Genital Tract GAS Infection ISIDOG Guidelines

Abstract

There has been an increasing worldwide incidence of invasive group A streptococcal (GAS) disease in pregnancy and in the puerperal period over the past 30 years. Postpartum Group A streptococci infection, and in particular streptococcal toxic shock syndrome (TSS) and necrotizing fasciitis, can be life threatening and difficult to treat. Despite antibiotics and supportive therapy, and in some cases advanced extensive surgery, mortality associated with invasive group A streptococcal postpartum endometritis, necrotizing fasciitis, and toxic shock syndrome remains high, up to 40% of postpartum septic deaths. It now accounts for more than 75,000 deaths worldwide every year. Postpartum women have a 20-fold increased incidence of GAS disease compared to non-pregnant women. Despite the high incidence, many invasive GAS infections are not diagnosed in a timely manner, resulting in potentially preventable maternal and neonatal deaths. In this paper the specific characteristics of GAS infection in the field of Ob/Gyn are brought to our attention, resulting in guidelines to improve our awareness, early recognition and timely treatment of the disease. New European prevalence data of vaginal GAS colonization are presented, alongside two original case histories. Additionally, aerobic vaginitis is proposed as a supplementary risk factor for invasive GAS diseases.

Keywords: Streptococcus pyogenes; endometritis; invasive GAS infection; maternal mortality; puerperal infection; sepsis.

Figure 1

Bedside fresh wet mount microscopy of S. viridians in vaginal fluid. The differential between other streptococci cannot be made on this picture alone, but in a very sick post-op or postpartum patient it is a rapid clue to suspect streptococcal or staphylococcal sepsis and a hint to undertake further sepsis workup and start timely antibiotic coverage. Small arrows: chains of cocci. Normal arrows: leukocytes indicating inflammatory response.