318 Archives ofDisease in Childhood 1994; 71: 318-322 Invasive group A streptococcus cariage in a child care centre after a fatal case Arch Dis Child: first published as 10.1136/adc.71.4.318 on 1 October 1994. Downloaded from

Michael M Engelgau, Charles H Woernle, Benjamin Schwartz, Norma J John M Horan Vance,

Abstract among children in child care are not After a fatal case of invasive group A recognised as a serious problem, with the streptococcal disease, serotype T-1, in a exception of strains associated with rheumatic child care centre, group A streptococcal fever or T-1 glomerulonephritis.13 prevalence was measured and risk Group A streptococcal infections may take factors for carriage were determined. A on more importance than previously because total of 87% (224/258) had throat culture of the increase in the occurrence of invasive tests. Group A streptococcus was isolated group A streptococcal the for from 57 disease, potential (25%), and of the 50 isolates transmission of the infection among children serotyped, 38 (76%) were T-1. Group in child care, and the recent increase in A streptococcal T-1 prevalence was the number of children child care Epidemic Intelligence 18% and attending Service, Division of (38/217) six of nine rooms had services.14 In order to address new concerns Field Epidemiology, children with group A streptococcal T-1 about invasive group A streptococcal disease Epidemiology isolates. The risk ofgroup A streptococcal and Program Office, develop interventions, an understanding T-1 carriage was increased for children of the of A Centers for Disease who epidemiology group streptococcal Control and shared the index case's room (odds infections in child care settings is important, Prevention, US Public ratio (OR)=2-7; 95% confidence interval the role of Health Service, including cultures and antimicrobial (CI)=0-8 to 9.4) and for each additional treatment12 or Department ofHealth hour prophylaxis. and Human Services, per week in child care (OR=1-03; After a single fatal case of invasive group A Atlanta, Georgia 95% CI=1'001 to 1P061); and decreased streptococcal disease in a child care attendee in M M Engelgau in children taking antibiotics in the Alabama, we initiated an investigation to Alabama Department preceding four weeks (OR=0*2; 95Gb determine the prevalence of group A strepto- ofPublic Health, CI=0-1 to 0.9). Carriage of the invasive coccus and identified risk factors for of Division of group A streptococcal carriage Epidemiology, strain could not be the organism among children attending the Montgomery, determined by identified risk factors centre. We also recommended Alabama alone. empirically C H Woernle antibiotic prophylaxis to all persons who had a (Arch Dis Child 1994; 71: 318-322) http://adc.bmj.com/ Division of Bacterial group A streptococcal isolate identified during and Mycotic Diseases, the investigation. National Center for Infectious Diseases, During the 1 980s, the occurrence of invasive Centers for Disease A Control and group streptococcal disease in children and Methods Prevention, adults increased in the United States and other Medical records of the index case were Department ofHealth countries. 1-7 A recent historical review of reviewed. and Attendance records and work Human Services, severe A on September 28, 2021 by guest. Protected copyright. Atlanta, Georgia group streptococcal diseases during schedules of all children and staff present at B Schwartz premodern and modem times described any time from approximately two weeks before periodic fluctuations in the incidence of until one and a half weeks after the index Alabama Department severe disease.8 It has been speculated ofPublic Health, that the patient's onset of illness on 1 August (specifi- Bureau of Clinical declining incidence and severity of group A cally 15 July until 10 August 1991, hereafter Laboratories, streptococcal infections earlier this century was referred to as the study period) were obtained Montgomery, Alabama due to improved living N J Vance conditions, a possible from the child care centre. A questionnaire decrease in the organism's virulence, and was administered to parents to determine Division of Field the effect of antibiotics.9 The reasons for the symptoms of recent illness and medical Epidemiology, recent re-emergence of severe group A Epidemiology strepto- treatment and to supplement data from day Program Office, coccal