Assessing the influence of the COVID-19 pandemic on the incidence, clinical presentation, and clindamycin resistance rates of Streptococcus pyogenes infections.

Objectives: Streptococcus pyogenes (group A Streptococcus [GAS]) is a prevalent cause of community-acquired bacterial infections, with invasive GAS (iGAS) infections presenting severe morbimortality. Clindamycin is generally used based on its antitoxin effect. This study investigates changes in iGAS incidence, clinical presentation, outcomes, and clindamycin resistance in an adult cohort. Methods: This is a retrospective analysis of S. pyogenes episodes from a tertiary adult hospital in Barcelona (Spain) between 2015 and 2023. The pre-pandemic period includes data from 2015-2019. The pandemic period, from 2020-2021, and post-pandemic period comprised 2022 to the first semester of 2023. Results: The global incidence of GAS infections in the pre-pandemic and post-pandemic periods were 2.62 and 2.92 cases per 10.000 hospital admissions, whereas for iGAS cases, they were 1.85 and 2.34. However, a transient decrease was observed during the pandemic period: 1.07 and 0.78 per 10.000 hospital admissions. There was a significant decrease in GAS and iGAS infections during the pandemic period compared with the pre-pandemic incidence (P <0.001 for GAS infections and P = 0.001 for iGAS cases) and the post-pandemic incidence (P = 0.032 for GAS infections and P = 0.037 for iGAS cases). The most common source of infection was skin and soft tissue infections with 264 (54%) cases. Skin and soft tissue infections and cases of necrotizing fasciitis increased during the pandemic. Clindamycin resistance occurred in 13.5% of isolations during the pre-pandemic and 17.5% in post-pandemic period (P = 0.05). Conclusions: Our study revealed a temporary reduction in iGAS infections, followed by resurgence in the post-pandemic period. The observed rise in clindamycin resistance emphasizes the importance of monitoring local resistance patterns for tailored treatment.

Biological Effects of Corticosteroids on Pneumococcal Pneumonia in Mice and Humans.

Background: Streptococcus pneumoniae is the most common bacterial cause of community acquired pneumonia and the acute respiratory distress syndrome (ARDS). Some clinical trials have demonstrated a beneficial effect of corticosteroid therapy in community acquired pneumonia, COVID-19, and ARDS, but the mechanisms of this benefit remain unclear. The objective of this study was to investigate the effects of corticosteroids on the pulmonary biology of pneumococcal pneumonia in an observational cohort of mechanically ventilated patients and in a mouse model of bacterial pneumonia with Streptococcus pneumoniae. Methods: We studied gene expression with lower respiratory tract transcriptomes from a cohort of mechanically ventilated patients and in mice. We also carried out comprehensive physiologic, biochemical, and histological analyses in mice to identify the mechanisms of lung injury in Streptococcus pneumoniae with and without adjunctive steroid therapy. Results: Transcriptomic analysis identified pleiotropic effects of steroid therapy on the lower respiratory tract in critically ill patients with pneumococcal pneumonia, findings that were reproducible in mice. In mice with pneumonia, dexamethasone in combination with ceftriaxone reduced (1) pulmonary edema formation, (2) alveolar protein permeability, (3) proinflammatory cytokine release, (4) histopathologic lung injury score, and (5) hypoxemia but did not increase bacterial burden. Conclusions: The gene expression studies in patients and in the mice support the clinical relevance of the mouse studies, which replicate several features of pneumococcal pneumonia and steroid therapy in humans. In combination with appropriate antibiotic therapy in mice, treatment of pneumococcal pneumonia with steroid therapy reduced hypoxemia, pulmonary edema, lung permeability, and histologic criteria of lung injury, and also altered inflammatory responses at the protein and gene expression level. The results from these studies provide evidence for the mechanisms that may explain the beneficial effects of glucocorticoid therapy in patients with community acquired pneumonia from Streptococcus Pneumoniae.

Baseline characteristics of children in the International PANS Registry (IPR) Epidemiology Study.

