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January 20, 1993, Vol 269, No. 3 >
ARTICLE | January 20, 1993

The Changing Epidemiology of Invasive Group A Streptococcal Infections and the Emergence of Streptococcal Toxic Shock-like Syndrome: Title and subTitle BreakA Retrospective Population-Based Study FREE

Charles W. Hoge, MD; Benjamin Schwartz, MD; Deborah F. Talkington, PhD; Robert F. Breiman, MD; Elizabeth M. MacNeill, MD; Steven J. Englender, MD, MPH
[+] Author Affiliations

Reprint requests to (address from United States) USA Medical Component, Armed Forces Research Institute of Medical Sciences (AFRIMS), APO AP 96546, or (address from outside of United States) Armed Forces Research Institute of Medical Sciences (AFRIMS), 315/6 Rajvithi Rd, Bangkok 10400, Thailand (Dr Hoge).


JAMA. 1993;269(3):384-389. doi:10.1001/jama.1993.03500030082037
Text Size: A A A
Published online
Article
References

Objective.  —To determine disease incidence and changes in the epidemiology of invasive group A streptococcal infections in a community in Arizona.

Design and Setting.  —We retrospectively surveyed microbiology records from all 10 hospitals in Pima County, Arizona, to identify patients who had Streptococcus pyogenes isolated from blood, sterile body fluid, or tissue biopsy specimens between April 1985 and March 1990. Demographic and clinical information was abstracted from the medical records of these patients.

Patients.  —A total of 128 patients with a median age of 53.5 years (range, 6 months to 96 years).

Outcome Measures.  —Racial/ethnic differences in disease incidence; mortality and changes in the clinical spectrum of disease over the study period.

Results.  —The annual age-adjusted incidence was 4.3 per 100 000 but was 46.0 per 100000 among Native Americans. Advanced age, age less than 5 years, hypotension, and multi-organ system involvement were significantly associated with increased mortality. From 1985 to 1990, the proportion of infections with hypotension, rash, desquamation, renal impairment, and gastrointestinal involvement increased significantly (χ2 for trend P≤.02 for each feature). A toxic shock—like syndrome occurred in 8% of infections since 1988, compared with none of the infections between 1985 and 1987 (P=.04). Patients with the syndrome were younger than patients with other invasive infections (median age 15 vs 54 years, P=.02), and were less likely to have underlying medical conditions (P=.008).

Conclusions.  —Significant changes occurred in the spectrum of invasive group A streptococcal infections in Pima County, Arizona, between 1985 and 1990. Native Americans were at increased risk of acquiring these infections. Patients with the streptococcal toxic shock—like syndrome had epidemiologic features that distinguished them from patients with other invasive infections, including younger age and less underlying illness.(JAMA. 1993;269:384-389)

