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Brief report
Epidemiological changes in invasive Streptococcus pyogenes infection during the UK alert period: A molecular comparative analysis from a tertiary Spanish hospital in 2023
Cambios epidemiológicos en la infección invasiva por Streptococcus pyogenes durante el periodo de alerta en Reino Unido: análisis molecular comparativo de un hospital terciario español en 2023
Alfredo Maldonado-Barruecoa, Iván Bloisea, Emilio Cendejas-Buenoa,b, Francisco López-Rodrigoa, Julio García-Rodrígueza,b, Fernando Lázaro-Peronaa,
Corresponding author
fernandolazaroperona@gmail.com

Corresponding author.
a Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz, Madrid, Spain
b CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">On December 2nd&#44; 2022&#44; the Health Security Agency from London &#40;United Kingdom&#44; UK&#41; alerted of an increase of <span class="elsevierStyleItalic">Streptococcus pyogenes</span> &#40;Group A <span class="elsevierStyleItalic">Streptococcus</span>&#44; GAS&#41; invasive infections&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Characterization of the GAS isolates showed that the recently described M1<span class="elsevierStyleInf">UK</span> clone and <span class="elsevierStyleItalic">emm12</span> were predominant during the outbreak&#46; The emergence of the <span class="elsevierStyleItalic">S&#46; pyogenes</span> clone during the UK alert period has raised concerns about the potential spread and impact of these strains&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> especially when the M1<span class="elsevierStyleInf">UK</span> clone has been reported in other countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the pre COVID-19 pandemic period&#44; the National Center for Microbiology of Spain &#40;National Institute Carlos III&#41; reported the first nationwide microbiological&#44; epidemiological and characterization study of invasive GAS disease between 2007 and 2019 being the <span class="elsevierStyleItalic">emm1</span>&#44; <span class="elsevierStyleItalic">emm89</span>&#44; and <span class="elsevierStyleItalic">emm3</span> the most prevalent <span class="elsevierStyleItalic">emm</span> types in our country&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Meanwhile&#44; in Madrid &#40;Spain&#41;&#44; it has been recently reported an increase of the GAS infections in children compared with the first two pandemic COVID-19 years &#40;2020&#8211;2021&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> and a non-significant increase of <span class="elsevierStyleItalic">S&#46; pyogenes</span> bloodstream infections &#40;GAS-BSI&#41; in children population&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to investigate possible changes on the genomic epidemiology and incidence of invasive GAS at our tertiary care center&#44; focusing on bloodstream infections&#44; during the UK alert period &#40;2023&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We recovered all GAS isolated from blood cultures between January and May 2023&#46; Blood cultures were incubated using the Virtuo&#8482; system &#40;BioM&#233;rieux&#174;&#44; Marcy l&#8217;Etoile&#44; France&#41; and identified according to the protocol described by Garc&#237;a-Clemente et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Demographic&#44; clinical&#44; and analytical data of patients with GAS-BSI was retrospectively collected from the hospital medical records&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; pyogenes</span> DNA extraction was carried out using the DNeasy&#174; blood &#38; Tissue kit &#40;Qiagen GmbH&#44; Hilden&#44; Germany&#41; and sequenced in the Ion GeneStudio S5 system &#40;Thermo Fisher Scientific&#44; Massachusetts&#44; EEUU&#41; using the NEBNext&#174; Fast DNA Library Prep Set for Ion Torrent&#8482; &#40;New England Biolabs&#44; Ipswich MA&#44; USA&#41;&#46; Genome assembly was performed using spades v3&#46;14&#46;1 &#40;<a href="https://github.com/ablab/spades">https&#58;&#47;&#47;github&#46;com&#47;ablab&#47;spades</a>&#41; and <span class="elsevierStyleItalic">emm</span> typing using the emmtyper tool v0&#46;2&#46;0 &#40;<a href="https://github.com/MDU-PHL/emmtyper">https&#58;&#47;&#47;github&#46;com&#47;MDU-PHL&#47;emmtyper</a>&#41;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Analysis of virulence genes was performed using abricate v1&#46;0&#46;1 &#40;<a href="https://github.com/tseemann/abricate">https&#58;&#47;&#47;github&#46;com&#47;tseemann&#47;abricate</a>&#41; and the Virulence Factor DataBase &#40;<a href="https://www2.cdc.gov/vaccines/biotech/strepblast.asp">https&#58;&#47;&#47;www2&#46;cdc&#46;gov&#47;vaccines&#47;biotech&#47;strepblast&#46;asp</a>&#41;&#46; Determination of the M1<span class="elsevierStyleInf">UK&#47;global</span> clone analysis through SNP analysis using the Geneious prime 2023&#46;0&#46;2&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> software&#46; Sequencing