Group A Streptococccal Infections in Children - What Has Changed?

At the time of publication, the UK is experienced the effects of an increase in cases of group A streptococcal (GAS) infections in children.  Scarlet Fever cases are more prevalent and there are more cases of invasive infection than in an average year.  Most importantly the number of deaths in children related to GAS infection is high and the associated news coverage has been significant.

When our clinical landscape changes, the question should always be: What has changed and what should I be doing differently?  Let's look at each element of practice around GAS infections and see what has or should have changed.

Recognising the seriously unwell child

The clinical task of recognising the unwell child is actually business as usual.  It remains the case that the vast majority of children who are unwell have uncomplicated upper respiratory tract infections with very low likelihood of developing complications or invasive infection.

The UKHSA has stated that the GAS infections are of normal pathogenicity which in the UK means very low risk of complications or invasive infection.  The number of viral infections circulating has also risen substantially which means that the probability of any one febrile child having GAS is likely to be similar to normal times.

In any case our task of recognising the seriously unwell child remains the same as at any other time.  It is and always has been a complex business which cannot be reduced to a formula.  It is also the case that any febrile child, no matter how well, can go on to develop a serious illness such as sepsis or meningitis.  That has always been true and all the information we are getting suggests that the risk of that happening to a child without signs of invasive infection at the time of assessment remains very small.

Diagnosing Uncomplicated Group A Streptococcal Infection

This remains as problematic as ever.  GAS infection has always been a reasonably common cause of URTI including tonsillitis.  Scarlet fever aside, there is no one clinicial feature with a high predictive value for GAS infection.  Decision tools such as FeverPAIN are misleadingly named because they only moderately separate children into groups with different risks of having GAS.  As the score goes up the likelihood of GAS also goes up but a significant number of children will have GAS infection with a low score.  

Tools such as CENTOR and FeverPAIN were never introduced to help clinicians to treat GAS more often.  Quite the opposite - these tools were developed to reduce antibiotic prescribing in a culture of default antibiotic use for all sore throats.

Throat swabs are often used as a means of identifying who definitely has GAS.  There are two big problems with bacterial throat swabbing though.  The first is that GAS is a normal commensal in throats and can be found even in asymptomatic cases.  The second is that the result takes time.  Due to pressures on microbiology services that time is likely to be longer at the moment.  The usefulness of a swab result two to three days into an illness is therefore questionable.

The current recommendation from the UKHSA is to prescribe antibiotics to children with a FeverPAIN score of 3 or more.  Throat swabs are only recommended for cases of invasive infection, scarlet fever or diagnostic uncertainty.  I have assumed that diagnostic uncertainty cannot refer to being unsure as to whether an URTI/ tonsillitis is viral or bacterial as we can never be certain in any case, regardless of FeverPAIN score.

Antibiotic Choice

This has been very interesting.  The UKHSA continues to recommend Penicillin V as the first choice antibiotic both for uncomplicated URTI/ tonsillitis and for scarlet fever despite the known very low compliance rate.  Pen V tastes very unpleasant and as a result less than half of children will complete a course.  This recommendation to use Pen V has always been based on the low risk posed by GAS infection, balanced against the risk to the population of liberal use of broad spectrum antibiotics.  The continued recommendation to use Pen V as first line implies a continuation of where we were before.  The effect of antibiotics is too small to change to antibiotics with better compliance rates as the harm from using broad spectrum antibiotics is believed to be greater than the benefits.

The element that has changed the most is probably the numbers seeking a medical assessment of their child, anxieties about the dangers of GAS and an increased expectation of antibiotics.  If you're already good at managing all of those things then you are equipped for this moment in time.  If you're still learning how to manage anxieties then this situation will be a great learning opportunity!

What parents often worry about - fever and rashes, are some of the least important factors in recognising serious illness in children.  Fever is not a predictor of serious illness and even a sandpaper rash indicates Scarlet Fever which is still low risk for invasive GAS.

This brings us back to the issue of recognising the unwell child.  That is still the most important task in each assessment, even if the chance of finding a child with invasive infection is small.  Here's a very condensed guide to separating the unwell children into groups.  Note that neither fever nor rash make the shortlist of key features.

The key things that have changed are volume of children presenting and  the level of anxiety in the accompanying adults.  The features of serious illness and the effectiveness of decision tools and antibiotics remain the same as always.