REFERENCES

1 +
Massel BF, Chute CG, Walker AM, Kurland GS.  Penicillin and the marked decrease in morbidity and mortality from rheumatic fever in the United States. N Engl J Med . 1988;;318:280-286.
2 +
Kohler W, Gerlach D, Knoll H.  Streptococcal outbreaks and erythrogenic toxin type A. Zentralbl Bakteriol Mikrobiol Hyg . 1987;;266:104-115.
3 +
Bisno AL.  The rise and fall of rheumatic fever. JAMA . 1985;;254:538-541.
4 +
Quinn RW.  Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever. Rev Infect Dis . 1989;;11:928-953.
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Veasy GL, Wiedmeier SE, Orsmond GS, et al.  Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med . 1987;;316:421-428.
6 +
Wallace MR, Garst PD, Papadimos TJ, Oldfield EC III.  The return of acute rheumatic fever in young adults. JAMA . 1989;;262:2557-2561.
7 +
Martin PR, Hoiby EA.  Streptococcal serogroup A epidemic in Norway 1987-1988. Scand J Infect Dis . 1990;;22:421-429.
8 +
Communicable Disease Surveillance Centre.  Surveillance of streptococcal infections: bacteraemia and meningitis 1975-88. Communicable Dis Rep . 1990;;26:3-4.
9 +
Braunstein H.  Characteristics of group A streptococcal bacteremia in patients at the San Bernardino County Medical Center. Rev Infect Dis . 1991;; 13:8-11.
10 +
Centers for Disease Control.  Group A beta-hemolytic streptococcal bacteremia—Colorado, 1989. MMWR . 1990;;39:3-11.
11 +
Wheeler MC, Roe MH, Kaplan EL, Schlievert PM, Todd JK.  Outbreak of group A Streptococcus septicemia in children: clinical, epidemiologic, and microbiological correlates. JAMA . 1991;;266:533-537.
12 +
Givner LB, Abramson JS, Wasilauskas B.  Apparent increase in the incidence of invasive group A beta-hemolytic streptococcal disease in children. J Pediatr . 1991;;118:341-346.
13 +
Stromberg A, Romanus V, Burman LG.  Outbreak of group A streptococcal bacteremia in Sweden: an epidemiologic and clinical study. J Infect Dis . 1991;;164:595-598.
14 +
Begovac J, Marton E, Lisic M, Beus I, Bozinovic D, Kuzmanovic N.  Group A beta-hemolytic streptococcal toxic shock-like syndrome. Pediatr Infect Dis J . 1990;;9:369-370.
15 +
Hribalova V.  Streptococcus pyogenes and the toxic shock syndrome. Ann Intern Med . 1988;;108: 772.
16 +
Lersch C, Gain T, Siemens MV, Hagenmuller F, Classen M.  Toxic shock—like syndrome due to severe hemolytic group A streptococcal infection. Klin Wochenschr . 1990;;68:523-525.
17 +
Cone LA, Woodard DR, Schlievert PM, Tomory GS.  Clinical and bacteriologic observations of a toxic shock—like syndrome due to Streptococcus pyogenes. N Engl J Med . 1987;;317:146-149.
18 +
Bartter T, Dascal A, Carroll K, Curley FJ.  Toxic strep syndrome. Arch Intern Med . 1988;;148:1421-1424.
19 +
Stevens DL, Tanner MH, Einship J, et al.  Severe group A streptococcal infections associated with a toxic shock—like syndrome and scarlet fever toxin A. N Engl J Med . 1989;;321:1-8.
20 +
The Tucson Profile, August 1989 . Tucson, Ariz: Indian Health Service, Office of Health Program Research and Development; 1989;.
21 +
Facklam RR, Carey RB.  Streptococci and aerococci.  In: Lannette EH, Balows A, Hausler WJ, Shadomy HJ, eds. Manual of Clinical Microbiology . 4th ed. Washington, DC: American Society for Microbiology; 1985;:154-175.
22 +
Moody MD, Padula J, Lizana D, Hall CT.  Epidemiologic characterization of group A streptococci by T-agglutination and M-precipitation tests in the public health laboratory. Health Lab Sci . 1965;;2:149-161.
23 +
