Oral Presentation Lancefield International Symposium for Streptococci and Streptococcal Diseases 2025

From random towards randomised care of patients with invasive streptococcal infections – current clinical practice and areas of equipoise (117612)

Sarah Tavlian 1 , Joshua Osowicki 2 , Ouli Xie 1 , Asha C Bowen 3 , Joshua S Davis 4 , Steven YC Tong 1 5 , Katherine B Gibney 1 5
  1. Peter Doherty Institute of Infection and Immunity, Melbourne, VIC, Australia
  2. Murdoch Children's Research Institute, Melbourne, Victoria, Australia
  3. Department of Infectious Diseases, , Perth Children’s Hospital, Perth, Western Australia, Australia
  4. Department of Infectious Diseases, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
  5. Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia

Background: Life-threatening invasive infections caused by Streptococcus pyogenes and Streptococcus dysgalactiae subsp. equisimilis (SDSE) are rapid-onset and often fatal infections that are increasing in incidence globally. In the absence of evidence from randomised controlled trials (RCTs), clinical management for these conditions varies. An understanding of current management approaches and areas of clinical equipoise is needed ahead of planning RCTs.

Methods: Two web-based surveys were distributed to Staphylococcus aureus Network Adaptive Platform (SNAP) trial clinicians in April 2024. Survey-1 addressed clinical management practices for S. pyogenes and SDSE bacteraemia, research (domain) priorities, and areas of clinician equipoise. ‘Domains’ included backbone antibiotics (e.g. penicillin, ceftriaxone), adjunctive antibiotics (e.g. clindamycin, linezolid), and immunomodulation (intravenous immunoglobulin). Survey-2 collected aggregate annual numbers of blood culture isolates (bacteraemic episodes) for selected streptococci and enterococci from 2019—2023. 

Results: Survey-1 respondents (n=65 clinicians from nine countries) ranked S. pyogenes as the highest priority pathogen for inclusion in an RCT, and ‘adjunctive antibiotics’ as the highest priority domain. Despite this, only 51% (S. pyogenes) and 65% (SDSE) of respondents were willing to randomise RCT participants with severe disease to receive 'no adjunctive antibiotics'. Survey-2 included 17 sites across 6 countries. From 2019­—2023, sites reported 2103 SDSE, 2023 Streptococcus agalactiae (Group B Streptococcus) and 1987 S. pyogenes bacteraemic episodes across the life course from neonates to the elderly.

Conclusion: High-quality evidence is needed to guide treatment of invasive streptococcal diseases. Ongoing clinician engagement will enhance research question prioritisation and feasibility for future trials.