disease remain unclear; the increase care attendance records. Mean hours per Centers for Disease may be associated with changes in the serotype week at the centre and room location were Control and distribution. A recent investigation of group A determined from questionnaire information or Prevention, US Public streptococcal Health Service, disease in the United States centre records for respondents and from centre Department ofHealth between 1972 and 1988 reported that the records alone for non-respondents. and Human Services, proportion of the disease caused by serotypes Between one and two weeks after illness Atlanta, Georgia M-1 and M-3 increased significantly and onset in the index case J M Horan (August 8-14), throat that these serotypes are more likely to cause swabs for group A streptococcus were obtained Correspondence and reprint invasive disease.'0 from the requests to: Dr Michael M staff and, after parental informed Engelgau, Division of The spread of group A streptococcal consent, children who attended the centre Diabetes Translation, infection in child care,11 12 National Center for Chronic primarily through during the study period. Cultures were not Disease Prevention and large aerosolised respiratory droplets and taken for other organisms. We calculated Health Promotion, CDC, direct contact, occurs because of the A 1600 Clifton Road, Mailstop high group streptococcal T-1 prevalence by K-10, Atlanta, Georgia degree of shared secretions and close physical dividing the number of children with group A 30333, USA. contact among young children in this setting. streptococcal T-1 isolates by the total number Accepted 13 July 1994 Currently, group A streptococcal infections excluding those with non-serotyped isolates. Invasive group A streptococcus carriage in a child care centre after a fatal case 319

For all who had group A streptococcal isolates few hours of presentation. Group A strepto-

during the culture survey, an antimicrobial coccus, subsequently determined to be Arch Dis Child: first published as 10.1136/adc.71.4.318 on 1 October 1994. Downloaded from regimen of oral penicillin for 10 days with serotype T-1, was isolated from the blood. rifampicin added on the final four days was recommended.15 Antibiotic use information and repeat cultures were obtained between CHILD CARE CENTRE INVESTIGATION five and 10 days after completion of the The child care centre had nine rooms to which antibiotic regimen. Reported antibiotic use children were assigned with others consistent was confirmed by a doctor by telephone or with their age and developmental level. Two mail. rooms had children with a mean age <1 year in Throat swabs were transported to and which limited child to child contact occurred; then cultured by the Bureau of Clinical five rooms had children with a mean age Laboratories, Alabama Department of Public between 1 and 4 years where extensive child to Health, at the Montgomery Laboratory. child contact occurred and play items were The Respiratory Bacterial Reference commonly shared; and two rooms had children Laboratory, Centers for Disease Control with a mean age >4 years. and Prevention (CDC), Atlanta, Georgia, Throat swabs were obtained for culture performed T serotyping by the slide agglutina- from 224 (87%) of 258 attendees and 24 tion method and with antisera prepared at (96%) of 25 staff. More than two thirds of CDC; no M serotyping was performed the parents or guardians of the participating because essentially all serotype T-1 strains are attendees (152/224, 68%) and staff (20/24, M-1 serotype.16 17 No further characterisation 83%) completed questionnaires. of the organism was performed. A recent Fifty eight per cent of the attendees were report suggests that there is little variation in white and 52% were boys. On average, the genome within this serotype.'8 attendees were present at the child care centre Data were entered using Epi Info computer 23 hours per week (range 0-5-66). Fifty seven software (CDC, Atlanta, Georgia). Categorical (25%) attendees had group A streptococcal variables were compared using the Mantel- isolates. Of the 50 (88%) isolates that were Haenszel x2 test or two tailed Fisher's exact serotyped, 38 (76%) were T-1 and 12 (24%) test as appropriate. SAS computer software were T-25. The overall group A streptococcal (SAS Institute, Cary, North Carolina) was T-1 prevalence was 18% (38/217, seven used for the