Clindamycin and intravenous immunoglobulins in pediatric invasive group A streptococcal disease: what is the evidence?

Invasive group A streptococcal disease (iGAS) can present with severe manifestations, including sepsis, necrotizing fasciitis, and streptococcal toxic shock syndrome. Although β-lactam antibiotics are considered standard therapy, the role of adjunctive treatments, particularly clindamycin and intravenous immunoglobulin (IVIG), in children with these severe manifestations remains debated. Clindamycin is effective irrespective of pathogen load and is suggested to inhibit toxin production, while IVIG is hypothesized to modulate the immune response through multiple mechanisms, including neutralization of superantigens. The rarity of iGAS in children and the relatively low pediatric mortality rate (2-10%) complicate gathering evidence, with most data derived from small, low-quality studies. Evidence is often extrapolated from adult studies, despite substantial differences in mortality rates (30-80%). In this narrative review, we discuss the available evidence on the use of adjunctive therapies in severe pediatric iGAS and its possibility in guiding clinical management. Conclusion: Current evidence does not allow definitive conclusions regarding the benefit of clindamycin or IVIG in severe pediatric iGAS. Treatment decisions therefore largely rely on expert consensus and individualized clinical judgment. Ongoing multicenter studies, such as PEGASUS, aim to clarify the role of these adjunctive therapies and guide evidence-based practice.  What is Known: • β-Lactams are first-line treatment for pediatric invasive group A streptococcal disease (iGAS). • Clindamycin and IVIG have been suggested as adjuncts in severe iGAS, but recommendations differ, and many countries have no formal guidance. What is New: • This review shows that evidence supporting clindamycin and IVIG in children with iGAS remains limited and is largely extrapolated from adult studies. It highlights variability in clinical practice, safety and cost concerns, and the need for larger-scale pediatric studies.