PONE-D-22-28601The epidemiology of superficial Streptococcal A (impetigo and pharyngitis) infections in Australia: A systematic review.PLOS ONE

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Reviewer #1: Yes

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Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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6. Review Comments to the Author

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Reviewer #1: Work by Wiegele and colleagues appears methodologically sound and is well presented. If the paper does not bring real new information to the field, it provides an up-to-date review of superficial Strep A infection in Australia. The focus on (previously known) knowledge gaps with suggestions to improve future research is a noticeable strength.

Suggestions:

1) Consider adding a few more words about inclusion and exclusion criteria of the systematic review. Since the methods have been previously published (Wiegele, PLOS ONE, 2021) this reviewer found complicated to understand the scope without reading the methods paper.

2) The microbiological side of the inclusion/exclusion criteria remains confusing to this reviewer. In the methods paper it is stated that "Studies that were pathogen-specific, other than Streptococcal A, where participants numbered less than 20 and those describing a cohort not including children (defined as 0–16 years) will be excluded." In the discussion of the current manuscript, it is stated lines 396-399 that "Few studies reported on microbiological data from the patient cohort for either impetigo 50,53,56,59,60,62 (n=6) or pharyngitis 35,43,50 (n=3) disease resulting in insufficient power for statistical analysis based on GAS+ detection. This likely reflects clinical guidelines which discourage microbiologic sampling of pharyngitis and impetigo."

=> How do you therefore define "sGAS" without microbiological GAS confirmation? Please clarify in the methods, an apologies if I missed something.

This confusion (clinical skin infection without microbiological characterization versus GAS skin infection) seems to be present throughout the MS and especially in the discussion. Maybe define clearly each of the two situations with two different terms?

3) The discussion if logically focused on the Australian situation. However, please consider mentioning how the Australian experience can lead to improvement in the sGAS surveillance elsewhere in the world.

Minor Comments:

Line 93-95: "... not well described". Where? Do you mean in Australia? In at risk population? In the world? Please clarify.

Line 217 last word: "bar" should probably be replaced by "but"?

The conclusion is relatively lengthy with some repetition. Editing those would be great.

Reviewer #2: The article is interesting and well-written. This is a well-executed systematic review and meta-analysis.

It is striking that search strategies, title and abstract screen were completed by only one investigator (lines 132-133). Authors should justify why the title and the abstract screen were not done by at least two investigators independently and to what extent this might affect the inclusion of the articles.

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Reviewer #1: No

Reviewer #2: No

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The epidemiology of superficial Streptococcal A (impetigo and pharyngitis) infections in Australia: A systematic review.

PONE-D-22-28601R1

Dear Dr. Wiegele,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Inge Roggen, M.D., Ph.D.

Academic Editor

PLOS ONE

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