multivariate logistic regression unserotyped isolates were excluded). Children analysis. Variables examined in this analysis who had group A streptococcal T-1 isolates included age, race, sex, total attendees in attended six of the nine rooms; T-1 isolates classroom, entry time ofday, hours per week in accounted for over half the total group A day care, index case classmate, and antibiotic streptococcal isolates in four rooms and all the use during the month before the culture group A streptococcal isolates in two other http://adc.bmj.com/ survey. rooms. The index case's room had the highest prevalence of group A streptococcal T-1 carriage (6/16, 38%). Attendees who shared Results the index case's room were 2-4 times more INVASIVE CASE likely to have a group A streptococcal T-1 The index case was a 22 month old girl who isolate than children in other rooms (6/16 v attended the child care centre for several 32/201; confidence interval (CI)=1 2 to 4 8). months and was present between 35 and 40 The risk ofhaving a group A streptococcal T-1 on September 28, 2021 by guest. Protected copyright. hours per week during the month before onset isolate was also related to the number of hours of the illness. She had experienced no previous per week spent at the centre (X2 for trend=4 8, serious illnesses or hospitalisations and had p=003, table 1). The three rooms in which received all recommended vaccinations. She the group A streptococcal T-1 prevalence was saw her physician three days before her death zero included both rooms with the youngest for a mild illness characterised by rash and children (mean age <1 year). fever. The rash, which was maculopapular with Among children whose parents responded some vesicles, was distributed over the torso, to the questionnaire, those who were given face, the plantar aspect of one foot and was in her oral cavity. She was suspected to have Table 1 Throat culture resultsforparticipating attendees, by mean weekly duration in child care;figures are per cent varicella. Her temperature was 101 4°F. She (number/total) was treated symptomatically and did not receive antibiotics. She developed vomiting Group A Group A Duration streptococcal*t streptococcal T-lt1 and diarrhoea on the second day of illness. (hours/week) isolates isolated Relatively suddenly on the third day of illness 0-9 11-1 (5/45) 7 0 (3/43) she developed respiratory distress and returned 10-19 25-9 (7/27) .15-4 (4/26) for further medical evaluation. Upon re- 20-29 25-6 (10/39) 18 4 (7/38) 30-39 39-1 (9/23) 34-8 (8/23) examination she was found to have severe 40-49 36-6 (11/30) 30-0 (9/30) respiratory distress and shock. There were 50-59 0 (0/3) 0 (0/3) several haemorrhagic vesicular skin lesions 60-69 0 (0/3) 0 (0/3) on her trunk and extremities. A chest Total 24-7 (42/170) 18-7 (31/166) radiograph revealed a right middle and *Excludes 54 with unknown duration. lower lobe cavity pneumonia. She went into tX2 for linear trend: group A streptococcal isolates=3-7, arrest, was p=0 05; group A streptococcal T-1 isolates=4-8, p=0 03. cardiorespiratory resuscitation tExcludes 54 with unknown duration and four with unsuccessful, and the patient died within a unserotyped group A streptococcal isolate. 320 Engelgau, Woernle, Schwartz, Vance, Horan

Table 2 Frequency (%) ofsigns and symptoms among isolate worked in a classroom where no the 111 attendees who did not take antibiotics for whom T-1 questionnaire responses are available, by group A isolates were identified in children, and the Arch Dis Child: first published as 10.1136/adc.71.4.318 on 1 October 1994. Downloaded from streptococcal T-1 status other worked in a room where 28% carried T-1 isolates. Culture status After the 38 attendees who had group A Group A streptococcal T- 1 isolates were notified of streptococcal Negative* p Sign/symptom T-1 (n=26) (n=85) Value their culture result and antibiotics were recommended, 34 received some Fever 23 17 0-56 (89%) Sore throat 23 13 0-22 treatment (varying agents and durations). One Cough 19 27 0-42 of the two staff members who had a A Earache 4 6 0 59 group Rhinorrhoea 23 27 0-69 streptococcal T-1 isolate took antibiotics after Fever, sore throat 19 8 0-15 receiving the positive culture Fever, sore throat, cough 12 7 0 43 report. Eighteen Fever, sore throat, cough, (45%, 17 attendees and one adult) of the 40 rhinorrhoea 12 7 0-43 who had T-1 isolates were recultured; 16 had taken