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Posted on 22 Dec 2022
Paediatric

In 2022, there has been a marked increase in the number of cases of Group A streptococcal infections and in other bacterial infections, including Streptococcus pneumoniae, in the Victorian community. Children and adolescents with signs of a serious bacterial infection should be treated promptly with antibiotics and referred.

This year, there have been over 60 children with Group A streptococcal infections admitted to the Royal Children’s Hospital (RCH), including 30 invasive infections, and an additional 100 Emergency Department presentations with sore throat, scarlet fever and skin infections.
 
Since September, the number of invasive Group A streptococcal infections that RCH has identified from blood (bacteraemia), pleural fluid (empyema), tissue (necrotising fasciitis) or joint, has been similar (21 cases) to that seen in an average year (20-25 cases per year), and in much higher numbers than seen in the pandemic years 2020 and 2021 (4 and 3 cases per year, respectively). Monash Children’s Hospital has seen 12 cases of invasive Group A streptococcal infection in 2022.  

There have been at least 3 deaths from invasive streptococcal infections or toxic shock syndrome this year, including 2 caused by Group A streptococcus, and many other children with Group A streptococcal sepsis have required intensive care.

Signs and symptoms

The signs of invasive streptococcal disease are non-specific but include more than one of: 

  • fever 
  • erythematous sunburn-like rash (scarlet fever rash, which may be subtle or florid) 
  • cold or mottled limbs
  • limb pain 
  • not wanting to walk
  • poor feeding
  • abdominal pain, vomiting
  • lethargy
  • throat infection
  • pneumonia and pleural effusion
  • oliguria. 

Advice for clinicians

While many streptococcal infections can be similar to a viral infection, and streptococcal infection often follows a virus, the presence of multiple signs or their extreme nature (for example, a mottled, febrile child or adolescent who refuses to walk), signals likely serious bacterial infection rather than a common viral syndrome. 

  • Take a careful history and record a timeline of the illness for every child and adolescent.
  • Be alert to the child or adolescent who is more unwell than you would expect with a viral illness or had a viral illness and then became more unwell.  
  • Do a full assessment of the severity of illness, including cardiovascular assessment (skin mottling and temperature, peripheral pulse volume, capillary refill, blood pressure).  
  • Do a blood culture, full blood examination and venous blood gas in any child with persistent, multiple, or severe signs listed above that may indicate serious bacterial infection.
  • If the child has clinical or laboratory signs* of serious bacterial infection commence antibiotics immediately and seek review by a senior paediatric doctor. Initial antibiotics should include a third-generation cephalosporin, plus flucloxacillin or clindamycin. 

Early resuscitation with oxygen, antibiotics and fluid is critical for those with sepsis, as is urgent escalation. Transfer to a tertiary centre may be required, contact PIPER (1300 137 650). 

* Signs of a serious infection on full blood count are neutrophilia, neutropenia or leukopenia, a high immature neutrophil count (high bands, myelocytes, metamyelocytes), thrombocytopenia or marked thrombocytosis. Signs of severe sepsis on a venous blood gas include metabolic acidosis, lactate >3mmol/L, or hyponatraemia.