of non‐epidemic puerperal group A streptococcal infection. | None |
| Aronoff, 2008 | August 1996–August 2000 | Retrospective case series retrospective cohort | Hospitalizations, across the state of Florida | Report the detailed clinical and epidemiologic features of women hospitalized for postpartum invasive GAS disease in Florida during the 4‐year period of 1996–2000 | Secondary comparative analysis of a large Florida hospital discharge dataset obtained from the Florida Agency for Health Care Administration for women carrying the diagnosis of postpartum invasive GAS disease who were residents of Florida |
| Barnham, 2001 | 1980–1999 | Retrospective case series | Harrogate, York and Northallerton districts of North Yorkshire | To describe the features of invasive per‐partum Streptococcus pyogenes infection as it occurs in current day practice in North Yorkshire | None |
| Bauer, 2015 | 1999–2006 | Retrospective case series from cohort of maternal deaths | Various hospitals, Michigan | Identify maternal deaths due to sepsis in the state of Michigan from 1999 to 2006, review the events leading to diagnosis, and evaluate treatment to identify areas for improvement | None |
| Bengner, 2019 | 2018 | Retrospective case series | Various hospitals, Sweden | Describe two minor outbreaks of cot fever in various hospitals in Sweden, where investigation was able to detect infection from staff to patients. | None |
| Busowski, 2013 | Not reported | Retrospective case series | Single hospital, Orlando, Florida | Present recent, single institution experience with four GAS peripartum cases occurring over a 5‐year period | None |
| CDC, 1999 | July 1996–August 1997 | Retrospective case series | Single hospital, Maryland | Describe nosocomial outbreaks of GAS infection in Maryland during 1996–1997 | None |
| Chuang, 2002 | 1995–2002 | Retrospective cohort study | Various hospitals, USA | Quantify the burden of invasive postpartum GAS disease in a multistate population | None |
| Dan, 1990 | 1979–1986 | Retrospective case series | Two urban hospitals, Tel Aviv | Review our experience with the clinical spectrum produced by group A streptococcal bloodstream invasion and propose a practical classification of its various presentations | None |
| Daneman, 2005 | January 1, 1992–December 31, 2000 | Prospective, population‐based surveillance (Cohort) | All microbiology laboratories serving Ontario hospitals | Describe the epidemiology of hospital‐associated invasive GAS infections in Ontario and evaluate the risk of cross‐transmission in hospitals | None |
| Davis, 2010 | 1991–2009 | Prospective case–control | Two tertiary care centers in Salt Lake City, Utah | Investigate the association of innate immune response gene polymorphisms and puerperal group A streptococcal sepsis. | None |
| Denoude, 2005 | August 2, 2001–December 31, 2003 | Retrospective case series | Institute for Public Health Surveillance reporting across 18 establishments, France | Describe reported cases of nosocomial infections of invasive GAS | None |
| Deutscher, 2011 | 2007–2009 | Retrospective case–control | Population‐based multistate surveillance | Describe the burden and characteristics of infection in pregnant and postpartum women | To determine whether pregnant and postpartum women are at higher risk of pneumococcus, GAS and GBS infections and of complications from these infections, compared with nonpregnant women. |
| Dietz, 2003 | May–June 2002 | Retrospective case series | University Hospital, Belgium | Describe the course, diagnostics and treatment of a pseudo epidemic of puerperal GAS | Discuss measures to prevent epidemic and prevent further spread of infection |
| Eriksson, 2003 | November 1, 1996–October 31, 1997 | Prospective case–control | Laboratory‐based prospective surveillance of all public bacteriological laboratories in Sweden | Survey epidemiological and clinical characteristics of invasive GAS infections in Sweden during 1996–1997 | Study the spread of GAS clones among invasive and non‐invasive infections |
| Gordon, 1994 | Not reported | Retrospective case series | Maternity ward, UK | Report an outbreak of eight cases of GAS puerperal sepsis in which communal use of bidets during the postnatal period appears to have been responsible for the spread of infection. | None |
| Gustafson, 2017 | Retrospective case series | Denmark | To present the clinical differences in group A streptococcal infection | None | |
| Kaiser, 2018 | January 1991–September 2017 | Prospective case series | Registry from voluntary reporting by physician or microbial case log, Salt Lake City Region | Identify admission clinical and demographic characteristics associated with adverse outcomes including death, hysterectomy, ICU admission, mechanical ventilation and blood transfusion | Facilitate patient counseling, prognostication, and resource allocation |