and *Includes seven who had group penicillin rifampicin, while two took A streptococcal T-25 isolates. only penicillin for 10 days. Among the 16 who took penicillin and rifampicin, two (13%) antibiotics (for any illness) at any time during repeat cultures were positive for group A strep- the four weeks preceding the culture survey tococcus T- 1. Of the two who took only were less likely to have group A streptococcal penicillin, one was repeat culture positive for T-1 isolates than those who did not take anti- group A streptococcus T-1. biotics (3/36 v 26/111; relative risk (RR)=0.4; No further invasive cases occurred among 95% CI=0 1 to 1 1). Among the 26 attendees people associated with the child care centre who had group A streptococcal T-1 isolates and none were reported in other community and the 85 attendees who had negative members during the several months after this cultures and did not use antibiotics, the case. proportions reporting fever or respiratory signs and symptoms were similar (table 2). No sign or symptom alone or in combination was Discussion statistically associated with group A strepto- This investigation showed that carriage of the coccal T-1 positivity. Seventeen (63%) of the invasive organism was widespread, suggesting 26 attendees who had T-1 isolates who did transmission may have occurred readily at the not use antibiotics reported no respiratory centre. The organism was recovered from symptoms or fever during the study period. children in two thirds of the nine rooms, with Four (15%) of these 26 had a parent reported the highest prevalence in the index case's rash some ofwhich parents suspected were due room. The absence of group A streptococcal to varicella. carriage among children <1 year old may http://adc.bmj.com/ Data for 138 attendees for whom centre reflect their decreased mobility (nearly all were records and questionnaire data were available confined to cribs while at the centre) and less were analysed by multivariate logistic regres- child-to-child contact and use of common play sion. Because both the entry time of day and items in this age group compared with older the total hours per week at the centre were children. The staff had a low group A strepto- highly correlated, only hours per week at the coccal T-1 prevalence and apparently did not centre was included in the analysis. In contribute to the spread of infection, although on September 28, 2021 by guest. Protected copyright. addition, age, the total number of attendees in the role of staff in other institutional outbreaks the classroom, and classroom assignment were remains unclear.3 11 also highly correlated. Of these factors, only The risk of group A streptococcal carriage sharing the index case's room was included in among children increased as time spent in the analysis. Race and sex were excluded from the centre increased. A similar association the final analysis because neither factor had a has been noted between the occurrence of significant effect and inclusion did not change Haemophilus influenzae type b invasive disease the effect of other factors. Therefore, the hours and day care exposure.'9 As might be per week at the centre, sharing the index case's expected, antibiotic use before the culture room, and antibiotic use the month before the survey was protective against group A strepto- culture survey, were included in the final coccal T-1 carriage. analysis by multivariate logistic regression. Fever and other respiratory signs and Increased time in child care was a significant symptoms in those who did not receive risk factor (odds ratio (OR)= 1-03; 95% antibiotics during the study period were CI=1-001 to 1.061) and antibiotic use was uncommon for both those who had group protective (OR=0-22; 95% CI=0.06 to 0-87). A streptococcal T-1 isolates and negative While the risk of group A streptococcal T-1 cultures. Excluding persons who took carriage was greater among children sharing antibiotics (some of whom possibly had group the index case's room, this was not statistically A streptococcal T-1 related illness) for this significant (OR=2-7; 95% CI=0-8 to 9 4). evaluation would tend to minimise our ability Over half (14/24, 58%) of the participating to detect an association between reported signs staff members were between 20 and 30 years and symptoms and culture positivity. old (range 19 to 54) and almost all were female However, because the primary focus of this (23/24, 96%). Two (8%) of 24 had group A investigation was to detect potential predictors streptococcal isolates; both isolates were of group A streptococcal T-1 carriage among serotype T- 1. One staff person who had a T- 1 children in child care and antibiotic use was Invasive group A streptococcus carniage in a child care centre after a fatal case 321

