Infections à Streptococcus pyogenes ou streptocoque du groupe A chez l’enfant : données du Centre national de référence (CNR)

National epidemiological study reveals longer paediatric bone and joint infection stays for infants and in general hospitals

AIM

Published studies have suggested that two to five days of intravenous treatment could effectively treat paediatric bone and joint infections (PBJI), allowing a faster discharge. This study analysed the factors associated with PBJI hospital stays lasting longer than five days using the French National Hospital Discharge Database.

METHODS

We selected children under 15 years hospitalised in 2013 with haematogenous PBJIs using a validated French algorithm based on specific diagnosis and surgical procedure codes. Risk factors for stays of more than five days were analysed using logistic regression.

RESULTS

In 2013, 2717 children were hospitalised for PBJI, with 49% staying more than five days. The overall incidence of 22 per 100 000, was highest in males and toddlers. The main causes were septic arthritis (50%) and osteomyelitis (46%) and 50% of the pathogens were Staphylococci. The odd ratios for stays of five days or more were infancy, coded bacteria and sickle cell disease (7.0), having spondylodiscitis rather than septic arthritis (2.2) and being hospitalised in a general hospital rather than a teaching hospital (1.6).

CONCLUSION

Half of the hospital stays exceeded five days, despite scientific evidence supporting a shorter intravenous antibiotherapy regimen. Greater knowledge and widespread use of short treatment regimens are needed.

When should clinicians suspect group A streptococcus empyema in children? A multicentre case-control study in French tertiary care centres

BACKGROUND

The incidence of invasive group A streptococcus (GAS) infections is increasing worldwide, whereas there has been a dramatic decrease in pneumococcal invasive diseases. Few data describing GAS pleural empyema in children are available.

OBJECTIVE

To describe the clinical and microbiological features, management and outcome of GAS pleural empyema in children and compare them with those of pneumococcal empyema.

DESIGN, SETTING AND PATIENTS

Fifty children admitted for GAS pleural empyema between January 2006 and May 2013 to 8 hospitals participating in a national pneumonia survey were included in a descriptive study and matched by age and centre with 50 children with pneumococcal empyema.

RESULTS

The median age of the children with GAS pleural empyema was 2 (range 0.1-7.6) years. Eighteen children (36%) had at least one risk factor for invasive GAS infection (corticosteroid use and/or current varicella). On admission, 37 patients (74%) had signs of circulatory failure, and 31 (62%) had a rash. GAS was isolated from 49/50 pleural fluid samples and from one blood culture. The commonest GAS genotype was emm1 (n=17/22). Two children died (4%). Children with GAS empyema presented more frequently with a rash (p<0.01), signs of circulatory failure (p=0.01) and respiratory disorders (p=0.02) and with low leucocyte levels (p=0.04) than children with pneumococcal empyema. Intensive care unit admissions (p<0.01), drainage procedures (p=0.04) and short-term complications (p=0.01) were also more frequent in patients with GAS empyema.

CONCLUSIONS

Pleural empyema following varicella or presenting with rash, signs of circulatory failure and leucopenia may be due to GAS. These features should prompt the addition to treatment of an antitoxin drug, such as clindamycin.

Comparative epidemiology of Streptococcus pyogenes emm-types causing invasive and noninvasive infections in French children by use of high-resolution melting-polymerase chain reaction

BACKGROUND

This study aims to analyze the epidemiology of Group A streptococci (GAS) emm-types causing invasive and noninvasive infections in French children.

METHODS

From September 2009 to May 2011, we analyzed GAS isolates from 585 pharyngitis, 125 invasive infections and, for the first time in France, 32 healthy carriers. M protein gene (emm) typing of the isolates was carried out by a new rapid technique, combining 3 multiplex-polymerase chain reactions (PCRs) coupled to high-resolution melting (HRM) curves, able to detect 13 major emm-types (emm 1, 3, 4, 6, 11, 12, 22, 28, 75, 77, 87, 89 and 102).

RESULTS

GAS belonging to emm-type 1 were more frequently found among invasive infections than among pharyngitis (24.0% vs. 11.5%, P < 0.001); emm 4 and 89 were more common in pharyngitis than in invasive infections (emm-type 4, 17.4% vs. 6.4%, P = 0.002 and emm-type 89, 9.9% vs. 2.4%, P = 0.006, respectively) and emm 3 and 4 were more common in cases of pharyngitis associated with scarlet fever (21.6% vs. 6.0%, P < 0.001 and 29.3% vs. 14.5%, P < 0.001, respectively).

CONCLUSION

HRM method enables the rapid emm-typing of a large number of isolates in epidemiological studies. Comparison of GAS causing invasive and noninvasive infections in the same population of children displays an unbalanced repartition of emm-types.

