Effectiveness of Clindamycin and Intravenous Immunoglobulin, and Risk of Disease in Contacts, in Invasive Group A Streptococcal Infections
Effectiveness of Clindamycin and Intravenous Immunoglobulin, and Risk of Disease in Contacts, in Invasive Group A Streptococcal Infections
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DOI：
10.1093/cid/ciu304
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发表时间：
2014-08-01
影响因子：
11.8
通讯作者：
Andrews, Ross
中科院分区：
文献类型：
--
作者：
Carapetis, Jonathan R.;Jacoby, Peter;Andrews, Ross
背景使用克林霉素和静脉注射免疫球蛋白（IVIG）治疗侵袭性A组链球菌（iGAS）感染，以及密切接触者是否需要预防性抗生素，仍然存在争议。不太可能进行对照试验，因此前瞻性、观察性研究提供了最好的数据来指导实践。从2002年3月到2004年8月，我们在澳大利亚维多利亚州（人口490万）对iGAS感染进行了基于人群的前瞻性主动监测。确定了84例严重iGAS感染（链球菌中毒性休克综合征、坏死性筋膜炎、脓毒性休克或GAS蜂窝织炎伴休克）。克林霉素治疗的患者比克林霉素未治疗的患者有更严重的疾病，但死亡率较低（15% vs 39%;比值比[OR]，0.28; 95%置信区间[CI]，0.10 - 0.15）。80）。在同时接受IVIG的患者中，病死率更低（7%）。与克林霉素未治疗患者相比，克林霉素治疗患者（0.31; 95%CI，0.09 -1.12）和克林霉素+IVIG治疗患者（0.12; 95%CI，0.01 -1.29）的死亡率OR的校正点估计值较低。三例确诊的iGAS感染病例发生在指示病例的家庭接触者中。接触者中iGAS疾病的发病率是安哥拉人群发病率的2011倍（95%CI，413-5929）。我们的数据表明，克林霉素治疗严重iGAS感染的患者大大降低了死亡率，这种效果可能会通过与IVIG同时治疗而增强。在索引病例的1个月内，家庭接触者中iGAS疾病的风险急剧增加，突出了抗生素预防的潜在作用。
Background. The use of clindamycin and intravenous immunoglobulin (IVIG) in treatment of invasive group A streptococcal (iGAS) infection, and the need for prophylactic antibiotics in close contacts, remains contentious. Controlled trials are unlikely to be conducted, so prospective, observational studies provide the best data to inform practice.Methods. We conducted population-based, prospective, active surveillance of iGAS infections throughout the state of Victoria, Australia (population 4.9 million), from March 2002 through August 2004.Results. Eighty-four cases of severe iGAS infection (streptococcal toxic shock syndrome, necrotizing fasciitis, septic shock, or GAS cellulitis with shock) were identified. Clindamycin-treated patients had more severe disease than clindamycin-untreated patients but lower mortality (15% vs 39%; odds ratio [OR], 0.28; 95% confidence interval [CI],.10-. 80). Among those who received concurrent IVIG, the fatality rate was lower still (7%). The adjusted point estimate of the OR for mortality was lower in clindamycin-treated patients (0.31; 95% CI,.09-1.12) and clindamycin plus IVIG-treated patients (0.12; 95% CI,.01-1.29) compared with clindamycin-untreated patients. Three confirmed cases of iGAS infection occurred in household contacts of index cases. The incidence rate of iGAS disease in contacts was 2011 (95% CI, 413-5929) times higher than the population incidence in Victoria.Conclusions. Our data suggest that clindamycin treatment of patients with severe iGAS infections substantially reduces mortality and that this effect may be enhanced by concurrent treatment with IVIG. The dramatically increased risk of iGAS disease among household contacts within 1 month of the index case highlights a potential role for antibiotic prophylaxis.