Epidemiology and Management of Pediatric Group A Streptococcal Pneumonia With Parapneumonic Effusion: An Observational Study

Abstract

Background: During autumn/winter 2022, UK pediatricians reported an unseasonal increase in invasive group A streptococcal infections; a striking proportion presenting with pneumonia with parapneumonic effusion.

Methods: Clinicians across the United Kingdom were requested to submit pseudonymized clinical data using a standardized report form for children (<16 years) admitted between September 30, 2022 and February 17, 2023, with microbiologically confirmed group A streptococcal pneumonia with parapneumonic effusion.

Results: From 185 cases submitted, the median patient age was 4.4 years, and 163 (88.1%) were previously healthy. Respiratory viral coinfection was detected on admission for 101/153 (66.0%) children using extended respiratory pathogen polymerase chain reaction panel. Molecular testing was the primary method of detecting group A streptococcus on pleural fluid (86/171; 50.3% samples). Primary surgical management was undertaken in 171 (92.4%) children; 153/171 (89.4%) had pleural drain inserted (96 with fibrinolytic agent), 14/171 (8.2%) had video-assisted thoracoscopic surgery. Fever duration after admission was prolonged (median, 12 days; interquartile range, 9-16). Intravenous antibiotic courses varied in length (median, 14 days; interquartile range, 12-21), with many children receiving multiple broad-spectrum antibiotics, although evidence for additional bacterial infection was limited.

Conclusions: Most cases occurred with viral coinfection, a previously well-recognized risk with influenza and varicella zoster, highlighting the need to ensure routine vaccination coverage and progress on vaccines for other common viruses (eg, respiratory syncytial virus, human metapneumovirus) and for group A streptococcus. Molecular testing is valuable to detect viral coinfection and confirm invasive group A streptococcal diagnosis, expediting the incorporation of cases into national reporting systems. Range and duration of intravenous antibiotics administered demonstrated the need for research on the optimal duration of antimicrobials and improved stewardship.

FIGURE 1.

Antibiotic administration in the study cohort. A: Length of antibiotic course. Length of intravenous, oral, and total antibiotic course for children 0–16 years old in the cohort, showing median and interquartile range for each category. Participants with incomplete information on the length of course omitted from each respective violin plot. B: Antimicrobial agents administered. Heatmap showing number of participants who received each of the antimicrobial agents shown. Agents without an intravenous or oral route of administration shaded out in gray.

FIGURE 2.

Viral codetections in the study cohort. A: Absolute counts of viruses detected in the cohort. B: Representation of the five most common viruses co-detected over time in the cohort (darker shade), plotted alongside semi-quantitative measure of UK virus incidence (lighter shade), calculated from UKHSA hospital surveillance data. In general, incidence of co-detected viruses in PPE cohort follows national incidence trends. Some viruses (eg, HMPV) appear over-represented relative to concurrent national incidence. Supplemental Digital Content 2 (Methods) contains detail on how relative incidence curves were calculated. SARS-CoV-2 indicates severe acute respiratory syndrome coronavirus 2.