shown to affect carriage, this group was Limitations of our study included the length

excluded for this analysis. of time required to conduct the culture survey, Arch Dis Child: first published as 10.1136/adc.71.4.318 on 1 October 1994. Downloaded from An important question is whether those who the grouping of children's exposure by single harbour group A streptococcus after a case of rooms when some actually had exposure to invasive group A streptococcal disease in a day other rooms, and the lack of complete data care centre can be identified by means other both on the serotype of some children positive than an institution-wide culture survey. Of the for group A streptococcal infection and the risk factors identified, sharing the room with amount of time spent in the centre. the index case identified only a fraction (16%) During the one week culture survey the of the carriers. Antibiotic use during the study group A streptococcal carriage rate for those period occurred in approximately 25% of who were cultured during the last half of the attendees and was associated with a protective week was similar to the rate for those cultured effect from the carrier state, although nearly during the first half of the week (25% v 26%, 10% (3/36) ofantibiotic users had T-1 isolates. respectively). The room assignment of each Reported clinical signs and symptoms were child was used to represent the location of relatively uncommon in carriers and were not exposure at the centre during the study. predictive of carriage status. The risk of Because children were consolidated into rooms carriage increased with increasing time spent at during low attendance periods a misclassifica- the centre, although some who attended fewer tion of room exposure was probably random than 10 hours per week were carriers. In and likely resulted in creating a relatively more summary, none of these factors alone or in uniform exposure for all children at the centre combination predicted all who were carriers. regardless of assigned rooms. The effect of other infectious agents or Children positive for group A streptococcal environmental cofactors on carriage were not infection with no serotype information were in specifically addressed in this study. three different rooms and their number of Another important issue is the potential hours per week in child care (available for only role of antibiotic treatment after a case of four of the seven), on average, was less than invasive disease to prevent secondary that for children who had complete serotype invasive disease. Because T serotype status information (12 v 30, respectively). The 54 was initially unknown, antibiotic treatment children for whom the duration in child care was recommended to all who had group A was not available attended eight of the streptococcal isolates; most attendees and staff nine classrooms and the group A streptococcal who had isolates received treatment. After this carriage rate among them was similar to intervention, no further cases of invasive that among children for whom attendance disease occurred, although it is unclear information was complete (15/54; 28% v whether this was due to antibiotic administra- 42/170; 25%). tion. Although antibiotic treatment of those In conclusion, we discovered that group A culture positive in a child care centre'2 and streptococcal T- 1 (the invasive strain) carriage http://adc.bmj.com/ mass prophylaxis with penicillin in military was common among attendees. The use of risk recruits have curtailed epidemic non-invasive factors for carriage during this investigation group A streptococcal disease,20 any untreated did not identify all carriers. Therefore, individual can serve as a reservoir and attempts to eradicate an invasive organism in transmit infection to those previously treated. this setting would require at least a culture Several logistic problems may hinder effective survey (with 100% sensitivity) of the entire implementation of prophylactic regimens.21 centre and effective treatment of all identified on September 