Atypical Influx: Navigating Invasive Group A Streptococcus Cases in Emergency General Surgery

Abstract

Abstract Aim To highlight the rising national incidence of iGAS infections, particularly during the post emergency phase of the COVID-19 pandemic, and emphasise its significance as a differential diagnosis in acutely unwell emergency surgical patients. Methods Data was gathered retrospectively from December 2022 - August 2023. Inclusion criteria were emergency surgical patients testing positive for GAS isolated from sterile sites, or non-sterile sites in case of septic shock. Results Six cases (four females, two males), with a mean age of 55 (36-67) were identified. Four had necrotizing fasciitis, one bacterial peritonitis in the presence of a ventriculo-peritoneal shunt, and one streptococcal bacteremia. All presented in septic shock, with metabolic acidosis and multiorgan impairment. The initial diagnosis was clinical in 66% of cases. iGAS was confirmed via wound, peritoneal fluid, tissue or blood culture in five patients and via genital swab in one. 50% of cases were sensitive to clindamycin and amoxicillin. Two received IV immunoglobulins. All cases were managed according to Sepsis 6 protocols, involving multidisciplinary teams. Five patients underwent immediate surgery for debridement and washout. The mortality rate was 16.6%. Three patients were transferred to tertiary centres once stabilised (1 for neurosurgical input, and 2 for plastics grafting). Conclusion It is crucial for frontline doctors to consider iGAS as a differential when encountering critically ill surgical patients. Simultaneous systemic resuscitation, early surgical intervention, multidisciplinary care, tailored antibiotic therapy and immunoglobulins are essential to minimise morbidity and mortality.