Outcomes and management of pregnancy and puerperal group A streptococcal infections: A systematic review

Value of collaborative investigation by hospital infection control, public health services and a national reference laboratory during an increase in puerperal sepsis

BACKGROUND

In a Dutch tertiary care hospital, two cases of puerperal sepsis were diagnosed within 16 days in June-July 2022. The subsequent outbreak investigation emphasizes the value of collaboration between hospital infection control, regional public health services (PHS) and a national reference laboratory. The aim was to identify possible causes of this increase to prevent further cases of puerperal sepsis.

METHODS

Hospital infection control identified a group of puerperal sepsis cases clustered within the last year in the hospital, a cluster caused by S. pyogenes emm12.0. The hospital and PHS performed contact tracing of cases and HCW involved, investigating epidemiological links, and screening of HCW. The Netherlands Reference Laboratory for Bacterial Meningitis (NRLBM) identified additional regional cases. Subsequently, whole genome sequencing (WGS) analysis was performed on clinical, HCW and regional S. pyogenes isolates.

RESULTS

Four maternity ward patients were diagnosed with puerperal sepsis caused by S. pyogenes emm12.0 between April and November 2022. Although no additional epidemiological links were identified, all four cases resided within a 6.6 km radius. WGS analysis showed that the four cases were part of an 11-case cluster. Screening of HCW (n = 197) identified two individuals carrying clonally related S. pyogenes isolates.

CONCLUSIONS

Collaboration between hospital, PHS, and NRLBM resulted in an overview of possible epidemiological links. Centralized collection of iGAS case information and strain typing are critical to place hospital clusters in the context of local epidemiology. An increase in healthcare-associated infections may not necessarily imply in-hospital transmission.

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024: part 4-trauma, burn, obstetrics, acute pancreatitis/liver failure, and others

Disseminated intravascular coagulation (DIC) is a complex condition with diverse etiologies. While its association with sepsis has been widely studied, less focus has been given to DIC arising from other critical conditions, such as trauma, burns, acute pancreatitis, and obstetric complications. The 2024 Clinical Practice Guidelines, developed by the Japanese Society on Thrombosis and Hemostasis (JSTH), aim to fill this gap and offer comprehensive recommendations for managing DIC across various conditions. This study, Part 4 of the guideline series, addresses DIC management in trauma, burns, obstetric complications, acute pancreatitis/liver failure, viral infections, and autoimmune diseases. For trauma-associated DIC, early administration of fresh-frozen plasma (FFP), coagulation factor concentrates such as fibrinogen and prothrombin complex concentrates, and tranexamic acid is recommended. The guidelines also highlight DIC in obstetrics, which is associated with massive bleeding, and recommend the administration of fibrinogen concentrate, antithrombin concentrate, and tranexamic acid. Through a systematic review of the current evidence, the guidelines provide stratified recommendations aimed at improving clinical outcomes in DIC management beyond sepsis, thereby serving as a valuable resource for healthcare providers globally.

Antibiotic chemoprophylaxis for close contacts of invasive group A streptococcus in community settings: Evidence review

OBJECTIVES

Revised UK guidelines for the management of contacts of invasive group A Streptococcus (iGAS) infection in community settings were published in December 2022. We present the findings of a narrative review which informed the public health recommendations around the provision of antibiotic chemoprophylaxis detailed in the updated guidelines.

METHODS

We conducted a literature review of studies reporting the risk of iGAS infection associated with specific risk factors.

RESULTS

There was strong epidemiological evidence for an increased risk of iGAS infection in contacts who are older individuals, post-partum women, neonates and individuals with chickenpox infection; evidence on the impact of influenza co-infection, injecting drug use or being homeless in increasing risk of iGAS infection was less robust.

CONCLUSIONS

The guidelines made recommendations to offer chemoprophylaxis to close contacts of iGAS cases who are aged ≥75 years, pregnant ≥37 weeks gestation, post-partum, neonates or those with a recent history of, or current chickenpox infection. Systematic data collection evaluating the use of chemoprophylaxis and other control measures is recommended.

