CHARACTERISTICS OF INVASIVE GROUP A BETA HEMOLYTIC STREPTOCOCCAL INFECTIONS IN CRITICALLY ILL CHILDREN. 274

Objective: To describe clinical and microbiological characteristics of a cluster of critically ill children with Group A Beta Hemolytic Streptococcal (GABS) infections. Design: Concurrent review. Setting: Pediatric intensive care unit of a university teaching hospital. Patients: Six children (mean age 3.4±2 yrs) with culture-proven GABS disease. Interventions: After routine hemodynamic and intensive care management, culture isolates of GABS were sent to the CDC, Atlanta GA, for surface protein identification and to the University of Minnesota Microbiology Department for exotoxin typing.Results: Five of six children were admitted in a 16 week period between March and July, 1994; the sixth in April, 1995. GABS was the causative organism for two cases of pneumonia with empyema and one case each of peritonitis, superinfection of thermal burn with inhalation injury, mastoiditis presenting as status epilepticus, and overwhelming septic shock. Bacteremia was documented in 4 of 6 patients (67%). Four patients (67%) fulfilled streptococcal shock syndrome(SSS) criteria.* The mean PRISM was 16±9 and the mortality rate was 17%. The acute respiratory distress syndrome (ARDS) occurred in four of five patients who required mechanical ventilation while the fifth was intubated for airway control. Pulmonary artery catheterization was performed in three patients. Two had elevated cardiac indices (CI)(5.9 and 4.73 I/min/m²) while the third, who died, had a depressed (2.33 I/m/m²) CI despite resuscitation. Systemic vascular resistances were decreased (788 dyneseccm²/cm⁵) or normal (1587) in the survivors and low normal(1438) in the patient who died. Four patients (67%) either had varicella or had recently been exposed to it. None had received ibuprofen. Evaluation of four GABS isolates revealed each produced exotoxin B, either alone, or in conjunction with exotoxin A. No M or T type predominance was identified.Conclusion: A cluster of invasive GABS cases occurred in a one year period. Hemodynamic patterns were similar to those seen in septic shock. Heightened suspicion for GABS disease should be maintained in ill children who have recently had, or been exposed to, varicella.