28, 2021 by guest. Protected copyright. Parents may not contact their child's doctor as carriers or mass treatment of all associated advised, doctors may not be aware of or may with the centre. This approach does not take disagree with the need for prophylaxis, and into account the potential environmental and parents may have difficulty obtaining and family group A streptococcal reservoirs. or administering the medication. Further Further studies of invasive group A strepto- understanding of the actual risk of secondary coccal disease in child care are needed to better invasive group A streptococcal disease after an define risk factors for carriage and secondary index case is needed before the effectiveness of invasive disease and to assess the effectiveness antibiotic intervention can be assessed. of interventions aimed at reducing or elimi- Three of 18 who received antibiotics after nating the risk of secondary disease. With the their initial positive culture result had group A increasing incidence of group A streptococcal streptococcal T-1 isolated on repeat culture invasive disease, doctors should continue to despite the effectiveness of penicillin alone or diagnose and treat group A streptococcal penicillin plus rifampicin for bacteriological infections aggressively. cure of group A streptococcal disease.'5 22 The We would especially like to thank Moye Davis, RN, Pat bacteriological failures observed in Williams, RN, Sharon Thompson, RN, Najmul Chowdhury, children who received these antibiotic treat- MBBS, MPH, and others from the Alabama Department in of Public Health, along with Nathan Ruben, MD, for their ments, part, may reflect poor compliance invaluable assistance in conducting this study. We also with antibiotic treatment or the length of would like to thank Robert Facklam, PhD, CDC, for time between performing the T serotyping tests and Nancy Barker, MS, antibiotic completion and CDC, for statistical support and assistance with the-multivariate reculturing allowing reinfection.'5 Because an,alysis. repeat cultures were obtained for less than half of the treated carriers, culture results and 1 Givner LB, Abramson JS, Wasilauskas B. Apparent increase in the incidence of invasive group A beta-hemolytic bacteriological failures should be interpreted streptococcal disease in children. J Pediatr 1991; 118: with caution. 341-6. 322 Engelgau, Woernle, Schwartz, Vance, Horan

2 Wheeler MC, Roe MH, Kaplan EL, Schlievert PM, Todd severe or JK. Outbreak of group A streptococcus septicemia in broken skin, outbreaks with fatal children. Clinical, epidemiologic, and microbiologic cases are possible. The paper by Engelgau and Arch Dis Child: first published as 10.1136/adc.71.4.318 on 1 October 1994. Downloaded from correlates. JAMA 1991; 266: 533-7. us 3 Centers for Disease Control and Prevention. Nursing home colleagues reminds of this and shows how outbreaks of invasive group A streptococcal infections - investigations should be done. Three aspects Illinois, Kansas, North Carolina, and Texas. MMWR Morb Mortal Wlkly Rep 1990; 39: 577-9. merit a comment: the organism, the route of 4 Centers for Disease Control and Prevention. Group A infection, and the outbreak management. beta-hemolytic streptococcal bacteremia - Colorado, an 1989. MMWR Morb Mortal Wkly Rep 1990; 39: 3-6, 11. The M type protein of S pyogenes is 5 Stromberg A, Romanus V, Burman LG. Outbreak of group important determinant of its pathogenesis A streptococcal bacteremia in Sweden: an epidemiological and clinical study. J Infect Dis 1991; 164: 595-8. and epidemiology. This is clearest in 6 Stevens DL. Invasive group A streptococcus infections. Clin glomerulonephritis, which is the sequel of Infect Dis 1992; 14: 2-13. 7 Benjamin EM, Gershman M, Goldberg BW. Community- infections by a few M types (for example, acquired invasive group a beta-hemolytic streptococcal M types 12, 49, 55, and 60). T type 1 is infections in Zuni indians. Arch Intern Med 1992; 152: 1881-4. equivalent to M type 1 in this incident, but T 8 Katz AR, Morens DM. Severe streptococcal infections in typing is less specific for most other types. M historical perspective. Clin Infect Dis 1992; 12: 298-307. type 1 is the type most often in 9 Bisno AL. Group A streptococcal infections and acute reported rheumatic fever. NEnglJMed 1991; 325: 783-93. overwhelming infection, but it is a common 10 Schwartz B, Facklam R, Breiman RF. Changing epidemi- to ology of group A streptococcal infections in the USA. strain and typing is most likely be done for Lancet 1190; 336: 1167-71. the bacteraemic and other severe infections. 