| Knowles, 2015 | January 1, 2005–December 31, 2012 | Prospective cohort | Two tertiary referral maternity hospitals in Dublin, Ireland | Incidence, bacterial etiology, gestation/ stage at delivery, mode of delivery, antibiotic resistance, admission to augmented care, maternal, fetal and neonatal outcome | None |
| Lamagni, 2008 | January 1, 2003–December 31, 2004 | Prospective cohort | Strep‐EURO project: 11 participating European countries | Compare the epidemiological patterns of invasive S. pyogenes among the 11 participating countries in the Strep‐Euro project | None |
| LeBail, 2007 | January 1, 1997–December 31, 2005 | Prospective cohort | University hospitals, France | Incidence of postpartum infections with GAS in maternity hospitals | None |
| Leonard, 2019 | January 1, 2010–December 31, 2016 | Retrospective cross‐sectional | London and the South East of England | Describe postpartum invasive GAS infection including management of mothers and their neonates to determine whether public health guidelines have been followed | None |
| Lepoutre, 2011 | November 2006–November 2007 | Prospective cross‐sectional | Acute care hospitals (voluntary) across 22 administrative regions, France | Estimate the burden of invasive GAS infections with or without a positive blood culture, characterize the clinical presentations, assess predisposing factors and outcomes, describe the molecular characteristics and antibiotic susceptibility of GAS strains isolated from invasive infections and assess the level of implementation of the recommendations on antibiotic prophylaxis among household contacts. | None |
| Lev‐Sagie 2017 | February 2008–August 2010 | Prospective cohort | Tertiary care hospitals, Hadassah University, Israel | Evaluate the incidence of long‐term vaginal carriage of GAS among women with a prior infection | None |
| Luca‐Harari, 2008 | 2003–2004 | Prospective population‐based surveillance | Microbiology departments, Denmark | Understand the epidemiology of invasive GAS disease in Denmark | None |
| O'Loughlin, 2007 | January 1, 2000–December 31, 2004 | Population‐based surveillance | Centers for Disease Control and Preventions' Active Bacterial Cord surveillance, 10 US sites | Report the current epidemiologic characteristics of invasive GAS infections and estimate potential impact of a multivalent vaccine | None |
| Rottenstreich, 2019 | 2005–2017 | Retrospective cohort | University hospitals (2), Israel | Determine incidence, associated risk factors, clinical course and outcome of pregnancy‐related GAS infections | None |
| Safar, 2011 | January 1, 2005–December 31, 2006 | Prospective cohort | Auckland public hospital (metropolitan) surveillance data | Study the effects of invasive GAS on the Auckland population | Establish the direction of further investigations and focus interventions in New Zealand |
| Schuitemaker, 1998 | 1983–1992 | Retrospective case series | Maternal Mortality Committee, Central Bureau of Statistics and Dutch Perinatal Database systems | The effect of the changed epidemiology of GAS on maternal mortality was investigated | None |
| Shinar, 2016 | January 2008–May 2015 | Retrospective case series | Tertiary care center, Israel | Describe the epidemiologic and clinical characteristics of peripartum GAS infections in an attempt to develop better preventive strategies | None |
| Strobaek, 1991 | January 1, 1987 to December 31, 1989 | Retrospective cohort | 58 general hospitals in Denmark (of 99) and one hospital in Greenland | Determine whether the epidemic of GAS was reflected within the hospitals by nosocomial cases among hospitalized patients | None |
| Strus, 2010 | October 16–23, 2007 | Retrospective case series | Hospital of the Ministry of Internal Affairs and Administration in Krakow, Poland | To analyze the characteristics of the S. pyogenes strains involved in the outbreak in Krakow Poland, including the emm gene as well as genes coding for superantigens | Pulse field gel electrophoresis (PFGE) was used to determine the genetic relatedness among the isolates. The source of infection and probable routes of transmission of the outbreak strain were investigated using fluorescent in situ hybridization (FISH) as a rapid method for detecting S. pyogenes carriage |
| Tanaka, 2019 | January 2010–December 2016 | Retrospective case series | Japanese healthcare institutions | Provide an in‐depth analysis of the maternal death cases related to sepsis reported in Japan | None |
| Thewessen, 1999 | NR | Prospective case series | University hospital, Netherlands | Describe a cluster of patients with puerperal infection and report the epidemiological and microbiological investigation | None |
| Trell, 2020 | August–December, 2018 | Retrospective case series | Single hospital in Lund, Region Skaane, Sweden | Describe the use of whole genome sequencing to investigate an outbreak of postpartum S. pyogenes emm75 infections related to an asymptomatic carrier working in a maternity ward | None |
