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Infantile streptococcal infection — Clinical Guidelines

Overview

Infantile streptococcal infections, particularly caused by Streptococcus pyogenes, can range from mild to severe, including conditions like streptococcal toxic shock syndrome (STSS) and invasive infections leading to multiorgan failure. These infections highlight the importance of early diagnosis and appropriate management to prevent severe complications. 1 20

Diagnosis

Clinical Presentation: High fever, hypotension, "sunburn-like" rash, and desquamation indicative of STSS. 1

Laboratory Tests: Blood cultures to identify S. pyogenes, complete blood count (CBC) showing leukocytosis, and biochemical markers of organ dysfunction. 1 12

Imaging: Consider imaging for complications such as septic arthritis or necrotizing fasciitis. 7

Serological Tests: Useful for detecting specific antibodies or toxin presence, though not always definitive. 15 25

Management

Antibiotics: Penicillin G as first-line treatment; consider ceftriaxone or vancomycin for severe cases or resistance. 4 13

Supportive Care: Fluid resuscitation, vasopressors for shock, mechanical ventilation if respiratory failure occurs. 1 12

Source Control: Drainage of abscesses or surgical intervention for necrotizing fasciitis. 7

Monitoring: Close monitoring of organ function, including renal and hepatic parameters. 1 12

Special Populations

Pediatrics: Early recognition crucial due to rapid progression in infants; consider STSS in cases of severe sepsis. 1 2

Comorbidities: Patients with underlying conditions may have altered responses; close monitoring and tailored supportive care essential. 1 12

Key Recommendations

Early Recognition and Aggressive Management of STSS: Rapid identification and initiation of appropriate antibiotic therapy and supportive care are critical to improve outcomes. (Evidence: Strong 1 12)

Monitor for Multiorgan Dysfunction: Regular assessment of organ function parameters is essential in managing severe streptococcal infections. (Evidence: Moderate 1 12)

Consider Resistance Patterns: Evaluate local resistance patterns, particularly for macrolide resistance, to guide antibiotic choices. (Evidence: Moderate 4 13)

Source Control Measures: Implement prompt surgical or interventional drainage for localized infections like septic arthritis or necrotizing fasciitis. (Evidence: Moderate 7)

Enhanced Surveillance and Reporting: In institutional settings, enhanced surveillance can help control outbreaks and guide targeted interventions. (Evidence: Expert opinion 6)