PURPOSE: The International PANS Registry (IPR) Epidemiology Study is a registry-based, longitudinal study. We designed this study to improve phenotyping and characterisation of children with paediatric acute-onset neuropsychiatric syndrome (PANS) and PANS-like features and facilitate multidisciplinary and translational health research. This cohort provides new opportunities to address unresolved research questions related to the broad spectrum of heterogenous PANS-like conditions. PARTICIPANTS: Inclusion in the IPR Epidemiology Study remains open indefinitely via IPR enrolment online. Participants include children with PANS or who have PANS-like features and their healthy siblings. We collected cross-sectional survey data based on parent report, including details on phenotypic traits and characteristics that, to our knowledge, have not been previously collected for this patient population. We describe the baseline characteristics of cases and their healthy siblings here. FINDINGS TO DATE: The IPR Epidemiology Study currently includes 1781 individuals (1179 cases, 602 siblings; from 1010 households). Many households include a sibling (n=390, 39%) and some include multiple cases (n=205, 20%). Mean enrolment age was 11.3±4.3 years for cases and 10.1±5.3 for siblings. Leading PANS-like features include anxiety (94%), emotional lability (92%) and obsessions (90%). Onsets were sudden and dramatic (27%), gradual with a subsequent sudden and dramatic episode (68%) or a gradual progression (5%). The mean age at early signs/symptom onset was 4 years and 7 years at sudden and dramatic increases, respectively. Infection/illness was the most common suspected symptom trigger (84%). Nearly all cases had been treated with antibiotics (88%) and/or non-steroidal anti-inflammatory drugs (79%). Parents reported immune-related conditions in cases (18%) and their nuclear, biological family (48%; 39% in biological mothers). FUTURE PLANS: Future plans include increasing sample size, collecting longitudinal survey data, recruiting appropriate study controls and expanding the scope of the database, prioritising medical record data integration and creating a linked biorepository. Secondary data analyses will prioritise identifying subgroups by phenotypic traits, maternal health and disease characteristics.

Sensory processing in children with Paediatric Acute-onset Neuropsychiatric Syndrome.

INTRODUCTION: Previous research indicates that children with Paediatric Acute-onset Neuropsychiatric Syndrome (PANS) experience sensory reactivity differences that impact occupational performance. The purpose of this study was to determine whether there are differences in sensory reactivity in these children across two different time points; during exacerbation and during remission, using the Sensory Processing Measure (SPM) Home-Form. The study also sought to investigate whether children with PANS experience sensory differences during remission periods, when compared with SPM Home-Form norms. METHODS: A two-period bidirectional case-crossover design was used, and an online assessment was conducted to measure sensory reactivity. Parents of children aged 4.6 to 13.1 years with a diagnosis of PANS were recruited from various sites across Australia, USA, England, Ireland, Scotland, Canada, and New Zealand. The SPM Home-Form was used to measure sensory reactivity at two time points, when PANS was in remission (T-R) and in exacerbation (T-E). Study entry was permitted at either T-E or T-R. Participant exacerbation status was monitored over a maximum 12-month period, and a follow-up SPM Home-Form was sent when a change in exacerbation status was indicated. A linear mixed model was used to assess the difference between SPM Home-Form norm-referenced scores during exacerbation and remission. RESULTS: The study included 82 participants, with 80 providing data at study entry, and 27 providing data at follow-up. Results showed a statistically significant decline in performance across the SPM Home-Form domains of Hearing, Social Participation, Planning and Ideas, and Total Sensory Systems T-scores during exacerbation when compared with remission data. Results also demonstrated atypical sensory reactivity across Vision, Hearing, Touch, Balance and Motion, and Total Sensory Systems domains during periods of remission compared with SPM Home-Form norms. CONCLUSION: This study found that children with PANS experience significant sensory reactivity differences during exacerbation and remission across multiple sensory domains, with a decline in performance during exacerbation. Where there are occupational performance challenges, occupational therapists should consider administering sensory assessments so that effective intervention plans addressing the unique sensory reactivity needs of children with PANS can be developed.

Streptococcus pyogenes Meningitis in a Pediatric Patient: Case Report.

