Reduction in pediatric hospitalizations for varicella-related invasive group a streptococcal infections in the varicella vaccine era

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Abstract

Objectives

To assess changes in hospitalization rates for invasive group A streptococcal (IGAS) and varicella-associated IGAS (VA-IGAS) infections at a pediatric hospital over a period of 9 years, to characterize clinical features of patients with IGAS infections, and to assess frequency of macrolide-resistant IGAS isolates.

Study design

Medical records of all hospitalized patients with group A streptococcus isolated from a normally sterile site from 1993 to 2001 were reviewed. Data collected included demographics, clinical course, microbiologic features, outcome, and presence of streptococcal toxic shock syndrome (STSS) or necrotizing fasciitis (NF). Annual hospitalization rates for IGAS were determined.

Results

There were 144 patients with IGAS infections, including 11 (8%) with STSS or NF. Overall mortality rate was 2% (3/144) but 18% (2/11) among patients with STSS or NF. Preexisting varicella was present in 16% (23/144); 4 of 23 VA-IGAS cases had STSS or NF. Although there was no change in annual hospitalization rates for IGAS infections during the study period, the percentage of VA-IGAS hospitalizations decreased from 27% in the prevaccine era (1993 to 1995), to 16% during vaccine implementation (1996 to 1998) and 2% during widespread vaccine use (1999 to 2001) (linear-by-linear association, P = .001). Macrolide resistance was low in 1993 to 1995 (5%, 1/19) and 1996 to 1998 (0%, 0/42) among tested IGAS isolates and increased significantly in 1999 to 2001 (13%, 5/38) (Fisher exact, P = .035).

Conclusions

A decline in pediatric varicella-related IGAS hospitalizations was temporally associated with utilization of varicella vaccine. These data reinforce the importance of universal varicella vaccination for children. Increasing macrolide resistance among IGAS isolates indicates a need for continued surveillance.

Section snippets

Methods

We performed a retrospective medical record review of all patients with GAS isolated from a sterile site that were admitted to Children's Memorial Hospital, a pediatric tertiary care hospital, between January 1, 1993, and December 31, 2001. Subjects were identified from microbiology laboratory records. Cases were excluded if (1) culture from only a nonsterile site was identified (vaginal, throat, sputum, superficial, etc); (2) source of GAS culture was not well documented; (3) culture yielded

Results

During the 9-year study period, 238 hospitalized patients with GAS thought to be isolated from a normally sterile site were identified. A total of 235 medical records (99%) were available for a preliminary review. Among these, 91 records were excluded, based on our criteria. The primary reason for exclusion was recovery of GAS only from a superficial site, accounting for 59 cases. Twenty-nine cases were excluded for mixed growth without predominance of GAS, and 3 cases were excluded for

Discussion

This retrospective study documented a significant decline in varicella-associated IGAS hospitalizations temporally associated with increasing utilization of varicella vaccine. The proportion of IGAS hospitalizations that were varicella-associated declined from 27% in the prevaccine era (1993 to 1995) to 16% during vaccine implementation (1996 to 1998) and to only 2% with widespread vaccine use in Illinois (1999 to 2001). This finding of a significant reduction in VA-IGAS hospitalizations

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    Presented in part at the Pediatric Academic Societies' Meeting, May 3, 2003, Seattle, Washington.

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