There is paucity of data on the invasive group A Streptococcal disease in children, especially from the developing countries. As an infection in children could take a life-threatening course, an early diagnosis and prompt treatment can go a long way in achieving positive therapeutic outcome. In the present study, 3 infants were detected to have bacteremia due to group A Streptococcus as per their positive blood cultures. There is need to create an awareness among clinicians regarding prevalence of GAS infections. The increasing isolation of organisms in this era of anti-microbial drug resistance necessitates regular epidemiological monitoring of invasive GAS infections in developing countries also.
Keywords: Bacteremia, group a streptococcus, infant, India, streptococcus pyogenes
|How to cite this article:
Singla N, Rani H, Kaistha N, Guglani V, Chander J. Group A Streptococcus bacteremia among infants: A study from tertiary health care center of North India. Ann Trop Med Public Health 2012;5:613-4
|How to cite this URL:
Singla N, Rani H, Kaistha N, Guglani V, Chander J. Group A Streptococcus bacteremia among infants: A study from tertiary health care center of North India. Ann Trop Med Public Health [serial online] 2012 [cited 2017 Nov 14];5:613-4. Available from: https://www.atmph.org/text.asp?2012/5/6/613/109319
Group A Streptococcus (GAS) or Streptococcus pyogenes causes wide range of infections, from relatively mild sore throat and skin infections to life-threatening invasive disease. Invasive GAS infections are defined as an isolation of GAS from normally sterile anatomical sites. Household crowding, Varicella Zoster virus infection, and use of non-steroidal anti-inflammatory drugs (NSAIDS) have been found to be the major risk factors for invasive infections in children along with malignancy, immunosuppression, and age less than 2 years.  There is paucity of data about the clinical features of children with an invasive GAS disease and on the epidemiological and clinical characteristics of this disease, in comparison with adult patients.  The initial clinical presentation and laboratory findings are often non-specific in children with a greater proportion of hospitalizations than in adults. A prompt and reliable diagnosis is necessary for positive therapeutic outcome; however, it requires substantial degree of both, knowledge and suspicion. Hereby, we highlight series of cases where invasive GAS presented as bacteremia in 3 infants.
A 2-months-old female child presented in pediatric emergency of our institution with shortness of breath and refusal to feed for about 4 hours. On examination, she was found to be in the condition of septic shock with hypothermia, respiratory failure along with oral candidiasis. She was started on intravenous fluids, dopamine, and anti-microbials (ceftriaxone and amikacin along with fluconazole). But her condition deteriorated despite cardio-pulmonary resuscitation. She could not be revived and was declared dead after about 8 hours of admission. The antenatal history of her mother was normal, and the child was born by normal delivery at full-term without any complication. She was on exclusive breast feeding and had been immunized with BCG vaccine. Her sodium, potassium, urea, and creatinine levels were found to be 123 mEq/L, 4.8 mEq/L, 60 mg/dl, and 1.2 mg/dl, respectively. Blood culture of the child grew Streptococcus pyogenes after 48 hours of incubation.
An 8-months-old female child was admitted with chief complaint of multiple small abscesses all over the body for the last 15 days and fever for 10 days. There was also a 2 ˜ 2 cm ulcer of irregular margins with pus discharge in the right axillary region. She was diagnosed as case of septicemia with multiple abscesses. She was started on intravenous cloxacillin 300 mg 6 hourly and amikacin 90 mg once-a-day. Blood culture grew S. pyogenes after 48 hours of incubation. However, pus culture from skin abscess grew Staphylococcus aureus. Patient was put on the same antibiotic regimen and improved, hence was discharged on 12 th day of admission.
A 1-year-old male child was admitted to the pediatric emergency with chief complaint of fever for duration of 7 days along with an abdominal distension for 2 days, which was increasing progressively. He was in acute renal failure (ARF) as per the history of no urine output in last 24 hours given by parents. On examination, multiple small pustules resembling pyoderma were observed on the body. The clinical diagnosis was made as septicemia with pneumonia and ARF. On admission, the child was in respiratory distress. He was given oxygen with mask, along with I/V fluids, dopamine, cloxacillin, and ceftriaxone. Cardio-pulmonary resuscitation was done, but the child expired within an hour of admission. Later on, blood culture grew S. pyogenes after 48 hours of incubation.
The spectrum of GAS acute invasive disease includes erysipelas, cellulitis, endometritis, pneumonia, septicemia, meningitis, necrotizing fasciitis, and streptococcal toxic shock syndrome (STTS). A definite case of streptococcal toxic shock syndrome is characterized by isolation of group A Streptococcus from any sterile site, hypotension, and presence of two or more of the following clinical or laboratory findings: Renal impairment, coagulopathy, liver abnormalities, acute respiratory distress syndrome, extensive tissue necrosis, and erythematous rash. The entity has been reported to be associated with significant morbidity and mortality (more than 60%). These 3 children were of probable STSS (PSTSS). 
The WHO data on current evidence for burden of group A Streptococcal diseases published in 2005 clearly states that the incidence of GAS bacteremia in neonates is 0.55 per 1,000 live births while in children under 1 year, 2 years, and 5 years is 96, 63, and 29 per 100,000, respectively, with GAS being the 3 rd most common cause of neonatal bacteremia and is the most common cause of bacteremia in infants aged 7-59 days.  However, the epidemiology, incidence, and mortality of invasive GAS infection has not been properly studied from developing countries like India. Despite an extensive search on PubMed, we could not find much data on GAS bacteremia in India, especially in pediatric age group. ,
All our cases had two common risk factors: Being less than 2 years old and from low socio-economic strata. These 3 cases aptly emphasize that invasive GAS infections can occur in infant age group, have a fulminant, rapidly progressive course and are associated with high mortality (2 died, out of 3 in this series) as has been reported by other workers also.  In routine, in an infant, the causative agents for bacteremia are thought to be gram-negative organisms like Escherichia coli or sometimes gram-positive organisms such as S. aureus. There is a need to create more awareness among clinicians regarding prevalence of GAS infections.
The group A Streptococcus is considered to be a sensitive organism. All the 3 strains in the present series were sensitive to penicillin, amoxycillin, cephalexin, erythromycin, and ciprofloxacin. Traditionally, penicillin is considered as the drug of choice. However, there are reports of emergence of drug resistance among GAS to various groups of antibiotics from all over the world including India. , The newer approaches like use of clindamycin and intravenous immunoglobulin have been found to be of useful and can substantially reduce morbidity as well as mortality. Clindamycin suppresses production of GAS virulence proteins, enhances their phagocytosis by neutrophils and is immune to the inoculum effect as compared to penicillins. 
We conclude that a high index of suspicion is essential to promptly recognize and treat GAS bacteremia. It is further emphasized that increasing incidence, life-threatening nature, and emergence of anti-microbial drug resistance necessitates regular epidemiological monitoring of invasive GAS in developing countries also.
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