Although severe invasive infections caused by S. pyogenes (GAS) have been reported with increasing frequency during the past decade, it is not entirely clear whether these reports reflect an actual increase in the incidence of disease or increased awareness. The latter is likely, due to the dramatic nature of the infections and the coining of the phrase "flesh-eating bacteria" by the tabloid press to describe invasive necrotizing infections caused by GAS. It is believed that there has been a true, recent increase in the GAS virulence properties that may account for the changes in clinical diseases caused by GAS. Few population-based studies exist on its prevalence. Reports on the incidence range from 1.5/100,000 population in Canada to 4.4 /100,000 in the Arizona. 1 13 STSS may be underdiagnosed when associated with GAS invasive infections, since 90 percent of patients are in shock or develop shock within 4 to 6 h of admission. Prospective population-based surveillance studies from Canada from 1991 through 1995 demonstrated an incidence of STSS associated with necrotizing fasciitis to be 13 to 46 percent. 1 13 There have also been recent reports of toxic shock-like syndrome caused by non-group A streptococcal infection, specifically groups B, C, and G. In 1998, a documented group B streptococcal necrotizing fasciitis and STS-like syndrome was reported in three patients with significant underlying disease; the authors postulate that group B streptococcus has acquired an increased ability to cause fasciitis and may be the cause of a new clinical syndrome in adults. —I I6

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