A multicentre observational study of paediatric head and neck abscesses.

INTRODUCTION: In winter of 2022/3 paediatric ENT surgeons across the UK observed that the incidence of severe abscesses in the head and neck and associated complications was higher than seen in previous years. We aimed to collate and evaluate data from across the UK to establish if this was a true rise in cases, and to describe the factors associated. METHODS: A multicentre retrospective data collection was undertaken from 13 units across the UK. Patients admitted between September 2022-February 2023 with a head and neck abscess including sinogenic, otogenic, deep and superficial neck abscesses were included. Demographic, disease specific, management and outcome data were collected. Hospital episode statistic data were also requested and analysed to allow for comparison with previous 10 years of head and neck abscesses. RESULTS: 262 patients with abscesses of the head and neck were admitted during the study period, 100 between September and November and 163 between December and February. Mastoid abscesses were the most common abscess across both groups. The rate of group A streptococcus + culture results rose significantly from 12 % in autumn group to 30 % in winter (p = 0.02). The rate of intracranial complications rose from 10 % to 18 % (p = 0.11) and the rate of venous thrombosis rose over the same timeframe from 3 % to 14 % (p = 0.01). DISCUSSION: This study demonstrated a statistically significant rise in the rate of group A streptococcus associated abscesses when comparing Autumn and Winter 2022/2023. Over the same timeframe a statistically significant rise in the proportion of patients with venous thromboses associated with H&N abscesses was noted. Interestingly, despite perceived national consensus regarding a spike in abscess incidence, the number of abscesses seen in winter 2022/2023 was in keeping with expected rates of paediatric H&N abscesses, based on pre covid year-on-year rise in incidence.

Epidemiology of scarlet fever in Victoria, Australia, 2007-2017.

In the last 10-15 years, there has been a global resurgence of scarlet fever, an infection historically associated with significant morbidity and mortality. It is unknown whether scarlet fever incidence has increased in Australia. We aimed to examine the incidence, predictors and severity of scarlet fever in the state of Victoria, Australia from 2007 to 2017, analyzing scarlet fever emergency department (ED) presentations, hospitalizations and deaths. Of the 1 578 scarlet fever cases during the study period, most occurred in children aged <10 years (1 344, 85%), in males (882, 56%), and during winter and spring months (918, 57%). There were no deaths with scarlet fever, however, 374 cases (24%) were admitted to hospital. The annual incidence of scarlet fever was stable during the study period (mean, 2.5; range, 1.9-3.1 cases per 100 000). Annual incidence was highest in children aged <5 years (19.3 per 100 000), and was 21% higher in males than females, adjusting for age and year (incidence rate ratio, 1.21, 95%CI 1.09-1.34). Whilst scarlet fever ED presentations and hospitalizations were stable in Victoria from 2007 to 2017, the recent identification of a Streptococcus pyogenes variant in Australia associated with epidemic scarlet fever overseas highlights the risk of future outbreaks.

Streptococcus pyogenes flexor tenosynovitis.

We describe a case of Group A streptococcal infection originally presenting as flexor tenosynovitis. Group A Streptococcus outbreaks have been recently described in developed countries, which constitutes an epidemiological shift that hand surgeons should be aware of.

Housing Initiatives to Address Strep A Infections and Reduce RHD Risks in Remote Indigenous Communities in Australia.

Group A Streptococcus (Strep A) skin infections (impetigo) can contribute to the development of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This is of particular concern for Indigenous residents of remote communities, where rates of ARF and RHD are much higher than their urban and non-Indigenous counterparts. There are three main potential Strep A transmission pathways: skin to skin, surface to skin, and transmission through the air (via droplets or aerosols). Despite a lack of scientific certainty, the physical environment may be modified to prevent Strep A transmission through environmental health initiatives in the home, identifying a strong role for housing. This research sought to provide an outline of identified household-level environmental health initiatives to reduce or interrupt Strep A transmission along each of these pathways. The identified initiatives addressed the ability to wash bodies and clothes, to increase social distancing through improving the livability of yard spaces, and to increase ventilation in the home. To assist with future pilots and evaluation, an interactive costing tool was developed against each of these initiatives. If introduced and evaluated to be effective, the environmental health initiatives are likely to also interrupt other hygiene-related infections.

