Invasive Group A Streptococcal Infections -- United Kingdom, 1994

On May 27, 1994, the Communicable Disease Surveillance Center in England reported that six persons in Gloucestershire had disease characteristic of invasive group A streptococcal infection (GAS) with necrotizing fasciitis. Three patients died. Patients ranged in age from 46 to 68 years. Group A streptococcal isolates from blood or joint fluid from five patients were typed by the Public Health Laboratory Service Streptococcus Reference Laboratory. Four different types were identified (M1 {2}, M3, M5, and M-nontypable).

Since 1992, the total number of laboratory reports of systemic GAS in England and Wales has remained stable; during the first 16 weeks of 1994, a total of 200 blood isolates were reported, compared with 212 and 200 during the first 16 weeks of 1993 and 1992, respectively.

Adapted from: Communicable Disease Report 1994;4(21).

Reported by: Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The report from the United Kingdom underscores the potential for severe disease associated with GAS. GAS is associated with a broad spectrum of complications in humans, the most common being streptococcal pharyngitis. Serious invasive disease, which occurs less commonly, is defined by isolation of the bacteria from usually sterile sites and is associated with case-fatality rates of 10%-20%. One form of invasive GAS, necrotizing fasciitis, is characterized by destruction of muscle and fat tissue.

Based on extrapolation of incidence rates determined by active surveillance in four states during 1989-1991, 10,000-15,000 cases of invasive GAS occurred annually in the United States; necrotizing fasciitis occurred in 5%-10% of patients (case-fatality rate: 28%) (CDC, unpublished data, 1992). These findings were consistent with a retrospective review of all invasive GAS in Pima County, Arizona, during 1986-1990; in this review, necrotizing fasciitis was identified in 6.5% of infections (1). Interest in necrotizing fasciitis as a serious manifestation of invasive GAS increased in 1989 following a report of 20 patients with group A streptococcal toxic-shock syndrome, of whom 11 had necrotizing fasciitis (2); a subsequent case definition for this syndrome included necrotizing fasciitis as one component (3). Since 1991, there has been no active surveillance for invasive GAS in the United States; although passive surveillance exists, this disease is not reportable in most states.

Development of invasive GAS appears to be facilitated by the presence of specific virulent strains and predisposing host factors. To evaluate the role of strain characteristics, CDC examined group A streptococcal isolates from surveillance for postulated virulence factors including M-type, protease activity, and pyrogenic exotoxin production (4). Protease activity was significantly associated with necrotizing fasciitis; M-type 1 infection also was associated with protease activity. These findings suggest that certain group A streptococcal strains are more likely to cause necrotizing fasciitis when infection occurs. Other reports suggest that the risk for invasive GAS is associated with the presence of surgical or nonsurgical wounds, diabetes mellitus, and other underlying medical problems.

Rapid treatment is necessary to reduce the risk for death, and penicillin remains the treatment of choice for GAS. Although penicillin resistance has never been identified in group A Streptococcus, some strains are resistant to erythromycin (which is recommended as therapy in penicillin-allergic patients). In addition to antibiotics, surgical intervention is usually needed in cases of necrotizing fasciitis. The occurrence of the cluster of necrotizing fasciitis in England and the recent recognition of a streptococcal toxic-shock syndrome underscore the potential for group A streptococci to cause severe illness and new clinical syndromes and the need to monitor clinical manifestations and changes in the epidemiology of these infections (5).

References

1. Hoge CW, Schwartz B, Talkington DF, Breiman RF, MacNeill EM, Englender SJ. The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic-shock like syndrome. JAMA 1993;269:384-9.

2. Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infection associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989;321:1-7.

3. Working Group on Severe Streptococcal Infections. Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition. JAMA 1993;269:390-1.

4. Talkington DF, Schwartz B, Black CM, et al. Association of phenotypic and genotypic characteristics of invasive Streptococcus pyogenes isolates with clinical components of streptococcal toxic shock syndrome. Infect Immun 1993;61:3369-74.

5. CDC. Addressing emerging infectious disease threats: a prevention strategy for the United States. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

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