Towbin H, Staehelin T, Gorden J.  Electrophoretic transfer of proteins from polyacrylamide gels to nitrocellulose sheets: procedures and some application. Proc Natl Acad Sci U S A . 1979;;76:4350-4354.
24 +
Talkington DF, Schwartz B, Elliott JA, Hoge CW, Facklam RR. Analysis of streptococcal pyrogenic exotoxins A and B, and M-type, among invasive group A streptococcal strains. Presented at the 91st American Society for Microbiology Annual Meeting; May 5-9,1991; Dallas, Tex. Abstract B-271.
25 +
Camos-Filho N, Franco EL.  A microcomputer program for multiple logistic regression by unconditional and conditional maximum likelihood methods. Am J Epidemiol . 1989;;129:439-444.
26 +
Davis JP, Osterholm MT, Helms CM, et al.  Tri-state toxic-shock syndrome study, II: clinical and laboratory findings. J Infect Dis . 1982;;145:441-448.
27 +
Frances J, Warren RE.  Streptococcus pyogenes bacteraemia in Cambridge: a review of 67 episodes. Q J Med . 1988;;68:603-613.
28 +
Colorado Dept of Health.  Surveillance for group A streptococcal bacteremia in metropolitan Denver. Colo Dis Bull . 1991;;18( (2) ).
29 +
Redd SC, Facklam RR, Collin S, Cohen ML.  Rapid group A streptococcal antigen detection kit: effect on antimicrobial therapy for acute pharyngitis. Pediatrics . 1989;;82:576-581.
30 +
Dajani AS, Ferrieri P, Wannamaker L.  Endemic superficial pyoderma in children. Arch Dermatol . 1973;;108:517-522.
31 +
Longstaffe S, Postl B, Kao H, Nicolle L, Ferguson CA.  Rheumatic fever in native children in Manitoba. Can Med Assoc J . 1982;;127:497-498.
32 +
Coulehan J, Grant S, Reisinger K, Killian P, Rogers KD, Kaltenbach C.  Acute rheumatic fever and rheumatic heart disease on the Navajo reservation, 1962-77. Public Health Rep . 1980;;95:62-68.
33 +
Ward JI, Margolis HS, Lum MK, Fraser DW, Bender TR, Anderson P.  Haemophilus influenzae disease in Alaskan Eskimos: characteristics of a population with an unusual incidence of invasive disease. Lancet . 1981;;1:1281-1285.
34 +
Wotton KA, Stiver HG, Hildes JA.  Meningitis in the central Arctic: a 4-year experience. Can Med Assoc J . 1981;;124:887-890.
35 +
Coulehan JL, Michaels RH, Williams KE, et al.  Bacterial meningitis in Navajo Indians. Public Health Rep . 1984;;99:404-409.
36 +
Yost GC, Kaplan AM, Bustamante R, Ellison C, Hargrave AF III, Randall DL.  Bacterial meningitis in Arizona American Indian children. AJDC . 1986;;140:943-946.
37 +
Duma RJ, Weinberg AN, Medrek TF, Kunz LJ.  Streptococcal infections: a bacteriologic and clinical study of streptococcal bacteremia. Medicine . 1969;; 48:87-127.
38 +
Bibler MR, Rouan GW.  Cryptogenic group A streptococcal bacteremia: experience at an urban general hospital and review of the literature. Rev Infect Dis . 1986;;8:941-951.
39 +
Dan M, Maximova S, Siegman-Igra Y, Gutman R, Rotmensch HH.  Varied presentations of sporadic group A streptococcal bacteremia: clinical experience and attempt at classification. Rev Infect Dis . 1990;;12:537-542.
40 +
Burkert T, Watanakunakorn C.  Group A streptococcal bacteremia in a community teaching hospital—1980-1989. Clin Infect Dis . 1992;;14:29-37.
41 +
Laboratory Center for Disease Control.  Invasive streptococcal disease in British Columbia. Can Dis Wkly Rep . 1990;;16:257-259.
42 +
Schlievert PM, Shands KN, Dan BB, Schmid GP, Nishimura RD.  Identification and characterization of an exotoxin from Staphylococcus aureus associated with toxic-shock syndrome. J Infect Dis . 1981;;143:509-516.
43 +