Treatment outcomes and their predictors in children hospitalized with varicella complicated by bacterial superinfections after pandemic of COVID-19 - a retrospective multicenter analysis of real-life data in Poland.

PURPOSE: The aim of this study was to analyze treatment outcomes and their predictors in children hospitalized due to varicella complicated by bacterial superinfections after pandemic of COVID-19. METHODS: This retrospective study analyzed data collected in a multicenter, nationwide, observational database dedicated for children aged 0-17 years hospitalized due to bacterial complications of varicella in 9 Polish tertiary healthcare inpatient centers. The primary endpoint of this study was the treatment outcome established after the end of hospital management assessed at a 4-point scale. The secondary endpoint was defined as the necessity of surgical intervention. RESULTS: There were 458 patients with a median age of 4 (IQR 2-6) years. After the completed treatment, 319 (69%) participants were found fully recovered; 132 (29%) had transient complications; 2 (0.5%) had persistent complications; and 1 child (0.5%) died. Multivariate analysis revealed that implementation of ibuprofen in pre-treatment management of a child with varicella was associated with a 4.07-fold (2.50-6.60) increase in risk of complications after the treatment and it was associated with 2.87 times (1.39-5.89) higher risk of surgical intervention necessity. For other pre-hospital interventions (implementation of acyclovir, antibiotics or antihistaminics) no significant impact was observed. GAS infection increased the necessity of surgical intervention by 7.51 (3.64-15.49) times. CONCLUSIONS: One-third of patients treated for bacterial complications of varicella have post-treatment complications, most of them transient. GAS infection increases the need for surgical intervention. The use of ibuprofen in the treatment of varicella significantly increases the risk of complications and the need for surgical intervention.

A severe case of reactive infectious mucocutaneous eruption associated with two possible triggers: Coronavirus and group A streptococcus.

Reactive infectious mucocutaneous eruption (RIME) is a newly defined condition characterized by mucocutaneous blistering secondary to upper respiratory infections and encompasses Mycoplasma pneumoniae-induced rash and mucositis, broadening the disease spectrum to include various infectious etiologies. We present a severe RIME case involving a 5-year-old female with concurrent coronavirus NL63 and group A streptococcus infections. Diagnosis complexity stemmed from overlapping clinical features with other severe mucocutaneous eruptions such as Stevens-Johnson syndrome/toxic epidermal necrolysis/drug-induced necrolysis. This case underscores the need for comprehensive infectious workup and emphasizes the clinical diagnostic spectrum of drug-induced and infection-induced desquamative skin and mucosal disease.

Second-line drug-resistant TB and associated risk factors in Karakalpakstan, Uzbekistan.

BACKGROUND: Drug-resistant TB (DR-TB) remains a major public health threat. In 2022, Uzbekistan reported 2,117 cases of DR-TB, with 69% tested for fluoroquinolone resistance. Limited information is available on the prevalence of resistance to bedaquiline, linezolid, and fluoroquinolone, which are key components of the all-oral treatment regimen for rifampicin-resistant TB in Uzbekistan. METHODS: A retrospective study was conducted using extensive programmatic data from 2019 to 2023 in Uzbekistan. We assessed second-line drug-resistant TB (SLDR-TB) rates using phenotypic drug susceptibility testing (pDST). Demographic and clinical characteristics associated with SLDR-TB were analysed using multivariable logistic regression models based on the Allen-Cady approach. RESULTS: In total, 2,405 patients with TB who had undergone pDST were included (median age 40 years, 47% female). The overall SLDR-TB resistance rate was 24% (95% CI 22-26). Prevalence of resistance to bedaquiline, linezolid, moxifloxacin, levofloxacin, and amikacin were respectively 3.1%, 0.8%, 15%, 13%, and 12%. Risk factors for SLDR-TB were resistance to rifampicin and/or isoniazid, exposure to clofazimine, retreatment status, contact with drug-susceptible TB case or DR-TB case, and diabetes. CONCLUSIONS: The high prevalence of SLDR-TB is of major concern, emphasising the need for baseline pDST in RR-TB treatment. Identified risk factors can aid early detection of at-risk individuals and inform clinical practice.