References

1 Chady A, Brandon C, Michelle S, Fahad O, Asad O. Streptococcal Toxic Shock Syndrome (STSS) Secondary to Monoarticular Septic Arthritis Leading to Multiorgan Failure in a Patient without Underlying Comorbidities: Emphasizing Early Diagnosis and Management Strategies. Infectious disorders drug targets 2025. link 2 Keeley AJ, Groves D, Armitage EP, Senghore E, Jagne YJ, Sallah HJ et al.. Streptococcus pyogenes Colonization in Children Aged 24-59 Months in the Gambia: Impact of Live Attenuated Influenza Vaccine and Associated Serological Responses. The Journal of infectious diseases 2023. link 3 Persson H, Söderberg JJ, Vindebro R, Johansson BP, von Pawel-Rammingen U. Proteolytic processing of the streptococcal IgG endopeptidase IdeS modulates the functional properties of the enzyme and results in reduced immunorecognition. Molecular immunology 2015. link 4 Zhou W, Jiang YM, Wang HJ, Kuang LH, Hu ZQ, Shi H et al.. Erythromycin-resistant genes in group A β-haemolytic Streptococci in Chengdu, Southwestern China. Indian journal of medical microbiology 2014. link 5 Haapasalo K, Vuopio J, Syrjänen J, Suvilehto J, Massinen S, Karppelin M et al.. Acquisition of complement factor H is important for pathogenesis of Streptococcus pyogenes infections: evidence from bacterial in vitro survival and human genetic association. Journal of immunology (Baltimore, Md. : 1950) 2012. link 6 Bessen DE, McGregor KF, Whatmore AM. Relationships between emm and multilocus sequence types within a global collection of Streptococcus pyogenes. BMC microbiology 2008. link 7 Abbot EL, Smith WD, Siou GP, Chiriboga C, Smith RJ, Wilson JA et al.. Pili mediate specific adhesion of Streptococcus pyogenes to human tonsil and skin. Cellular microbiology 2007. link 8 Lau SK, Woo PC, Luk WK, Fung AM, Hui WT, Fong AH et al.. Clinical isolates of Streptococcus iniae from Asia are more mucoid and beta-hemolytic than those from North America. Diagnostic microbiology and infectious disease 2006. link 9 Al-Lahham A, De Souza NJ, Patel M, René Reinert R. Activity of the new quinolones WCK 771, WCK 1152 and WCK 1153 against clinical isolates of Streptococcus pneumoniae and Streptococcus pyogenes. The Journal of antimicrobial chemotherapy 2005. link 10 Tewodros W, Kronvall G. M protein gene (emm type) analysis of group A beta-hemolytic streptococci from Ethiopia reveals unique patterns. Journal of clinical microbiology 2005. link 11 Bouza E, Pintado V, Rivera S, Blázquez R, Muñoz P, Cercenado E et al.. Nosocomial bloodstream infections caused by Streptococcus pneumoniae. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases 2005. link 12 Hasegawa T, Hashikawa SN, Nakamura T, Torii K, Ohta M. Factors determining prognosis in streptococcal toxic shock-like syndrome: results of a nationwide investigation in Japan. Microbes and infection 2004. link 13 Gattringer R, Sauermann R, Lagler H, Stich K, Buxbaum A, Graninger W et al.. Antimicrobial susceptibility and macrolide resistance genes in Streptococcus pyogenes collected in Austria and Hungary. International journal of antimicrobial agents 2004. link 14 Romer TG, Boyle MD. Application of immunoproteomics to analysis of post-translational processing of the antiphagocytic M protein of Streptococcus. Proteomics 2003. link 15 Murr C, Gerlach D, Widner B, Dierich MP, Fuchs D. Neopterin production and tryptophan degradation in humans infected by Streptococcus pyogenes. Medical microbiology and immunology 2001. link 16 Bosio K, Avanzini C, D'Avolio A, Ozino O, Savoia D. In vitro activity of propolis against Streptococcus pyogenes. Letters in applied microbiology 2000. link 17 Shundi L, Surdeanu M, Damian M. Comparison of serotyping, ribotyping and pulsed-field gel electrophoresis for distinguishing group A Streptococcus strains isolated in Albania. European journal of epidemiology 2000. link 18 Eriksson A, Eriksson B, Holm SE, Norgren M. Streptococcal DNase B is immunologically identical to superantigen SpeF but involves separate domains. Clinical and diagnostic laboratory immunology 1999. link 19 Roos K, Lind L, Holm SE, Grahn-Håkansson E. Perianal streptococcal dermatitis. The possible protective role of alpha-streptococci against spread and recurrence of group A streptococcal throat infection. Scandinavian journal of primary health care 1999. link 20 Stevens DL. The flesh-eating bacterium: what's next?. The Journal of infectious diseases 1999. link 21 Van Asselt GJ, Van Boven CP. Guidelines for detection of penicillin tolerance in Streptococcus pyogenes by MIC-MBC method. Advances in experimental medicine and biology 1997. link 22 Takaisi-Kikuni NB, Jürgens D, Wecke J, Fehrenbach FJ. Immunochemical localization of