Management of Invasive Group A Streptococcal Infections in Children: The European Society for Pediatric Infectious Disease Guidelines.

BACKGROUND

Invasive group A streptococcal (iGAS) infections in children, although rare, are associated with significant morbidity and mortality, and their incidence has risen globally in recent years. Evidence for optimal management in children is limited. These guidelines aim to provide evidence-based recommendations for the management of pediatric iGAS, including antibiotic therapy, adjunctive nonantibiotic therapies and prophylaxis of close contacts.

METHODS

The ESPID Guidelines Committee convened a multidisciplinary working group. A systematic literature search of pediatric studies published from 2003 to 2023 in PubMed, Embase and the Cochrane Library was performed. Clinical questions with pediatric data were formulated as PICO and assessed using the GRADE approach, with consensus achieved through a modified Delphi process. For clinically important questions lacking sufficient evidence, narrative synthesis with nongraded expert consensus was used. Additional publications until August 2025 contributed qualitatively but were not formally GRADE-graded.

RESULTS

Penicillins remain the first-line therapy for iGAS. In severe or toxin-mediated infections (eg, necrotizing fasciitis or streptococcal toxic shock syndrome), adjunctive clindamycin is suggested, with linezolid as an alternative where clindamycin resistance is confirmed or in central nervous system disease. Intravenous immunoglobulin may be considered in life-threatening toxin-mediated disease, whereas evidence for corticosteroids is insufficient. Prophylaxis is recommended for high-risk household contacts (neonates, postpartum women, elderly, immunocompromised, and recent varicella infection) and considered for all contacts in outbreak settings.

CONCLUSIONS

These ESPID guidelines provide evidence-based recommendations for the management of pediatric iGAS. Given the rarity and limited trial data, most recommendations are weak and supported by low-quality evidence, highlighting the need for high-quality pediatric studies.