Japan Maternal Death Exploratory Committee. Proposals for improving maternal safety (2023 edition): Insights from the analysis of maternal deaths in Japan

The maternal mortality rate remains approximately 4 per 100 000 deliveries. Between January 2010 and July 2024, 629 maternal deaths were reported, of which 590 were reviewed. The Maternal Safety Proposal summarizes these cases. Deaths from obstetric hemorrhage decreased from 28% in 2010 to 7% in 2019 but rose to approximately 20% in 2022 and dropped to 10% in 2023. In the past 4 years, suicide has surpassed obstetric hemorrhage as a leading cause of death. In 2023, intracranial hemorrhage/infarction became the leading cause, with six cases reported. Cardiopulmonary collapse from amniotic fluid embolism, along with cardiovascular, infectious, and pulmonary diseases, has remained stable at 6%-10%. Initial symptoms leading to death occurred during the antepartum (38%), intrapartum (41%), or postpartum periods (21%), with cases distributed across general hospitals, small maternity delivery facilities, and non-medical settings, including homes. The following are the year's maternal safety proposals: For pregnant women experiencing anxiety, a comprehensive evaluation addressing biological, psychological, and social factors should be conducted to identify key problem areas. Epidural analgesia during labor carries the risk of serious complications. Obstetricians and anesthesiologists must be aware of these risks to ensure the proper management of anesthesia and delivery. Pregnant and postpartum women are at a high risk of invasive group A streptococcal infections, and early screening and timely intervention should be prioritized. Pathological autopsy remains the most effective method for determining the cause of death and should be recommended to bereaved families in all cases of maternal death.

Necrotizing Fasciitis of the Forearm in a 20-Week Pregnant Woman: Case Report and Literature Review

Background and Clinical Significance: Necrotizing fasciitis (NF) is a rare skin and soft tissue infection that progresses rapidly to necrosis and can be life-threatening. The incidence varies by geographic region but is generally low, with a mortality rate ranging between 11 and 22%. Early diagnosis and treatment are crucial for survival, particularly in patients with underlying conditions such as immune suppression, diabetes, obesity, trauma, recent surgical procedures, or renal pathology. However, the relationship between pregnancy and NF has not been extensively studied. Case Presentation: The case presented involves a 37-year-old, 20-week pregnant woman, who presented to the emergency department with septic shock and left forearm compartment syndrome. She reported no recent trauma or obvious source of contamination. The patient was immediately admitted and taken to the operating room. During admission, she underwent three surgeries, consisting of staged debridement, fasciectomy, and vacuum therapy and skin grafting. The patient was carefully monitored in the intensive care unit and multiple obstetrical consultations were performed to monitor the fetus. The patient was discharged with a fully integrated graft and with the donor area undergoing epithelialization. Conclusions: This case highlights the importance of early diagnosis and treatment of NF, particularly in high-risk patients, and the need for further research into the relationship between pregnancy and NF.

Streptococcal toxic shock syndrome in the immediate postpartum period

In the puerperal phase, streptococcal toxic shock syndrome is a relatively uncommon occurrence. However, there has been a rise in the prevalence of more aggressive strains of Group A Streptococcus (GAS), leading to significant maternal morbidity and mortality. In this report, we present a case of a postpartum patient who developed streptococcal toxic shock syndrome with substantial inflammation shortly after delivery. The patient presented on the second postpartum day with hypotension, high fever, hypogastric tenderness and anaemia. After timely workup and appropriate antibiotic therapy, the patient fully recovered. Culture studies confirmed Gram-positive septicaemia with the presence of Streptococcus pyogenes in both the patient's blood and a previously inserted intrauterine device (IUD). This case underscores the importance of maintaining a high index of suspicion for GAS as the cause of puerperal infections despite its rarity. This results in prompt administration of antibiotics and source control, preventing consequences and avoiding mortality.

SOMANZ position statement for the investigation and management of sepsis in pregnancy 2023

BACKGROUND

The Society of Australia and New Zealand (SOMANZ) published its first sepsis in pregnancy and the postpartum period guideline in 2017 (Aust N Z J Obstet Gynaecol, 57, 2017, 540). In the intervening 6 years, maternal mortality from sepsis has remained static.

AIMS

To update clinical practice with a review of the subsequent literature. In particular, to review the definition and screening tools for the diagnosis of sepsis.

MATERIALS AND METHODS

A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women analysed the clinical evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system following searches of Cochrane, Medline and EMBASE. Where there were conflicting views, the authors reviewed the topic and came to a consensus. All authors reviewed the final position statement.