data of all isolates are available at the European Nucleotide Archive &#40;ENA&#41; under the Project PRJEB64433&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Antimicrobial susceptibility was performed using the microdilution method with MicroScan Walkaway&#8482; &#40;Beckman Coulter&#174;&#44; Indianapolis&#44; IN&#44; USA&#41; system using the MSTRP&#43; 6 panel&#46; The MIC values were interpreted following EUCAST breakpoints&#44; version 12&#46;0 &#40;<a href="http://www.eucast.org/clinical_breakpoints/">http&#58;&#47;&#47;www&#46;eucast&#46;org&#47;clinical&#95;breakpoints&#47;</a>&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">We diagnosed 35 cases of GAS-BSI during the months of January&#8211;May of the years 2017&#8211;2023&#46; Between 2017 and 2022&#44; there were 21 cases with a median number of 3&#46;5 &#91;IQR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;5&#8211;4&#46;5&#93; per year&#44; while the number of cases during the same period in 2023 reached 14 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; During the 2017&#8211;2022 period&#44; there were 9 out of 21 GAS-BSI cases in pediatric population &#40;42&#46;9&#37;&#41; with a mean age of 4 years while in the 2023 period and only 3 out of 14 cases occurred in children &#40;21&#46;43&#37;&#41; with a mean age of 7 years&#46; In relation to the focus of GAS-BSI bloodstream infections in 2023&#44; ten out of the 14 patients &#40;71&#46;4&#37;&#41; had a cutaneous focus&#44; three of 14 &#40;21&#46;4&#37;&#41; had a respiratory portal of entry and one patient &#40;7&#46;2&#37;&#41; had an abdominal focus&#46; Twelve of the 14 patients &#40;85&#46;71&#37;&#41; were pregnant women or had a previous pathology such as transplantation&#44; diabetes&#44; COPD or cancer&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">According to the WGS analysis of 2023 GAS-BSI isolates&#44; we reported eight <span class="elsevierStyleItalic">emm</span> types&#58; <span class="elsevierStyleItalic">emm1</span>&#44; <span class="elsevierStyleItalic">emm12</span>&#44; <span class="elsevierStyleItalic">emm4</span>&#44; <span class="elsevierStyleItalic">emm5</span>&#44; <span class="elsevierStyleItalic">emm11</span>&#44; <span class="elsevierStyleItalic">emm22</span>&#44; <span class="elsevierStyleItalic">emm28</span>&#44; and <span class="elsevierStyleItalic">emm109</span> being the most frequent the <span class="elsevierStyleItalic">emm1</span> &#40;6&#47;14&#44; 42&#46;9&#37;&#41;&#44; and <span class="elsevierStyleItalic">emm12</span> &#40;2&#47;14&#44; 14&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Among the six GAS <span class="elsevierStyleItalic">emm1</span>&#44; five out of the six <span class="elsevierStyleItalic">emm1</span> types &#40;83&#46;3&#37;&#41; presented the 27 SNPs associated with the M1<span class="elsevierStyleInf">UK</span> clone&#46; The fourteen GAS-BSI isolates were susceptible to beta-lactams&#44; macrolides&#44; clindamycin and fluoroquinolones&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">We analyzed the presence of 11 superantigen genes for each GAS-BSI isolated sequenced by WGS including <span class="elsevierStyleItalic">smeZ</span>&#44; <span class="elsevierStyleItalic">speA</span>&#44; <span class="elsevierStyleItalic">speC</span>&#44; <span class="elsevierStyleItalic">speG</span>&#44; <span class="elsevierStyleItalic">speH</span>&#44; <span class="elsevierStyleItalic">speI</span>&#44; <span class="elsevierStyleItalic">speJ</span>&#44; <span class="elsevierStyleItalic">speK</span>&#44; <span class="elsevierStyleItalic">speL</span>&#44; <span class="elsevierStyleItalic">speM</span> and <span class="elsevierStyleItalic">ssa</span> genes&#46; The mainly superantigen genes found were the streptococcal mitogenic exotoxin Z &#40;<span class="elsevierStyleItalic">smeZ</span>&#41; &#40;14&#47;14&#44; 100&#37;&#41;&#44; followed by <span class="elsevierStyleItalic">speG</span> &#40;12&#47;14&#44; 85&#46;7&#37;&#41;&#44; <span class="elsevierStyleItalic">speC</span> &#40;10&#47;14&#44; 71&#46;4&#37;&#41;&#44; and <span class="elsevierStyleItalic">speJ</span> &#40;7&#47;14&#44; 50&#37;&#41; genes&#46; All five <span class="elsevierStyleItalic">emm1</span> M1<span class="elsevierStyleInf">UK</span> clones had <span class="elsevierStyleItalic">speA</span> and <span class="elsevierStyleItalic">speJ</span> superantigen genes&#46; However&#44; the only M1<span class="elsevierStyleInf">global</span> clone had <span class="elsevierStyleItalic">speJ</span> but not <span class="elsevierStyleItalic">speA</span> superantigen genes&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The emergence of the M1<span class="elsevierStyleInf">UK</span> clone and <span class="elsevierStyleItalic">emm12</span> strains in the United Kingdom raised concerns about their potential spread and impact&#44; especially when such increase of cases has been also reported in other countries