Paper
Group A streptococcal carrier versus acute infection: the continuing dilemma.
Published Feb 15, 2010 · H. Hill
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
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Abstract
An age old question reappears in the article by Johnson et al in this issue of Clinical Infectious Diseases [1]. Defining what is an acute infection due to group A strep-tococci versus the carrier state of this very common pathogen is of considerable significance because nonsuppurative sequel-ae, such as acute rheumatic fever and acute glomerulonephritis, are said to only follow acute disease. Moreover, transmission of group A streptococci and the development of invasive disease are felt to be associated more often, if not exclusively , with a new acquisition and acute infection rather than the carrier state. The problem, of course, is that as much as 20%–25% of the school-age population may be positive for group A streptococci during the late winter and spring months, even extending into June here in Utah. Intercurrent, viral infection may result in the patient being seen and tested by an-tigen detection or group A streptococcal culture for this very common pathogen. A positive result for streptococci will likely result in antimicrobial therapy being administered for 5–10 days, depending on the antimicrobial agent selected, because such therapy has been shown to markedly decrease the incidence (90%) of acute rheumatic fever, decrease acute glomeru-lonephritis by perhaps 50%, and aid in preventing invasive disease and further spread. Numerous authors, including these same investigators at the University of Minnesota, have pointed out that se-rologic studies targeting nonspecific strep-tococcal extracellular products, such as streptolysin O and DNase B, may be useful in differentiating the carrier state of group A streptococci from acute infection. Longitudinal analysis of group A streptococcal culture results combined with sequential serologic studies have confirmed what Zimmerman et al [2] reported years ago in patients and families they followed in 3 Colorado communities. This group reported that certain families acquired a new streptococcal M or T type that often persisted in individual patients and the family for extended periods of time, up to 2–3 years in some cases. These " carriers " often developed significantly elevated nonspe-cific streptococcal antibody responses but almost never seem to develop nonsup-purative sequelae. The present studies by Johnson et al [1] certainly confirm those findings. As one who has observed the streptococcal world for the past ∼40 years, including working with the group at the Fort Collins Centers for Disease Control and Prevention Streptococcal Disease Laboratory and with the streptococcal group at the University of Minnesota, I am struck by how …
Defining acute group A streptococcal infection from carrier state is crucial for preventing invasive disease and transmission, as carriers often develop elevated nonspetcoccal antibody responses without developing nonsuppurative sequelae.
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