2022 group A streptococcus

Group A Streptococcal (hereafter GAS) infections have variable clinical presentations, ranging from mild to severe. Skin, soft tissue and respiratory tract infections from GAS may result in tonsillitis,
pharyngitis, scarlet fever, impetigo, erysipelas, cellulitis, and pneumonia.

Invasive GAS (iGAS) is rare and results in signs of severe sepsis. However as noted there have been increased cases resulting in death within the UK during December 2022.

The UKHSA have highlighted that current (Dec 2022) iGAS infection notifications remain unusually high for this time of year, particularly in children. Marked increases in scarlet fever notifications are also being seen. Investigations are underway following reports of an increase in lower respiratory tract GAS infections in children over the past few weeks, which have caused severe illness. A high burden of co-circulating viral infections may be contributing to the increased severity and complications through co-infection. Clinicians should continue to be mindful of potential increases in invasive disease and maintain a high index of suspicion in relevant patients as early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be life-saving.

More information can be found the UKHSA briefing document 2022-098

• Have a low threshold to consider and empirically prescribe antibiotics to children presenting with features of GAS infection, including where secondary to viral respiratory illness.
  • Prompt initiation of appropriate antibiotics remains key
• Consider taking a bacterial throat swab to assist with differential diagnosis - swabs are not required for all but may be considered where there is diagnostic uncertainty, or concerns regarding antibiotic resistance
• If discharging children with presumed respiratory viral infection, they should be safety netted with advice to return if clinical deterioration, and how to seek help
• Maintain a low threshold for considering pulmonary complications of GAS

As of December 2022, in Scotland GAS is not a notifiable disease.

However, the paediatric team (led by Laura Jones, Consultant Paediatrician, Infectious diseases and Immunology) wishes sick children with positive microbiology to be reported to them.

For sick children meeting the reporting criteria (see attached protocol), please contact the health protection team on Health.protection@nhslothian.scot.nhs.uk, with the patient name, CHI and contact telephone number.

There has been no circulated reporting guidelines for adult patients; however if patients are unwell it may be worth contacting microbiology for notification and further advice.

NICE guideline 84 recommends using the FeverPAIN or Centor scores to assess risk. The 9th December NHS England guidance (PN00058) suggests that children with a FeverPAIN score of 3 or more should be prescribed antibiotics.

It has been agreed that we can use either or phenoxymethylpenicillin or amoxicillin for GAS; amoxicillin is possibly better tolerated.

It is still a 10 day course for suspected scarlet fever.

Due to stock shortages, it has been recommended that when they can children should be prescribed tablet form antibiotics. This is on an off-label basis. More information can be found at: https://www.sps.nhs.uk/articles/using-solid-oral-dosage-form-antibiotics-in-children/

Older children can be asked to take the tablets whole. Younger children can have their tablets crushed as follows (advise thanks to Alison Cockburn, pharmacy team WGH)

Notes for all medications

• The dispersed or crushed tablet, or opened capsule, will taste bitter so it may be helpful to use a strongly flavoured drink or food to mask the taste – use a small amount to ensure the child swallows the whole dose and give the dose straight away.
• Ensure the person preparing the medication does not have an allergy to it

Phenoxymethylpenicillin

Form: (Penicillin V) tablets 250mg

These are film-coated but can be dispersed in water, or crushed and mixed with liquid or soft food. To disperse the tablet:

• Place the tablet in the barrel of a 10ml oral syringe
• Replace the plunger
• Draw up approximately 5ml of water and 2ml of air
• Shake well and allow to disperse (this may take up to 10 minutes)
• Ensure all contents of the syringe are given

Alternatively the tablet may be mixed with 5 to 10ml of water in a small glass or medicine cup and stirred well.

Amoxicillin

Form: Amoxicillin capsules, 250mg and 500mg

These capsules can be opened and the contents mixed with liquid or soft food.

Other antibiotics

Clarithromycin, erythromycin, azithromycin and cefalexin tablets may be administered using the same method as for penicillin v tablets.

Health Protection Report: https://www.gov.uk/government/publications/group-a-streptococcal-infections-activity-during-the-2022-to-2023-season

Guidance: https://www.gov.uk/government/collections/group-a-streptococcal-infections-guidance-and-data

Safety netting documents: https://what0-18.nhs.uk/professionals/gp-primary-care-staff/safety-netting-documents-parents

Notification of infectious diseases: https://www.gov.uk/government/collections/notifications-of-infectious-diseases-noids