CONTEXTE: La TB résistante aux médicaments (DR-TB) reste une menace majeure pour la santé publique. En 2022, l'Ouzbékistan a signalé 2 117 cas de DR-TB, dont 69% ont été testés pour la résistance aux fluoroquinolones. Les informations sur la prévalence de la résistance à la bédaquiline, au linézolide et aux fluoroquinolones, qui sont des composants clés du traitement entièrement oral de la TB résistante à la rifampicine en Ouzbékistan, sont limitées. MÉTHODES: Une étude rétrospective a été menée en utilisant des données programmatiques exhaustives de 2019 à 2023 en Ouzbékistan. Nous avons évalué les taux de TB résistante aux médicaments de deuxième ligne (SLDR-TB, pour l'anglais, « second-line drug-resistant TB ¼) en utilisant des tests de sensibilité phénotypique aux médicaments (pDST). Les caractéristiques démographiques et cliniques associées à la SLDR-TB ont été analysées à l'aide de modèles de régression logistique multivariés basés sur l'approche Allen-Cady. RÉSULTATS: Au total, 2 405 patients atteints de TB ayant subi un pDST ont été inclus (âge médian de 40 ans, 47% de femmes). Le taux global de résistance à la SLDR-TB était de 24% (CI à 95% 22­26). La prévalence de la résistance à la bédaquiline, au linézolide, à la moxifloxacine, à la lévofloxacine et à l'amikacine était respectivement de 3,1%, 0,8%, 15%, 13% et 12%. Les facteurs de risque de SLDR-TB comprenaient la résistance à la rifampicine et/ou à l'isoniazide, l'exposition à la clofazimine, le statut de retraitement, le contact avec un cas de TB sensible aux médicaments ou de DR-TB, et le diabète. CONCLUSIONS: La prévalence élevée de la SLDR-TB est une source de préoccupation majeure, soulignant la nécessité de réaliser des pDST de base dans le traitement de la TB résistante à la rifampicine. Les facteurs de risque identifiés peuvent aider à la détection précoce des individus à risque et à informer la pratique clinique.

Post-pandemic increase in invasive group A strep infections in New Zealand.

BACKGROUND: Since October 2022, multiple high-income countries have reported an increase in invasive group A streptococcal (iGAS) infections. This study describes trends in iGAS infections in Aotearoa New Zealand (NZ) between 2017 and 2023, and examines associations of iGAS incidence, COVID-19 eras, and acute respiratory infections (ARI). METHODS: Analyses include national-level surveillance data on iGAS and ARI. Multivariable Poisson regression was used to examine relationships between COVID-19 era and iGAS incidence, and Pearson pairwise correlations were calculated to examine trends between ARI and iGAS. FINDINGS: A sharp increase in iGAS was observed in 2023, with notable increases among children aged under ten years. Indigenous Maori and Pacific peoples were disproportionately affected. emm1 and emm12 were commonly reported in 2022-2023. Compared to pre-pandemic, iGAS decreased significantly during the COVID-19 restrictions era and increased once COVID-19 restrictions were relaxed, after adjusting for ethnicity, sex, and age. ARI was moderately correlated with iGAS (r = 0∙55) in 2022-2023. INTERPRETATION: Though delayed, NZ's recent iGAS trends mirror those seen in the 2022/2023 multi-country iGAS surge. These findings expand existing research, suggesting a link between the easing of COVID-19 measures, increased ARI circulation, and the rise in iGAS. Continued and improved iGAS surveillance, is needed to better understand iGAS epidemiology and support public health response. iGAS in NZ will become notifiable in late 2024, which should help improve iGAS monitoring and support public health response. FUNDING: This research received no specific funding, though iGAS surveillance and typing in NZ is funded by the Ministry of Health, which was not involved in the analysis, interpretation, design, or any aspect of this study. No authors were paid to write this manuscript.

Group A Streptococcus infections in children and adolescents in the post-COVID-19 era: a regional Italian survey.