RESULTS

This position statement has abandoned the use of the quick Sequential Organ Failure Assessment score (qSOFA) score to diagnose sepsis due to its poor performance in clinical practice. Whilst New Zealand has a national maternity observation chart, in Australia maternity early warning system charts and vital sign cut-offs differ between states. Rapid recognition, early antimicrobials and involvement of senior staff remain essential factors to improving outcomes.

CONCLUSION

Ongoing research is required to discover and validate tools to recognize and diagnose sepsis in pregnancy. Australia should follow New Zealand and have a single national maternity early warning system observation chart.

A Death From Necrotizing Wound Infection After Cesarean Section: Resurgence of Group A Streptococcal Puerperal Sepsis

ABSTRACT

Necrotizing wound infections are potentially lethal complications of surgeries, including cesarean deliveries. A 32-year-old female with obesity and hidradenitis suppurativa (HS) underwent uncomplicated cesarean section. Four days later, she developed abdominal pain and imaging showed ascites; she was treated with antibiotics. She progressed to septic shock and expired the following day from cardiopulmonary arrest. Hospital blood cultures grew no microorganisms. Autopsy revealed soft tissue purulence around the incision and copious purulent ascites without evidence of tubo-ovarian abscess, retained products of conception, or emboli. Microscopic examination of the tissues demonstrated inflammatory debris with neutrophils and gram-positive cocciform bacteria. Postmortem bacterial cultures had no growth. Paraffin blocks submitted to the Centers for Disease Control Infectious Disease Pathology Branch revealed Streptococcus pyogenes. Historically, group A streptococcus (GAS) was a major cause of peripartum mortality, and the prevalence of puerperal sepsis-associated deaths declined with antibiotic usage. Although the rates of mortality have remained stable in the United States, GAS has made a resurgence over recent decades. Additionally, there is some evidence in the literature of cutaneous bacterial biofilms associated with HS. Theoretically, this could have increased the risk of perioperative infection due to colonization or secondary infection of HS lesions.

Invasive group A Streptococcus infection (Streptococcus pyogenes): Current situation in Spain

Group A ß-hemolytic Streptococcus (S. pyogenes), also known as GAS, is a Gram-positive bacterium. It can be easily identified in the microbiology laboratory by its ability to hemolyse blood in culture media. This bacterium is highly virulent due to its production of enzymes and toxins, and its ability to cause immunologically mediated diseases such as rheumatic fever and post-streptococcal glomerulonephritis. GAS is the primary cause of bacterial pharyngotonsillitis, although it is typically a benign and non-invasive disease. However, it also has the potential to cause severe skin and soft tissue infections, necrotising fasciitis, bacteraemia and endocarditis, pneumonia and empyema, and streptococcal toxic shock syndrome, without any age or predisposition limits. The term invasive GAS disease (iGAS) is used to refer to this group of conditions. In more developed countries, iGAS disease has declined thanks to improved hygiene and the availability of antibiotics. For example, rheumatic fever has practically disappeared in countries such as Spain. However, recent data suggests a potential increase in some iGAS diseases, although the accuracy of this data is not consistent. Because of this, the COVID and Emerging Pathogens Committee of the Illustrious Official College of Physicians of Madrid (ICOMEM) has posed several questions about invasive GAS infection, especially its current situation in Spain. The committee has enlisted the help of several experts in the field to answer these questions. The following lines contain the answers that we have collaboratively produced, aiming to assist not only the members of ICOMEM but also anyone interested in this topic.

Infection route associated with invasive group A streptococcal toxic shock syndrome in maternal deaths: Nationwide analysis of maternal mortalities in Japan

OBJECTIVES

To clarify the infection route in maternal death due to invasive group A streptococcal (GAS) infection and toxic shock syndrome (TSS).

METHODS

A retrospective study was conducted on maternal deaths due to GAS-TSS in Japan between January 2010 and March 2024. The final causal diagnosis of maternal death and the infection routes of GAS were analysed using medical records, laboratory data and autopsy findings.

RESULTS

Among the 616 maternal deaths during the study period, 48 (8%) involved infectious diseases. The most common infection was invasive GAS (56%, n = 27), 21 (78%) and six cases occurred during the antepartum and puerperium periods, respectively. In the GAS-TSS group, 71% (15/21) infections were originated the upper respiratory tract. However, in the puerperium cases, 67% (4/6) were infected from the genital tract. In addition, no maternal deaths due to GAS-TSS were reported during the COVID-19 pandemic period in Japan from 2020 to 2023.