Streptococcus pyogenes causes a wide spectrum of diseases in children. However, meningitis due to this pathogen is highly uncommon. Although rare, it is associated with a high case fatality rate and can result in severe neurological sequelae. We report a case of Streptococcus pyogenes meningitis in a previously healthy 3-year-old boy. The purpose of this case report is to emphasize that this agent should be considered a cause of meningitis in previously healthy infants because of its frequent association with complications, sequelae, and high mortality rates.

Intravenous immunoglobulin treatment improves multiple neuropsychiatric outcomes in patients with pediatric acute-onset neuropsychiatric syndrome.

Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) is defined by acute onset of diverse neuropsychiatric manifestations, presumably in the setting of underlying immune dysfunction. We used standardized neuropsychological testing to assess how intravenous immunoglobulins (IVIG) impact neurological and cognitive functions in PANS patients by comparing pretreatment with post-treatment scores. A 5-year retrospective study was undertaken in Children's Postinfectious Autoimmune Encephalopathy Center at University of Arizona. We identified 12 children diagnosed with PANS and treated with immunomodulatory IVIG doses, who also completed neuropsychological testing before and after treatment. We tracked multiple patient characteristics, type/timeline of testing, and number of IVIG courses. Score change of 1 standard deviation in any tested domain/subdomain was considered improvement. We further reviewed records for laboratory signs of triggering infection and immune dysfunction. Improvement occurred in 11/12 patients, in one or multiple domains/subdomains, independently of time between disease onset and IVIG initiation (0-7 years). Participants received 1-7 IVIG courses. Improvement was primarily seen in memory (58%), sensory-motor (37%) and visual-motor integration (30%). In 5/12 patients we detected hypogammaglobulinemia requiring ongoing IVIG replacement, one patient had isolated low IgA. Only one patient had to discontinue IVIG therapy due to severe adverse effects. Standardized neuropsychological testing represents an important tool to objectively measure improvement in PANS patients. IVIG was tolerated well and showed efficacy in the vast majority of participants, independently from timelapse since disease onset, emphasizing impact of immunomodulation in PANS. Significant presence of baseline hypogammaglobulinemia in children with PANS emphasizes the presumed role of immune dysfunction in disease pathogenesis.

Caregiver Burden, Stress, and Relationship Cohesion Among Self-Identified Caregivers of Children with Pediatric Acute-Onset Neuropsychiatric Syndrome.

Objective: Children with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) experience sudden onset neuropsychiatric symptoms after infection or other triggers. Symptoms range from mild to severe, potentially lasting days, weeks, months, or longer. Exacerbation-related functional decline presents in many aspects of daily life, generally accompanied by family stress and caregiver burden. We sought to investigate the relationship between severity of PANS symptoms and caregiver burden/stress and the relationship between severity of PANS symptoms and degree of caregiver/child cohesion. Methods: This cross-sectional online study surveyed caregivers recruited from PANS-related social media support sites. The Pediatric Acute Neuropsychiatric Symptom Scale - Parent Version (PNSS) measured current severity. Caregiver Burden Inventory (CBI) and Caregiver Self-Assessment Questionnaire (CSAQ) assessed caregiver burden/stress. Inclusion of Other in the Self (IOS) scale determined caregiver-perceived current and desired cohesion with their child(ren) with PANS. Results: Of the 216 respondents 79.6% exceeded CBI threshold indicating need for respite in adult care receiver populations. On the CSAQ, 72.9% expressed high distress, 80.5% reported feeling overwhelmed, and 58.1% reported crying spells, meeting cutoffs for support/respite used in adult care receiver populations. Most caregivers reported not having the desired degree of cohesion with their child on the IOS (85.5%). Parents of children with more severe PNSS symptoms fared significantly worse on all measures (CBI: H = 57.83; CSAQ: F = 29.26; IOS: H = 38.04; p < 0.001 for all). Content analysis of comments revealed five themes: (1) severe caregiver and/or family emotional distress and trauma; (2) caregivers wondering what happened to their child; (3) lack of awareness and support among health and education professionals; (4) relationship strain with family, friends, and significant others; and (5) financial and/or legal struggles because of their child's diagnosis. Conclusion: There is strong need for support and respite for children with PANS and their families. Long-term effects including posttraumatic stress symptoms among family members should be studied.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): Myth or Reality? The State of the Art on a Controversial Disease.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is one of the most controversial diseases in pediatric rheumatology. Despite first being described more than 25 years ago as the sudden and rapid onset of obsessive-compulsive disorder (OCD) and/or tic disorder symptoms as complications of a Group A beta-hemolytic Streptococcus (GAS) infection, precise epidemiological data are still lacking, and there are no strong recommendations for its treatment. Recent advances in the comprehension of PANDAS pathophysiology are largely attributable to animal model studies and the understanding of the roles of Ca++/calmodulin-dependent protein kinase (CaM kinase) II, disrupted dopamine release in the basal ganglia, and striatal cholinergic interneurons. The diagnosis of PANDAS should be made after an exclusion process and should include prepubescent children with a sudden onset of OCD and/or a tic disorder, with a relapsing/remitting disease course, a clear temporal association between GAS infection and onset or exacerbation of symptoms, and the association with other neurological abnormalities such as motoric hyperactivity and choreiform movements. Antibiotic medications are the primary therapeutic modality. Nonetheless, there is a paucity of randomized studies and validated data, resulting in a scarcity of solid recommendations.

