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Streptococcal Disease

Streptococcal Disease is a topic covered in the 5-Minute Emergency Consult.

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  • Increase in frequency of aggressive streptococcal necrotizing skin infection noted in 1980s and dubbed “flesh-eating bacteria.”
  • Affects otherwise healthy patients aged 20–50 yr who did not have underlying predisposing diseases.
  • Rapid progression of shock and multiorgan dysfunction, with death occurring within 1–2 days.
  • Incidence is 3–4 per 100,000 in industrialized countries
  • Invasive infections caused by group A Streptococcus (GAS) include:
    • Necrotizing fasciitis (NF):
      • Progressive, rapidly spreading soft tissue infection located within the deep fascia and subcutaneous fat
    • Streptococcal toxic shock syndrome (STSS):
      • May occur in patients with GAS associated NF.
      • Portals of entry for streptococci include vagina, pharynx, mucosa, and skin.
      • Unknown cause in 50% of cases.
    • “Other” invasive disease defined as isolation of GAS from a normally sterile body site (i.e., sepsis, bacteremic pneumonia, septic arthritis, etc.)
  • Occurs sporadically, with occasional outbreaks in long-term care facilities and hospitals.
  • Rate of invasive GAS disease 6 times the annual incidence of meningococcal disease.

STSS Case Definition
  • Isolation of GAS from sterile or nonsterile body site
  • Hypotension
  • 2 or more of the following:
    • Renal impairment
    • Coagulopathy
    • Liver abnormalities
    • Acute respiratory distress
    • Extensive tissue necrosis (NF)
    • Erythematous rash


  • NF:
    • GAS is causative in 10% of cases. Blunt trauma is risk factor.
    • Mixed anaerobic and aerobic organisms are found in 70% of cases.
    • Staphylococcus aureus, Clostridium species, and other enteric organisms
  • Streptococcal toxic shock syndrome:
    • Occurs when susceptible host is infected with virulent strain
    • M protein types 1, 3, and 28 are most common.
    • Pyrogenic exotoxins (e.g., A, B, and C) produce fever and shock via activation of tumor necrosis factor and interleukins.
    • Nonsteroidal anti-inflammatory drugs appear to mask or predispose patients.
    • Risk factors:
      • Age <10 or >60 yr
      • Cancer
      • Renal failure
      • Leukemia
      • Severe burns
      • Corticosteroids

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Rosen, Peter, et al., editors. "Streptococcal Disease." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307068/all/Streptococcal_Disease.
Streptococcal Disease. In: Rosen P, Shayne P, Barkin AZ, et al, eds. 5-Minute Emergency Consult. 5th ed. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307068/all/Streptococcal_Disease. Accessed April 25, 2019.
Streptococcal Disease. (2016). In Rosen, P., Shayne, P., Barkin, A. Z., Wolfe, R. E., Hayden, S. R., Barkin, R. M., & Schaider, J. J. (Eds.), 5-Minute Emergency Consult. Available from https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307068/all/Streptococcal_Disease
Streptococcal Disease [Internet]. In: Rosen P, Shayne P, Barkin AZ, Wolfe RE, Hayden SR, Barkin RM, Schaider JJ, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2019 April 25]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307068/all/Streptococcal_Disease.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Streptococcal Disease ID - 307068 ED - Rosen,Peter, ED - Shayne,Philip, ED - Barkin,Adam Z, ED - Wolfe,Richard E, ED - Hayden,Stephen R, ED - Barkin,Roger M, ED - Schaider,Jeffrey J, BT - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307068/all/Streptococcal_Disease PB - Lippincott Williams & Wilkins ET - 5 DB - Emergency Central DP - Unbound Medicine ER -