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Outbreak of Invasive Group A Streptococcal Disease Among Children Attending a Day-Care Center

Agüero, Jesús PhD, MD*†; Ortega-Mendi, Manuel MD; Eliecer Cano, Maria MD*; González de Aledo, Alvaro MD; Calvo, Jorge MD*; Viloria, Luis MD; Mellado, Purificación MD§; Pelayo, Teresa MD; Fernández-Rodríguez, Amparo PhD; Martínez-Martínez, Luis PhD, MD*†

The Pediatric Infectious Disease Journal: July 2008 - Volume 27 - Issue 7 - p 602-604
doi: 10.1097/INF.0b013e31816a0e0a
Original Studies

Background: Most cases of invasive group A streptococcal (GAS) disease arise sporadically in the community, but outbreaks of severe invasive GAS infections have been reported in closed environments, such as military populations, family communities and hospitals. An outbreak of invasive GAS disease involving 3 cases of streptococcal toxic shock syndrome (TSS), one with a fatal course, occurred among children attending a day-care center located in Cantabria, Northern Spain.

Objective: To determine the characteristics of GAS isolates obtained from the outbreak environment.

Methods: GAS isolates obtained from children attending the same day-care facility, staff members, and family contacts were assayed for emm typing, pulse-field gel electrophoresis (PFGE), and toxin-gene content. One isolate obtained from the fatal case was also characterized by multilocus sequence typing. Antimicrobial susceptibility testing was done. Strains from patients unrelated to the outbreak were included for comparison.

Results: All GAS isolates from children attending the day-care center, including those from streptococcal TSS cases, shared the same emm type 4, genomic pattern by PFGE (A) and toxin-gene profile. Neither the emm type nor the PFGE pattern or toxin gene profile of the outbreak-associated strains were encountered among GAS isolated from household or staff contacts.

Conclusions: A clone of GAS belonging to emm type 4 and characterized by a specific PFGE pattern and toxin-gene profile was responsible for a community outbreak of streptococcal TSS disease in a child day-care center in Spain. This is the first day-care outbreak reported in our country.

From the *Service of Microbiology, University Hospital Marqués de Valdecilla; †Department of Molecular Biology, University of Cantabria, Santander; ‡General Directorate of Public Health, Govern of Cantabria; §Section of Microbiology, Hospital Laredo, Cantabria; and ¶National Institute of Toxicology and Forensic Sciences, Madrid, Spain.

Accepted for publication January 22, 2008.

Address for correspondence: Jesús Aguero, MD, PhD, Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Avda. de Valdecilla s/n, 39008 Santander, Spain. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.