# Current Clinical Practice on the Management of Invasive Streptococcus Pyogenes Infections in Children: A Survey-Based Study

## TL;DR

This study surveyed Italian pediatric infectious disease specialists about their current practices for treating severe streptococcus infections in children, highlighting both common approaches and areas of uncertainty.

## Contribution

The study provides insights into the variability of clinical practices for managing invasive GAS infections in children in Italy, emphasizing the need for standardized guidelines.

## Key findings

- Clinicians commonly use penicillin or ceftriaxone as first-line therapies for invasive GAS infections.
- Clindamycin is often combined with beta-lactam antibiotics, except for brain abscesses where linezolid is preferred.
- There is significant disagreement on the use of IVIG, corticosteroids, and timing for de-escalation of antibiotic therapy.

## Abstract

Background/Objectives: Streptococcus pyogenes (Group A Streptococcus, GAS) is a major human pathogen that causes a wide spectrum of diseases. While mild infections like pharyngitis and impetigo are common, severe and invasive infections, though less frequent, pose significant health risks, particularly in children. In recent years, the re-emergence of hypervirulent GAS strains has heightened global concern. Nowadays, the absence of universally accepted guidelines compels clinicians to rely on a combination of clinical judgment, microbiological data and available evidence to manage these infections effectively. Our aim was to assess the current management of invasive GAS (iGAS) infections in Italy and the variability in therapeutic and preventive approaches. Methods: A web-based current clinical practice survey about invasive and severe GAS infections was designed according to the Checklist for Reporting of Survey Studies (CROSS) methodology and circulated among the members of the Italian Society of Pediatric Infectious Diseases (SITIP). Results: The survey reveals that while many practices are commonly shared among clinicians, particularly regarding first-line therapies (penicillin or ceftriaxone depending on the infection site), significant uncertainties remain, particularly about the use of combined antibiotic regimens and supportive treatments. The use of combined antibiotic regimens was considered appropriate as first-line therapy for STSS, NF and brain abscesses. Clindamycin was the preferred agent for combination with beta-lactam for most infections, except for brain abscesses, where linezolid was favored. However, there was disagreement regarding the optimal timing for de-escalation to beta-lactam monotherapy. Responses varied widely concerning the indications and dosages for IVIG, as well as the use of corticosteroids. Conclusions: Addressing the burden of invasive GAS (iGAS) infections in children requires enhanced surveillance, early recognition, prompt treatment and preventive strategies. Further work to increase surveillance, e.g., developing national registries, and to standardize the management of the disease, e.g., developing country-specific guidelines, is essential to build solid evidence on the most effective approaches.