such as France&#44; the Netherlands&#44; Finland&#44; Sweden or USA&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9&#8211;12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In the same way&#44; our findings indicate an increase in the number of GAS-BSI in our setting during January&#8211;May 2023 compared to the same period in previous years but&#44; contrary to other countries reports&#44; at the expense of the increase in the number of cases in adults&#46; As there have been no changes in the attended population or blood culture extraction protocols in children&#44; the cause of this discrepancy is yet unknown and will be studied in the future&#46; However&#44; it is important to highlight that in the two years prior to the increase in GAS-BSI cases&#44; marked by the SARS-CoV-2 pandemic&#44; the number of cases were exceptionally low&#44; so it is plausible a relationship between the two events&#46; In addition&#44; our current genomic epidemiology of GAS-BSI seems dominated by the M1<span class="elsevierStyleInf">UK</span> clone followed by the <span class="elsevierStyleItalic">emm12</span>&#44; similar to the data reported in the UK during the GAS alert 2022&#8211;2023&#46; This should bring the attention as the M1<span class="elsevierStyleInf">UK</span> clone detected in Madrid produces both the <span class="elsevierStyleItalic">speA</span> and <span class="elsevierStyleItalic">speJ</span> superantigens that might be related to higher invasiveness of these strains&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Our main limitation is that we have not characterized the <span class="elsevierStyleItalic">S&#46; pyogenes</span> strains isolated from blood cultures in our setting in the 2017&#8211;2022 period&#46; Nonetheless&#44; this limitation is compensated by the extensive national and local data published in previous years&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> Moreover&#44; we did not include in our study other invasive GAS samples &#40;pleural fluid&#44; CSF&#44; pneumonia&#44; necrotizing fasciitis&#41; as they were scarce and more heterogeneous&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; this study provides preliminary insights into the genomic epidemiology and incidence of GAS-BSI during the UK alert period in 2023&#46; The observed increase in GAS-BSI cases overall&#44; but not in children&#44; suggests differences in the affected population in our environment&#46; The predominance of the M1<span class="elsevierStyleInf">UK</span> clone and the presence of specific superantigen genes among the isolates highlight the need for continued surveillance and further investigation into the molecular characteristics and clinical implications of circulating GAS strains&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethics approval</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ethical review and approval were not required for the study on human participants in accordance with the local legislation and institutional requirements&#46; The data used are from clinical samples that were necessary for the clinical diagnosis of the patients&#46; The epidemiological <span class="elsevierStyleItalic">S&#46; pyogenes</span> study was not included in the clinical report of the patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">Not funding&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0100" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To study the genomic epidemiology of <span class="elsevierStyleItalic">Streptococcus pyogenes</span> causing bloodstream infections &#40;GAS-BSI&#41; in a Spanish tertiary hospital during the United Kingdom invasive <span class="elsevierStyleItalic">S&#46; pyogenes</span> outbreak alert&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective epidemiological analysis of GAS-BSI during the January&#8211;May 2017&#8211;2023 period&#46; WGS was performed using Ion torrent GeneStudio&#8482; S5 system for <span class="elsevierStyleItalic">emm</span> typing and identification of superantigen genes in <span class="elsevierStyleItalic">S&#46; pyogenes</span> isolated during the 2022&#8211;2023 UK outbreak alert&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">During 2023&#44; there were more cases of GAS-BSI compared to the same period of previous year with a non-significant increase in children&#46; Fourteen isolates were sequenced&#46; The <span class="elsevierStyleItalic">emm1</span> &#40;6&#47;14&#44; 42&#46;9&#37;&#41; and <span class="elsevierStyleItalic">emm12</span> &#40;2&#47;14&#44; 14&#46;3&#37;&#41; types predominated&#59; 5 of 6 &#40;75&#37;&#41; <span class="elsevierStyleItalic">emm1</span> isolates were from the M1<span class="elsevierStyleInf">UK</span> clone&#46; The most detected superantigen genes were <span class="elsevierStyleItalic">speG</span> &#40;12&#47;14&#44; 85&#46;7&#37;&#41;&#44; <span class="elsevierStyleItalic">speC</span> &#40;10&#47;14&#44; 71&#46;4&#37;&#41;&#44; <span