Scarlet Fever/ Group A Strep

Overview

Group A streptococcus diagnosis and treatment guidelines:

• Scarlet fever: symptoms, diagnosis and treatment - GOV.UK (www.gov.uk)(1)
• Scarlet fever | Health topics A to Z | CKS | NICE (2)

Scarlet fever is a notifiable disease and if suspected then UK Health Security Agency (formerly PHE) should be informed. Diagnosis is usually clinical but a throat swab can be taken for confirmation. Do not wait for confirmation of diagnosis to start treatment.

****STOP PRESS**** April 2024

There has been cluster of confirmed cases of invasive Group A Streptococcal infection (iGAS) in people in People Who Inject Drugs (PWID) in central Bristol. Please see the Health Security Agency letter.for details.

DIagnosis

Symptoms of Scarlet Fever (2)

• Sore throat
• Fever > 38.3
• Rash (after 12 – 48 hrs) – red and sandpaper like in light skin, may only feel it in darker skin
• Flushed face but pale around mouth
• Cervical lymphadenopathy
• Strawberry tongue
• Peeling skin of fingers/toes/groin as rash fades
• Be vigilant for features of Sepsis

See also:  Group A Strep: The symptoms to look out for - NHS BNSSG ICB

When to send a throat swab*

• Diagnostic uncertainty
• Child from area of local breakout
• Penicillin allergy (to confirm alternative is correct antibiotic)
• Regular contact with vulnerable people

*Please include clinical details when sending a swab including an appropriate allergy history, and/or details of the antibiotic being prescribed. 

Management

Treatment of suspected cases in primary care 

(See Red Flag section below for more severe presentations or suspected IGAS)

1. Prescribe antibiotics:

• 1st choice: Penicillin V for 10 days for suspected Scarlet Fever.
• 2nd choice: Amoxicillin (if compliance is an issue for younger children) for 10 days.
• If Penicilllin allergic: Clarithromycin for 5 days for suspected Scarlet Fever.

(See BNNSG formulary - antimicrobial guidelines (page 4) for further details and further information below)

If liquid medications are not available then tablets should be prescribed. These should be swallowed whole if possible. Advice on swallowing pills for children can be found at KidzMed Carer-leaflet.pdf (e-lfh.org.uk)

There is also advice on crushing and dispersing different antibiotics below:

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

Send EPS tokens for antibiotics so it may be dispensed and collected from any pharmacy in case of supply issues.

2. Provide patient information: Scarlet fever - NHS (www.nhs.uk). Patients should exclude themselves from school/work until 24 hours after antibiotics have been started and take precautions to prevent passing on the infection. They should avoid contact with people at high risk of complications of scarlet fever.

3. GIve safety-netting advice to patients and parents of children to represent if  worsening or persistent symptoms and have a low threshold for referral to secondary care (see Red Flag section below).

4. Report suspected or confirmed cases to the local health protection team*- Notifiable diseases: form for registered medical practitioners - GOV.UK (www.gov.uk)

*UKHSA South West Centre Health Protection Team, 2 Rivergate, Temple Quay, Bristol, BS1 6EH

Red Flags

People at increased risk of Invasive Group A Strep (IGAS)

· At extremes of the age range, such as the very young and old, or postpartum women.

· Who are immunocompromised, immunosuppressed, or with other comorbidities.

· With concurrent chickenpox or influenza.

· Who inject drugs or are alcohol dependent.

Management of Suspected Invasive Group A Strep (IGAS)

If there are symptoms/signs of Sepsis then direct patient to:

• Childrens Hospital Emergency Department if aged under 16 or contact the Childrens Hospital ED advice line if you are not sure.
• Adult ED if aged 16 or over.

ED Pressures and Safety- netting advice

The Childrens Hospital ED department kindly request that GPs consider the following before directing to ED:

• See patients F2F – and review F/U with clear safety netting advice and guidance.
• Safety netting for fevers should include that viral illnesses are frequently ongoing for 5-7 days at the moment, and this should not be unexpected.
• Key things as always are to get the fever down with paracetamol/ibuprofen and then reassess the child – if perking up/looking happier then reassuring. If remains lethargic and unwell when fevers settled then need to be assessed.
• Reaffirm that the height of a fever for a child over 6 months has no correlation with degree of illness.
• Equally a fever not going down with paracetamol /ibuprofen has no correlation with degree of illness.
• Encourage people to download the HandiApp for self-care. Or direct to the Wessex Healthier Together website (great pragmatic self-care website endorsed by RCPCH and available in multiple languages).
• (Note- Myths debunked about EBV rash with amoxicillin (only with ampicillin))
• Note increase in Flu presentations (and dont forget at risk children who present within 36hours can be presided Zanamivir)
• Encourage flu vaccine

Resources

(1) Scarlet fever: symptoms, diagnosis and treatment - GOV.UK (www.gov.uk)

(2) Scarlet fever | Health topics A to Z | CKS | NICE

(3) Scarlet fever - NHS (www.nhs.uk)

(4) FeverPAIN criteria

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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