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GPs warned to have ‘low threshold’ for antibiotics in potential strep A infections

GPs warned to have ‘low threshold’ for antibiotics in potential strep A infections

GPs have been advised to ‘have a low threshold’ for prescribing antibiotics to children presenting with symptoms associated with group A streptococcal infections.

UK public health officials have issued the advice across primary care, emergency and paediatric services amidst concern over high levels of infections and the deaths of seven children since September.

GP consultations for scarlet fever and disease notifications are rising more steeply than expected for this time of year as are cases of invasive group A streptococcus, although less pronounced, the UK Health Security Agency has warned.

Officials are also investigating an increase in lower respiratory tract group A streptococcal infections, particularly empyema, in children over the past few weeks.

In an urgent letter to GPs, UKHSA said: ‘Given the unusually high level of GAS (group A strep) and viral co-circulation in the community, health care professionals are asked to 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.’

It said that parents of children with viral infections such as flu or chickenpox should be given advice about signs that could suggest secondary bacterial infection.

‘GPs should maintain a low threshold for prompt referral to secondary care of any children presenting with persistent or worsening symptoms,’ it continued.

According to the letter, a ‘high burden of co-circulating viral infections may be contributing to the increased severity and complications through co-infection’.

And GP should ‘consider taking a throat swab to assist with differential diagnosis or if the patient is thought to be part of an outbreak (to confirm aetiology), allergic to penicillin (to determine antimicrobial susceptibility) or in regular contact with vulnerable individuals’.

A total of 4,622 notifications of scarlet fever were received from week 37 to 46 this season (2022 to 2023) in England, with 851 notifications received in week 46 compared with an average of 1,294 (range 258 to 2,008) for this same period (weeks 37 to 46) in the previous five years, UKHSA figures show.

There is considerable variation across England with the highest rates seen in the North West.

Laboratory notifications of invasive group A streptococcus disease are also higher than seen over the past five years at 509 compared with 248. The highest rates to date have been reported in Yorkshire and Humberside.

 In a report issued on Friday, outlining the current disease trends, UKHSA also advised: ‘Clinicians should continue to be mindful of potential increases in invasive disease and maintain a high index of suspicion in relevant patients and provide safety netting advice as appropriate, as early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be life-saving.’

Professor Adam Finn, professor of paediatrics at the University of Bristol, said if infections were diagnosed early, they can usually be effectively treated with penicillin.

‘Lots of infections became rarer during the restrictions of the recent pandemic and are now coming back rapidly as mixing normalises. GAS is no exception and we have been seeing increasing numbers of cases in recent months.’

Dr Michael Head, senior research fellow in global health at the University of Southampton, said while public health surveillance was showing increase cases of scarlet fever and invasive group A streptococcal infection than would normally be seen at this time of year, across the whole year cases were higher in 2017/18.

‘After the pandemic response over the last two and a half years, it might be that we’re not yet back in line with usual seasonal expectations, and we do usually observe natural fluctuations in disease patterns.


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Please note, only GPs are permitted to add comments to articles

David Church 5 December, 2022 2:26 pm

Oh Great! – so now it is ‘antibiotics for everything!

Only last year (and next year, presumably) everyone will criticise GPs for giving antibiotics too readily.

And I see they have got aroudn the fact it is caused by Covid by using the new name : “C0-circulating viral infections” instead.

Patrick Pearson 5 December, 2022 2:32 pm

Our local pharmacy is reporting shortages of Pen V and Clarithromycin suspensions.

Patrufini Duffy 5 December, 2022 3:38 pm

Yes David. Then you get named and shamed on CQC unintelligent monitoring and Open Prescribing for antibiotics. Perverse. Psychological rape someone once coined it.

Keith M Laycock 5 December, 2022 5:58 pm

The validated CENTOR score for strep pharyngitis is readibly available and easy to use.

Each of the Centor criteria score 1 point (maximum score of 4). A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.26 Jan 2018

Sore throat (acute): antimicrobial prescribing | Guidance – NICE

“The UK Public Health Officials & UKHSA” have likely never heard of it.

David Mummery 5 December, 2022 7:14 pm

Going to be severe antibiotics shortages starting soon, pharmacies already running low….

Patrufini Duffy 5 December, 2022 8:04 pm

Yes David. They had a HRT Tsar immediately appointed, and for life threatening issues, not a lot of movement.

Anonymous 6 December, 2022 12:41 am

Most attendances at our local paediatric ED this week are related to:

-parents afraid of Strep throat following recent deaths and extensive media coverage
-GPs advising parents to attend ED with their children because ‘we all have been told to be extra vigilant’
– 111 sending them through as ‘they might need antibiotics’

Absolute madness. It’s clearly not sustainable long term.

Slobber Dog 6 December, 2022 8:33 am

We must cut down all antibiotic prescribing.
Except for sore throats.

John Glasspool 6 December, 2022 1:57 pm

Perhaps someone should ask Dame Sally Davies to come out of retirement to show GPS which cases need antibiotics? SHe was one of the worst critics of GPs.

Sadly, I don’t rate the Centaur criteria that much: if you’ve only got a 1% chance of having Strep, and it goes invasive, that’s still very bad news.

I’m also astonished that some doctors think a negative throat swab means no Strep. Ask any passing bacteriologist about how good throat swabs are.

And as to Dame Sally’s “antibiotic apocalypse”, well it struck me years ago that there are two populations when it comes to bacterial infections (largely) : namely the hospital ones, where there are “superbugs” and the community ones, where there aren’t, or very rarely, which is why Amoxicillin still works after 40 years or so. Rocket science it ain’t- unless you are in an ivory tower.

Patrufini Duffy 6 December, 2022 4:13 pm

Humans think they’re above nature. The pandemic taught them little. Evading bugs and blobs, the top predator, scared of “it”. You know, remember all those children with an ear infections, conjunctivitis and coughs “yes, but can I take him to swimming class” – sure, dump him in cold water privileged neglect.

Dr N 6 December, 2022 8:07 pm

Head above the parapet moment;

Its dreadful that these children have been so ill and some have died, but 8 children out of 7 million of the relevant age is 0.00011% effected. Is that an outbreak that warrants ‘prevention’?

Dylan Summers 7 December, 2022 11:24 am

@Dr N

Yes. When you factor in iatrogenic harms, it’s far from clear that increasing medical intervention for children with a sore throat will lead to a net benefit.

Nobbies Piles 7 December, 2022 9:53 pm

Once again anything other than ‘flavour of the month’ gets put on the back burner by the BBC: normal appointments will have to wait until the headlines are dominated by something else.

Patrufini Duffy 7 December, 2022 9:57 pm

There is a Government Department they never told you about. It is called the Department of Fear. Think about “it”. You’ll see it all forms, in all modes, in all words. The engine of control.

Dave Haddock 9 December, 2022 2:05 pm

There is a rapid result throat swab for Strep A, similar to the rapid Covid test, with good specifity and sensitivity, It’s widely used in Canada and the USA, and use dramatically reduces the need to prescribe antibiotics.
Sadly the NHS is often stuck a decade or more behind, and the endless media hysterics are not helping.

Dr. Michael Hfuhruhurr 9 December, 2022 11:47 pm

Dear Lord….I wonder if a pharmacist could dust off his pestle & mortar to grind up a tablet preparation of phenoxymethylpenicillin …into…like …a powder form…that could …be administered via whatever medium little Johnny, Janet or They can ingest…for all the good that it will do
The desire to be outraged rather than practical and proactive is no small part of the reason we are where we are….

In other news…..Dr N….can I come and work with you?