Scarlet Fever and Invasive Group A Streptococcus (iGAS) Infection

Clinicians should be aware of the unusually high seasonal pattern and maintain a high index of suspicion, especially in relevant patients (such as those with chickenpox, and women in the puerperal period).

Early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be lifesaving.

Signs and symptoms of Scarlet Fever

Scarlet fever is a common childhood infection caused by streptococcus pyogenes, or group A streptococcus (GAS).

Early illness:

The symptoms are non-specific in early illness and may include sore throat, headache, fever, nausea and vomiting.

12 to 48 hours:

Characteristic red, generalised pinhead rash develops, typically first appearing on the chest and stomach, rapidly spreading to other parts of the body, giving the skin a sandpaper-like texture. On more darkly pigmented skin, the scarlet rash may be harder to spot, although the ‘sandpaper’ feel should be present.

Patients typically have flushed cheeks and pallor around the mouth.

This may be accompanied by a ‘strawberry tongue’.

During convalescence:

Desquamation of the skin occurs at the tips of fingers and toes, less often over wide areas of the trunk and limbs.

Differential diagnosis:

Measles, glandular fever and slapped cheek infections.

Complications:

Although scarlet fever is usually a mild illness, patients can develop complications such as an ear infection, throat abscess, pneumonia, sinusitis or meningitis in the early stages and acute glomerulonephritis and acute rheumatic fever at a later stage.

Patients, or their parents, should keep an eye out for any symptoms which might suggest these complications and if concerned advised to seek medical help immediately.

Recommended actions:

• Suspected scarlet fever can be confirmed by taking a throat swab for culture of group A streptococcus, although a negative throat swab does not exclude the diagnosis.
• Consider taking a throat swab to:

i) assist with differential diagnosis

ii) if you suspect that the patient may be part of an outbreak

iii) if the patient is allergic to penicillin or iv) in regular contact with vulnerable individuals (e.g., healthcare worker)

• Prescribe antibiotics without waiting for the culture result if scarlet fever is clinically suspected:

 

 

• Advise exclusion from nursery / school / work for 24 hours after the commencement of appropriate antibiotic treatment
• Notify your Health Protection Team, including information on the school/nursery attended if relevant

Additional Information

Guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings 

Guidance for managing close contacts of invasive GAS disease and prevention of GAS infection in acute healthcare and maternity settings

Guidance for Health protection in education and childcare settings 

Information for the public on scarlet fever

Information for the public on sepsis

Primary Care Team Update 9 December 2022

Increase in invasive group A streptococcus (iGAS) infections, including empyema, in children

Due to high level of GAS and viral co-circulation in the community please see attached national briefing (02/12/22) from UKHSA.

There is also a latest blog from UKHSA which explains more about Group A Strep (GAS) and the infections it can cause, as well as how it is spread and what parents should look out for if their child is unwell.

Please click here to view a letter from NHS England to all community pharmacists on Group A Strep and Antibiotic supply, local recommendations are further down the email.

Communications toolkit (06/12/22) please click here to view a toolkit of information, images and messaging to be used on your social media channels and websites to support communications to patients/public.

You can also find and download our social media assets from the Campaign Resource Centre.

Use of Solid Oral Dose Forms of Antibiotics (tablets/capsules etc) in Children

The Specialist Pharmacy Service have provided guidance for using solid oral dose forms of antibiotics in children, where the liquid preparations are in short supply:

Using solid oral dosage form antibiotics in children – SPS – Specialist Pharmacy Service – The first stop for professional medicines advice

There is also a guide for teaching children to swallow tablets/capsules that may be helpful:

Guide for Tablet Capsule Swallowing (alderhey.nhs.uk)

Availability of Antibiotics for Group A Strep (GAS)

There are short term supply issues with some of the antimicrobials recommended to treat suspected Group A streptococcus (GAS) infections as detailed below:

FIRST LINE

Phenoxymethylpenicillin 

• 250mg tablets: supply very brittle

• All strengths of liquid preparations: unavailable at the moment and unlikely to be available until next week

Amoxicillin

•  250mg and 500mg capsules: available but supply is patchy

•  All strengths of liquid preparations (SF and non-SF): some availability, shortage in both strengths

NOTE: DO NOT PRESCRIBE AMOXICILLIN where there is strong clinical suspicion of glandular fever as part of the differential diagnosis.

Local microbiology advice is that GAS infections are 99.99% susceptible to penicillin-based preparations but they cannot make the same inference for other agents therefore penicillin-based preparations should be used unless contraindicated and consideration given to prescribing solid dose forms for older children who may be able to swallow the tablet or capsule.

ONLY IF PENICILLIN IS CONTRAINDICATED:

SECOND LINE supported by local microbiologists

Azithromycin

• 250mg tablets/ capsules: available but patchy supply

• Liquid: limited availability with some pharmacies able to order, others not

Other known antibiotic supply issues to date:

Suspensions

•  Clarithromycin – out but limited stock due sometime this month

·Co-amoxiclav also issue currently

When issuing a prescription for antibiotics for children, consider the following:

o Issuing acute eps token that patient can take to different pharmacies or printing the prescription.

o Telling the patient’s parent/carer to phone ahead to ensure medicine is available before setting of for the pharmacy.

o Issuing prescription for solid dosage forms for children, directing them to the advice on https://www.sps.nhs.uk/articles/using-solid-oral-dosage-form-antibiotics-in-children/ which details how to crush and mix the various solid dosage forms.

o Not specifying sugar-free for suspensions, giving the pharmacy scope to endorse as appropriate, and not having to return to the GP for amendment.

Notes:

• Stock availability has been provided from various sources and is correct to the best of our knowledge but please note this is an evolving situation and prescribers are advised to contact community pharmacy colleagues regarding the local stock situation.
• While supply issues persist, consider issuing a paper copy of an FP10 or EPS token to allow patients / parents to be able to phone/visit different pharmacies without the need for the prescription to be returned to the spine.

 

Infection Prevention and Control Precautions for all suspected/confirmed cases of

GAS 12/12/2022:

• Advise the patient to stay at home until they have completed at least 24 hours of antibiotic treatment
• Clinicians to wear gloves, aprons and Fluid Repellent Surgical Facemask (FRSM) with suspected and confirmed cases
• All PPE should be removed after examination of the patient and followed by hand decontamination
• Any reusable equipment e.g., thermometers, stethoscopes, pulse oximeter etc must be cleaned after use. Single use items e.g., tongue depressor to be thrown away immediately after use
• Items in contact with the patient should be cleaned after use e.g., couches, chairs door handles etc
• Ensure treatment and consulting rooms are cleaned in accordance with practice cleaning schedules in line with national cleaning standards. Report any cleaning concerns immediately to the cleaning contractors if cleaning is outsourced
• Ensure regular cleaning of the waiting area in line with practice schedules