11 Smith TD, Wilkinson V, Kaplan EL. Group A strepto- The M type is associated with coccus-associated respiratory tract infections in a day-care specific protec- center. Pediatrics 1989 83: 380-4. tive immunity, which should not be confused 12 Falck G, Kjellander J. Outbreak of group A streptococcal with the antibodies against exotoxins used in infection in a day-care center. Pediatr Infect DisJ 1992; 11: 914-9. diagnostic tests, of which streptolysin 0 is the 13 American Academy of Pediatrics. In: Peter G, ed. Report of best known. This the committee on infectious disease. 22nd Ed. Chicago, type specific immunity partly Illinois: AAP, 1991. explains why streptococcal diseases fluctuate 14 National Commission on Children. Beyond rhetoric: a new American agendafor children andfamilies. Washington DC: under the influence of herd immunity to National Commission on Children, 1991. common strains. 15 Chaudhary S, Bilinsky SA, Hennessy JL, et al. Penicillin V is one of several skin conditions and rifampin for treatment for group A streptococcal Chickenpox pharyngitis: a randomized trial of 10 days penicillin vs 10 that may become secondarily infected by days penicillin with rifampin during the final 4 days of therapy.Y Pediatr 1985; 106: 481-6. S pyogenes. Bums, insect bites, and minor 16 Wilson E, Zimmerman RA, Moody MD. Value of injuries are commoner portals of streptococcal T-agglutination typing of group A streptococci in epidemiologic investigations. Health and Laboratory skin infection, but seem to have less risk Science 1968; 5: 199-207. of bacteraemia with consequent shock, 17 Moody MD, Padula J, Lizana D, Hall CT. Epidemiologic or arthritis. Children are the characterization of group A streptococci by osteomyelitis, T-agglutination and M-precipitation tests in the public population in whom S pyogenes circulate most health laboratory. Health and Laboratory Science 1965; 2: 149-62. as they have least type specific immunity 18 Seppala H, Vuopio-Varkila J, Osterblad M, Jahkola and closest contacts with other infected Rummukainen M, Holm SE, Huovinen P. Evaluation of individuals. methods for epidemiologic typing ofgroup A streptococci. http://adc.bmj.com/ J InfectDis 1994; 169: 519-25. Streptococcal infection is endemic, and 19 Fleming DW, Leibenhaut MH, Albanes D, et al. Secondary virulent bacteria in children haemophilus influenzae type b in day-care facilities. Risk susceptible will factors and prevention. JAMA 1985; 254: 509-14. cause the occasional death. Should we 20 Gray GC, Escamilla J, Hyams KC, et al. Hyperendemic the contacts of streptococcus pylogenes infections despite prophylaxis investigate people who have with penicillin G benzathine. N Engl Y Med 1991; 325: severe streptococcal disease, when little is done 92-7. in the numerous mild cases? Is this not 21 Li KI, Dashefsiy B, Wald ER. Haemophilus influenzae type b colonization in household contacts for infected and col- shutting the stable door after the horse has onized children enrolled in day care. Paediatrics 1986; 78: on September 28, 2021 by guest. Protected copyright. 15-20. bolted? The death of a child creates a feeling 22 Reed BD, Huck W, Zazove P. Treatment ofbeta-hemolytic that 'something must be done'. The paper by streptococcal pharyngitis with cefaclor or penicillin. Efficacy and interaction with beta-lactamase-producing Engelgau et al shows that it is difficult to test organisms in the pharynx. JFam Pract 1991; 32: 138-44. everyone in a large group, and the time taken for laboratory tests diminishes the benefit of prophylactic treatment. The finding of Commentary lower carriage rates in children who had had Streptococcus pyogenes, the group A antibiotics recently, suggests that good access 3-haemolytic streptococcus, remains a to primary care is one reason why streptococcal troublesome micro-organism. Good hygiene, infections have become less threatening in antibiotics, and other attributes of a high modem times. standard of living have lessened the frequency R T MAYON-WHITE of severe infection, but the bacterium has kept Public Health Department, its virulence factors. Given a chance to Manor House, spread J7ohn Radcliffe Hospital, among close contacts and to invade through Oxford OX3 9DZ