164 Invasive Group a Streptococcal Infections: The Liverpool Experience 2009

Abstract

Background: Winter ‘08-’09 saw an increased incidence of invasive Group A Streptococcus infections (iGAS) above seasonal average, with an unusually high fatality rate (HPA data 25%).

Method: Eleven patients presented to our PICU between November 2008 and June 2009. Many of these children deteriorated very quickly despite full supportive measures, often after initial stabilisation. We aim to highlight the lessons we have learnt in their management.

Results: We treated 10 cases with toxic shock syndrome and 2 cases of necrotising fasciitis (NF) due to iGAS. 1 patient had both. Risk factors were identified in 9/11 (2 recent Varicella, 2 neonates, 3 chronic disease, 7 NSAIDs and 1 trauma). All patients with septic shock were under 9 years, with 4/10 (40%) under 1 year (European surveillance data shows risk highest under 1 yr). Both patients with NF only stabilised after extensive surgical debridement. Our male: female ratio was 1:1.6 which is at odds with surveillance data suggesting higher rates in males. Emm type reflected those circulating in the community (1,3,4,6,12,18, 75 & 89). 3 patients (27%) have died despite aggressive PICU management (including CVVH, HFOV), none of these patients received intravenous clindamycin. All those who survived have been treated with clindamycin in addition to cefotaxime. Clindamycin decreases cytokine and exotoxin production and is recommended in iGAS in addition to cefotaxime or benzylpenicillin.

Conclusion: We have learnt to act quickly when treating suspected iGAS with aggressive management (adding clindamycin to cefotaxime), and involving surgical team for early debridement when NF suspected.

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