CONCLUSION

Most antepartum GAS infections were from the upper respiratory tract. They may be reduced by preventive measures, including frequent disinfection, wearing masks and isolation from persons at high risk of carrying GAS, such as symptomatic children. On the other hand, GAS-TSS during puerperium infection via the genital tract.

Perinatal group A streptococcal infection in vagina and its impact on pregnancy outcomes

OBJECTIVE

To investigate the prevalence, antimicrobial susceptibility, and the effects on pregnancy and neonatal outcomes of Group A Streptococcal (GAS) infections in the vagina of perinatal women.

METHODS

From June 2020 to October 2022, 270 perinatal pregnant women underwent vaginal swabs for GAS culture. The antibiotic sensitivity of the positive strains was assessed. Based on GAS detection results, the patients were divided into an observation group (GAS positive) and a control group (GAS negative). Clinical data from both groups were collected to compare the vaginal microecological changes. The adverse outcomes for pregnancy and infants in both groups were retrospectively analyzed. Univariate and multivariate analyses were used to identify the risk factors for adverse outcomes.

RESULTS

Among the 270 pregnant women, 30 tested positive for GAS and 240 tested negative, with a colonization rate of 11.1%. No resistance to penicillin, ampicillin, linezolid, vancomycin, or tigecycline was found among the GAS strains. The resistance rates to tetracycline and clindamycin were 73.3% and 70.0%, respectively. Higher vaginal pH (≥4.5), and increased incidences of bacterial vaginitis, aerobic vaginitis, and microecological imbalances were observed in the observation group compared to the control group (all P<0.05). The observation group also experienced more adverse pregnancy and infant outcomes, such as chorioamnionitis, postpartum infections, fetal distress, and neonatal pneumonia (all P<0.05). Univariate and multivariate analyses indicated that a vaginal pH≥4.5 and microecological imbalance were positively associated with poor maternal and infant outcomes in women with GAS infections (all P<0.05).

CONCLUSIONS

The study found no β-lactam resistant GAS strains. Additionally, a higher vaginal pH (≥4.5) and microecological imbalance were linked to an increased risk of adverse pregnancy and infant outcomes in women with GAS infections.

Group A Streptococcus Infection in Neonatal Population: A Systematic Review of The Literature

(1) Background: The importance of group A streptococcus (GAS) infection severity has been recognized in children and adults. However, to our knowledge, there have been no systematic reviews or pooled assessments of the incidence and outcome of invasive GAS (iGAS) disease in neonates, a potentially high-risk population. Therefore, we performed a systematic review of available data regarding the risk factors, clinical presentation, and outcome of GAS infection in neonates. (2) Methods: An electronic search of the existing literature was carried out during the period July 2023-September 2023 in the PubMed and Scopus databases, considering studies referring to GAS infection in the neonatal population. (3) Results: Overall, 39 studies met all the inclusion criteria and were included in this review, evaluating data from 194 neonates. Unfortunately, there were a lot of missing data among the retrieved studies. Our systematic review highlighted the presence of differences with regards to clinical presentation, infection sites, and outcome of GAS invasive disease between neonates with early-onset (EOS) or late-onset sepsis (LOS). Common characteristics of EOS included respiratory distress, rapid deterioration, and high mortality rate irrespective of the infection site, while rash, gastrointestinal tract symptoms, and fever appeared to be the most frequent symptoms/clinical signs and manifestations of LOS disease. The management of severe invasive iGAS disease consists mainly of specific antimicrobial treatment as well as supportive care with fluids and electrolyte supplementation, minimizing or counteracting the effects of toxins. Furthermore, a mortality rate of approximately 14% was recorded for iGAS disease in the total of all studies' neonates. (4) Conclusions: Although iGAS is a rare entity of neonatal infections, the potential severity of the disease and the rapid deterioration requires the development of quick analysis methods for the detection of GAS allowing the prompt diagnosis and administration of the indicated antibiotic treatment. Furthermore, given the exceptional risk for both the pregnant woman and the neonate, it is very important to raise awareness and create easily accessible guidelines that could facilitate the prevention and management of maternal as well as the subsequent neonatal severe iGAS disease.