Invasive group A streptococcal infections requiring admission to ICU: a nationwide, multicenter, retrospective study (ISTRE study)
Authors: Orieux Arthur , Prevel Renaud , Dumery Margot , Lascarrou Jean-Baptiste , Zucman Noémie , Reizine Florian , Fillatre Pierre , Detollenaere Charles , Darreau Cédric , Antier Nadiejda , Saint-Léger Mélanie , Schnell Guillaume , La Combe Béatrice , Guesdon Charlotte , Bruna Franklin , Guillon Antoine , Varillon Caroline , Lesieur Olivier , Grand Hubert , Bertrand Benjamin , Siami Shidasp , Oudeville Pierre , Besnard Céline , Persichini Romain , Bauduin Pierrick , Thyrault Martial , Evrard Mathieu , Schnell David , Auchabie Johann , Auvet Adrien , Rigaud Jean-Philippe , Beuret Pascal , Leclerc Maxime , Berger Asaël , Ben Hadj Salem Omar , Lorber Julien , Stoclin Annabelle , Guisset Olivier , Bientz Léa , Khan Pierre , Guillotin Vivien , Lacherade Jean-Claude , Boyer Alexandre ,   ISTRE Group, Orieux Arthur , Prevel Renaud , Dumery Margot , Lascarrou Jean-Baptiste , Zucman Noémie , Reizine Florian , Fillatre Pierre , Detollenaere Charles , Darreau Cédric , Antier Nadiejda , Saint-Léger Mélanie , Schnell Guillaume , La Combe Béatrice , Guesdon Charlotte , Bruna Franklin , Guillon Antoine , Varillon Caroline , Lesieur Olivier , Grand Hubert , Bertrand Benjamin , Siami Shidasp , Oudeville Pierre , Besnard Céline , Persichini Romain , Bauduin Pierrick , Thyrault Martial , Evrard Mathieu , Schnell David , Auchabie Johann , Auvet Adrien , Rigaud Jean-Philippe , Beuret Pascal , Leclerc Maxime , Berger Asaël , Ben Hadj Salem Omar , Lorber Julien , Stoclin Annabelle , Guisset Olivier , Bientz Léa , Khan Pierre , Guillotin Vivien , Lacherade Jean-Claude , Boyer Alexandre 
Published: January 2024

Abstract
Background
Group A Streptococcus is responsible for severe and potentially lethal invasive conditions requiring intensive care unit (ICU) admission, such as streptococcal toxic shock-like syndrome (STSS). A rebound of invasive group A streptococcal (iGAS) infection after COVID-19-associated barrier measures has been observed in children. Several intensivists of French adult ICUs have reported similar bedside impressions without objective data. We aimed to compare the incidence of iGAS infection before and after the COVID-19 pandemic, describe iGAS patients’ characteristics, and determine ICU mortality associated factors.

Methods
We performed a retrospective multicenter cohort study in 37 French ICUs, including all patients admitted for iGAS infections for two periods: two years before period (October 2018 to March 2019 and October 2019 to March 2020) and a one-year after period (October 2022 to March 2023) COVID-19 pandemic. iGAS infection was defined by Group A Streptococcus isolation from a normally sterile site. iGAS infections were identified using the International Classification of Diseases and confirmed with each center's microbiology laboratory databases. The incidence of iGAS infections was expressed in case rate.

Results
Two hundred and twenty-two patients were admitted to ICU for iGAS infections: 73 before and 149 after COVID-19 pandemic. Their case rate during the period before and after COVID-19 pandemic was 205 and 949/100,000 ICU admissions, respectively (p < 0.001), with more frequent STSS after the COVID-19 pandemic (61% vs. 45%, p = 0.015). iGAS patients (n = 222) had a median SOFA score of 8 (5–13), invasive mechanical ventilation and norepinephrine in 61% and 74% of patients. ICU mortality in iGAS patients was 19% (14% before and 22% after COVID-19 pandemic; p = 0.135). In multivariate analysis, invasive mechanical ventilation (OR = 6.08 (1.71–21.60), p = 0.005), STSS (OR = 5.75 (1.71–19.22), p = 0.005), acute kidney injury (OR = 4.85 (1.05–22.42), p = 0.043), immunosuppression (OR = 4.02 (1.03–15.59), p = 0.044), and diabetes (OR = 3.92 (1.42–10.79), p = 0.008) were significantly associated with ICU mortality.

Conclusion
The incidence of iGAS infections requiring ICU admission increased by 4 to 5 after the COVID-19 pandemic. After the COVID-19 pandemic, the rate of STSS was higher, with no significant increase in ICU mortality rate.