BACKGROUND: Despite the worldwide increasing incidence of Group A Streptococcus (GAS) infections reported since December 2022, data on noninvasive GAS (nGAS) infections in the post COVID-19 era are limited. By a self-reported survey performed in an outpatient setting, we investigated the number and clinical features of GAS infections, the diagnostic work-up and the type of treatment utilized. In addition, the rate of influenza vaccination was evaluated. METHODS: In June 2023 family pediatricians involved in the study sent the survey to parents of patients aged 0-16 years. The survey included questions on GAS infections that occurred from January 1 to May 31, 2023. RESULTS: Among 3580 children, 20.3% had a GAS infection (0,8% < 1 year, 16,4% 1-3 years, 42,3% 3-6 years, 26,5% 6-9 years, 11,4%, 9-12 years, and 2,6% 12-16 years). Symptoms reported were sore throat (76.9%), fever (75.2%), tonsillar exudate (25.2%), lymphadenopathy (21.8%), and scarlet fever (14.7%). A single patient was hospitalized due to GAS meningitis. Twenty four percent of children had more than one GAS infection. In this group, frequencies of symptoms reported in the first and in the following infection were similar, except for fever and scarlet fever which were less frequent during relapses. GAS was identified by rapid antigen detection test in 81.0% of children. Eighty-nine per cent of children were treated with antibiotics, mostly amoxicillin/clavulanate (40.4%) and amoxicillin (39.4%). Thirty four percent of children received influenza vaccine. No difference was observed among immunized and not immunized regarding the number and characteristics of GAS infection. CONCLUSIONS: We reported a certain prevalence of nGAS infections in children, mainly those aged 3-6 years age, who were mostly characterized by a low score of symptoms, and in most of the cases diagnosed and treated using a microbiological test as confirmatory tool. In this new clinical setting, a national study would be useful to reach more significant data for the definition of a correct diagnosis and clinical management of nGAS infections in children. Moreover, it is important to improve flu vaccination campaign and coverage to protect children from coinfections that could worsen the disease and misdiagnose the etiology of pharyngitis.

Double trouble: Necrotizing tonsillitis in the setting of streptococcus pyogenes superinfection in a patient with Epstein-Barr virus.

Tonsillitis, the inflammation of the palatine tonsils, is a common cause of throat pain. It is most often due to viruses but can also be related to bacteria. Necrotizing tonsillitis is a rare complication of acute tonsillitis with relatively few cases reported in the literature. We present a case of necrotizing tonsillitis in a patient with mononucleosis related to infection by Epstein-Barr virus, with superinfection with Streptococcus pyogenes, or group A streptococcus. To our knowledge, this is the first case of this nature to be reported in the medical literature. While the role of radiologic imaging is generally of limited diagnostic utility in cases of uncomplicated tonsillitis, its use was invaluable in ascertaining the nature and scope of necrotizing tonsillitis in this case. Further research remains to determine whether viral or bacterial superinfection can be used to further stratify patients who present with sore throat.

Ongoing Excess Hospitalizations for Severe Pediatric Group A Streptococcal Disease in 2023-2024-A Single-Center Report.

A Europe-wide outbreak of invasive pediatric group A streptococcal infections (iGAS) began in fall 2022. Here, we report the evolution of GAS hospitalizations in children and adolescents during the second outbreak year in 2023-2024 at a tertiary center in Switzerland. Using prospective monitoring of all in-patient GAS cases below 16 years of age, including those with iGAS, we compared case frequencies and clinical characteristics in three time periods (2013-2020; 2022-2023; 2023-2024). Annual GAS hospitalizations increased from a median of 25 cases (range 11-28) in 2013-2020 to 89 and 63 cases, respectively, in 2022-2023 and 2023-2024. iGAS cases evolved similarly (2013-2020, 4 cases (3-8); 2022-2023, 32 cases; 2023-2024, 21 cases). The decline in cases from 2022-2023 to 2023-2024 included all types of GAS organ involvement, except suppurative infections in the head area, which remained largely unchanged (48 vs. 45 cases). Pleural empyema declined from 13 to 7 cases, possibly explained by a poor overlap of the GAS and influenza curves, respectively, in 2023-2024 compared to 2022-2023. These data document the prolongation of the GAS outbreak into its second winter season in 2023-2024.

Isolation, Genomic Characterization and Evolution of Six Porcine Rotavirus A Strains in a Pig Farming Group.