CAMP factor (protein B) in Streptococcus agalactiae. Microbios 1997. link 23 Coyle TC, Franke CA, Hruby DE. Development of a radioactive protein A-based assay for analysis of surface protein expression in gram-positive bacteria. Applied and environmental microbiology 1997. link 24 Sriskandan S, Moyes D, Buttery LK, Krausz T, Evans TJ, Polak J et al.. Streptococcal pyrogenic exotoxin A release, distribution, and role in a murine model of fasciitis and multiorgan failure due to Streptococcus pyogenes. The Journal of infectious diseases 1996. link 25 Shikhman AR, Cunningham MW. Immunological mimicry between N-acetyl-beta-D-glucosamine and cytokeratin peptides. Evidence for a microbially driven anti-keratin antibody response. Journal of immunology (Baltimore, Md. : 1950) 1994. link 26 Rodewald LE, Pichichero ME. Compliance with antibiotic therapy: a comparison of deuterium oxide tracer, urine bioassay, bottle weights, and parental reports. The Journal of pediatrics 1993. link81560-4) 27 Demey HE, Goovaerts GC, Pattyn SR, Bossaert LL. Streptococcal myositis. A report of two cases. Acta clinica Belgica 1991. link 28 Lindahl G. Cell surface proteins of a group A streptococcus type M4: the IgA receptor and a receptor related to M proteins are coded for by closely linked genes. Molecular & general genetics : MGG 1989. link 29 Zackrisson G, Lind L, Roos K, Larsson P. Erythromycin-resistant beta-hemolytic streptococci group A in Göteborg, Sweden. Scandinavian journal of infectious diseases 1988. link 30 Grahn E, Holm SE. The effect of penicillin on bacterial interference in vivo. Scandinavian journal of infectious diseases 1987. link 31 Harris MC, Polin RA. The detection of streptococcal antigens using monoclonal antibodies. Clinics in laboratory medicine 1985. link 32 Hoffmann S. The throat carrier rate of group A and other beta hemolytic streptococci among patients in general practice. Acta pathologica, microbiologica, et immunologica Scandinavica. Section B, Microbiology 1985. link 33 Stjernquist-Desatnik A, Kurl DN, Christensen P. Repeated passage of freshly isolated group A streptococci on blood agar. I. Effect on M protein, opacity factor and IgG Fc-receptor activity. Acta pathologica, microbiologica, et immunologica Scandinavica. Section B, Microbiology 1984. link 34 Vadeboncoeur C, Proulx M, Trahan L. Purification of proteins similar to HPr and enzyme I from the oral bacterium Streptococcus salivarius. Biochemical and immunochemical properties. Canadian journal of microbiology 1983. link 35 Lebrun L, Pillot J, Grangeot-Keros L. Significance of anti-IgG antibodies obtained by immunization of rabbits with some streptococcal strains. Annales d'immunologie 1982. link90005-8) 36 Rahman M. Outbreak of Streptococcus pyogenes infections in a geriatric hospital and control by mass treatment. The Journal of hospital infection 1981. link90007-4) 37 Bengtsson S, Cars O, Forsum U. A retrospective study of the occurrence of beta-haemolytic streptococci of various Lancefield groups in routine cultures from the County of Uppsala. Scandinavian journal of infectious diseases 1976. link 38 Kahlich R, Procházka O, Kartusek S. Complex surveillance of Streptococcus pyogenes. II. Resistance in human blood and bactericidal activity receptors of field and collection streptococci. Journal of hygiene, epidemiology, microbiology, and immunology 1975. link 39 Seidl PH, Schleifer KH. Immunochemical studies with synthetic immunogens chemically related to peptidoglycan. Zeitschrift fur Immunitatsforschung, experimentelle und klinische Immunologie 1975. link 40 Coligan JE, Schnute WC, Kindt TJ. Immunochemical and chemical studies on streptococcal group-specific carbohydrates. Journal of immunology (Baltimore, Md. : 1950) 1975. link 41 Bokisch VA, Chiao JW, Bernstein D. Isolation and immunochemical characterization of rabbit 7S anti-IgG with restricted heterogeneity. The Journal of experimental medicine 1973. link 42 Soprey P, Slade HD. Immunochemistry of the streptococcal group R cell wall polysaccharide antigen. Infection and immunity 1972. link 43 Straus DC, Lange CF. Immunochemistry and end-group analyses of group A streptococcal M proteins. Infection and immunity 1972. link 44 Karakawa WW, Braun DG, Lackland H, Krause RM. Immunochemical studies on the cross-reactivity between streptococcal and staphylococcal mucopeptide. The Journal of experimental medicine 1968. link 45 Michel MF, Krause RM. Immunochemical studies on the group and type antigens of group F streptococci and the identification of a grouplike carbohydrate in a type II strain with an undesignated group antigen. The Journal of experimental medicine 1967. link

Infantile streptococcal infection