Centers for Disease Control.  Case definitions for public health surveillance. MMWR . 1990;;39( (suppl RR-13) ):1-4.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Massel BF, Chute CG, Walker AM, Kurland GS.  Penicillin and the marked decrease in morbidity and mortality from rheumatic fever in the United States. N Engl J Med . 1988;;318:280-286.
2 +
Kohler W, Gerlach D, Knoll H.  Streptococcal outbreaks and erythrogenic toxin type A. Zentralbl Bakteriol Mikrobiol Hyg . 1987;;266:104-115.
3 +
Bisno AL.  The rise and fall of rheumatic fever. JAMA . 1985;;254:538-541.
4 +
Quinn RW.  Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever. Rev Infect Dis . 1989;;11:928-953.
5 +
Veasy GL, Wiedmeier SE, Orsmond GS, et al.  Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med . 1987;;316:421-428.
6 +
Wallace MR, Garst PD, Papadimos TJ, Oldfield EC III.  The return of acute rheumatic fever in young adults. JAMA . 1989;;262:2557-2561.
7 +
Martin PR, Hoiby EA.  Streptococcal serogroup A epidemic in Norway 1987-1988. Scand J Infect Dis . 1990;;22:421-429.
8 +
Communicable Disease Surveillance Centre.  Surveillance of streptococcal infections: bacteraemia and meningitis 1975-88. Communicable Dis Rep . 1990;;26:3-4.
9 +
Braunstein H.  Characteristics of group A streptococcal bacteremia in patients at the San Bernardino County Medical Center. Rev Infect Dis . 1991;; 13:8-11.
10 +
Centers for Disease Control.  Group A beta-hemolytic streptococcal bacteremia—Colorado, 1989. MMWR . 1990;;39:3-11.
11 +
Wheeler MC, Roe MH, Kaplan EL, Schlievert PM, Todd JK.  Outbreak of group A Streptococcus septicemia in children: clinical, epidemiologic, and microbiological correlates. JAMA . 1991;;266:533-537.
12 +
Givner LB, Abramson JS, Wasilauskas B.  Apparent increase in the incidence of invasive group A beta-hemolytic streptococcal disease in children. J Pediatr . 1991;;118:341-346.
13 +
Stromberg A, Romanus V, Burman LG.  Outbreak of group A streptococcal bacteremia in Sweden: an epidemiologic and clinical study. J Infect Dis . 1991;;164:595-598.
14 +
Begovac J, Marton E, Lisic M, Beus I, Bozinovic D, Kuzmanovic N.  Group A beta-hemolytic streptococcal toxic shock-like syndrome. Pediatr Infect Dis J . 1990;;9:369-370.
15 +
Hribalova V.  Streptococcus pyogenes and the toxic shock syndrome. Ann Intern Med . 1988;;108: 772.
16 +
Lersch C, Gain T, Siemens MV, Hagenmuller F, Classen M.  Toxic shock—like syndrome due to severe hemolytic group A streptococcal infection. Klin Wochenschr . 1990;;68:523-525.
17 +
Cone LA, Woodard DR, Schlievert PM, Tomory GS.  Clinical and bacteriologic observations of a toxic shock—like syndrome due to Streptococcus pyogenes. N Engl J Med . 1987;;317:146-149.
18 +
Bartter T, Dascal A, Carroll K, Curley FJ.  Toxic strep syndrome. Arch Intern Med . 1988;;148:1421-1424.
19 +
Stevens DL, Tanner MH, Einship J, et al.  Severe group A streptococcal infections associated with a toxic shock—like syndrome and scarlet fever toxin A. N Engl J Med . 1989;;321:1-8.
20 +
The Tucson Profile, August 1989 . Tucson, Ariz: Indian Health Service, Office of Health Program Research and Development; 1989;.
21 +
Facklam RR, Carey RB.  Streptococci and aerococci.  In: Lannette EH, Balows A, Hausler WJ, Shadomy HJ, eds. Manual of Clinical Microbiology . 4th ed. Washington, DC: American Society for Microbiology; 1985;:154-175.
22 +
Moody MD, Padula J, Lizana D, Hall CT.  Epidemiologic characterization of group A streptococci by T-agglutination and M-precipitation tests in the public health laboratory. Health Lab Sci . 1965;;2:149-161.
23 +
