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Previous Volume 335:547-554 August 22, 1996 Number 8 Next

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ABSTRACT

Background Several reports suggest that the incidence of invasive group A streptococcal infections, including streptococcal toxic shock syndrome and necrotizing fasciitis, is increasing.

Methods During 1992 and 1993 we conducted prospective, population-based surveillance of invasive group A streptococcal disease in Ontario, Canada. We reviewed clinical and laboratory records, searched for secondary cases of invasive disease, and cultured specimens from household contacts.

Results We identified 323 patients with invasive group A streptococcal infections, for an annual incidence of 1.5 cases per 100,000 population. The rates were highest in young children and the elderly. Fifty-six percent of the patients had underlying chronic illness. Risk factors for disease included infection with the human immunodeficiency virus, cancer, diabetes, alcohol abuse, and chickenpox. The most common clinical presentations were soft-tissue infection (48 percent), bacteremia with no septic focus (14 percent), and pneumonia (11 percent). Necrotizing fasciitis occurred in 6 percent of patients, and toxic shock in 13 percent. The mortality rate was 15 percent overall, but it was 29 percent among those over 64 years of age (P<0.001) and 81 percent among those with toxic shock (P<0.001). Fourteen percent of the cases were nosocomial, and 4 percent occurred in nursing home residents, often in association with disease outbreaks. Invasive disease occurred in 2 household contacts of patients with infection, for an estimated risk of 3.2 per 1000 household contacts (95 percent confidence interval, 0.39 to 12 per 1000).

Conclusions The elderly and those with underlying medical conditions are at greatest risk for invasive group A streptococcal disease, toxic shock, and necrotizing fasciitis. Invasive streptococcal infection is associated with a substantial risk of transmission in households and health care institutions.

Source Information

From the Division of Infectious Diseases, Hospital for Sick Children (H.D.D.), the Department of Microbiology, Mount Sinai and Princess Margaret Hospitals (A.M., K.G., D.C., D.E.L.), and the Department of Microbiology, Sunnybrook Health Sciences Centre, University of Toronto (A.E.S.) — all in Toronto; and the Centers for Disease Control and Prevention, Atlanta (B.S.).

Address reprint requests to Dr. Low at the Department of Microbiology, Mount Sinai Hospital, 600 University Ave., Toronto, ON M5G 1X5, Canada.

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Invasive Group A Streptococcal Infections
Couper R., Charytan D., Kujath P., Eckmann C., McGeer A., Low D. E., Davies H. D., Schwartz B., Holm S. E.
Extract | Full Text  
N Engl J Med 1997; 336:513-515, Feb 13, 1997. Correspondence