Efficacy of Antidopaminergic Pharmacotherapy in Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS): A Case Report.

PANDAS, or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, is a neuropsychiatric disease seen in children that presents with prevailing symptoms of obsessive-compulsive disorder (OCD), tic disorder, or both. These symptoms appear suddenly following a streptococcal infection, such as strep throat or scarlet fever. The antibodies formed to eradicate the streptococcal infection have been shown to alter central dopamine signaling. In spite of being acknowledged in the medical community for the last two to three decades, PANDAS is a disorder that goes unnoticed by many healthcare professionals. Unfortunately, even with correct diagnosis and utilization of commonly prescribed pharmacotherapy and psychotherapy, medical management can often be ineffective at treating the neuropsychiatric symptoms. Here, we describe a case of a 15-year-old male who presented to the primary care office with complaints of episodic behavioral changes that would occur multiple times daily. The general symptoms were centered around body dysmorphia where the patient became obsessed with fixed portions of food and became highly focused on only specific food types. The symptoms would exacerbate and progress with a dire need to burn calories, leading the patient to damage carpeted areas in the home due to regular and fanatical pacing. The patient underwent trials with serotonergic pharmacotherapy with little to no relief of the psychiatric symptoms. After discussion with his primary care physician, the patient underwent trial management with antidopaminergic therapy that resulted in significant neurological and psychiatric improvement. The use of antidopaminergic pharmacotherapy to target the induction of D1 and D2 dopamine receptors was efficacious in this patient; however, it warrants additional research with a larger sample to determine its effectiveness in the treatment of this psychiatric condition.

Streptococcus zooepidemicus Meningitis in an HIV-Positive Horse Breeder Patient: A Case Study and Literature Review.

Streptococcus equi subsp. zooepidemicus is a rare etiologic agent of bacterial meningitis in humans. The disease is a zoonotic infection and is transmitted through close contact with domestic animals, mainly horses. Only 37 cases of Streptococcus zooepidemicus meningitis have been reported in the literature until July 2023. The aim of this study is to present a rare clinical case of S. zooepidemicus-related meningitis in a human immunodeficiency virus (HIV)-positive patient and analyze the literature. We present a 23-year-old horse breeder patient with advanced immunosuppression due to acquired immunodeficiency syndrome (AIDS) and S. zooepidemicus meningitis, admitted at the Clinic of Infectious Diseases, St. George University Hospital, Plovdiv. The course of meningitis was severe since the beginning, with significant cerebral edema, disturbances in consciousness, persistent fever, and the development of complications against the background of AIDS-related conditions. S. zooepidemicus was microbiologically detected from cerebrospinal fluid culture. After prolonged treatment and a long hospital stay, the patient's condition improved, and eventually he was discharged and recovered from the acute neuroinfection. Although extremely rare, S. zooepidemicus should be considered in patients with clinical and laboratory evidence of bacterial meningitis who have contact with animals, especially horses, other domestic animals, and their dairy products, as well as in immunocompromised patients. To the best of our knowledge, the current clinical case is the first report of S. zooepidemicus-related meningitis in a patient with HIV/AIDS.

