So today I reviewed the podcast below and read the transcript. I also excerpted some quotes from the script to help fix it in my mind.
Note to myself: Best to reread the whole script.
Invasive Group A Streptococcal Infections – CPS Podcast by Ola.Rydz Apr 15, 2019 from PedsCases:
Here are excerpts from the above script.
Let us conclude this PedsCases podcast with a few take home points on invasive Group
A Strep management.
• Invasive Group A Strep incidence has been increasing, with children and the elderly at greatest risk
• Invasive Group A Strep causes a wide spectrum of disease, most often TSS, necrotizing fasciitis, bacteremia with no focal infection, and pneumonia
• Empiric therapy should always include a beta-lactam antibiotic and clindamycin
• All invasive Group A Strep, regardless of severity, is reportable
• All close contacts of those with invasive Group A Strep need to be alerted to signs and symptoms of invasive Group A Strep, but only a subset of these require chemoprophylaxis
• Where chemoprophylaxis is indicated, a 10 day course of a first generation cephalosporin is the recommended first line therapy
IGAS disease can be classified as non-severe or severe.
Non-severe IGAS refers to bacteremia, cellulitis, wound infections, soft tissue abscesses, lymphadenitis, septic arthritis, or osteomyelitis, but without evidence of streptococcal toxic shock syndrome (TSS) or soft tissue necrosis.
By contrast, severe invasive disease refers to one of the following presentations:
1. Streptococcal toxic shock syndrome.
– It is important to know that streptococcal toxic shock is clinically indistinguishable from staphylococcal toxic shock syndrome. It is characterized by hypotension, defined as systolic blood pressure less than the 5th percentile for age in children, and at least 2 of the following:
a. renal impairment (defined as creatinine level of at least 2X upper limit of normal for age or 2X patient’s baseline);
b. Coagulopathy (platelet count of 100×109/L or lower, or disseminated intravascular coagulation);
c. Liver function abnormality (levels of aspartate aminotransferase, alanine aminotransferase or total bilirubin >2X the upper limit of normal);
d. Acute respiratory distress syndrome; or,
e. Generalized erythematous macular rash that may desquamate later;
2. Soft-tissue necrosis (which includes necrotizing fasciitis (NF), myositis or gangrene);
- The majority of NF is polymicrobial, but of monomicrobial cases, IGAS is a leading cause. Necrotizing fasciitis presents with severe pain, induration, hemodynamic instability, and rapid progression. Necrotizing fasciitis caused by polymicrobial infection or clostridia is associated with presence of crepitus, while necrotizing fasciitis related to invasive Group A Strep is more commonly associated with a generalized rash, pharyngitis, conjunctivitis, and/or strawberry tongue.
3. Pneumonia, with isolation of Group A Strep from a sterile site such as pleural fluid. Note that bronchoalveolar lavage (BAL) is not considered to be from a sterile site. Clinically, Group A Strep pneumonia is indistinguishable from other causes of pneumonia, but it tends to progress more rapidly with development of large pleural effusions.
4. Meningitis – which is the rarest presentation of severe invasive Group A Strep.
5. A combination of the above.
6. Other life-threatening condition or Infection resulting in death
Classifying the presentation of the invasive Group A Strep disease is important, because it helps to guide management. So, with that in mind, let’s discuss what management looks like.
See Script for details on management.