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. 2025 May 6;333(17):1498-1507.
doi: 10.1001/jama.2025.0910.

Invasive Group A Streptococcal Infections in 10 US States

Christopher J Gregory  1 , Jennifer Onukwube Okaro  1 , Arthur Reingold  2   3 , Shua Chai  2   4 , Rachel Herlihy  5 , Susan Petit  6 , Monica M Farley  7 , Lee H Harrison  8 , Kathy Como-Sabetti  9 , Ruth Lynfield  9 , Paula Snippes Vagnone  9 , Daniel Sosin  10 , Bridget J Anderson  11 , Kari Burzlaff  11 , Tasha Martin  12 , Ann Thomas  12 , William Schaffner  13 , H Keipp Talbot  13 , Bernard Beall  1 , Sopio Chochua  1 , Yunmi Chung  1 , Soyoun Park  1 , Chris Van Beneden  1 , Yuan Li  1 , Stephanie J Schrag  1
Affiliations

Invasive Group A Streptococcal Infections in 10 US States

Christopher J Gregory et al. JAMA. .

Abstract

Importance: Invasive group A Streptococcus (GAS) infections are associated with substantial morbidity, mortality, and economic burden.

Objective: To update trends in invasive GAS disease incidence rates in 10 US states between 2013 and 2022.

Design, setting, and participants: Clinical, demographic, and laboratory data for invasive GAS cases were collected as part of population-based surveillance in the Active Bacterial Core surveillance network covering 34.9 million persons across 10 US states. A case was defined as isolation of GAS from a normally sterile site or from a wound in a patient with necrotizing fasciitis or streptococcal toxic shock syndrome between January 1, 2013, and December 31, 2022. Demographic and clinical data were collected from medical record review. From 2013 to 2014, available isolates were emm typed and antimicrobial susceptibilities determined using conventional methods; from 2015 onward, whole-genome sequencing was used.

Main outcomes and measures: Incidence rates by sex, age, race, and selected risk factors; clinical syndromes, outcomes, and underlying patient conditions; and isolate characteristics, including antimicrobial susceptibility.

Results: Surveillance in 10 US states identified 21 312 cases of invasive GAS from 2013 through 2022, including 1981 deaths. The majority of cases (57.5%) were in males. Among case-patients, 1272 (6.0%) were aged 0 to 17 years, 13 565 (63.7%) were aged 18 to 64 years, and 6474 (30.4%) were 65 years or older; 5.5% were American Indian or Alaska Native, 14.3% were Black, and 67.1% were White. Incidence rose from 3.6 per 100 000 persons in 2013 to 8.2 per 100 000 persons in 2022 (P < .001 for trend). Incidence was highest among persons 65 years or older; however, the relative increase over time was greatest among adults aged 18 to 64 years (3.2 to 8.7 per 100 000 persons). Incidence was higher among American Indian or Alaska Native persons than in other racial and ethnic groups. People experiencing homelessness, people who inject drugs, and residents of long-term care facilities had substantially elevated GAS incidence rates. Among tested isolates, those nonsusceptible to macrolides and clindamycin increased from 12.7% in 2013 to 33.1% in 2022.

Conclusions: Invasive GAS infections increased substantially in 10 US states during a surveillance period from 2013 to 2022. Accelerated efforts to prevent and control GAS are needed, especially among groups at highest risk of infection.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Reingold reported being the principal investigator on an emerging infections cooperative agreement from the US Centers for Disease Control and Prevention (CDC). Dr Herlihy reported receiving grants from the CDC’s Emerging Infections Program (EIP); and Epidemiology and Laboratory Capacity Cooperative Agreement funding during the conduct of the study. Ms Petit reported receiving grants to institution from the CDC’s EIP Cooperative Agreement during the conduct of the study. Dr Farley reported receiving grants to institution from the CDC during the conduct of the study. Dr Harrison reported being a data and safety monitoring board member for Merck; and a scientific advisory board member for Sanofi, Pfizer, and GSK outside the submitted work. Dr Lynfield reported receiving grants to institution from the CDC’s EIP Cooperative Agreement during the conduct of the study. Ms Snippes Vagnone reported receiving grants from Minnesota Department of Health during the conduct of the study. Dr Sosin reported receiving grants from the CDC during the conduct of the study and outside the submitted work. Dr Anderson reported receiving grants from the CDC’s EIP Cooperative Agreement during the conduct of the study. Dr Schaffner reported receiving grants from the CDC’s EIP Cooperative Agreement during the conduct of the study. Dr Talbot reported receiving grants from the CDC during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Incidence of Invasive Group A Streptococcus (GAS) Infections, 2013-2022
Data from annual Active Bacterial Core surveillance population. See eAppendix and eTable 1 in Supplement 1 for information on population denominators.
Figure 2.
Figure 2.. Emm Types Comprising ≥5% of Isolates From Invasive Group A Streptococcus Cases, 2013-2022
Figure 3.
Figure 3.. Percentage of Group A Streptococcus Isolates Nonsusceptible to Macrolides and Clindamycin, 2013-2022
aSusceptibility and resistance to macrolides predicted by testing erythromycin per Clinical and Laboratory Standards Institute susceptibility testing standards. bIncludes inducible and constitutive clindamycin nonsusceptibility.
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Comment in

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