Increase in Invasive Group A Strep Infections, 2022–2023

Findings: COVID-19 pandemic’s impact on group A strep infections

During the COVID-19 pandemic, severe infections caused by group A Streptococcus (group A strep) bacteria decreased by around 25% in the United States compared to the years right before the pandemic. These severe infections, called invasive group A strep (iGAS) infections, were especially low in children.

See the Data: Bact Facts Interactive

In 2020 and 2021, iGAS rates in children 2 through 17 years old were the lowest on record since 1997.

Use the Bact Facts Interactive Data Dashboard.

There were also low numbers of less severe group A strep infections (e.g., strep throat, scarlet fever) in all age groups. This was likely due to the steps many people took during the pandemic to prevent the spread of respiratory diseases (e.g., school and workplace closures, masking, physical distancing).

iGAS infections in 2022

Preliminary 2022 data indicated that iGAS infection levels in children

Increased earlier in the season (September through November) than in a typical year
Occurred during the same time as increases in respiratory viruses (e.g., influenza, respiratory syncytial virus [RSV]) and less severe group A strep infections
Were higher than pre-COVID-19 pandemic levels in some areas of the country

MMWR Notes from the Field

Increase in Pediatric Invasive Group A Streptococcus Infections — Colorado and Minnesota, October–December 2022

This report summarizes iGAS findings in two locations that reflect what was happening in many places across the United States in fall 2022.

iGAS infections in 2023

Preliminary 2023 data indicate

iGAS infections have remained high in children in some areas of the country even after respiratory viruses decreased in those areas
- This is occurring during the time when group A strep infections are normally highest (December through April)
Some areas of the country have also seen an increase in iGAS infections in adults, particularly in those aged 65 years or older

Less severe group A strep infections in 2022 and 2023

Based on preliminary 2022–2023 data, less severe group A strep infections in children have returned to levels similar to or higher than those seen in pre-pandemic years. Currently, these infections are at high levels throughout the country, as is typically seen from December through April.

Group A strep bacteria can cause a range of illnesses

Invasive disease means that germs invade parts of the body that are normally free from germs. When this happens, disease is usually very severe, requiring care in a hospital and even causing death in some cases. Necrotizing fasciitis and streptococcal toxic shock syndrome are examples of iGAS infections.

In addition to causing uncommon but severe and invasive infections, group A strep bacteria cause common and generally mild illnesses like strep throat and scarlet fever.

About GAS infections

Parents and other family members should

Learn about the symptoms for different group A strep infections
Seek medical care quickly for symptoms of severe group A strep infections
See a healthcare provider if they think they or their child has strep throat or another less severe group A strep infection
Make sure everyone in the household is up to date with flu and chickenpox vaccines, since getting these infections can increase risk for getting an iGAS infection

Healthcare providers should

Offer prompt vaccination against influenza and varicella to all eligible persons who are not up to date
Consider iGAS as a possible cause of severe illness
Educate patients, especially those at increased risk, on signs and symptoms of iGAS requiring urgent medical attention especially necrotizing fasciitis, cellulitis, and toxic shock syndrome
Obtain culture for suspected iGAS infections, including blood, wound, and pleural fluid cultures, as clinically indicated
Follow clinical practice guidelines for diagnosis and treatment of group A strep pharyngitis
Be mindful of potential alternative agents for treating confirmed group A strep pharyngitis in children due to the shortage of amoxicillin suspension
Notify appropriate local or state public health departments as soon as possible about unusually aggressive or severe iGAS cases or clusters of iGAS infections
Ask laboratories to hold iGAS isolates or send them to the state public health laboratory for temporary storage

Amoxicillin Shortage

There is a national shortage of the liquid antibiotic (amoxicillin suspension) most often prescribed to children to treat group A strep infections. The shortage is anticipated to last several months.

Clinicians: View the American Academy of Pediatrics guidance for alternative therapies during the shortage.

Parents: If your child’s doctor prescribes and you are unable to find liquid amoxicillin in your area, talk with the doctor about other antibiotic options.

State and Territorial Health Departments should

Conduct investigations of unusually aggressive or severe infections, clusters of iGAS infections, and potentially preventable infections (e.g., postpartum and post-surgical infections)
Urgently investigate group A strep infections among residents of long-term care facilities given the increased risk for disease and death among this vulnerable population
Follow CDC’s recommendations for preventing invasive group A streptococcal disease among household contacts of case-patients and postpartum and post-surgical patients

Related resources

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