| Viglionese, 1991 | May 1987–April 1990 | Retrospective case series | Single center, Boston, Massachusetts | Report characteristics and typing of two clusters of group A streptococcal postpartum infections | None |
| Wahl, 2007 | 1996–2002 | Retrospective cohort | National Reference Center, Germany | Identify the predominant emm types among a large collection of S. pyogenes isolates from invasive infections | Define the incidence and demographical risk‐factors for acquisition of invasive S. pyogenes infection in Germany |
| Study, year | Inclusion criteria | Exclusion criteria | Comparison group | Total eligible patients | Total patients enrolled | Total GAS infection | Total patients included | Total controls (if applicable) |
|---|---|---|---|---|---|---|---|---|
| Acosta, 2014 | All peripartum women diagnosed with severe sepsis (including septic shock) | Incomplete data | Severe sepsis without septic shock | All women giving birth in the UK (no specific number) | 365 | 32 | 32 | 757 |
| Alberts, 2018 | Suspicion of obstetric infection or inter injury between 2010–2014 | None | None | 50 | 50 | 6 | 6 | 0 |
| Alexander, 2018 | Postpartum GAS | None | None | 5 | 5 | 5 | 5 | NA |
| Anteby, 1999 | Patients from OBGYN department diagnosed with intrapartum or puerperal group A streptococcal infection | None | General population of women giving birth during that time, extracted from computerized medical records | 25 822 | 3403 | 47 | 47 | |
| Aronoff, 2008 |
‐Hospitalized with invasive GAS disease and reported to the Florida Department of Health ‐Isolation of GAS from a normally sterile site and clinically compatible presentation ‐Endometritis/postpartum sepsis noted on epidemiology surveillance form and/or pregnancy/peripartum checked in risk factor portion of the form and infection within 42 days of delivery ‐Women carrying the diagnosis of postpartum invasive GAS disease who were residents of Florida |
None | None | 257 + 2643 | 257 + 2643 | 257 + 2643 | 7 | 0 |
| Barnham, 2001 | Mother and/or baby with detected S. pyogenes bacteremia | None | None | 11 000 | 9 | 9 | 5 | 0 |
| Bauer, 2015 | Maternal sepsis | None | None | 1 047 857 live births; 558 pregnancy‐associated deaths; 151 pregnancy‐related deaths | 22 | 4 | 4 | 0 |
| Bengner, 2019 | Invasive GAS infection in puerperium | None | None | 823 | 5 | 5 | 5 | 0 |
| Busowski, 2013 | Puerperal sepsis | None | None | 4 | 4 | 4 | 4 | 0 |
| CDC, 1999 | GAS isolated from nonpharyngeal site in patient whose symptoms began more than 12 hours after admission | None | Randomly selected patients on obstetric ward during study period | 12 | 12 | 12 | 9 | 5 |
| Chuang, 2002 | Isolation of GAS from a normally sterile site (eg blood or CSF) or from a wound tissue culture when accompanied by necrotizing fasciitis or TSS in a resident of a surveillance area who was pregnant or in the postpartum period (ie </= 30 days after delivery) or who had clinician‐defined puerperal fever, chorioamnionitis, or septic abortion. | Cases in which GAS was isolated from the amniotic fluid or the placenta alone. | None | 3957 | 87 | 87 | 87 | 0 |
| Dan, 1990 | Patients with GAS bacteremia | None | None | 36 | 33 | 33 | 5 | 0 |
| Daneman, 2005 | GAS isolated from sterile‐site specimen. Cases were identified as hospital‐acquired if disease was neither present nor incubating at the time of hospital admission. Specific definitions were given for surgical site and peripartum infections. | None | None | 2351 | 291 | 291 | 86 | 0 |
| Davis, 2010 | Cases demonstrated clinical evidence of endometritis and/or had febrile illness during the postpartum period. They also had at least one positive culture for group A streptococcus from a normally sterile body site. | Unable to contact or declined participation | Racially matched healthy women with a history of term, uncomplicated deliveries and no history of puerperal infection | 48 | 28 | 28 | 28 | 54 |
| Denoude, 2005 | Invasive infection of GAS in postoperative or postpartum patients | Community infections or infections outside of specific patient population | None | 32 | 29 | 29 | 18 | 0 |
| Deutscher, 2011 | Illness in a woman aged 15–44 years with streptococcus isolated from a normally sterile body site during 2007–2009. | None | Non‐pregnant women with GAS infection | 1848 | 1848 | 439 | 90 | 349 |
| Dietz, 2003 | Invasive infection of GAS in the puerperium | None | None | 5 | 5 | 5 | 5 | 0 |
| Eriksson, 2003 | Women with GAS isolated from a normally sterile site or from a superficial site in a patient who developed a necrotizing infection or STSS. Also included were women with clinical signs of endometritis postpartum and for whom GAS was isolated from the cervix. | None | The first five GAS isolates from throat and superficial skin infections from 3 laboratories during the first 7 months of surveillance | 255 | 255 | 255 | 20 | 144 |