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• Tyrrell, G. J., Lovgren, M., Kress, B., Grimsrud, K. (2005). Invasive Group A Streptococcal Disease in Alberta, Canada (2000 to 2002). J. Clin. Microbiol. 43: 1678-1683 [Abstract] [Full Text]  
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• Tyrrell, G. J., Lovgren, M., Forwick, B., Hoe, N. P., Musser, J. M., Talbot, J. A. (2002). M Types of Group A Streptococcal Isolates Submitted to the National Centre for Streptococcus (Canada) from 1993 to 1999. J. Clin. Microbiol. 40: 4466-4471 [Abstract] [Full Text]  
• Ikebe, T., Wada, A., Inagaki, Y., Sugama, K., Suzuki, R., Tanaka, D., Tamaru, A., Fujinaga, Y., Abe, Y., Shimizu, Y., Watanabe, H., the Working Group for Group A Streptococci in Japa, (2002). Dissemination of the Phage-Associated Novel Superantigen Gene speL in Recent Invasive and Noninvasive Streptococcus pyogenes M3/T3 Isolates in Japan. Infect. Immun. 70: 3227-3233 [Abstract] [Full Text]  
• Skull, S A, Wang, E E L (2001). Current topic: Varicella vaccination{---}a critical review of the evidence. Arch. Dis. Child. 85: 83-90 [Full Text]  
• Lesko, S. M., O'Brien, K. L., Schwartz, B., Vezina, R., Mitchell, A. A. (2001). Invasive Group A Streptococcal Infection and Nonsteroidal Antiinflammatory Drug Use Among Children With Primary Varicella. Pediatrics 107: 1108-1115 [Abstract] [Full Text]  
• Huang, Y.-C., Hsueh, P.-R., Lin, T.-Y., Yan, D.-C., Hsia, S.-H. (2001). A Family Cluster of Streptococcal Toxic Shock Syndrome in Children: Clinical Implication and Epidemiological Investigation. Pediatrics 107: 1181-1183 [Abstract] [Full Text]  
• Ray, J. (2001). On the trail of necrotizing fasciitis in children. CMAJ 164: 175-175 [Full Text]  
• Kansal, R. G., McGeer, A., Low, D. E., Norrby-Teglund, A., Kotb, M. (2000). Inverse Relation between Disease Severity and Expression of the Streptococcal Cysteine Protease, SpeB, among Clonal M1T1 Isolates Recovered from Invasive Group A Streptococcal Infection Cases. Infect. Immun. 68: 6362-6369 [Abstract] [Full Text]  
• Sriskandan, S., Unnikrishnan, M., Krausz, T., Cohen, J. (2000). Mitogenic factor (MF) is the major DNase of serotype M89 Streptococcus pyogenes. Microbiology 146: 2785-2792 [Abstract] [Full Text]  
• Hsieh, T., Samson, L. M., Jabbour, M., Osmond, M. H. (2000). Necrotizing fasciitis in children in eastern Ontario: a case-control study. CMAJ 163: 393-396 [Abstract] [Full Text]  
• Cunningham, M. W. (2000). Pathogenesis of Group A Streptococcal Infections. Clin. Microbiol. Rev. 13: 470-511 [Abstract] [Full Text]  
• Pang, L. T. Y., Kum, W. W. S., Chow, A. W. (2000). Inhibition of Staphylococcal Enterotoxin B-Induced Lymphocyte Proliferation and Tumor Necrosis Factor Alpha Secretion by MAb5, an Anti-Toxic Shock Syndrome Toxin 1 Monoclonal Antibody. Infect. Immun. 68: 3261-3268 [Abstract] [Full Text]  
• DESCHEEMAEKER, P., VAN LOOCK, F., HAUCHECORNE, M., VANDAMME, P., GOOSSENS, H. (2000). Molecular characterisation of group A streptococci from invasive and non-invasive disease episodes in Belgium during 1993-1994. J Med Microbiol 49: 467-471 [Abstract] [Full Text]  
• Laupland, K. B., Davies, H. D., Low, D. E., Schwartz, B., Green, K., the Ontario Group A Streptococcal Study Group, , McGeer, A. (2000). Invasive Group A Streptococcal Disease in Children and Association With Varicella-Zoster Virus Infection. Pediatrics 105: 60e-60 [Abstract] [Full Text]  
• Committee on Infectious Diseases, (2000). Varicella Vaccine Update. Pediatrics 105: 136-141 [Abstract] [Full Text]  
• Mascini, E. M., Jansze, M., Verhoef, J., van Dijk, H. (1999). Relative Avidities of Human Immunoglobulin G Antibodies for Streptococcal Pyrogenic Exotoxins A and B. CVI 6: 977-980 [Abstract] [Full Text]  
• Feder, H. M. Jr, Lawrence, C. (1999). Group A Streptococcal Multifocal Septic Arthritis: A Case Report. CLIN PEDIATR 38: 481-483  
