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A must-read guide to Strep A for general practice nurses

A must-read guide to Strep A for general practice nurses

With general practice on alert for cases of Strep A, and high levels of concern among parents across the UK, GP Dr Toni Hazell gives top tips for nurses on the lookout.

Just as we start to hope that the pandemic might be behind us, primary care is again plunged into chaos with the arrival of a spike in cases of another infectious agent, accompanied by public panic and shortages of key medicines. Just what we need in the run up to Christmas.

Group A Streptococcus (GAS) is a commensal, a bacterium that lives normally in the throats of 5-15% of the population.1 It can cause pharyngitis, scarlet fever and skin infections, but if it invades a part of the body which is normally sterile (e.g. the lungs) then the patient has invasive Group A Streptococcus (iGAS) and become very unwell. Sadly, 15 children so far have died of iGAS in the past few weeks2, but we should not forget that this tragic outcome is still very rare – the table below shows how the risk amounts to less than two extra cases per 100,000 children, with the greatest increase in those aged 1-9.3

AgeiGAS average case numbers per 100,000 children (2017-2019)

 

iGAS average case numbers per 100,000 children (December 2022)
Under 11.11.3
1-40.52.3
5-90.31.1
10-140.10.2
Table: Risk of death from invasive Group A Streptococcus.

How do we spot a potential case?

In primary care, we see disease at an early stage, and it isn’t always possible to pick out who is going to get very sick. That child with one vomit and a touch of abdominal pain could be self-resolving infectious gastroenteritis or could be early appendicitis. How do we know which one of the hordes of miserable febrile children we see over winter is going to have iGAS, or meningitis, or pneumonia?

The answer is that we don’t, which is why safety-netting advice is important – tell the parent what symptoms should mean that they seek a review, and document in the notes that you have done so.

The first thing to do is trust your gut feeling. If a child makes your antennae tingle for some reason, listen to that – there is evidence that acting on our intuition in primary care has the potential to prevent unwell children being missed.4 I’m not a fan of the tannoy, preferring to get my patients from the waiting room myself. If a child has to be caught, because they are running round the room playing astronauts, they aren’t that sick. Conversely, if the child who is fifth on your list is sitting there listlessly, drooped in the arms of an adult, maybe you should see them first.

It is said that 80% of the diagnosis comes from the history5, so listen to the parent and let them talk. The NICE guidance on fever in under 5s6 reminds us to take seriously parental concern that their child has a fever (not all will have had access to a thermometer to validate this) and to look for non-specific symptoms such as a lack of response to social cues, not staying awake or difficulty in being roused, a weak or continuous cry, no smile, decreased activity and grunting.

My history always includes an enquiry about whether they are drinking and eating, whether they are playing and seem their usual self and whether they are more sleepy than usual. Documenting negative answers to these questions is important to protect yourself medicolegally and the use of a template or macro can be helpful here. Everyone will have a different threshold for seeking help, either from a more senior nurse or from a doctor –  know your threshold and act on it.

What is the case for antibiotics?

Moving on to the examination, parents often ask if they can ‘just bring him in so you can check his chest’, but I can’t remember the last time that a chest examination actually made a difference to my management. Far more important are the basic observations.

Do they look dehydrated – dry lips and mucous membranes or reduced skin turgor are worrying, and a capillary refill time of more than two seconds is very concerning. What is the heart rate and – tachycardia in a non-crying child should not be ignored and you need to know the different normal ranges for different ages or have easy access to this information. You can usually observe the respiratory rate before approaching the child (the parent can lift clothes up if needed) – it is much harder to do if the child starts crying, which some will do on your approach!

Table: Abnormal pulse rates at different ages (NICE)6

Age                                    Heart rate (beats per minute)

Less than 12 months      More than 160

12 to 24 months              More than 150

2 to 5 years                      More than 140

Table: Abnormal respiratory rates at different ages (NICE)6

Age                                    Respiratory rate (breaths per minute)

0 to 5 months                  More than 60

6 to 12 months               More than 50

12 months+                     More than 40

Other symptoms and signs that should worry you are shown in the NICE traffic light system for identifying risk of serious illness in under 5s, which can be accessed from the NICE website, and ideally have available in the form of a laminated colour printout to emphasise the green, amber, red classification. Listen to the chest and look in the throat, where you are looking for inflamed/red tonsils, pus on the tonsils and feeling for enlarged cervical lymph nodes.

If a child is seriously unwell – tachycardic, dehydrated etc – then your decision is easy. They need a same day review by paediatrics. If you think that a child needs hospital review, do not be dissuaded from sending them in because the local hospital seems busy. By far the trickier task is to manage the large numbers of children who don’t seem that ill, deciding who can be managed symptomatically with antipyretics and who needs antibiotics, trying to maintain some vestige of responsible antibiotic stewardship whilst at the same time not undertreating those who need antibiotics.

