Group A streptococcal infections are a major cause of benign and deadly human infections with their most destructive manifestation taking the form of necrotizing soft tissue infections (NSTIs) and toxic shock syndrome.
Discussion:
The mainstays of treatment have not changed since antibiotic agents were added to the standard of early diagnosis and aggressive surgical debridement, and the mortality rate continues to be staggering. In the age of targeted medicine, there is undoubtedly a need for a more precise approach to treating this spectrum of aggressive diseases.
Conclusion:
This review covers the basic biology and clinical presentation of NSTIs and group A streptococcal sepsis with particular attention to novel treatments that may transform care and outcomes.
Get full access to this article
View all access options for this article.
References
1.
CarapetisJR, SteerAC, MulhollandEK, et al.The global burden of group A streptococcal diseases. Lancet Infect Dis, 2005; 5:685–694.
2.
JonesJ. Surgical Memoirs of the War of the Rebellion: Investigation Upon the Nature, Causes, and Treatment of Hospital Gangrene, As Prevailed in the Confederate Armies 1861–1865. New York: Published for the U.S. Sanitary Commission by Hurd and Houghton; 1871.
3.
KriegA, DizdarL, VerdePE, et al.Predictors of mortality for necrotizing soft-tissue infections: A retrospective analysis of 64 cases. Langenbecks Arch Surg, 2014; 399:333–341.
HuaC, SbidianE, HemeryF, et al.Prognostic factors in necrotizing soft-tissue infections (NSTI): A cohort study. J Am Acad Dermatol, 2015; 73:1006–12.e8.
Ellis SimonsenS, Van OrmanE, HatchB, et al.Cellulitis incidence in a defined population. Epidemiol Infect, 2006; 134:293–299.
8.
KaoLS, LewDF, ArabSN, et al.Local variations in the epidemiology, microbiology, and outcome of necrotizing soft tissue infections: A multi-center study. Am J Surg, 2011; 202:139–145.
9.
MajeskiJA, AlexanderJW. Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg, 1983; 145:784–787.
10.
McHenryCR, PiotrowskiJJ, PetrinicD, et al.Determinants of mortality for necrotizing soft-tissue infections. Ann Surg, 1995; 221:558–565.
11.
WongC-H, KhinL-W, HengK-S, et al.The LRINEC (laboratory risk indicator for necrotizing fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med, 2004; 32:1535–1541.
12.
GiulianoA, LewisFJr., HadleyK, et al.Bacteriology of necrotizing fasciitis. Am J Surg, 1977; 134:52–57.
13.
HakkarainenTW, KopariNM, PhamTN, et al.Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg, 2014; 51:344–362.
14.
HackettSP, StevensDL. Superantigens associated with staphylococcal and streptococcal toxic shock syndrome are potent inducers of tumor necrosis factor-β synthesis. J Infect Dis, 1993; 168:232–235.
15.
MarrackP, BlackmanM, KushnirE, et al.The toxicity of staphylococcal enterotoxin B in mice is mediated by T cells. J Exp Med, 1990; 171:455–464.
16.
RamachandranG, TulapurkarME, HarrisKM, et al.A peptide antagonist of CD28 signaling attenuates toxic shock and necrotizing soft-tissue infection induced by Streptococcus pyogenes. J Infect Dis, 2013; 207:1869–1877.
17.
MarshallJC, MaierRV, JimenezM, et al.Source control in the management of severe sepsis and septic shock: An evidence-based review. Crit Care Med, 2004; 32.
18.
LederL, LleraA, LavoiePM, et al.A mutational analysis of the binding of staphylococcal enterotoxins B and C3 to the T cell receptor β chain and major histocompatibility complex class II. J Exp Med, 1998; 187:823–833.
AradG, LevyR, NasieI, et al.Binding of superantigen toxins into the CD28 homodimer interface is essential for induction of cytokine genes that mediate lethal shock. PLoS Biol, 2011; 9:e1001149.
21.
BulgerEM, MaierRV, SperryJ, et al.A novel drug for treatment of necrotizing soft-tissue infections: A randomized clinical trial. JAMA Surg, 2014; 149:528–536.
22.
Norrby-TeglundA, MullerMP, McGeerA, et al.Successful management of severe group a streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis, 2005; 37:166–172.
23.
de ProstN, SbidianE, ChosidowO, et al.Management of necrotizing soft tissue infections in the intensive care unit: Results of an international survey. Intensive Care Med. 2015; 41:1506–1508.
24.
DarenbergJ, IhendyaneN, SjölinJ, et al.Intravenous immunoglobulin g therapy in streptococcal toxic shock syndrome: A European randomized, double-blind, placebo-controlled trial. Clin Infect Dis, 2003; 37:333–340.
25.
KadriSS, SwihartBJ, BonneSL, et al.Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock: A propensity score–matched analysis from 130 US hospitals. Clin Infect Dis, 2017; 64:877–85.
26.
PerezEE, OrangeJS, BonillaF, et al.Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol, 2017; 139:S1–S46.
