Strep A is showing up in increased numbers of head and neck abscesses

Strep A is showing up in increased numbers of head and neck abscesses in one of the nation’s leading pediatric treatment centers. Researchers believe the higher incidence of this potentially dangerous infection mirrors a trend found in other hospitals, reflecting the potentially dangerous evolution of the biology and virulence of this streptococcal organism.

Head and neck abscesses are infrequent complications of upper respiratory infections, but they can occur suddenly and be rapidly progressive. If untreated, the abscesses can lead to airway obstruction, vision loss, intracranial infections, and even death. Although the use of antibiotics has generally decreased the morbidity and mortality of infections in the head and neck, other factors may allow serious infections to progress despite appropriate use of antibiotics.

Pediatric ear, nose, and throat specialists at a major pediatric treatment facility noted that, in a three month period, the incidence of head and neck abscesses significantly increased. An examination of this increase is reported in the study, “Increased Incidence of Head and Neck Abscesses in Children,” authored by Cristina E. Cabrera, Ellen S. Deutsch MD, Stephen Eppes MD, Stephen Lawless MD, Steven Cook MD, Robert C. O’Reilly MD, and James S. Reilly MD, all from the Nemours Childrens Clinics, Alfred I. duPont Hospital for Children, Wilmington, DE. Their findings are being presented at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting & OTO EXPO, being held September 19-22, 2004, at the Jacob K. Javits Convention Center, New York City, NY.

Methodology:

This research effort examined all children younger than 19 years admitted to the Alfred I duPont Hospital for Children of the Nemours Children’s Clinics, a tertiary care pediatric hospital, during the first quarters of 2000 through 2003, for suspicion of head and neck abscess or phlegmon [define] involving peritonsillar, retropharyngeal, and parapharyngeal spaces (upper airway); lateral neck; face; and orbital and intracranial complications of acute sinusitis. Patients with complications of dental disease or otitis media, such as acute coalescent mastoiditis, were excluded.

A retrospective review entailing all potentially relevant ICD-9 codes listed as either primary or secondary diagnosis was undertaken. The search included approximately 60 codes related to abscess, phlegmon, infection, adenitis [define]or adenopathy [define] in the head and neck, including sinuses and orbits [define], excluding dental and scalp infections and infections limited to the middle ear and mastoid. Records were searched from 1998 through 2003, identifying 4691 encounters with 2772 unique patients. Information about patients treated in 1998 and 1999 was not consistently available in electronic format, so this group of patients was eliminated from the review. The review was then limited to the first quarters of 2000 through 2003 because this time period included the greatest density of cases; 965 possible patient records were identified. Each patient record was then reviewed electronically; paper records were reviewed if necessary. Eighty-nine patients with relevant infections were identified.

Data gathered included the incidence and site of infection, age of the patient, and organisms reported from culture results. Abscesses were classified as neck abscesses, facial abscesses, abscesses surgically accessible trans-orally; and orbital and intracranial complications of acute sinusitis.

The number of total hospital admissions during the study periods was obtained to determine the proportion of patients with abscesses relative to the hospitalized patient census to calculate overall incidence. Outcome measures include incidence of infections relative to total hospital admissions evaluated by chi-square technique, description of abscess locations, and description of interventions and evaluation of identified organisms.

Results:

Incidence of infections relative to total hospital admissions was 0.7, 0.8, 0.7 and 1.8 percent; the incidence of infections in the first quarter of 2003 was significantly increased over the incidence in the first quarters of 2000, 2001 and 2002 (p<0.004).

Over the four quarters studied, 38 peritonsillar, retropharyngeal, or parapharyngeal infections; 26 neck infections; 13 orbital or intracranial complications of acute sinusitis, and 12 facial infections were identified. All infections were treated with intravenous antibiotics; additional surgical management was required for 66 (74 percent) infections; two were treated with by needle aspiration. There were no mortalities or other serious complications. The management of peritonsillar abscesses included incision and drainage (four patients), immediate tonsillectomy (five patients) and medical management (one patient), based on surgeon’s preference.

Microbiological cultures were obtained from 57 patients with results available for 47 patients. Seven cultures were reported as “no growth,” 30 demonstrated a single organism, three demonstrated two organisms and 12 demonstrated multiple organisms. Twenty-seven abscesses contained streptococcal species, most commonly group A streptococcus. Nine contained Staphylococcus species and atypical mycobacterium species were found in three abscesses. Cultures were not obtained in 25 patients, primarily those managed exclusively medically. Anaerobic cultures were sometimes not ordered and acid-fast bacillus (AFB) cultures were obtained based on clinical suspicion.

Conclusions:

The increased incidence of head and neck infections found over a three month period, and caused primarily by the group Strep A organism, does not appear to be related to overall hospital growth. It may reflect a trend toward more virulent infections related to the evolving biology of the streptococcal organism.

In the last 15 years, severe and invasive group A streptococcal infections have been increasingly reported nationally. Much of the attention has been focused on Streptococcal toxic shock syndrome and necrotizing the fibrous tissue beneath the skin, both of which may have fatal outcomes. Researchers noted an increase in cases of retropharyngeal abscesses in children in the Detroit area, over half of which were due to group A strep. This research reveals an expanded role of group A strep in other head and neck abscesses as well, and the findings are in agreement with reports from other institutions of an increasing incidence and virulence of streptococcal infections.