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Strep STORY BY

Dr. Zuber Mulla

A healthy 17-year-old is playing high-school football and is tackled. His thigh is bruised, he misses a few plays, but brushes it off.

As the days go by, the pain and swelling increases. He suddenly turns seriously ill, is rushed to the hospital, undergoes surgery and later dies.

Physicians find a bacterium known as Group A Streptococcus in his blood and muscle. This tragic case of "Invasive Group A Streptococcal disease" (GAS) occurred several years ago in Charleston, South Carolina.

Though rare, each year, we read headlines about a handful of otherwise healthy people who die from a seemingly minor scratch, insect bite or bruise. The culprit turns out to be a virulent form of bacterial infection.

What is Group A Strep?

It is simply a strain of bacteria that, depending on where it takes up residence, can be easily treated or turn deadly.

Take strep throat: millions of strep throat cases occur every year in the United States. This "noninvasive" infection is caused by the same Group A Streptococcus. It lives in the back of the throat, reproduces, and infects the tonsils and surrounding tissue. Sick as you might feel, the bug usually does not enter the main bloodstream-the highway throughout the body.

When this same bacterium (which may live harmlessly on the surface of our skin) enters our bloodstreams through a cut, an over-scratched bug bite or a surgical wound, you may have what is known as an invasive Group A strep (GAS) infection.

Invasive GAS is becoming a major public health attention-grabber. In the US, more than 8,000-10,000 cases occur each year—twice as often as some strains of E.coli and 4 times more likely to occur than meningococcal disease.

When strep hits the bloodstream, it can manifest in different ways including:

Necrotizing Fasciitis (NF) is the form that makes headlines. This bug has been dubbed the "flesh-eating" bacterium by the popular press for its ability to cause rapid destruction of soft tissue.

Patients are often young, healthy, suffer a cut or a bruise on their legs, and in a matter of days are hospitalized with extreme pain and progressive tissue damage that may lead to amputation or death.

Studies show though that in 45 percent of all cases, no definite entry point can be found. In about half of the patients who develop invasive GAS disease, the Strep entered through the skin.

About 10 million cases of the less-serious noninvasive group A streptococcal infection occur every year in the form of strep throat or impetigo (skin infection).

Who is at risk?

Very young children and the elderly seem to be at greater risk for developing invasive GAS. One study involving children in Ontario, Canada showed a marked increase in invasive GAS infection after the children came down with varicella (chicken pox.) They found that about 5 per 100,000 cases of chicken pox developed invasive strep infections, in comparison to less than 1 per 100,000 in the non-chicken pox infected population. Researchers believe that the bacterium enters the skin through the pox lesions.

Studies show that among adults ages 18-44, HIV infection and injectible drug use raised the risk. Persons 45 years old and older with a history of cancer or heavy therapeutic corticosteroid (steroid) use added to their risk of infection, as did heart disease, lung disease, surgical wounds, and diabetes. Alcoholism also was listed as a risk factor.

Hospital-based or "nosocomial" infections can occur from needle punctures or surgical wounds. For that reason, hospitals have rigorous hygiene guidelines for health care professionals and housekeeping staff.

Also, according to a study of invasive GAS in Atlanta, Ga., black-skinned Americans had a higher risk for invasive infection at 9.7 per 100,000 persons a year-a number 3 times higher than that of light-skinned Americans. Native Americans were also at higher risk.

Treatment

So how do you treat these nasty infections? Antibiotics like penicillin have been used for years to treat Group A strep infections. Aggressive surgery may also be required to remove dead tissue among patients with NF.

Researchers though are finding that another antibiotic, clindamycin, is more effective. Colorado researchers found that clindamycin did improve outcomes among children hospitalized for this disease.

Confirmation of these results came from a group of Florida patients during the largest study of its kind. We found that among 195 patients hospitalized for invasive GAS infections, that treatment with clindamycin reduced the mortality rate of the NF form of the infection by 89 percent. This study was published in the October 2003 issue of Southern Medical Journal.

Best Prevention is Still the Oldest

Old-fashioned cleanliness is still the best prevention: wash your hands and wash them correctly. Soap up well for about 15 seconds and then rinse vigorously while rubbing your hands together. (You literally can dislodge bacteria and wash it down the drain.) Good hand-washing should take about 30 seconds. (An easy trick to help you: hum the first verse of any song all the way through while you're rubbing.)

For daily hand-washing, in the absence of household illness, plain soap and water do the trick. Anti-bacterial soaps are not necessary. Save your anti-microbial agents for bathroom and kitchen cleaning.

When you have a cut or scrape, clean it with an alcohol swab, apply an over-the-counter triple antibiotic and cover with a band-aid. If you have an insect bite that begs to be scratched, relieve the itch with an over-the-counter anti-itch cream and then apply a triple antibiotic and cover.

If your child has strep throat, follow the pediatrician's instructions regarding the administration of the antibiotic. Keep your hands clean, away from your face and keep your child at home until he or she is fever-free for 24 hours. The same prevention applies to you.

Symptoms of Invasive GAS

According to the Centers for Disease Control and Prevention, the early signs and symptoms of necrotizing fasciitis include:

While the early signs and symptoms of STSS are:

Initial signs and symptoms may also include nausea, vomiting, and diarrhea.

On the positive side, a GAS vaccine is on the horizon, and, fortunately, most of us who come in contact with GAS will never develop invasive GAS disease.

Last Updated: 9-13-2004