Epidemiology of pediatric invasive group A streptococcus infection in a Saudi tertiary care center

BACKGROUND: Invasive group A Streptococcus (iGAS) infections in children can cause severe illness and lead to high rates of complications and death. While recent global reports show a rise in pediatric iGAS after the COVID-19 pandemic, there is limited data from Saudi Arabia. OBJECTIVES: Assess the clinical features, outcomes, and patterns of pediatric iGAS at a major tertiary center in Riyadh. DESIGN: Retrospective case series study. SETTING: King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh, Saudi Arabia. PATIENTS AND METHODS: Pediatric patients aged 14 years or younger who had symptoms of iGAS confirmed by a positive culture from January 2018 to May 2025. MAIN OUTCOMES MEASURES: Clinical features, outcomes, and patterns of pediatric iGAS. SAMPLE SIZE: 32 children. RESULTS: Out of the 585 total infections recorded, 32 cases were classified as iGAS and included in the study. Most infections happened in winter and spring, with (433/585) 74% occurring from November to April. The highest rates of iGAS were seen during the COVID-19 pandemic years. The average age of patients was 4.1 years, and 94% (n=30) had other health problems, mainly congenital heart disease (n=9, 28%) and hematology/oncology (n=8, 25%). Bacteremia was the most common presentation (n=17, 53%), followed by cellulitis/necrotizing fasciitis (n=9, 28%) and pneumonia (n=8, 25%). Eleven children (34%) needed intensive care, and the overall death rate was 9% (3/32), with all deaths in patients who had bacteremia. CONCLUSION: In our center, pediatric iGAS infections carry a substantial comorbidity and disease severity burden, frequently presenting with complex and aggressive clinical manifestations. These findings underscore the urgent need for heightened vigilance in high-risk children, improved diagnostic precision, and strengthened local surveillance systems to enhance prevention and optimize management of these serious infections. LIMITATIONS: Single-center, retrospective design and absence of rapid diagnostic testing.