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Table 1.  

Pediatric GAS primary peritonitis Cases from literature review, 1980–2022, n = 26 [3,4,14–30] Cases from Starship Hospital, Jan 1, 2010–Jun 30, 2022, n = 20
Median age (range) 7 y (2 wk–16 y) 2 y (3 wk–13 y)
   F 16/19 (84) 11/20 (55)
   M 3/19 (16) 9/20 (45)
Preceding throat or skin infection
   Pharyngitis 4/18 (22) 1/20 (5)
   Skin 3/18 (17) 5/20 (25)
STSS 7/18 (39) 6/20 (30)
   Peritoneal fluid or tissue 25/26 (96) 17/20 (85)
   Blood culture 5/26 (19) 9/20 (45)
   Other 1/26† 4/20 (20)‡
   Molecular method (16S) 3/25 (12) 0/20
   Culture 22/25 (88) 19/20 (95)
   Laparoscopy or laparotomy 21/25 (84%)§ 19/20 (95)
   VATS only NA 1/20 (5)
Median antibiotic duration (range), d 14 (10–61) 21 (14–42)
Clindamycin treatment 4/14 (29) 4/20 (20)
IVIG treatment 3/14 (21) 1/20 (5)
Median length of hospital stay (range), d 10 (4–47) 13 (5–31)
Deaths 0/19 0/20
emm types 3.1 (n = 1) 88 (n = 1), 65/69 (n = 1), 114 (n = 2), 118 (n = 1)§
M-type M3 (n = 1), M81 (n = 1), M2 (n = 1) NA

Table. Comparison of characteristics of cases of pediatric GAS primary peritonitis at Starship Children’s Hospital, New Zealand, 2010–2022, to previously described cases*

*Values are no. (%) except as indicated. IVIG, intravenous immunoglobulin; NA, not available; STSS, streptococcal toxic shock syndrome; VATS, video-assisted thoracoscopic surgery.
†From pleural aspirate.
‡From skin swab samples; 3/4 GAS-positive skin swabs also had a positive blood or intraoperative peritoneal culture.
§5/20 isolates were sent for emm typing.


Group A Streptococcus Primary Peritonitis in New Zealand Children: A Case Series

  • Authors: Amanda Taylor, MBChB; Brodie M. Elliott, MBChB; John Atkinson, MBChB, FRACS; Sally Roberts, MBChB, FRACP, FRCPA; Lesley Voss, MBChB, FRACP; Emma J. Best, MBChB, FRACP, MMED; Rachel Webb, MBChB, FRACP, MD
  • CME / ABIM MOC Released: 10/16/2023
  • Valid for credit through: 10/16/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

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    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care clinicians, pediatricians, infectious disease specialists, and other healthcare professionals who treat and manage children at risk for Group A streptococcus primary peritonitis.

The goal of this activity is for members of the healthcare team to be better able to assess characteristics and outcomes of Group A streptococcus primary peritonitis among children.

Upon completion of this activity, participants will:

  • Analyze clinical characteristics of pediatric cases of Group A Streptococcus primary peritonitis in the current study
  • Assess microbiologic findings in the current series of pediatric cases of Group A Streptococcus primary peritonitis
  • Evaluate clinical outcomes of Group A Streptococcus primary peritonitis among children


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  • Amanda Taylor, MBChB

    Starship Children’s Hospital
    Auckland, New Zealand

  • Brodie M. Elliott, MBChB

    Starship Children’s Hospital
    Auckland, New Zealand

  • John Atkinson, MBChB, FRACS

    Starship Children’s Hospital
    Auckland, New Zealand

  • Sally Roberts, MBChB, FRACP, FRCPA

    Auckland City Hospital
    Auckland, New Zealand

  • Lesley Voss, MBChB, FRACP

    Starship Children’s Hospital
    Auckland, New Zealand

  • Emma J. Best, MBChB, FRACP, MMED

    Starship Children’s Hospital
    The University of Auckland
    Auckland, New Zealand

  • Rachel Webb, MBChB, FRACP, MD

    Starship Children’s Hospital
    The University of Auckland
    Kidz First Hospital
    Counties Manukau
    Auckland, New Zealand


