High rates of group A streptococcus infection in England
In a UK Health Security Agency (UKHSA) report, notifications of scarlet fever and invasive group A streptococcus (iGAS) disease in England are higher than expected for this time of year.
Prompt treatment of children with scarlet fever with antibiotics is recommended to reduce risk of possible complications and limit onward transmission. If there is uncertainty about the diagnosis, obtain a throat swab prior to commencing antibiotics. Children with scarlet fever should stay at home until 24 hours of antibiotic treatment has been received.
Around 90% of cases occur in children under 10 years
Usually a mild illness, but is highly infectious
Presents with a generalised, erythematous rash, which feels like sandpaper
Often preceded by sore throat (pharyngitis, tonsillitis)
Pharyngeal erythema with exudates, palatal petechiae, and a red, swollen (strawberry) tongue are suggestive features.
Invasive group A streptococcal infection:
The relatively higher rates of iGAS in children this season may reflect increased rates of a preceding viral infection (including respiratory viruses and chickenpox)
Clinicians are advised to maintain a high index of suspicion, as early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be life-saving.
Further information from UKHSA:
Acute pharyngitis is characterised by acute onset of sore throat; the absence of cough, nasal congestion and discharge suggests a bacterial aetiology.
Rapid antigen detection tests allow immediate point-of-care assessment of group A Streptococcus (GAS) pharyngitis. However, nucleic acid amplification (via polymerase chain reaction) testing for GAS is becoming more common and is comparable to throat culture in sensitivity and specificity but is more rapid.
The goal of treatment of GAS is to prevent acute rheumatic fever, reduce the severity and duration of symptoms, and prevent transmission.
Acute pharyngitis is generally a self-limiting condition with resolution within 2 weeks. Infected individuals are not immune to reinfection with most aetiological pathogens. Treatment typically involves supportive care (e.g., analgesics) and treatment of the causative pathogen (e.g. antibiotics for GAS infections).
The only situation in which antibiotic prophylaxis to prevent GAS infections is recommended is for individuals with a history of rheumatic fever.
Acute pharyngitis is characterised by the rapid onset of sore throat and pharyngeal inflammation (with or without exudate). Absence of cough, nasal congestion, and nasal discharge suggests a bacterial, rather than viral, aetiology. Acute pharyngitis can be caused by a variety of viral and bacterial pathogens, including group A Streptococcus (GAS), as well as fungal pathogens (e.g., Candida albicans). Bacterial pharyngitis, in temperate climates, is more common in winter (or early spring), while enteroviral infection is more common in the summer and autumn. Acute pharyngitis is generally a self-limiting condition with resolution within 2 weeks.
History and exam
Key diagnostic factors
- presence of risk factors
- child or adolescent age
- winter or spring season (in bacterial pharyngitis)
- summer/autumn season (in enteroviral pharyngitis)
- rhinorrhoea, nasal congestion, and cough (in viral infection)
- sore throat
- pharyngeal exudate
- cervical adenopathy
- nausea, vomiting, and abdominal pain
- conjunctivitis (in measles)
- maculopapular rash (in measles)
- Koplik spots (in measles)
- scarlatiniform rash (in group A Streptococcus [GAS] pharyngitis)
Other diagnostic factors
- sexual activity or abuse (in HIV, gonorrhoeal, or chlamydial infection)
- treatment failure of penicillin
- pharyngeal ulceration (in tularaemia)
- pharyngeal grey membrane (in diphtheria)
- nasal colonisation with group A Streptococcus (GAS)
- GAS-infected contact
- sexual activity or abuse
- ingestion of non-domestic meats
- immunocompromised host
- use of inhaled corticosteroids
- lack of immunisation or vaccine failure
1st investigations to order
- rapid antigen test for group A Streptococcus (GAS)
- nucleic acid amplification (via polymerase chain reaction) for group A Streptococcus (GAS)
Investigations to consider
- culture of throat swab for group A Streptococcus (GAS)
- culture of throat swab for gonococcus or chlamydia
- serum monospot for Epstein-Barr virus infection
- Retropharyngeal, peritonsillar, and lateral abscess
- Infectious mononucleosis
- Pharyngitis (strep throat)
- Group A streptococcal (GAS) pharyngitis: a practical guide to diagnosis and treatment
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