| Gordon, 1994 | Mothers and infants with positive swabs for GAS whom were admitted or recently admitted to the maternity ward following the first identified case | None | None | 11 | 11 | 11 | 8 | 0 |
| Gustafson, 2017 | Postpartum GAS infection | None | None | 4 | 4 | 4 | 4 | 0 |
| Kaiser, 2018 | All patients with at least one positive culture for group A streptococci from a normally sterile body site (ie blood, urine, or endometrium) or non‐sterile body site (ie genital tract, wound) in addition to clinical suspicion for endometritis, defined as postpartum fever with no other alternative source identified | None | Women within the cohort were characterized into adverse and no adverse outcome groups* | 71 | 71 | 71 | 71 | 0 |
| Knowles, 2015 | All pregnant and postpartum women with sepsis | None | Patients without a diagnosis of sepsis | 136 897 | 276 | 12 | 12 | 136 625 |
| Lamagni, 2008 | Patients with S. pyogenes isolated from a normally sterile site or a nonsterile site in combination with clinical signs of STSS | None | None | 5522 | 3894 | 3894 | 107 | 0 |
| LeBail, 2007 | Women presenting with signs of clinical infection and GAS positive culture in the puerperium | None | None | 31 | 17 | 17 | 17 | 0 |
| Leonard, 2019 | All mothers or newborns with confirmed invasive GAS with onset within 28 days of birth, defined as either (1) isolated from a sterile site or (2) isolated from a normally nonsterile site but accompanied by a severe clinical presentation | None | None | 3 216 238 (1 598 069 live maternities) | 155 | 155 | 134 | 0 |
| Lepoutre, 2011 | Isolation of bacterium from a usually sterile site or from samples obtained from deep‐body‐site aspirates, intraoperative specimens, or a nonsterile site in association with one of the following clinical conditions: necrotizing fasciitis, clinically ascertained pneumonia, endometritis, salpingitis. or TSS not attributable to any other cause and defined according to the US Working Group on Severe Streptococcal Infections definitions. | None | None | 664 | 664 | 664 | 32 | 0 |
| Lev‐Sagie 2017 | Woman with prior vaginal GAS infection | None | Women admitted for labor without previous GAS infection, participating in a cross‐sectional study for the detection of vaginal group B streptococcus and GAS | 45 | 25 | 25 | 11 | 436 |
| Luca‐Harari, 2008 | All GAS isolation from blood or another normally sterile site of from non‐sterile sites with evidence of sepsis or sTSS recovered from hospitalized patients | None | None | 278 | 253 | 253 | 12 | 0 |
| O'Loughlin, 2007 | Isolation of GAS from a normally sterile site or from a wound specimen obtained from a surveillance area resident with necrotizing fasciitis or sTSS | None | Non | 5400 | 5400 | 5400 | 57 | 0 |
| Rottenstreich, 2019 | All symptomatic cases of culture‐proven pregnancy‐ related GAS infection | Asymptomatic patients or those with GAS positive cultures from the throat only | All other deliveries | 140 429 | 124 | 124 | 124 | 140 314 |
| Safar, 2011 | Patients with invasive GAS (isolate cultured from a previously sterile body cavity) residing in metropolitan Auckland | Women from whom GAS was isolated from amniotic fluid or placenta alone were excluded. Isolation of GAS from nonsterile site. Residence outside of metropolitan Auckland at the time of diagnosis. | None | 343 | 225 | 225 | 7 | 0 |
| Schuitemaker, 1998 | All cases of maternal death between 1983 and 1992 attributed to genital tract sepsis | None | None | 10 | 10 | 7 | 7 | 0 |
| Shinar, 2016 | All women with peripartum fever or marked abdominal tenderness and positive GAS cultures | None | None | 37 | 37 | 37 | 37 | 0 |
| Strobaek, 1991 | Patients with GAS bacteremia | No information from hospitals or when samples could not be traced back to patients. | None | 240 | 240 | 240 | 5 | 0 |
| Strus, 2010 | Patients with symptoms of suspected invasive GAS infection | None | Surgical procedures performed in same operating room period | 6 | 6 | 6 | 4 | 48 (10 CS, 38 other procedures) |
| Tanaka, 2019 | All cases of maternal death related to sepsis reported to the Japan Association of Obstetricians and Gynecologists | None | Maternal deaths related to infection from organisms other than GAS | 317 | 24 | 13 | 13 | 11 |
| Thewessen, 1999 | Women presenting with signs of clinical infection and GAS positive culture in the puerperium | None | None | 6 | 6 | 6 | 6 | 0 |
| Trell, 2020 | Women with signs and symptoms of postpartum infection in same maternity ward in southern Sweden | None | None | 6 | 6 | 6 | 6 | 0 |
| Viglionese, 1991 | Postpartum fever with positive GAS culture | None | Vaginal deliveries by physician at hospital | 9792 | 14 | 14 | 14 | 776 |
| Wahl, 2007 | Invasive GAS: isolation of S. pyogenes from either a normally sterile sample or from samples obtained from deep body site aspirates or intraoperatively. | Clinical data not available | None | 475 | 165 | 165 | 9 | 0 |