In Vitro Antibacterial Activity of Essential Oils against Streptococcus pyogenes

Streptococcus pyogenes plays an important role in the pathogenesis of tonsillitis. The present study was conducted to evaluate the in vitro antibacterial activities of 18 essential oils chemotypes from aromatic medicinal plants against S. pyogenes. Antibacterial activity of essential oils was investigated using disc diffusion method. Minimum Inhibitory Concentration of essential oils showing an important antibacterial activity was measured using broth dilution method. Out of 18 essential oils tested, 14 showed antibacterial activity against S. pyogenes. Among them Cinnamomum verum, Cymbopogon citratus, Thymus vulgaris CT thymol, Origanum compactum, and Satureja montana essential oils exhibited significant antibacterial activity. The in vitro results reported here suggest that, for patients suffering from bacterial throat infections, if aromatherapy is used, these essential oils, considered as potential antimicrobial agents, should be preferred.

Necrotizing upper limb fasciitis in a newborn: an uncommon life-threatening event

Necrotizing fasciitis is an uncommon but life-threatening infection in the pediatric population. It is rarely reported in neonates. In these rare cases, the reported origin of infection was the umbilical cord stump, infection due to circumcision, and similar lesions. We hereby report a 3-week-old neonate sustaining necrotizing fasciitis without detectable origin of infection. We describe the clinical course of her illness, the diagnostic process, and eventual surgical intervention. We discuss the importance of awareness to this potentially lethal infectious disease and the need for urgent use of certain imaging modalities and aggressive surgical approach.

Current insights in invasive group A streptococcal infections in pediatrics

A rising incidence of invasive group A Streptococcus infections (IGASI) has been noted in children in the past three decades. The relative frequency of the infection types showed marked differences to IGASI in adults, and severity of the disease resulted in a mortality rate usually comprising between 3.6% and 8.3%. The emm1-type group A Streptococcus (GAS) subclone displaying a particular pattern of virulence factors was widely disseminated and prevalent in children with IGASI while the emm3-type GAS subclone appeared as a recent emerging genotype. However, the implication of these hypervirulent clones in the increase of IGASI in children is still controversial. Recent advances in our knowledge on pathogenesis of IGASI underlined that deregulation of virulence factor production, individual susceptibility, as well as exuberant cytokine response are important factors that may account for the severity of the disease in children. Future changes in IGASI epidemiology are awaited from current prospects for a safe and effective vaccine against GAS. IGASI are complex infections associating septic, toxic, and immunological disorders. Treatment has to be effective on both the etiologic agent and its toxins, due to the severity of the disease associated to the spread of highly virulent bacterial clones. More generally, emergence of virulent clones responsible for septic and toxic disease is a matter of concern in pediatric infectiology in the absence of vaccination strategy.

Streptococcal pharyngitis: a prospective study of compliance and complications

Background. Uncertainty exists concerning the necessity of 10-day antibiotic treatment of group A beta hemolytic streptococcus (GABHS) pharyngitis. Objective. To assess the incidence of GABHS recurrence and suppurative and nonsuppurative complications in relation to compliance. Methods. (Design). Prospective cohort observational study. (Subjects). 2,000 children aged 6 months to 18 years with sore throat and positive GABHS culture. (Main Outcome Measures). Recurrence of symptomatic culture positive GABHS pharyngitis, incidence of suppurative, and long-term, regional, nonsuppurative complications of GABHS pharyngitis, over a ten year period. Results. 213 (11%) of the children received no treatment. Most children received antibiotics for only 4-6 days (in correlation with the duration of fever, which in most cases lasted up to 3 days). Three hundred and six (15.3%) children had clinically diagnosed recurrent tonsillopharyngitis; 236 (12.3%) had positive GABHS findings within 10 to 14 days and thirty-four (1.7%) within 21-30 days after the index positive GABHS culture. The remaining 1.3% had no positive culture despite the clinical findings. Almost all recurrences [236 (11.6%)] occurred within 14 days and 156 (7.6%) in the fully treated group. The presence of fever during the first 3 days of the disease was the most significant predictor for recurrence. Other predictors were the age younger than 6 years and the presence of cervical lymphadenitis. No increase in the incidence of nonsuppurative or suppurative complications was noted during the 10-year follow-up period, compared to the past incidence of those complications in Israel. Conclusions. Our data suggests that the majority of children discontinue antibiotics for GABHS tonsillopharyngitis a day or two after the fever subsides. The incidence of complications in our study was not affected by this poor compliance.

[Clustered cases of intrafamily invasive Streptococcus pyogenes infection (or group A streptococcus)]

Streptococcus pyogenes or group A streptococcus (GAS) is responsible for serious invasive infections with a risk of secondary infection in patients with more contact than in the general population. Regardless of clustering, few intrafamilial invasive infections have been reported despite a recent increase in the incidence of invasive GAS disease. We report the cases of two brothers, one a boy of 8.5 years with toxic shock syndrome with no bacteria identified and the second, 1 week later, his 14.5-year-old brother in hospital for sepsis due to GAS. The occurrence of a confirmed case of invasive GAS and a probable case within such a short period met the definition of clustered cases. Both brothers showed no risk factors for invasive disease and no gateway including skin was found. Antibiotic therapy was initiated in the family as recommended by the French Higher Council of Public Hygiene.