Pediatric Central Nervous System Infections Due to Group A Streptococcus: A Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this systematic review is to synthesize observational evidence on pediatric group A Streptococcus (Streptococcus pyogenes-GAS) central nervous system (CNS) infections regarding epidemiologic, clinical and microbiological characteristics. METHODS: A systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies up to June 2026. Eligible studies reported pediatric patients 0-18 years of age with microbiologically confirmed CNS GAS infection. Observational studies and case reports/series were synthesized descriptively and were not included in the meta-analysis. RESULTS: Twenty-six independent cohorts were included in the meta-analysis, and 80 observational studies and case reports/series were additionally used for the descriptive analysis. Nine pediatric bacterial meningitis cohorts (N = 5369), including 55 GAS cases, were analyzed, and random-effects pooled proportion for GAS meningitis was 2.4% [95% confidence interval (CI): 1.1-4.9; I2=77.0%; Q-test P < 0.001]. Seventeen pediatric invasive GAS (iGAS) cohorts (N = 5496), including 216 CNS GAS cases, were analyzed, and random-effects pooled proportions for GAS meningitis was 4.4% (95% CI: 3.3-5.8; I2=63.4%; Q-test P < 0.001). Epidemiologic characteristics did not differ significantly between children included in the meta-analysis and in observational cohorts. In the combined descriptive analysis, 158/300 children (52.7%) were female. Among 289 children with age-group data, 144/289 (49.8%) were ≥5 years, 75/289 (26.0%) were 1-4 years and 70/289 (24.2%) were <1 year old. Mortality was 44/265 (16.6%). Among 156 typed isolates/cases, emm1 (62/156, 39.7%) and emm12 (24/156, 15.4%) predominated. CONCLUSIONS: Pediatric CNS GAS infection is uncommon but clinically severe and frequently underrecognized. Early identification could optimize management and prevent complications.