Strep A – enough is enough

In 2016 a third of GPs thought that the downward pressure on antibiotic prescribing was fueling the increase in cases of bacterial infections such as Scarlet fever. The recent report by Public Health England shoed that the number of notifications were double the average of the past 5 seasons. All nine regions in England are reporting an increase and the North East, North West, Yorkshire and Humber, the South East and South West reporting rates more than twice as high.

The reporting of invasive strep A infection is up 73% on last season. This is particularly worrying as the mortality in this condition is high at 15-20%. 14% of these are children under 10 and consequently an increase in the number of children dying is also expected to be higher than last season. In 2012 two children died. In 2016 twenty children died. Will it be thirty or forty this season? Every child is valuable – we should not accept this.

We are the only country in the western world, perhaps the whole world to be experiencing this high level of Strep A infection. Where many countries have introduced rapid tests, we have not. Is that a coincidence – I think not.

The good news is that no isolates have been found to be resistant to penicillin and general resistance patterns to other antibiotics has not changed.

The same bacteria cause strep throat, scarlet fever and invasive strep A. Transmission from person to person must be controlled. People with a strep A sore throat will remain infection for 14 days or more, returning to work or school and supporting the transmission of the bacteria. Within 24 hours of starting an antibiotic people cease to be infectious and can return to work or school without transmitting the bacteria.

Lord O’Neil in his report, commissioned by David Cameron, recommended that we should make better use of rapid diagnostics to cut unnecessary use of antibiotics. He went further to recommend that it should be mandatory by 2020 that the prescription of antibiotics should be informed by testing technology where available.

Where are we up to on this? Apparently NICE believes that there are some GPs that routinely test, but I am not sure where they are. The Birmingham Children’s Hospital routinely tests children and they have reduced antibiotic use by 70%. The use in community pharmacy was lauded into the NHS Innovation Accelerator and the local innovation networks, but as far as I know no CCG has commissioned it. NICE sticks with the clinical risk score FEVERPAIN – it is better than nothing, but it is hardly very sensitive, contributing to the unnecessary use of antibiotics and missing many patients with infections.

However, several community pharmacies have gone it alone. They have introduced testing to patients as a program of test and treat with advice to reduce transmission. Well done – it needs healthcare professionals to make a stand.

It is about time that Mr Hunt took a lead in this. He should insist that every GP and every community pharmacy that manages a patient with a sore throat completes a proper examination and uses a rapid antigen detection test to confirm the presence of strep A in the throat. In patients that are positive, appropriate antibiotics should be started immediately and the patient should be given information to reduce transmission.

Further more Mr Hunt should support the diagnosis and reporting of Scarlet Fever in community pharmacy.

We need to get on top of this. Indiscriminate downward pressure on antibiotic prescribing and the failure to use available technology as recommended in the report commissioned by the Government is not acceptable.



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