A Descriptive Analysis of Pediatric Invasive Group A Streptococcal Infections in Charlotte, North Carolina, With Insights Into Rapid Streptococcal Testing Trends

Group A Strep (GAS) is typically a disease of school-aged children; however, recent surveillance data demonstrate rising rates of invasive GAS (iGAS) among children < 3 years of age. Severe iGAS is associated with substantial pediatric morbidity and mortality. Despite this, clinical guidelines continue to discourage routine GAS testing in children < 3 years, and local data describing age-specific testing patterns, positivity rates, and characterization of pediatric iGAS cases are limited.

A retrospective chart review was performed to review iGAS, necrotizing fasciitis (NF), and strep toxic shock syndrome (STSS) cases in pediatric patients under 18 years at a large, urban, pediatric hospital (January 2022 – June 2025). We also retrospectively reviewed the rate of rapid antigen detection testing (RADT) per year, and the percentage of positive tests per age group from 2016 – 2024.

Of the 37 included cases of iGAS, NF, or STSS, 35.1% were < 3 years, 51.4% were ages 3-14, and 13.5% were >14 years. Three patients died, two of which were < 3 years of age. ICU admission was needed in 14 of the 37 cases, 5 of which (35.7%) were < 3 years. Rates of RADT testing over the nine-year period showed a drop during the COVID-19 pandemic (2020 – 2022) but saw an increase afterwards (2023 – 2024) with an average rate of testing of 222 and 384 per 1000 children per year, respectively. Additionally, the percentage of positive RADT tests in children < 3 increased from 11.7% pre-covid to 14.7% post-covid.

A high percentage of iGAS cases were in patients < 3 years of age, including two of the three deaths at our hospital. Furthermore, there is an increase in the rate of RADT tests over the 9-year study period. Further testing is needed to determine if RADT testing guidelines should be re-evaluated in children less than 3 with the rising cases of iGAS.