A manifestation of GAS which always needs antibiotics is scarlet fever. These children present with non-specific symptoms of a cold, such as a sore throat, fever or headache, but within two days they have a typical rash which starts on the torso, feels like sandpaper and may spread to the limbs, but spares the palms and soles. Deep red lines may be seen in the flexures and the child may have a white coating on their tongue, which peels off to leave the tongue looking red and swollen. This is known as strawberry tongue. Later features can include peeling skin on the fingertips and toes and a flushed face, with the area around the mouth remaining pale. Treatment is 10 days of oral penicillin V, with other options including amoxicillin, macrolides and cefalexin. Macrolides are the first choice for those with penicillin allergy.7,8

For those with a sore throat, recent interim advice on the iGAS outbreak has suggested that we use the FeverPAIN decision making tool9 and that we use antibiotics if the score is three or more. This is somewhat controversial as the tool gives one point for presentation within three days of symptoms – presumably meant to identify serious illness, but at the moment probably just an effect of panic in the general population. However, this advice has been issued by a document co-authored by NHSE, NICE and a variety of Royal Colleges7 and so it would be unwise to ignore it.

FeverPAIN criteria (from NICE guidance NG849)

– Fever (during previous 24 hours)

– Purulence (pus on tonsils)

– Attend rapidly (within 3 days after onset of symptoms)

– Severely Inflamed tonsils

– No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause. A score of 0 or 1 is thought to be associated with a 13 to 18% likelihood of isolating streptococcus. A score of 2 or 3 is thought to be associated with a 34 to 40% likelihood of isolating streptococcus. A score of 4 or 5 is thought to be associated with a 62 to 65% likelihood of isolating streptococcus.

Is a swab necessary?

Patients may ask you if they need a throat swab, the idea of swabbing the throat being much more acceptable now than it was prior to the pandemic. At the moment, there is no suggestion that we should be swabbing everyone and, as always, you should think about how a test will affect your management before you do it.

GAS is a commensal, so a positive swab in a well child doesn’t necessarily warrant treatment. No test is 100% sensitive – a negative test in an unwell child wouldn’t make you send them home untreated. And of course, swabs take days to come back and so are unhelpful in the initial decision as to whether to treat. The NICE CKS page on scarlet fever8 suggests swabbing if a case is suspected to be part of an outbreak, on the advice of the local health protection team, and also if there is a true allergy to penicillin. The recent interim guidance document suggests swabbing if there is diagnostic uncertainty or concerns regarding antibiotic resistance7. A ‘swab everybody’ policy is unwise and likely to cause problems when positive swabs come back on well children.

Other things to consider

It is no surprise that a lowered threshold for antibiotic prescribing has caused shortages, and this might be the point where some children have to learn the very useful skill of swallowing tablets, a skill that some adults claim not to have mastered. A useful article10 gives online resources to show children how to do this, as well as discussing the circumstances in which tablets can be crushed or capsules can be opened, though doing this means that the prescribing is off-licence – local guidelines will tell nurse prescribers whether they are able to prescribe off-licence or not.

Schools should not be asking us for letters to confirm that children are unwell – they should accept the word of the parent – and children with sore throats do not generally need a prolonged period of time off school. Those with scarlet fever can return 24 hours after the start of antibiotics11 (though they would remain infectious for 2-3 weeks if not treated).

Decisions about prescribing prophylactic antibiotics for contacts should be made by public health, not by individual clinicians in primary care – it has been suggested that we consider it for certain close contacts of a case. A close contact is defined as prolonged contact in a household-type setting during the seven days before the onset of symptoms and up to 24 hours after initiation of appropriate antimicrobial therapy. Those who might need prophylaxis include women who are, or have recently been, pregnant (≥ 37 weeks or within one month of delivery), those aged under 28 days or 75 or over, and those who develop chickenpox within a week before or two days after exposure to iGAS, but the decision to give prophylaxis should be made by public health – our only role is to notify them of the diagnosis via the notifiable diseases form.

We don’t know how long this situation will last, though we all hope it will be shorter than the pandemic, and none of us can predict with 100% certainty who will become seriously ill. The key tenets of healthcare remain – work within the limits of your safe abilities (it is not up to you to make up for failings elsewhere within the NHS), take a good history, examine thoroughly, document well and give good safety-netting advice. Then go home, relax, switch off and enjoy the time when you’re not at work. You cannot pour from an empty cup and looking after yourself is at least as important as looking after your patients.

References

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