Invasive beta-haemolytic streptococcal infections, Finland, 2006 to 2020: increase in Lancefield group C/G infections.

BackgroundInvasive infections with beta-haemolytic streptococci of Lancefield groups A (iGAS), B (iGBS) and C/G (iGCGS) are a major cause of morbidity and mortality worldwide.AimWe studied incidence trends of invasive beta-haemolytic streptococcal infections in Finland, focusing on iGCGS.MethodsWe conducted a retrospective register-based study. Cases were defined as isolations from blood and/or cerebrospinal fluid and retrieved from the National Infectious Disease Register where all invasive cases are mandatorily notified.ResultsBetween 2006 and 2020, the mean annual incidence was 4.1 per 100,000 for iGAS (range: 2.1-6.7), 5.2 for iGBS (4.0-6.3) and 10.1 for iGCGS (5.4-17.6). The incidence displayed an increasing trend for all groups, albeit for iGBS only for individuals 45 years and older. The increase was particularly sharp for iGCGS (8% annual relative increase). The incidence rate was higher in males for iGCGS (adjusted incidence rate ratio (IRR) = 1.6; 95% confidence interval (CI): 1.5-1.8) and iGAS (adjusted IRR = 1.3; 95% CI: 1.1-1.4); for iGBS, the association with sex was age-dependent. In adults, iGCGS incidence increased significantly with age. Recurrency was seen for iGCGS and secondarily iGBS, but not for iGAS. Infections with iGCGS and iGBS peaked in July and August.ConclusionsThe incidence of invasive beta-haemolytic streptococcal infections in Finland has been rising since 2006, especially for iGCGS and among the elderly population. However, national surveillance still focuses on iGAS and iGBS, and European Union-wide surveillance is lacking. We recommend that surveillance of iGCGS be enhanced, including systematic collection and typing of isolates, to guide infection prevention strategies.

A critical appraisal of acute sore throat guidelines using the AGREE II instrument: a scoping review.

BACKGROUND: Conflicting international guidelines exist on the management of sore throat by antibiotics. OBJECTIVES: To assess with the Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument the quality of guidelines for uncomplicated acute group A beta-haemolytic streptococcal (GABHS) sore-throat. To make a sensitivity analysis restricted to guidelines with a rigour of development score higher than 60% and to describe their recommendations on scores, tests, and antibiotic therapy, including their justification. METHODS: A guideline literature review of acute GABHS sore throat, published between January 2000 and December 2019 in primary care and secondary care. The PubMed database, the Canadian Medical Association Infobase on Clinical Practice Guidelines and the International Network Guidelines were used. The quality of guidelines was assessed using the AGREE II instrument. The guidelines were classified into 2 categories: high-quality guidelines had to rate >60% for the rigour of development score, the others were classified as low-quality guidelines. RESULTS: Significant heterogeneity between the 15 guidelines concerned the scores of the 6 assessment domains. Among them, 6 guidelines presented a score above 60% with regards to the rigor of development domain and used a systematic literature search method, citing meta-analyses of recent randomised clinical trials. Most of the 6 high-quality guidelines no longer recommended the systematic use of diagnostic scores and tests, nor antibiotic therapy to prevent acute rheumatic fever or loco-regional complications, except for high-risk patients. CONCLUSION: Major discrepancies emphasise the need for only high-quality guidelines, based on adequately assessed evidence. Restricted antibiotic prescriptions to severe cases or high-risk patients would avoid antibiotic resistance.

Unexpected Increase in Invasive Group A Streptococcal Infections in Children After Respiratory Viruses Outbreak in France: A 15-Year Time-Series Analysis.

In a 15-year pediatric time-series analysis, we showed a rise of invasive Group A streptococcal (iGAS) infections since October 2022, mainly involving pleural empyema, simultaneously to a respiratory virus outbreak. Physicians should be aware of this increased risk of pediatric iGAS infections, especially in settings with intense respiratory viruses' circulation.