class="elsevierStyleItalic">speJ</span> &#40;7&#47;14&#44; 50&#37;&#41;&#44; and <span class="elsevierStyleItalic">speA</span> &#40;5&#47;15&#44; 33&#46;3&#37;&#41;&#46; <span class="elsevierStyleItalic">speA</span> and <span class="elsevierStyleItalic">speJ</span> were predominant in M1<span class="elsevierStyleInf">UK</span> clone&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our genomic epidemiology in 2023 is similar to the reported data from the UK outbreak alert in the same period and different from previous national <span class="elsevierStyleItalic">S&#46; pyogenes</span> surveillance reports&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudiar la epidemiolog&#237;a gen&#243;mica de aislados de <span class="elsevierStyleItalic">Streptococcus pyogenes</span> causantes de bacteriemia &#40;GAS-BSI&#41; en un hospital de tercer nivel espa&#241;ol durante la alerta por incremento de infecciones invasivas por <span class="elsevierStyleItalic">S&#46; pyogenes</span> en el Reino Unido&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis epidemiol&#243;gico retrospectivo de GAS-BSI durante el periodo enero-mayo 2017-2023&#46; Se realiz&#243; una secuenciaci&#243;n de genoma completo con el sistema Ion torrent GeneStudio&#8482; S5 de los aislados obtenidos durante la alerta de brote del Reino Unido 2022-2023 para tipificaci&#243;n <span class="elsevierStyleItalic">emm</span> e identificaci&#243;n de genes de superant&#237;genos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante el periodo enero-mayo de 2023 hubo m&#225;s casos de GAS-BSI que en el mismo periodo de a&#241;os anteriores con un aumento no significativo en ni&#241;os&#46; Se secuenciaron 14 aislados&#46; Predominaron los tipos <span class="elsevierStyleItalic">emm1</span> &#40;6&#47;14&#44; 42&#44;9&#37;&#41; y <span class="elsevierStyleItalic">emm12</span> &#40;2&#47;14&#44; 14&#44;3&#37;&#41;&#59; 5 de 6 &#40;75&#37;&#41; aislados <span class="elsevierStyleItalic">emm1</span> eran del clon M1<span class="elsevierStyleInf">UK</span>&#46; Los genes de superant&#237;genos m&#225;s detectados fueron <span class="elsevierStyleItalic">speG</span> &#40;12&#47;14&#44; 85&#44;7&#37;&#41;&#44; <span class="elsevierStyleItalic">speC</span> &#40;10&#47;14&#44; 71&#44;4&#37;&#41;&#44; <span class="elsevierStyleItalic">speJ</span> &#40;7&#47;14&#44; 50&#37;&#41; y <span class="elsevierStyleItalic">speA</span> &#40;5&#47;15&#44; 33&#44;3&#37;&#41;&#46; Los genes <span class="elsevierStyleItalic">speA</span> y <span class="elsevierStyleItalic">speJ</span> predominaron en el clon M1<span class="elsevierStyleInf">UK</span>&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestra epidemiolog&#237;a gen&#243;mica de <span class="elsevierStyleItalic">Streptococcus pyogenes</span> causantes de bacteriemia en 2023 es similar a los datos comunicados por el Reino Unido durante el mismo periodo y diferente de los informes nacionales previos de vigilancia&#46;</p></span>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Number of <span class="elsevierStyleItalic">S&#46; pyogenes</span> bloodstream infections &#40;GAS-BSI&#41; by population age and per years &#40;January&#8211;May&#44; 2017&#8211;2023&#41;&#46;</p>"
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      "titulo" => "References"
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                  "referenciaCompleta" => "Group A streptococcal infections&#58; report on seasonal activity in England&#44; 2022&#8211;2023&#46; GOVUK&#46; <a target="_blank" href="https://www.gov.uk/government/publications/group-a-streptococcal-infections-activity-during-the-2022-to-2023-season/group-a-streptococcal-infections-report-on-seasonal-activity-in-england-2022-to-2023">https&#58;&#47;&#47;www&#46;gov&#46;uk&#47;government&#47;publications&#47;group-a-streptococcal-infections-activity-during-the-2022-to-2023-season&#47;group-a-streptococcal-infections-report-on-seasonal-activity-in-england-2022-to-2023</a> &#91;consulted 4&#46;7&#46;23&#93;&#46;"
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            1 => array:3 [
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                      "titulo" => "The ongoing <span class="elsevierStyleItalic">Streptococcus pyogenes</span> &#40;Group A <span class="elsevierStyleItalic">Streptococcus</span>&#41; outbreak in London&#44; United Kingdom&#44; in December 2022&#58; a molecular epidemiology study"
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                            4 => "T&#46;G&#46;S&#46; Williams"
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                      "titulo" => "Invasive <span class="elsevierStyleItalic">Streptococcus pyogenes</span> infections &#40;2011&#8211;2018&#41;&#58; EMM-type and clinical presentation"
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Article information
ISSN: 2529993X
Original language: English
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