Not at present. Watch for more guidance.
Your questions about Strep A answered following the webinar on 9 December 2022
1. Do we need to put 'At Risk' children on prophylaxis? e.g. IgA deficient?
2. How would you suggest dealing with close contacts e.g. siblings who also have signs of a viral infection but do not meet the criteria for treatment?
No antibiotics for contacts except for invasive GAS (not for strep throat or scarlet fever).
3. Is there any risk to pregnant women? Any guidelines for pregnant mothers in households of infected children?
Advise caution as in any infection. No guidelines yet – watch this space.
4. Is there a way of finding out which pharmacies have 5 day stocks vs 10 days?
Prescribe 10 days and if pharmacy have 5 days they will issue an ‘owing’ ticket and provide further supply when more is available. There are supplies coming through.
5. Who should be notified? Classical scarlet fever or strep+ swab and fever, nodes etc..
Notify scarlet fever and invasive group A Strep ONLY. You do not need to notify for strep throat.
6. Can we use EtM when our chemists run out of Pen V tablets? Ran out of suspension for a few days again. Temperature checks very helpful before seeing GP. Forehead thermometer seems accurate
Yes. Please see prescribing guidance for children.
7. Is that triage route same at UHL i.e. all children go via UCC? Should we be providing letters at minimum and bleeping paeds registrar wherever we are sending children?
Unable to comment – please seek local info from UHL. As a general rule a brief letter (just a few lines) is usually a basic minimum for referrals and will in most cases assure the child is seen by the Paeds team and not just UCC (unless they have a paeds specialist there – winter pressures).
8. Do we know the reasons behind the drug shortages? Manufacturing? Transport? Ingredient shortages?
Increased demand and distribution concerns. No problems reported with manufacturing.
9. If the swab is negative, can we stop the antibiotics?
Yes.
10. How are you going to share the antibiotic guide with us / does it include details of BD dose for pen V?
Please see prescribing guidance for children. BD dose for PenV is just the same total daily dose divided by two.
11. If you are giving 5 days of one drug, and at review feel they need another 5 days, and that same drug isn't available, is it acceptable to use a 2nd line /different drug for the following 5 days?
Yes. While not ideal, it is still safe and and effective to do this. Please see prescribing guidance for children.
12. How would you suggest dealing with close contacts e.g. siblings who also have signs of a viral infection but do not meet the criteria for treatment?
No treatment needed
13. If we give 5 days’ pen v and then we do need have to extend to 10 days, is it ok to give an alternative abx if no pens now available?
Yes. While not ideal, it is still safe and effective to do this. Please see prescribing guidance for children.
14. Seeing a lot of quite unwell young adults unusually high fevers/ HR / lymph nodes sore red throat only - should we be swabbing these routinely also or are we less worried?
Please use Centor or Fever pain score in prescribing guidance for children.
15. I have seen children with high fever 39-40 but no sore throat or other sx apart from coryzal or cough. Should we be still swabbing for Strep A and Covid?
COVID – yes. Use Centor or fever pain to determine swabbing for Strep A.
16. Is there a role for compulsory face masks in schools?
Controversial re: risk/benefit. Please await formal guidance.
17. There are some chemists around selling rapid strep tests that are advertising to patients ... do we need to be aware of this as some patients have been paying to have it done?
Discussion around efficacy and sensitivity of tests. A positive rapid/POC test is a rule in (treat as a definite positive), a negative test is NOT a rule-out (do not assume it is a true negative).
18. Are you continuing 10 days abx for those with positive swabs, or still stopping at 5 days for those?
Positive swabs should have 10 days of treatment.
19. Is there a role for trimethoprim?
No. Please see prescribing guidance for children.
20. How sensitive is the test?
Lab M,C & S – very sensitive. POC/rapid tests – less sensitive.
21. Is Centor on the ROP?
Not yet – work in progress.
22. Any particular age group that we see the cases most commonly?
School age children (generally under 12, but can be young adults)
23. What’s your advice on stopping a/b if swab negative?
Can stop immediately.