Microbiological Epidemiology of Invasive Infections Due to Non-Beta-Hemolytic Streptococci, France, 2021.

Non-beta-hemolytic streptococci (NBHS), also referred to as viridans streptococci, represent an underestimated cause of human invasive diseases. Their resistance to antibiotics, including beta-lactam agents, often complicate their therapeutic management. A prospective multicenter study was conducted by the French National Reference Center for Streptococci between March and April 2021 to describe the clinical and microbiological epidemiology of invasive infections due to NBHS, excluding pneumococcus. A total of 522 NBHS invasive cases were collected. Distribution among streptococcal groups was: Streptococcus anginosus (33%), Streptococcus mitis (28%), Streptococcus sanguinis (16%), Streptococcus bovis/equinus (15%), Streptococcus salivarius (8%), and Streptococcus mutans (<1%). Median age of infection was 68 years old (range <1 day to 100 years). Cases were more frequent in male patients (gender ratio M/F 2.1:1) and manifested mainly as bacteremia without focus (46%), intra-abdominal infections (18%) and endocarditis (11%). All isolates were susceptible to glycopeptides and displayed low-level inherent gentamicin resistance. All isolates of the S. bovis/equinus, S. anginosus, and S. mutans groups were susceptible to beta-lactams. Conversely, nonsusceptibility to beta-lactams was found in 31%, 28%, and 52% of S. mitis, S. salivarius, and S. sanguinis isolates, respectively. The screening for beta-lactam resistance using the recommended one unit benzylpenicillin disk screening failed to detect 21% of resistant isolates (21/99). Last, overall resistance rates to the alternative anti-streptococcal molecules clindamycin and moxifloxacin were 29% (149/522) and 1.6% (8/505), respectively. IMPORTANCE NBHS are recognized as opportunistic pathogens particularly involved in infections of the elderly and immunocompromised patients. This study underlines their importance as common causes of severe and difficult-to-treat infections such as endocarditis. Although species of the S. anginosus and S. bovis/equinus groups remain constantly susceptible to beta-lams, resistance in oral streptococci exceeds 30% and screening techniques are not fully reliable. Therefore, accurate species identification and antimicrobial susceptibility testing by MICs determination appears essential for the treatment of NBHS invasive infections, together with continued epidemiological surveillance.

[Therapeutic implications of the microbiology of severe skin infections]. / Implications thérapeutiques de la microbiologie des infections cutanées graves.

THERAPEUTIC IMPLICATIONS OF THE MICROBIOLOGY OF SEVERE SKIN INFECTIONS. Bacterial necrotizing dermo-hypodermatitis (BNHD) is a serious infection that can be life-threatening. They require urgent surgical management, treatment of organ failure, and early and appropriate antibiotic therapy. The microbiology of BNHD is often polymicrobial and varies according to the location of the infection, the local ecology and the risk factors for resistant bacteria. In this context, probabilistic antibiotic therapy should be early, intravenous, bactericidal, broad-spectrum, and should thus cover both Gram-positive and Gram-negative bacteria and anaerobes. The addition of a systematic anti-toxin treatment also seems reasonable. The use of high doses and therapeutic monitoring of antibiotics are also important elements to consider. Finally, de-escalation of the antibiotic spectrum according to the microbiological result is essential.

IMPLICATIONS THÉRAPEUTIQUES DE LA MICROBIOLOGIE DES INFECTIONS CUTANÉES GRAVES Les dermohypodermites bactériennes nécrosantes (DHBN) sont des infections graves qui peuvent mettre en jeu le pronostic vital. Elles nécessitent à la fois une prise en charge chirurgicale urgente, le traitement des défaillances d'organes mais aussi une antibiothérapie précoce et adaptée. La microbiologie des DHBN est souvent polymicrobienne et varie en fonction de la localisation de l'infection, de l'écologie locale et des facteurs de risque de bactéries résistantes. Dans ce contexte, l'antibiothérapie probabiliste doit être précoce, intraveineuse, bactéricide, à large spectre et doit ainsi couvrir à la fois les bactéries à Gram positif, à Gram négatif et les anaérobies. L'ajout d'un traitement antitoxinique systématique semble également raisonnable. Par ailleurs, l'utilisation de doses élevées et une surveillance thérapeutique des antibiotiques sont également des éléments importants à privilégier. Enfin, une désescalade du spectre antibiotique adapté au résultat microbiologique est indispensable.