Porcine rotavirus (PoRV) is a significant enteric pathogen causing gastroenteritis in piglets, which causes huge economic loss to the Chinese pig industry. In this study, six porcine rotavirus A strains were isolated from three adjacent sow farms belonging to the same company within one year, which suffered severe diarrhea outbreaks. AHBZ2303 (G11P[7]) and AHBZ2305 (G9P[23]), AHBZ2304 (G9P[23]) and AHBZ2312 (G4P[6]), AHBZ2310 (G9P[23]) and AHBZ2402 (G5P[23]) were isolated from Farm A, B and C, respectively. All six isolates were related to human rotavirus through complete genome analysis, suggesting the potential cross-species infection between humans and pigs. Evolutionary analysis revealed that AHBZ2303 and AHBZ2304 likely emerged simultaneously in Farm A and B, and then AHBZ2304 was introduced to Farm A and C, leading to the emergence of AHBZ2305 and AHBZ2310. Recombination and large variation were identified for AHBZ2312 and AHBZ2402. These findings provided insights into the transmission and evolution of PoRV among farms and underscored the need for enhanced monitoring to mitigate the risk of outbreaks from novel variants.

Passive Immunotherapy of Cynomolgus Monkeys with Anti-Rotavirus IgY.

Immunoglobulins Y (IgY) purified from egg yolks of hens represents an attractive, cost-effective alternative for the development of new diagnostic and therapeutic platforms. In this study, we evaluated the therapeutic efficacy of rotavirus-specific IgY in a cynomolgus monkey (Macaca fascicularis) model. Animals were experimentally infected with human rotavirus Group A (RVA), the most common cause of severe acute diarrhoea among young children worldwide. Animals were administered human RVA (3.1 × 107 FFU/mL) by oral gavage, challenged with 2.5 mg of anti-RVA IgY orally, and monitored for five days according to clinical, haematological and biochemical parameters; serum electrolyte levels; viral shedding; and histopathological changes. Immunotherapy with anti-RVA IgY had a protective effect against severe rotavirus-induced enteritis in four of the ten treated monkeys, as evidenced by histopathological findings. Although only one animal had diarrhoea, all but one exhibited virus shedding regardless of the treatment.

Bacterial Tracheitis: A New Presentation of a Well-Known Disease.

Bacterial tracheitis (BT) is an uncommon life-threatening condition that results in acute upper airway obstruction. Classical signs include a toxic appearance, stridor, tachypnoea, and fever, often leading to rapid clinical deterioration. Recent studies have shown a shift in BT epidemiology and presentation, where stridor and respiratory distress are now predominant. A poor response to corticosteroids or nebulized epinephrine is also commonly described, along with a need for mechanical ventilation. We present the case of a five-year-old boy admitted to the emergency department with cough, stridor, and dyspnea that had significantly worsened over the previous hours. He presented reasonable general condition, marked retractions, poor air entry, stridor, and wheezing. Investigation revealed a slight elevation of C-reactive protein and leukocytosis with neutrophilia. Anteroposterior x-ray showed narrowing of subglottic airways (steeple sign). There was no response to oral/nebulized corticoids, nebulized adrenaline, or bag-valve-mask oxygenation. Antibiotic therapy with ceftriaxone was initiated. Due to deteriorating clinical conditions with severe respiratory acidosis, orotracheal intubation was required. Later Streptococcus pyogenes was isolated in the bronchial secretions and a targeted antibiotic regimen was administered. Progressive clinical and analytical improvement was observed with no complications. Although uncommon, BT remains a severe infectious condition affecting otherwise healthy children. Our case underscores the severity of the disease and the imperative for invasive interventions to achieve favorable outcomes. It also supports recent findings indicating a shift in predominant symptoms and prognosis. Clinicians must be vigilant and knowledgeable, recognizing that worsening stridor and respiratory distress unresponsive to conservative treatment are key indicators for diagnosing BT.

Stratification of Group A Streptococcal Pharyngitis Children Using Unsupervised Learning.

