Since late 2022, an increase in Streptococcus pyogenes (Group A Streptococcus, GAS) infections, both non-invasive and invasive (iGAS), has been reported globally. This study investigates iGAS cases complicated by recurrent infection (rGAS). From January to September 2023, four adults with severe iGAS suffered from rGAS. Clinical and whole-genome sequencing data were analysed. All patients required ICU admission and surgical debridement during their initial iGAS. The median interval between the initial iGAS and rGAS was 25.5 days, with a median duration of antibiotic treatment of 25 and 17.5 days, respectively. Patients A (female, age 69) and B (male, age 46) had upper limb necrotising fasciitis complicated by a subsequent cellulitis at the exact location. GAS emm1.3 (M1UK) was isolated in both patients, but patient A´s isolates carried a type-IV secretion system (T4SS), and this patient had a more severe course of infection. Patient C (male, age 66) had two episodes of bacteremia caused by GAS emm89.0 carrying T4SS and GAS emm12.37 with a frameshift in the rocA gene. Patient D (female, age 69) had upper limb cellulitis with bacteremia during the initial iGAS and upper limb cellulitis with septic gonitis as two concurrent manifestations of rGAS. All three isolates were identical, belonging to emm12.0 and carrying a 79 amino acid deletion in the SclA. Patients B and C had a reduced function of the complement lectin pathway and CD19+ lymphocyte deficiency. A combination of strain virulence factors and host immune deficiencies may predispose patients with iGAS to recurrence.

3rd Department of Surgery 1st Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Childhood Leukaemia Investigation Prague Department of Paediatric Haematology and Oncology 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Anaesthesiology and Intensive Care 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Immunology 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Infectious Diseases and Travel Medicine 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Medical Microbiology 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

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