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. 2025 Dec 3.
doi: 10.1097/INF.0000000000005055. Online ahead of print.

Increasingly Frequent Parapneumonic Empyema by Group A Streptococcus Is More Severe Than by Streptococcus pneumoniae

Catarina Miguel Boto  1 , Sofia Raposo Carneiro  1 , Margarida Ramalho  2 , Inês Passos Coelho  2 , Isabel Moitinho de Almeida  2 , Carolina Ferreira  3 , Maria Luís Tomé  4 , Maria Sousa Dias  4 , Ana Araújo Carvalho  5 , Rita Machado  5 , Marta Oliveira  6 , Miguel Seruca  7 , Leonor Boto  8 , Filipa Prata  2 , Raquel Penteado  9 , Anália Carmo  10 , Fernanda Rodrigues  3 , Margarida Tavares  4 , Sandra Rebelo  11   12   13 , Manuela Ribeiro  14 , Joana Gomes-Silva  15 , Ana Friães  15 , Catarina Silva-Costa  15 , Mário Ramirez  15 , José Melo-Cristino  15 , Ana Pereira Lemos  1 , Catarina Gouveia  1   16
Affiliations

Increasingly Frequent Parapneumonic Empyema by Group A Streptococcus Is More Severe Than by Streptococcus pneumoniae

Catarina Miguel Boto et al. Pediatr Infect Dis J. .

Abstract

Background: Streptococcus pneumoniae (Sp) is the leading bacterial pathogen causing complicated pneumonia, that is, with parapneumonic effusion/pleural empyema (PPE/PE). In 2022, there was a rise in group A Streptococcus (GAS)-complicated pneumonias in children.

Methods: We reviewed the clinical characteristics of Sp- or GAS-complicated pneumonias admitted to 4 Portuguese tertiary hospitals, in 2018-2023.

Results: Of the 128 cases, 107 were by Sp and 21 by GAS, with a rise in PPE/PE in 2023. Pathogens were identified by molecular methods (89.8%) or culture (16.4%) from pleural fluid or blood. The mean age was 3.8 years (standard deviation 2.9) and 52.3% were male. Children with GAS PPE/PE were more likely to have rash (57.1% vs. 3.8%, P < 0.001), pharyngitis (52.4% vs. 19.8%, P = 0.004), septic shock (28.6% vs. 0.9%, p<0.001), higher procalcitonin (PCT) (80 vs. 2.13 ng/mL, P = 0.005), higher rates of admission to the intensive care unit (81.0% vs. 55.1%, P = 0.030) and of invasive mechanical ventilation (38.1% vs. 11.2%, P = 0.005). Fatality rate was similar in both groups (4.8% vs. 0%, P = 0.164). Among cases where genotyping was possible, 4/7 GAS were emm1 (3/4 M1UK sublineage, all in 2023) and 64/88 Sp were serotype 3.

Conclusions: Sp serotype 3 remains the leading cause of PPE/PE in children in Portugal. The increase in GAS PPE/PE cases in 2023 followed an expansion of the M1UK sublineage in Portugal. GAS should be considered, especially in children presenting with rash, pharyngitis or higher PCT levels. Adequate antimicrobial and clinical management of GAS PPE/PE could be crucial to improve outcomes.

Keywords: pediatric pneumonia; pleural empyema.

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Conflict of interest statement

The molecular study of this work was partly supported by an unrestricted research grant from Pfizer and a grant awarded by the Sociedade Portuguesa de Microbiologia Clínica e Doenças Infecciosas. The opinions expressed in this paper are those of the authors. The authors have no conflicts of interest to disclose.

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