Sharp increase in the incidence and severity of invasive Streptococcus pyogenes infections in children after the COVID-19 pandemic (2019-2023): A nationwide multicenter study

Abstract

OBJECTIVES: A global surge in pediatric invasive group A streptococcal infection (iGAS) was reported after autumn 2022. This study analyzed the epidemiology and severity of iGAS in Spain, comparing two periods; P1: pre-outbreak (January 2019-September 2022) versus P2: outbreak (October 2022-July 2023). METHODS: Children ?16 years with iGAS enrolled in the Spanish PedGAS-net (2019-2023), were included. Bacterial isolates were analyzed for emm typing, antibiotic susceptibility, and whole genome sequencing. Multivariate analysis identified risk factors for PICU admission and mortality. RESULTS: 558 cases were included; 307 (55.1%) were male, with a median age of 43.9 months (IQR:19.3-84.1). There were significantly more iGAS in P2 (35.7 vs. 4.5 cases/month, P < 0.001), with higher PICU admissions (51.3% vs. 30.8%, P < 0.001). Pneumonia was the most common syndrome (32.3%), with pleural effusion in 58.3%. Of the 130 samples available for emm-typing, the most frequent were emm1 (56.1%) and emm12 (27.1%). 245 (43.9%) required PICU admission. Factors associated with PICU were streptococcal toxic shock syndrome (STSS), pneumonia, necrotizing fasciitis, acute kidney failure, and previous consultation before diagnosis. The emm1 (especially M1(UK)) increased PICU risk. 11 children (2.0%) died. STSS, sepsis, and central nervous system infection were associated with mortality. CONCLUSION: In Spain, pediatric iGAS cases sharply increased during 2022-2023, with a remarkable increase in severity. Epidemiological surveillance of iGAS remains crucial.