Clinical and molecular epidemiological features of critically ill patients with invasive group A Streptococcus infections: a Belgian multicenter case-series

Marijke Peetermans; Veerle Matheeussen; Cedric Moerman; Fréderic De Rydt; Sabine Thieren; Emily Pollet; Michael Casaer; Benjamin De Backer; Rudi De Paep; Yves Debaveye; Lars Desmet; Stefanie Desmet; Els I M Duval; Vincent Fraipont; Dieter Geysels; Greet Hermans; Frederik Lahaye; Xavier Mathy; Philippe Meersseman; Cécile Meex; Jozef Van Herck; Stefanie van Kleef-van Koeveringe; Nathalie Layios; Joost Wauters; Philippe G Jorens

doi:10.1186/s13613-024-01249-7

Clinical and molecular epidemiological features of critically ill patients with invasive group A Streptococcus infections: a Belgian multicenter case-series

Ann Intensive Care. 2024 Jan 29;14(1):19. doi: 10.1186/s13613-024-01249-7.

Authors

Marijke Peetermans^#^{1

2}, Veerle Matheeussen^#^{3

4}, Cedric Moerman^{5

6}, Fréderic De Rydt^{5

7}, Sabine Thieren^{8

9}, Emily Pollet⁸, Michael Casaer^{10

11}, Benjamin De Backer¹², Rudi De Paep⁵, Yves Debaveye^{10

11}, Lars Desmet¹³, Stefanie Desmet¹⁴, Els I M Duval⁵, Vincent Fraipont¹⁵, Dieter Geysels³, Greet Hermans⁸, Frederik Lahaye⁵, Xavier Mathy¹⁵, Philippe Meersseman⁸, Cécile Meex¹⁶, Jozef Van Herck⁵, Stefanie van Kleef-van Koeveringe³, Nathalie Layios^#^{17

18}, Joost Wauters^#^{8

19}, Philippe G Jorens^#^{5

20}

Affiliations

¹ Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. marijke.peetermans@uzleuven.be.
² Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. marijke.peetermans@uzleuven.be.
³ Department of Microbiology and Belgian Reference Centre for Invasive β-Hemolytic Streptococci, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium.
⁴ Laboratory of Medical Biochemistry and Laboratory of Medical Microbiology, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Antwerp, Belgium.
⁵ Department of Adult and Pediatric Intensive Care Medicine, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium.
⁶ Department of Anesthesiology and Critical Care Medicine, GZA Hospital Group, Antwerp, Belgium.
⁷ Department of Anesthesiology, Chirec Hospitals, Brussels, Belgium.
⁸ Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
⁹ Department of Anesthesiology, VITAZ Hospital, Sint-Niklaas, Belgium.
¹⁰ Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
¹¹ Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
¹² Service de Microbiologie Clinique, CHR Citadelle, Bd du Douzième de Ligne 1, 4000, Liège, Belgium.
¹³ Pediatric Intensive Care Unit, Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
¹⁴ Laboratory for Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
¹⁵ Service des Soins Intensifs, CHR Citadelle, Bd du Douzième de Ligne 1, 4000, Liège, Belgium.
¹⁶ Service de Microbiologie Clinique, University Hospital Liège, Avenue de l'Hôpital, 4000, Liège, Belgium.
¹⁷ Department of Intensive Care, University Hospital Liège, Avenue de l'Hôpital, 4000, Liège, Belgium.
¹⁸ Département des Sciences Cliniques, University of Liège, 4000, Liège, Belgium.
¹⁹ Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
²⁰ Department of Medicine and Health Sciences, Laboratory of Experimental Medicine and Pediatrics (LEMP), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Antwerp, Belgium.

^# Contributed equally.

Abstract

Background: Recent alerts have highlighted an increase in group A streptococcal (GAS) infections since 2022 in Europe and the United States. Streptococcus pyogenes can cause limited skin or mucosal disease, but can also present as severe invasive disease necessitating critical care. We performed a multicenter retrospective study of patients with GAS infections recently admitted to Belgian intensive care units (ICUs) since January 2022. We describe patient characteristics and investigate the molecular epidemiology of the S. pyogenes strains involved.

Results: Between January 2022 and May 2023, a total of 86 cases (56 adults, 30 children) with GAS disease were admitted to critical care in the university hospitals of Leuven, Antwerp and Liège. We noted a strikingly high incidence of severe community-acquired pneumonia (sCAP) (45% of adults, 77% of children) complicated with empyema in 45% and 83% of adult and pediatric cases, respectively. Two-thirds of patients with S. pyogenes pneumonia had viral co-infection, with influenza (13 adults, 5 children) predominating. Other disease presentations included necrotizing fasciitis (23% of adults), other severe skin/soft tissue infections (16% of adults, 13% of children) and ear/nose/throat infections (13% of adults, 13% of children). Cardiogenic shock was frequent (36% of adults, 20% of children). Fifty-six patients (65%) had toxic shock syndrome. Organ support requirements were high and included invasive mechanical ventilation (77% of adults, 50% of children), renal replacement therapy (29% of adults, 3% of children) and extracorporeal membrane oxygenation (20% of adults, 7% of children). Mortality was 21% in adults and 3% in children. Genomic analysis of S. pyogenes strains from 55 out of 86 patients showed a predominance of emm1 strains (73%), with a replacement of the M1_global lineage by the toxigenic M1_UK lineage (83% of emm1 strains were M1_UK).

Conclusions: The recent rise of severe GAS infections (2022-23) is associated with introduction of the M1_UK lineage in Belgium, but other factors may be at play-including intense circulation of respiratory viruses and potentially an immune debt after the COVID pandemic. Importantly, critical care physicians should include S. pyogenes as causative pathogen in the differential diagnosis of sCAP.

Keywords: Community-acquired pneumonia; Critical care; Empyema; Group A streptococci; Influenza; Invasive; Necrotizing fasciitis; Streptococcus pyogenes; Toxic shock syndrome; Viral coinfection.