Abstract
We observed an increase in notifications of puerperal group A Streptococcus (GAS) infections in July and August 2018 throughout the Netherlands without evidence for common sources. General practitioners reported a simultaneous increase in impetigo. We hypothesised that the outbreak of puerperal GAS infections resulted from increased exposure via impetigo in the community.We conducted a case–control study to assess peripartum exposure to possible, non-invasive GAS infections using an online questionnaire. Confirmed cases were recruited through public health services while probable cases and controls were recruited through social media. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) with logistic regression analysis.We enrolled 22 confirmed and 23 probable cases, and 2,400 controls. Contact with persons with impetigo were reported by 8% of cases and 2% of controls (OR: 3.26, 95% CI: 0.98–10.88) and contact with possible GAS infections (impetigo, pharyngitis or scarlet fever) by 28% and 9%, respectively (OR: 4.12, 95% CI: 1.95–8.68). In multivariable analysis, contact with possible GAS infections remained an independent risk factor (aOR: 4.28, 95% CI: 2.02–9.09).We found an increased risk of puerperal fever after community contact with possible non-invasive GAS infections. Further study of this association is warranted.
Highlights
Group A Streptococcus (GAS, or Streptococcus pyogenes) infection can manifest as invasive and noninvasive disease
Confirmed cases were defined as culture-confirmed cases of puerperal GAS infection notified by laboratories and clinicians via Municipal Public Health Services (MHS) to the National Institute for Public Health and the Environment (RIVM), fulfilling the following notification criteria: fever within 21 days post-partum and isolation of GAS from a normally sterile body site or urogenital tract [15]
Our study suggests that contact with non-invasive GAS infections in the community in late pregnancy or puerperium increased the risk of puerperal GAS infection
Summary
Group A Streptococcus (GAS, or Streptococcus pyogenes) infection can manifest as invasive and noninvasive disease. Non-invasive infections with GAS such as impetigo, pharyngitis and scarlet fever are common [1,3,4]. Women in the first 30 days of puerperium have a 20-fold increased risk of invasive GAS infection compared with non-pregnant women of reproductive age [8,9]. Invasive GAS infections in puerperium often present as endometritis or sepsis with a genital focus, but can manifest at a non-genital site, and as GAS bacteraemia without a clear focus [8,10]. The source of invasive GAS infection in puerperium is often the woman’s throat or that of a close contact [11]. Healthcare workers carrying GAS are a possible source, and maternity ward clusters of puerperal GAS infections occur occasionally [9]
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