Urbina Tomas, Faucheux Lilith, Lavillegrand Jean-Rémi, Massol Julien, Lecronier Marie, de Roux Quentin, Turpin Matthieu, Menard William, Gautier Melchior, Barnaud Guilene, Roux Damien, Luyt Charles-Edouard, Vieillard-Baron Antoine, Voiriot Guillaume, Mongardon Nicolas, Decavele Maxens, Pène Frédéric, Joffre Jérémie, Ait-Oufella Hafid, de Prost Nicolas, Maury Eric
Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France.
Service de Médecine Intensive-Réanimation, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France.
Crit Care. 2025 Jun 12;29(1):239. doi: 10.1186/s13054-025-05469-6.
Invasive group A streptococcus (iGAS) infection incidence is rising. These infections have been studied as a whole but can be associated with critical illness in a population with a wide array of underlying conditions, sites of infection and clinical presentations. Using an unsupervised clustering approach, we aimed to identify specific clinical phenotypes regarding presentation, management and outcome.
This was a retrospective multicentric study including all patients admitted to one of 9 ICUs of Paris University Hospitals for an iGAS infection between 01/03/2018 and 01/08/2023. iGAS infection was defined as GAS growth in any microbiological sample from a sterile site. Patients were grouped according to a clustering algorithm (k-prototypes) using a comprehensive set of clinical and biological variables available upon ICU admission. Clusters were described and clinical presentation, management and outcome were compared.
148 patients were included. According to the Silhouette criterion, patients were grouped in 3 clusters, and 7 patients remained unclassified. Cluster 1 (n = 73) comprised a greater proportion of less severely-ill female patients with painful skin and soft tissue infections, a quarter of whom had taken non-steroidal anti-inflammatory drugs. Cluster 2 (n = 42) was characterized by a high rate of respiratory infections with frequent viral co-infections. Cluster 3 (n = 26) included mostly socially deprived patients with high rates of chronic alcohol consumption and psychiatric illness, with severe organ dysfunction related to otherwise pauci-symptomatic skin and soft tissue infections. There was no significant difference in time to source control across clusters (0 [0-0] vs 0 [0-0] vs 0 [0-1] days, p = 0.12). Patients included in cluster 2 less frequently received antitoxin antibiotics than patients from clusters 1 and 3 (79% vs 45% vs 69%, p < 0.001) and tended to more frequently require ECMO support (3% vs 12% vs 0%, p = 0.07), while those from cluster 1 were less likely to receive invasive mechanical ventilation (48% vs 74% vs 77%, p = 0.005). There was no difference in ICU-mortality between clusters (19% vs 29% vs 31%, p = 0.32).
Based on simple and readily available clinical admission characteristics of critically ill patients with iGAS, unsupervised clustering analysis identified three specific patient populations that differed regarding ICU management. Whether tailoring management would affect outcome warrants further research.
侵袭性A组链球菌（iGAS）感染的发病率正在上升。以往对这些感染进行了整体研究，但在患有各种基础疾病、感染部位和临床表现的人群中，它们可能与危重病相关。我们旨在采用无监督聚类方法，确定关于临床表现、治疗和结局的特定临床表型。
这是一项回顾性多中心研究，纳入了2018年3月1日至2023年8月1日期间在巴黎大学医院9个重症监护病房之一因iGAS感染入院的所有患者。iGAS感染定义为来自无菌部位的任何微生物样本中A组链球菌生长。根据聚类算法（k-原型），使用重症监护病房入院时可用的一组全面的临床和生物学变量对患者进行分组。描述各聚类，并比较临床表现、治疗和结局。
共纳入148例患者。根据轮廓系数标准，患者被分为3个聚类，7例患者未分类。聚类1（n = 73）包括比例更高的病情较轻的女性患者，患有疼痛性皮肤和软组织感染，其中四分之一服用过非甾体抗炎药。聚类2（n = 42）以呼吸道感染率高且频繁合并病毒感染为特征。聚类3（n = 26）主要包括社会经济条件差、慢性酒精消耗量高且患有精神疾病的患者，伴有与症状轻微的皮肤和软组织感染相关的严重器官功能障碍。各聚类之间在实现源头控制的时间上无显著差异（0[0 - 0]天 vs 0[0 - 0]天 vs 0[0 - 1]天，p = 0.12）。聚类2中的患者比聚类1和聚类3中的患者接受抗毒素抗生素治疗的频率更低（79% vs 45% vs 69%，p < 0.001），且更倾向于更频繁地需要体外膜肺氧合（ECMO）支持（3% vs 12% vs 0%，p = 0.07），而聚类1中的患者接受有创机械通气的可能性较小（48% vs 74% vs 77%，p = 0.005）。各聚类之间在重症监护病房死亡率方面无差异（19% vs 29% vs 31%，p = 0.32）。
基于iGAS感染危重症患者简单且易于获取的临床入院特征，无监督聚类分析确定了在重症监护病房管理方面存在差异的三个特定患者群体。调整管理是否会影响结局值得进一步研究。