  • Jill Russell, BA

    Emerging Infectious Diseases 

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline; Johnson & Johnson

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    Associate Director, Accreditation and Compliance, Medscape, LLC


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Group A Streptococcus Primary Peritonitis in New Zealand Children: A Case Series

Authors: Amanda Taylor, MBChB; Brodie M. Elliott, MBChB; John Atkinson, MBChB, FRACS; Sally Roberts, MBChB, FRACP, FRCPA; Lesley Voss, MBChB, FRACP; Emma J. Best, MBChB, FRACP, MMED; Rachel Webb, MBChB, FRACP, MDFaculty and Disclosures

CME / ABIM MOC Released: 10/16/2023

Valid for credit through: 10/16/2024, 11:59 PM EST


Absract and Introduction


Group A Streptococcus (GAS) primary peritonitis is a rare cause of pediatric acute abdomen (sudden onset of severe abdominal pain); only 26 pediatric cases have been reported in the English language literature since 1980. We discuss 20 additional cases of pediatric primary peritonitis caused by GAS among patients at Starship Children’s Hospital, Auckland, New Zealand, during 2010–2022. We compare identified cases of GAS primary peritonitis to cases described in the existing pediatric literature. As rates of rates of invasive GAS increase globally, clinicians should be aware of this cause of unexplained pediatric acute abdomen.


Streptococcus pyogenes, or group A Streptococcus (GAS), causes a wide spectrum of disease ranging from superficial skin infection and pharyngitis to invasive infections, such as sepsis, empyema, necrotizing fasciitis, meningitis, osteomyelitis, and septic arthritis[1]. GAS is responsible for the toxin-mediated complications of scarlet fever and streptococcal toxic shock syndrome, as well as the postinfectious sequelae rheumatic fever and poststreptococcal glomerulonephritis[2].

Primary peritonitis is defined as a bacterial infection within the peritoneal cavity in the absence of ascites or an intraabdominal source of infection, such as appendicitis[3,4]. Primary peritonitis is an uncommon manifestation of invasive GAS (iGAS) disease; a 2016 report found it accounted for 4.6% of children with iGAS in Finland[5]. Pediatric primary peritonitis itself is rare, reportedly accounting for 1%–3% of children experiencing acute abdomen (sudden onset of severe abdominal pain), and is most commonly caused by S. pneumoniae, gram-negative organisms, and staphylococcal species[3].

In late 2022, the United Kingdom, United States, Australia, and several countries in Europe reported unexpectedly high rates of iGAS and scarlet fever, particularly in children <10 years of age[6–10]. Rates of iGAS in the United Kingdom during this period are reported to be higher than in the years before the COVID-19 pandemic (2017–2019) and substantially higher than those reported during 2020–2021[11]. With increased GAS circulation, media coverage, and heightened community awareness, clinicians globally should be aware of the vast spectrum of invasive disease caused by GAS, including primary peritonitis.

In New Zealand, iGAS disease is not notifiable to Public Health authorities[12]. Surveillance relies on individual laboratories sending clinically relevant iGAS isolates to the Institute of Environmental Science and Research (ESR) for typing[13]. The most recent ESR report (2016) describes an iGAS incidence of 9.0/100,000 population in New Zealand; rates were inequitably high among New Zealand Māori (23.5/100,000 population) and Pacific peoples (73.9/100,000 population) compared with rates among persons of European or other ethnicities (4.3/100,000 population)[13]. Incidence of iGAS is highest in children <1 year of age[13]. Although ESR laboratory surveillance provides some information on the burden of iGAS in New Zealand, its passive nature suggests that reported rates are likely to be an underestimate.

Consistent with the high burden of iGAS disease in children in New Zealand, clinicians at Starship Children’s Hospital in Auckland have observed that GAS is a major cause of primary peritonitis in the pediatric population. We evaluated the incidence, clinical features, and management of children admitted to this tertiary pediatric center with GAS primary peritonitis during January 1, 2010–June 30, 2022, to provide a better understanding of the clinical features of GAS primary peritonitis in a contemporary setting with a high burden of iGAS disease. In addition, we reviewed and compared identified cases with reports in the English language literature.