Background and objectives Group A Streptococcus (GAS) is the most frequent cause of bacterial pharyngitis, and it is advised to selectively use rapid antigen detection testing (RADT). Currently, the decision to perform this test is based on pediatricians' observations, but the criteria are not well-defined. Therefore, we utilized unsupervised learning to categorize patients based on the clinical manifestations of GAS pharyngitis. Our goal was to pinpoint the clinical symptoms that should prompt further examination and treatment in patients diagnosed with pharyngitis. Methods We analyzed categorical data from 305 RADT-positive patients aged three to 15 years using the K-modes clustering method. Each explanatory variable's relationship with cluster variables was statistically examined. Finally, we tested the differences between clusters for continuous variables statistically. Results The K-modes method categorized the cases into two clusters. Cluster 1 included older children with lymph node tenderness, while Cluster 2 consisted of younger children with cough and rhinorrhea. Conclusion Differentiating streptococcal pharyngitis from common cold or upper respiratory tract infection based on clinical symptoms alone is challenging, particularly in young patients. Future research should focus on identifying indicators that can aid in suspecting streptococcal infection in young patients.

Case report: Abscesses in children caused by invasive group A Streptococcus.

Streptococcus is one of the common pathogens of suppurative infections. Invasive group A Streptococcus (iGAS) infections often develop from skin or soft tissue infections, and streptococcal toxic shock syndrome is considered the main cause of death in Chinese children with iGAS infectious disease. However, soft tissue infections caused by iGAS infections, especially the formation of abscesses, are relatively rare. A retrospective study was conducted, and pediatric in-patients who were diagnosed with an iGAS infection identified by cultures from normally sterile sites and treated in a tertiary hospital during 2016-2018 were included. A total of 14 patients were identified, which included 10 boys and four girls. The patients had an age range from 3 months to 10 years and were diagnosed with soft tissue infections and a formation of abscesses caused by iGAS infections. The most common sites of infections were the lower limbs. In five patients, the abscess was accompanied by fever, and the local soft tissue showed redness, swelling, tenderness, and an elevated skin temperature. Laboratory findings included an increased white blood cell (WBC) count in 12 patients, an increased C reactive protein (CRP) level in seven patients, and an increased erythrocyte sedimentation rate (ESR) in 10 patients. No patients had an elevated procalcitonin level. For all 14 patients, we performed puncture and drainage of abscesses, and cultured GAS from the drainage fluid. All children also received antibiotic treatment. During 2 months of follow-up, the patients' condition remained stable and no evidence of kidney or heart damage was observed. For pediatric patients with abscesses, early diagnosis, prompt treatment with incision and drainage, and immediate culture of the drainage fluid are important. Upon confirmation of an iGAS infection, ß-lactam antibiotics should be given to provide effective treatment, and in some patients with poor therapeutic outcomes, the use of vancomycin as an alternative can achieve the desired results.

The Emergence and Impact of the M1UK Lineage on Invasive Group A Streptococcus Disease in Aotearoa New Zealand.

M1UK is associated with current surges in invasive infection globally, partly due to increased production of superantigen streptococcal pyrogenic exotoxin A. We show that M1UK is now the dominant invasive emm1 lineage in Aotearoa New Zealand and is genomically related to community infections, suggesting that measures that effectively prevent group A Streptococcus pharyngitis in children could reduce invasive disease.

Amoxicillin vs. placebo to reduce symptoms in children with group A streptococcal pharyngitis: a randomized, multicenter, double-blind, non-inferiority trial.