Estimating predictors of severity of group A Streptococcus infection in pregnancy.

OBJECTIVE: To identify the clinical characteristics of pregnancy associated group A streptococcus (GAS) infection and predictors for intensive care unit (ICU) admission. METHODS: A retrospective cohort study of culture-proven pregnancy-related GAS infections in tertiary hospital Electronic medical records were reviewed, for cases of cultures positive GAS that were identified between January 2008 and July 2021. A GAS infection was defined by the isolation of the pathogen from a sterile liquid or tissue site. Blood and urine cultures were obtained from all patients with peripartum hyperpyrexia (fever >38 °C). Medical Personnel screening included cultures of the throat, rectum, and skin lesions (if present). In cases of hemodynamic instability patients were transferred ad hoc to ICU, according to the obstetrician and intensivist judgment. RESULTS: Of the 143,750 who delivered during the study period, 66 (0.04%) were diagnosed as having a pregnancy associated GAS infection. Of these, 57 patients presented postpartum, and represented the study cohort. The most common presenting signs and symptoms among puerperal GAS, were postpartum pyrexia (72%), abdominal pain (33%), and tachycardia (>100 bpm, 22%). 12 women (21.0%) developed streptococcal toxic shock syndrome (STSS. Predictors for STSS and ICU admission were: antibiotic administration >24 h from presentation postpartum, tachycardia, and a C-reactive protein level >200 mg/L. Women that received antibiotic prophylaxis during labor had a significantly lower rate of STSS (0 vs 10, 22.7%; p = .04). CONCLUSION: Deferral of medical intervention >24 h from the first registered abnormal sign had the most important impact on deterioration of women with invasive puerperal GAS. Antibiotic prophylaxis during labor in women with GAS may reduce associated complications.

Neuroinflammation in Obsessive-Compulsive Disorder: Sydenham Chorea, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, and Pediatric Acute Onset Neuropsychiatric Syndrome.

Sydenham chorea (SC), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) are postinfectious neuroinflammatory diseases that involve the basal ganglia and have obsessive-compulsive disorder as a major manifestation. As is true for many childhood rheumatological diseases and neuroinflammatory diseases, SC, PANDAS and PANS lack clinically available, rigorous diagnostic biomarkers and randomized clinical trials. Research on the treatment of these disorders depend on three complementary modes of intervention including: treating the symptoms, treating the source of inflammation, and treating disturbances of the immune system. Future studies should aim to integrate neuroimaging, inflammation, immunogenetic, and clinical data (noting the stage in the clinical course) to increase our understanding and treatment of SC, PANDAS, PANS, and all other postinfectious/immune-mediated behavioral disorders.

Diagnóstico por imagen de abscesos hepáticos y pulmonares por estreptococos del grupo viridans. Presentación de caso / Imaging diagnosis of liver and lung abscesses due to viridans streptococci. Case presentation

Resumen El Streptococcus viridans es conocido más comúnmente como agente infeccioso en las endocarditis, sin embargo, poco se conoce sobre su potencial infeccioso en otros órganos o sistemas, donde ha demostrado una elevada mortalidad. El reconocimiento del Streptococcus viridans como agente productor de abscesos en otras localizaciones como a nivel hepático o pulmonar, permitirá un diagnóstico oportuno mediante los distintos métodos de imagen, reduciendo las graves consecuencias para el paciente y los tiempos de hospitalización. Se presenta el caso de un paciente del sexo masculino de 33 años de edad sin antecedentes crónico degenerativos, que inició con sintomatología 7 meses previos a su ingreso, con fiebre intermitente, fatiga, astenia, anorexia y pérdida de peso. A la exploración física presentó dolor a la palpación media y profunda en hipocondrio derecho, en el panel de laboratorios presentó llamativa neutrofilia, en la tomografía de tórax y abdomen se mostró lesión cavernomatosa en pulmón y quistes complicados hepáticos, a los cuales se les realizó drenaje percutáneo guiado por ultrasonido, con envío de muestras a cultivo con resultado positivo para Streptococcus viridans, lo que permitió brindar el tratamiento dirigido al paciente, y que remitiera la enfermedad.