24. Do we know the reasons for this rapid rise of invasive Strep A cases?
Post Covid mixing, susceptible population, first ‘proper’ Xmas, thought NOT likely to be a different serovar/variant of strep.
25. Is the five days based on your ability to hand out complete packs in ED? 10 days remains the recommended treatment time for suspected Strep I think?
5 days is due to supply issues. Ideal is still 10 days.
26. Can pharmacies email or phone local surgeries twice a day with updates of what they actually DO have in stock to save every practice contacting them individually?
OneBromley are trying to arrange for local pharmacies to email their local PCN with regular updates of supply situation.
27. How to look out for glomerulonephritis?
Urine dip if obvious haematuria. BP if positive.
28. So we give 5 days treatment and give 10 in positive swab? Or 5 enough?. What about in cases where no swab done (my own GP surgery for example not swabbing) we wouldn't know if swabs positive?
Treat for 10 days if no swab taken and meets criteria.
29. When using tablets round doses where you can to half or whole tablets
Pragmatism – yes. Or suspend in water in a syringe and give measured dose of suspension.
30. Do we just send to ED?? Or call ahead?
The usual referral guidelines apply. Please call hospital and bleep Paeds Registrar if concerned enough to make paeds referral. Please also pen a few lines for referral.
31. What is the criteria for admission if suspecting iGAS?
All iGAS are very sick – they are all admitted.
32. If we give 5 days’ supply, how are we to review the patients in time given the appointment pressures?
Please give 10 day prescription if unable to review.
33. Is rapid Strep Ag test a replace of throat swab ?
Lab M,C & S – very sensitive. POC/rapid tests – less sensitive. A positive rapid/POC test is a rule in (treat as a definite positive), a negative test is NOT a rule-out (do not assume it is a true negative)
34. Does this mean all children presenting with a sore throat require a throat swab?
No – please see FeverPAIN or Centor criteria.
35. Antibiotics- your slide didn’t give a dose for amoxicillin. CKS say to use the following is that what you recommend?
Standard BNF and CKS dosing. Please see prescribing guidance for children.
36. Given the supply challenges noted and is true in the ground - is there any advantage when ministers are openly and in public denies it - any opinion?
A political question – we are dealing with the clinical response
37. Is the guidance in Primary Care to prescribe 5 days and review or 10 days?
Pragmatism – if unable to review at 5 days then prescribe 10 days.
38. How would you suggest dealing with close contacts e.g. siblings who are also have signs of a viral infection but do not meet criteria for treatment?
Advised no antibiotics are indicated.
39. To be clear we are treating every child with fever and cervical nodes?
Please treat as per fever pain and Centor criteria.
40. Is there a system being set up so we can check local pharmacy supplies?
OneBromley are trying to arrange for local pharmacies to email their local PCN with regular updates of supply situation.
41. Southwark have agreed to purchase 1000 PoC tests, will this be the same in other boroughs?
Indeterminate sensitivity of POC/rapid tests – we do not recommend rapid testing and prefer lab testing.
42. In Mdcalc CENTOR score, you get a point for age 3-14, which means all children of this age with a fever would get ABx... do you use age as a point?
Please see fever pain and mentor calculations in prescribing guidance for children.
43. We don't normally see rheumatic fever in developed countries so do we need to give the 10 day course rather than 5-7 days?
Precise cause/aetiology of reduced incidence of rheumatic fever is complex. Please give 10 days of antibiotics unless able to review at 5 days.
44. Are there any patterns we should be aware of for these children who end up severely ill?
No defined pattern emerged yet – still small numbers.
45. Do these children who develop strep pneumonia first develop any symptoms we could recognise this with first? (e.g., do they seem to develop scarlet fever and then develop respiratory symptoms)?
No defined pattern emerged yet – watch for more guidance.
46. Do they ever develop tonsillitis first, or are they just going straight to developing pneumonia?
Almost always have strep throat first. Then develop complications of streptococcal infection.