Stay safe.  Hopefully this post becomes redundant soon for all of the right reasons!

Edward Snelson

@sailordoctor

Swabbing decks not throats

Understanding Traffic Lights - The Unwell Child and What to Do Next

When I am driving and see a traffic light ahead the first thought is, "Am I supposed to stop or go?" My next thought is, "what might it change to and what do I do then?"  Assessing the unwell child is like that.  It's not just about the snapshot.  Guidelines look a moment in time but the unwell child is in constant flux making that approach problematic.

The traffic light system for unwell children has been around for a very long time.  It is used across Primary and Secondary care to aid clinicians in their attempts to risk assess febrile and unwell children with all of the non-specific signs and symptoms with which they present.  

I am often asked if I use the traffic light system in my own practice.  The answer is yes and no.  Yes - the system is a useful hierarchy of signs and symptoms.  No - because most childhood illnesses are too dynamic for a snapshot to be completely valid.  Things change constantly.  A risk assessment based on a moment in time is far too simplistic.

That doesn't mean that observation of the child is necessary for decision making.  In most cases it's simply a question of asking how the lights are changing and what I'm going to do with that.

Amber turning green

A 2 year old child presents with a cough, runny nose and a fever.  The parent reports that a couple of hours ago they looked pale and lethargic.  They were shivering, felt hot centrally but had cold hands and feet.  Now they have none of those things happening.  They are walking, talking and cheerfully interactive.

This is a very common scenario.  Parents and carers will often express a certain paradoxical frustration with the apparent wellness of the child.  The child appeared seriously unwell a couple of hours ago and the parent is now feeling that you will think that they have over-reacted.  It is a good thing to acknowledge how unwell the child was and use that as an opportunity to explain why you as a clinician are happy with the child despite how concerning the child's appearance was.  

Giving or signposting to something written is also important.

Green turning amber

A 2 year old child presents with a cough, runny nose and a fever.  When you see them they are miserable but alert and interactive.  They have a temperature of 39.5, heart rate of 160 and are refusing to drink.  They last had any symptomatic treatment 6 hours ago.  The parent reports (you have to ask about this - it won't usually be volunteered) that 2 hrs ago they looked much better and were drinking a bit.

Unlike actual traffic lights, unwell children swing from green to amber and back to green quite normally during uncomplicated self-limiting infections.  There is a reason that we mostly see unwell children between the age of 6 months and six years.  It's not because they are high risk for dangerous infections.  In fact quite the opposite - it is a stage of life characterised by extreme response to simple infections.  The normal physiological response can look bad but usually resolves to reveal a reassuring baseline.  In many ways, a febrile unwell 2 week old is easier from a decision making point of view - that is a very high risk presentation.  A febrile unwell 2 year old is low risk but that presents a different problem - how to recognise the small number that do have a serious illness.

What can be terribly inconvenient is the above situation.  The snapshot we are given is not green but also not red.  Red is also easier from a decision making point of view.  Amber presentations make us have to decide what to do next.  Here are your options:

Every clinician will have a preferred option.  Many working in Primary Care do not feel the need to have a face to face reassessment if the child improves in behaviour and activity.  That is completely valid as such improvement is a good demonstration of physiological change and evidence that the baseline state of the child (active, interactive, good oral intake and no increased work of breathing) is not consistent with sepsis or meningitis for example.

Really good safety-netting advice empowers the parent to make that assessment in a way that is dynamic and continuous.  A reassessment in whatever form (face to face or remote) facilitates documentation of improvement and adds value to the safety-netting advice by giving the opportunity for the parent to further discuss the illness, what to expect and when to worry.

Amber children are a fair bit of work but they are a great opportunity to do what we should consider core business.  We can take a group of children who are reasonably low risk and look for signs (e.g. increased work of breathing, meningism or unexplained tachycardia) that this one is the one with something that needs immediate intervention.  For those that are within what is expected of an uncomplicated infection we can make sure that they have symptomatic treatment in the assumption that they will demonstrate a baseline state of reasonable wellness that effectively rules out serious illness.  Finally we can equip the person caring for that child with the ability to recognise signs of serious illness should those develop later.  That is a lot of great care.

Edward Snelson
Paediatric off-roader
@sailordoctor

Disclaimer - drive on the road when you can, off the road when you have to but always get home safely.  If you need help, call.