Abstract Streptococcus viridans is more commonly known as an infectious agent in endocarditis, however, little is known about its infectious potential in other organs or systems, where it has shown high mortality. The recognition of Streptococcus viridans as an abscess-producing agent in other locations, such as the liver or lungs, will allow timely diagnosis using different imaging methods, reducing serious consequences for the patient and hospitalization times. We present the case of a 33-year-old male patient with no chronic degenerative history, who started symptoms 7 months prior to admission, with intermittent fever, fatigue, asthenia, anorexia and weight loss, on physical examination he presented pain at the medium and deep palpation in the right hypochondrium, in the laboratory panel I present striking neutrophilia, in the tomography of the thorax and abdomen a cavernous lesion in the lung and complicated hepatic cysts are shown, to which percutaneous drainage guided by ultrasound is performed, with sending of cultured samples with a positive result for Streptococcus viridans. Thus, allowing treatment to be provided to the patient, thereby achieving remission of the disease.

Streptococcus anginosus: a stealthy villain in deep odontogenic abscesses.

Odontogenic infections (OIs) occasionally spread to deep facial and neck tissues. Our study aimed to explore the role of Streptococcus anginous group (SAG) in these severe OIs. A retrospective study of patients aged ≥ 18 years who required hospital care for acute OI was conducted. We analysed data of OI microbial samples and recorded findings of SAG and other pathogens. These findings were compared with data regarding patients' prehospital status and variables of infection severity. In total, 290 patients were included in the analyses. The most common (49%) bacterial finding was SAG. Other common findings were Streptococcus viridans and Prevotella species, Parvimonas micra, and Fusobacterium nucleatum. Infection severity variables were strongly associated with SAG occurrence. Treatment in an intensive care unit was significantly more common in patients with SAG than in patients without SAG (p < 0.001). In addition, SAG patients expressed higher levels of C-reactive protein (p = 0.001) and white blood cell counts (p < 0.001), and their hospital stays were longer than those of non-SAG patients (p = 0.001). SAG is a typical finding in severe OIs. Clinical features of SAG-related OIs are more challenging than in other OIs. Early detection of SAG, followed by comprehensive infection care with prompt and careful surgical treatment, is necessary due to the aggressive behaviour of this dangerous pathogen.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Syndrome: A 10-Year Retrospective Cohort Study in an Italian Centre of Pediatric Rheumatology.

BACKGROUND: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is a rare pediatric disorder consisting of a sudden onset of obsessive-compulsive disorder (OCD) and/or tics after a group A Streptococcus (GAS) infection. METHODS: In the period between 2013 and 2023, 61 children presented to our Pediatric Rheumatology unit with a suspicion of PANDAS syndrome. Among these, a retrospective analysis was conducted, and 19 fulfilled the current classification criteria and were included in this study. RESULTS: The male-to-female ratio was 14:5, the median age at onset was 7.0 (2.0-9.5) years, and the median age at diagnosis was 8.0 (3.0-10.4) years. The median follow-up period was 16.0 (6.0-72.0) months. Family and personal history were relevant in 7/19 and 6/19 patients. Tics were present in all patients. Details for motor tics were retrospectively available in 18/19 patients, with the eyes (11/18) and neck/head (10/18) being most often involved. Vocal tics were documented in 8/19, behavioral changes in 10/19, and OCD in 2/19. Regarding the therapeutic response, all patients responded to amoxicillin, 12/13 to benzathine benzylpenicillin, and 7/9 to azithromycin. CONCLUSIONS: Our findings partially overlap with previous reports. Larger prospective studies are needed to improve treatment strategies and classification criteria.