New interim clinical guidance issued on group A streptococcus in children

NHS England and the UK Health Security Agency (UKHSA) have issued new interim clinical guidance on diagnosing and treating children with suspected group A streptococcus infection.

Streptococcus pyogenes (Photo: BSIP/Getty Images)

The guidance, which has been endorsed by NICE, the RCGP, the Royal College of Paediatrics and Child Health, and the Royal Pharmaceutical Society, applies until the end of January 2023 when it will be reviewed.

The guidance repeats previous warnings from the UKHSA that cases of scarlet fever and invasive group A streptococcus (iGAS) are higher than would be expected at this time of year.

It highlights that an unusually high number of children are presenting with 'lower respiratory tract GAS infections, including pulmonary empyema' and suggests that the high level of iGAS cases 'may reflect increases in the co-circulation of respiratory viruses'.

GPs are urged to have a low threshold 'to consider and empirically prescribe antibiotics to children presenting with features of GAS infection, including when the presentation may be secondary to viral
respiratory illness'.

The guidance says that given the 'increased likelihood of group A strep as a cause of sore throat in children' the current recommendation is now to 'prescribe antibiotics to children with a FeverPAIN score of 3 or more'.

Current guidance relating to prescribing antibiotics in adults remains in place.

Referring to secondary care

GPs are also advised to have a low threshold for referring any children with persistent or worsening symptoms to secondary care.

The guidance adds that GPs should also 'maintain a low threshold for considering pulmonary complications of GAS, especially if presenting with an illness compatible with bacterial pneumonia, and concurrent or recent scarlet fever, or GAS infection or the patient was recently in contact with a case of scarlet fever/GAS infection'. It adds that 'prompt initiation of appropriate antibiotics remains key'.

The new advice says existing guidance about fever in under 5s, sore throat, scarlet fever and sepsis should continue to be followed. It provides a number of 'practice points' that clinicians should consider to help identify scarlet fever and sore throat cases that could benefit from antibiotics.

Prescribing advice

Phenoxymethylpenicillin (penicillin V) remains the first line antibiotic of choice. If this is unavailable amoxicillin, then macrolides and cefalexin are alternatives – in that order of preference.

In children with non severe-penicillin allergy, macrolides should be prescribed first line, with cefalexin as an alternative. In those with severe allergy, macrolides should still be prescribed first line with co-trimoxazole second line.

The guidance adds: 'In the current circumstances clinicians should be aware that a five-day course will be appropriate for many children, at the discretion of the treating clinician'. However it also points to current NICE guidance on antibiotic treatment for sore throat that suggests 10 days 'may increase the chance of microbiological cure'.

Close contacts

The UKHSA should be notified of all cases of severe group A strep infection. The guidance suggests that some close contacts of cases, which is defined as prolonged contact within the seven days before symptoms and up to 24 hours after treatment starts, should receive antibiotic prophylaxis. These include:

  • pregnant women from ≥37 weeks gestation
  • neonates and women within the first 28 days of delivery
  • older household contacts (≥75 years)
  • individuals who develop chickenpox with active lesions either seven days prior to onset in the iGAS case or within 48 hours after the iGAS case commences antibiotics, if exposure is ongoing.

On Thursday 8 December chief pharmaceutical officer for England, David Webb, wrote to all community and hospital pharmacists to reassure them that there is 'sufficient' antibiotic stock in the UK to cope with the current levels of increased demand. 

Mr Webb acknowledged that pharmacies have had problems ordering antibiotics, in particular phenoxymethylpenicillin (penicillin V), but suggested the issue should be temporary.

Meanwhile NHS England has instructed integrated care systems to set up acute respiratory infection hubs to help boost capacity for in-person appointments after the surge in demand due to concerns about strep A infection.

GPs have said that demand for appointments this week has hit new highs. Data from the UK Health Security Agency show that there have been 13 deaths from invasive group A strep (iGAS) in children aged under 18 in England. Two further deaths have occurred in children across the UK - one in Wales and one in Northern Ireland.

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