Last reviewed: 28 Dec 2022
Last updated: 25 Jan 2023
25 Jan 2023

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.

The Centers for Disease Control and Prevention (CDC) is looking into an increase in iGAS infections among children in the US.

Scarlet fever:

  • Around 90% of cases occur in children under 10 years

  • Usually a mild illness, but is highly infectious

  • Presents with a generalized, 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 CDC:

Original source of update



History and exam

Key diagnostic factors

  • pain on swallowing
  • fever (>100.5°F [>38°C])
  • tonsillar exudate
More key diagnostic factors

Other diagnostic factors

  • sudden onset of sore throat
  • headache
  • abdominal pain
  • nausea and vomiting
  • presence of cough or runny nose
  • tonsillar erythema
  • tonsillar enlargement
  • enlarged anterior cervical lymph nodes
Other diagnostic factors

Risk factors

  • age between 5 and 15 years
  • contact with infected people in enclosed spaces (e.g., child care centers, schools, prison)
More risk factors

Diagnostic investigations

1st investigations to order

  • throat culture
  • rapid streptococcal antigen test
More 1st investigations to order

Investigations to consider

  • serologic testing for streptococci
  • WBC count and differential
  • heterophile antibodies
  • vaginal and cervical, or penile, and rectal cultures
  • HIV viral load assay
  • lateral cervical view x-ray, exposed for soft tissue
More investigations to consider

Treatment algorithm


acute tonsillitis not due to group A beta-hemolytic streptococcal infection

acute tonsillitis due to group A beta-hemolytic streptococcal infection


recurrent episodes of tonsillitis



Christos Georgalas, PhD, DLO, FRCS (ORL-HNS)
Christos Georgalas

Professor of Surgery - Head and Neck

University of Nicosia



CG declares that he has no competing interests.

Eleftherios Margaritis, PhD, MSc, MD
Eleftherios Margaritis

Otolaryngologist - Head and Neck Surgeon

Collaborator in Otolaryngology

ENT Department

Hippokration University Hospital




EM declares that he has no competing interests.

Peer reviewers

Itzhak Brook, MD, MSc

Professor of Pediatrics and Medicine

Georgetown University




IB declares that he has no competing interests.

Chris Del Mar, MB BChir, FRACGP MD, MA, FAFPHM


Faculty of Health Sciences and Medicine

Bond University

Gold Coast




CDM is an author of a number of references cited in this topic.

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  • Calculators

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