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Management of Invasive Group A Streptococcal Infections in Children: The European Society for Pediatric Infectious
Elena Chiappini1,2, Roberta Pellegrino1,2, Irene Dalpiaz1,2
1From the Infectious Diseases Unit, Meyer Children's University Hospital IRCCS, Florence, Italy.
Insights
Updated guidelines recommend penicillins as first-line treatment for invasive group A streptococcal (iGAS) infections in children. Adjunctive therapies and prophylaxis strategies are also outlined, emphasizing the need for more pediatric research.
Area of Science:
- Pediatric Infectious Diseases
- Microbiology
- Clinical Guidelines
Background:
- Invasive group A streptococcal (iGAS) infections in children are rare but serious, with increasing global incidence.
- Optimal management strategies for pediatric iGAS are not well-established.
- Existing evidence for pediatric iGAS treatment is limited, necessitating updated guidelines.
Purpose of the Study:
- To provide evidence-based recommendations for managing pediatric invasive group A streptococcal infections.
- To outline optimal antibiotic therapy, adjunctive nonantibiotic treatments, and prophylaxis for close contacts.
- To address the rising incidence and significant morbidity/mortality associated with pediatric iGAS.
Main Methods:
- Systematic literature search of pediatric studies (2003-2023) in major databases.
- Formulation of PICO questions and assessment using the GRADE approach.
- Consensus achieved through a modified Delphi process and narrative synthesis for low-evidence areas.
Main Results:
- Penicillins are recommended as the first-line antibiotic therapy for iGAS.
- Adjunctive clindamycin or linezolid is suggested for severe or toxin-mediated infections.
- Prophylaxis is recommended for high-risk household contacts and considered in outbreak settings.
Conclusions:
- These guidelines offer evidence-based management recommendations for pediatric iGAS.
- Most recommendations are based on low-quality evidence due to limited trial data.
- High-quality pediatric studies are crucial to improve future management strategies.
Background:
Invasive group A streptococcal (iGAS) infections in children, although rare, are associated with significant morbidity and mortality, and their incidence has risen globally in recent years. Evidence for optimal management in children is limited. These guidelines aim to provide evidence-based recommendations for the management of pediatric iGAS, including antibiotic therapy, adjunctive nonantibiotic therapies and prophylaxis of close contacts.
Methods:
The ESPID Guidelines Committee convened a multidisciplinary working group. A systematic literature search of pediatric studies published from 2003 to 2023 in PubMed, Embase and the Cochrane Library was performed. Clinical questions with pediatric data were formulated as PICO and assessed using the GRADE approach, with consensus achieved through a modified Delphi process. For clinically important questions lacking sufficient evidence, narrative synthesis with nongraded expert consensus was used. Additional publications until August 2025 contributed qualitatively but were not formally GRADE-graded.
Results:
Penicillins remain the first-line therapy for iGAS. In severe or toxin-mediated infections (eg, necrotizing fasciitis or streptococcal toxic shock syndrome), adjunctive clindamycin is suggested, with linezolid as an alternative where clindamycin resistance is confirmed or in central nervous system disease. Intravenous immunoglobulin may be considered in life-threatening toxin-mediated disease, whereas evidence for corticosteroids is insufficient. Prophylaxis is recommended for high-risk household contacts (neonates, postpartum women, elderly, immunocompromised, and recent varicella infection) and considered for all contacts in outbreak settings.
Conclusions:
These ESPID guidelines provide evidence-based recommendations for the management of pediatric iGAS. Given the rarity and limited trial data, most recommendations are weak and supported by low-quality evidence, highlighting the need for high-quality pediatric studies.
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