The efficacy of antibiotic therapy for group A streptococcus (GAS) pharyngitis is debated. The role of antibiotics in preventing complications seems limited, with the main potential benefit being symptom duration reduction. Our study aimed to evaluate whether a placebo is non-inferior to amoxicillin in reducing fever duration. We randomized 88 children between 3 and 15 years of age presenting with acute symptoms of pharyngitis and a positive rapid antigen detection test for GAS to receive 6-day treatment with either placebo (n = 46) or amoxicillin (n = 42). The primary outcome was the difference in fever duration, with a non-inferiority threshold set at 12 h. The secondary outcomes included pain intensity and complications of streptococcal pharyngitis. The mean difference in fever duration between the amoxicillin and placebo groups was 2.0 h (95% CI, - 8.3 to 12.3) in the per-protocol analysis and 2.8 h (95% CI, - 6.5 to 12.2) in the intention-to-treat analysis. Treatment failure was observed in six participants in the placebo group and two in the amoxicillin group (relative risk, 2.15; 95% CI, 0.44-10.57). All patients were identified early and recovered well. There was no clinically relevant difference in pain intensity between groups over the 7 days following randomization, with the largest difference of 0.5 (95% CI, - 0.62-1.80) observed on day 3. CONCLUSION: Placebo appears to be non-inferior to amoxicillin in reducing fever duration. Pain intensity and risk of complications were similar between the two groups. These findings support the restrictive antibiotic treatment for streptococcal pharyngitis. WHAT IS KNOWN: • Group A streptococcus pharyngitis is a common reason for prescribing antibiotics in pediatric care. • In high-income countries, while antibiotic treatment has not been effective in preventing non-suppurative complications, the primary justification for their use remains the reduction of symptoms. WHAT IS NEW: • Our results suggest that antibiotics have a limited impact on the duration of fever and the intensity of pain in children with streptococcal pharyngitis. • Considering that suppurative complications can be promptly treated if they arise, we recommend a more judicious approach to antibiotic prescriptions. TRIAL REGISTRATION: The trial is registered at the US National Institutes of Health (ClinicalTrials.gov) # NCT03264911 on 15.08.2017.

A surge in the incidence of invasive Group A Streptococcus hand infections: a single Hand Unit experience.

We highlight an increase in the number of invasive Group A streptococcal soft tissue infections and present the impact of those on the hand surgery service, based on a single Hand Unit experience at the Pulvertaft Hand Centre.

Nationwide upsurge in invasive disease in the context of longitudinal surveillance of carriage and invasive Streptococcus pyogenes 2009-2023, the Netherlands: a molecular epidemiological study.

Since 2022, many countries have reported an upsurge in invasive group A streptococcal (iGAS) infections. We explored whether changes in Streptococcus pyogenes carriage rates or emergence of strains with potentially altered virulence, such as emm1 variants M1UK and M1DK, contributed to the 2022/2023 surge in the Netherlands. We determined emm (sub)type distribution for 2,698 invasive and 351 S. pyogenes carriage isolates collected between January 2009 and March 2023. Genetic evolution of emm1 was analyzed by whole-genome sequencing of 497 emm1 isolates. The nationwide iGAS upsurge coincided with a sharp increase of emm1.0 from 18% (18/100) of invasive isolates in Q1 2022 to 58% (388/670) in Q1 2023 (Fisher's exact test, P < 0.0001). M1UK became dominant among invasive emm1 isolates in 2016 and further expanded from 72% in Q1 2022 to 96% in Q1 2023. Phylogenetic comparison revealed evolution and clonal expansion of four new M1UK clades in 2022/2023. DNase Spd1 and superantigen SpeC were acquired in 9% (46/497) of emm1 isolates. S. pyogenes carriage rates and emm1 proportions in carriage isolates remained stable during this surge, and the expansion of M1UK in iGAS was not reflected in carriage isolates. During the 2022/2023 iGAS surge in the Netherlands, expansion of four new M1UK clades was observed among invasive isolates, but not carriage isolates, suggesting increased virulence and fitness of M1UK compared to contemporary M1 strains. The emergence of more virulent clades has important implications for public health strategies such as antibiotic prophylaxis for close contacts of iGAS patients.IMPORTANCEThis study describes the molecular epidemiology of invasive group A streptococcal (iGAS) infections in the Netherlands based on >3,000 Streptococcus pyogenes isolates from both asymptomatic carriers and iGAS patients collected before, during, and after the COVID-19 pandemic period (2009-2023) and is the first to assess whether changes in carriage rates or carried emm types contributed to the alarming post-COVID-19 upsurge in iGAS infections. We show that the 2022/2023 iGAS surge coincided with a sharp increase of emm1, particularly the toxicogenic M1UK variant, in invasive isolates, but not in carriage isolates. These findings suggest that increased virulence and fitness of M1UK likely contributes to an increased dissemination between hosts. The emergence of a more virulent and fit lineage has important implications for iGAS control interventions such as antibiotic prophylaxis for close contacts of iGAS patients and calls for a reappraisal of iGAS control interventions and guidelines.