Towbin H, Staehelin T, Gorden J.  Electrophoretic transfer of proteins from polyacrylamide gels to nitrocellulose sheets: procedures and some application. Proc Natl Acad Sci U S A . 1979;;76:4350-4354.
24 +
Talkington DF, Schwartz B, Elliott JA, Hoge CW, Facklam RR. Analysis of streptococcal pyrogenic exotoxins A and B, and M-type, among invasive group A streptococcal strains. Presented at the 91st American Society for Microbiology Annual Meeting; May 5-9,1991; Dallas, Tex. Abstract B-271.
25 +
Camos-Filho N, Franco EL.  A microcomputer program for multiple logistic regression by unconditional and conditional maximum likelihood methods. Am J Epidemiol . 1989;;129:439-444.
26 +
Davis JP, Osterholm MT, Helms CM, et al.  Tri-state toxic-shock syndrome study, II: clinical and laboratory findings. J Infect Dis . 1982;;145:441-448.
27 +
Frances J, Warren RE.  Streptococcus pyogenes bacteraemia in Cambridge: a review of 67 episodes. Q J Med . 1988;;68:603-613.
28 +
Colorado Dept of Health.  Surveillance for group A streptococcal bacteremia in metropolitan Denver. Colo Dis Bull . 1991;;18( (2) ).
29 +
Redd SC, Facklam RR, Collin S, Cohen ML.  Rapid group A streptococcal antigen detection kit: effect on antimicrobial therapy for acute pharyngitis. Pediatrics . 1989;;82:576-581.
30 +
Dajani AS, Ferrieri P, Wannamaker L.  Endemic superficial pyoderma in children. Arch Dermatol . 1973;;108:517-522.
31 +
Longstaffe S, Postl B, Kao H, Nicolle L, Ferguson CA.  Rheumatic fever in native children in Manitoba. Can Med Assoc J . 1982;;127:497-498.
32 +
Coulehan J, Grant S, Reisinger K, Killian P, Rogers KD, Kaltenbach C.  Acute rheumatic fever and rheumatic heart disease on the Navajo reservation, 1962-77. Public Health Rep . 1980;;95:62-68.
33 +
Ward JI, Margolis HS, Lum MK, Fraser DW, Bender TR, Anderson P.  Haemophilus influenzae disease in Alaskan Eskimos: characteristics of a population with an unusual incidence of invasive disease. Lancet . 1981;;1:1281-1285.
34 +
Wotton KA, Stiver HG, Hildes JA.  Meningitis in the central Arctic: a 4-year experience. Can Med Assoc J . 1981;;124:887-890.
35 +
Coulehan JL, Michaels RH, Williams KE, et al.  Bacterial meningitis in Navajo Indians. Public Health Rep . 1984;;99:404-409.
36 +
Yost GC, Kaplan AM, Bustamante R, Ellison C, Hargrave AF III, Randall DL.  Bacterial meningitis in Arizona American Indian children. AJDC . 1986;;140:943-946.
37 +
Duma RJ, Weinberg AN, Medrek TF, Kunz LJ.  Streptococcal infections: a bacteriologic and clinical study of streptococcal bacteremia. Medicine . 1969;; 48:87-127.
38 +
Bibler MR, Rouan GW.  Cryptogenic group A streptococcal bacteremia: experience at an urban general hospital and review of the literature. Rev Infect Dis . 1986;;8:941-951.
39 +
Dan M, Maximova S, Siegman-Igra Y, Gutman R, Rotmensch HH.  Varied presentations of sporadic group A streptococcal bacteremia: clinical experience and attempt at classification. Rev Infect Dis . 1990;;12:537-542.
40 +
Burkert T, Watanakunakorn C.  Group A streptococcal bacteremia in a community teaching hospital—1980-1989. Clin Infect Dis . 1992;;14:29-37.
41 +
Laboratory Center for Disease Control.  Invasive streptococcal disease in British Columbia. Can Dis Wkly Rep . 1990;;16:257-259.
42 +
Schlievert PM, Shands KN, Dan BB, Schmid GP, Nishimura RD.  Identification and characterization of an exotoxin from Staphylococcus aureus associated with toxic-shock syndrome. J Infect Dis . 1981;;143:509-516.
43 +
Centers for Disease Control.  Case definitions for public health surveillance. MMWR . 1990;;39( (suppl RR-13) ):1-4.

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