• Berkovitch, M., Vaida, A., Zhovtis, D., Bar-Yohai, A., Earon, Y., Boldur, I. (1999). Group A Streptococcal Pharyngotonsillitis in Children Less Than 2 Years of Age More Common Than is Thought. CLIN PEDIATR 38: 361-363  
• Duff, B. A., Denny, F. W., Kiska, D. L., Lohr, J. A. (1999). Invasive Group A Streptococcal Disease in Children. CLIN PEDIATR 38: 417-423  
• Desai, M., Efstratiou, A., George, R., Stanley, J. (1999). High-Resolution Genotyping of Streptococcus pyogenes Serotype M1 Isolates by Fluorescent Amplified-Fragment Length Polymorphism Analysis. J. Clin. Microbiol. 37: 1948-1952 [Abstract] [Full Text]  
• Basma, H., Norrby-Teglund, A., Guedez, Y., McGeer, A., Low, D. E., El-Ahmedy, O., Schwartz, B., Kotb, M. (1999). Risk Factors in the Pathogenesis of Invasive Group A Streptococcal Infections: Role of Protective Humoral Immunity. Infect. Immun. 67: 1871-1877 [Abstract] [Full Text]  
• Watson, W. J., Powers, K. S. (1999). Primary Peritonitis Associated with Streptococcal Toxic Shock-like Syndrome. CLIN PEDIATR 38: 175-177  
• GERSHON, A. (1998). Varicella: to vaccinate or not to vaccinate?. Arch. Dis. Child. 79: 470-471 [Full Text]  
• (1998). Varicella-Related Deaths Among Children--United States, 1997. Arch Dermatol 134: 891-892 [Full Text]  
• (1998). Varicella-Related Deaths Among Children--United States, 1997. JAMA 279: 1773-1774 [Full Text]  
• Louie, L., Simor, A. E., Louie, M., McGeer, A., Low, D. E. (1998). Diagnosis of Group A Streptococcal Necrotizing Fasciitis by Using PCR To Amplify the Streptococcal Pyrogenic Exotoxin B Gene. J. Clin. Microbiol. 36: 1769-1771 [Abstract] [Full Text]  
• Basma, H., Norrby-Teglund, A., McGeer, A., Low, D. E., El-Ahmedy, O., Dale, J. B., Schwartz, B., Kotb, M. (1998). Opsonic Antibodies to the Surface M Protein of Group A Streptococci in Pooled Normal Immunoglobulins (IVIG): Potential Impact on the Clinical Efficacy of IVIG Therapy for Severe Invasive Group A Streptococcal Infections. Infect. Immun. 66: 2279-2283 [Abstract] [Full Text]  
• The Working Group on Prevention of Invasive Group, (1998). Prevention of Invasive Group A Streptococcal Disease Among Household Contacts of Case-Patients: Is Prophylaxis Warranted?. JAMA 279: 1206-1210 [Abstract] [Full Text]  
• Asnis, D. S., Knez, T. (1998). Group A Streptococcal Meningitis. Arch Intern Med 158: 810-814 [Full Text]  
• Stockbauer, K. E., Grigsby, D., Pan, X., Fu, Y.-X., Mejia, L. M. P., Cravioto, A., Musser, J. M. (1998). Hypervariability generated by natural selection in an extracellular complement-inhibiting protein of serotype M1 strains of group A Streptococcus. Proc. Natl. Acad. Sci. USA 95: 3128-3133 [Abstract] [Full Text]  
• Committee on Infectious Diseases, (1998). Severe Invasive Group A Streptococcal Infections: A Subject Review. Pediatrics 101: 136-140 [Abstract] [Full Text]  
• Hagberg, C., Radulescu, A., Rex, J. H. (1997). Necrotizing Fasciitis Due to Group A Streptococcus after an Accidental Needle-Stick Injury. NEJM 337: 1699-1699 [Full Text]  
• Couper, R., Charytan, D., Kujath, P., Eckmann, C., McGeer, A., Low, D. E., Davies, H. D., Schwartz, B., Holm, S. E. (1997). Invasive Group A Streptococcal Infections. NEJM 336: 513-515 [Full Text]  
• Cockerill, F. R. III, MacDonald, K. L., Thompson, R. L., Roberson, F., Kohner, P. C., Besser-Wiek, J., Manahan, J. M., Musser, J. M., Schlievert, P. M., Talbot, J., Frankfort, B., Steckelberg, J. M., Wilson, W. R., Osterholm, M. T. (1997). An Outbreak of Invasive Group A Streptococcal Disease Associated With High Carriage Rates of the Invasive Clone Among School-aged Children. JAMA 277: 38-43 [Abstract]  
• (1996). Patterns in Severe Group A Strep Infections. Journal Watch Dermatology 1996: 14-14 [Full Text]  
• (1996). PATTERNS IN SEVERE GROUP A STREP INFECTIONS. JWatch General 1996: 3-3 [Full Text]  
• Holm, S. E. (1996). Invasive Group A Streptococcal Infections. NEJM 335: 589-591 [Full Text]