Strep A has made headlines this winter, and with good cause. Some media coverage has made it seem as though Strep A is ‘the new Covid’: a previously unknown infection sweeping the nation.
In truth, while there are several factors contributing to the current greater than anticipated number of cases – including the end of Covid restrictions such as wearing masks and social distancing, which has made people more susceptible to infections – Strep A is nothing new.
Unlike the Covid-19 outbreak of 2020, Strep A and its management are well understood (see box below). However, recent case numbers appear to be higher than we would normally expect, particularly in children.
A stark illustration comes in the form of data from the UK Health Security Agency (UKHSA), which shows that more than 35,600 cases of scarlet fever, which is caused by Step A, were reported by the end of 2022. This is a huge jump on the fewer than 5,000 cases recorded during the same period in the last comparably high season (2017-18). There have also been a significant number of deaths. UKHSA data to 1 January 2023 show 29 deaths in under 18s in England compared to 27 deaths in this age group across the whole of the 2017-18 winter season.
So, what’s different this season? An added complication in the Strep A story: difficulty obtaining the antibiotics that are required to treat the infection.
This has put pharmacies front and centre of the problem, and protocols have been published enabling substitutions to be made if the prescribed medicine cannot be provided. This is not a straightforward switch, but rather one where the pharmacist must use their professional skill and judgement to decide which of the specified alternatives is most appropriate, with the patient then agreeing to the change.
What is strep A?
Strep A – or, to give it its full name, Group A Streptococcus, is also known as GAS and Streptococcus pyogenes. It is a bacterium that spreads from person to person via contact with skin, respiratory particles or contaminated objects such as towels or bedding, or from eating food prepared by someone who has the infection.
Once contracted, the bacterium can cause a diverse range of infections of the skin, soft tissues and respiratory tract, leading to symptoms such as sore throat, fever, aching muscles, rash, and nausea and vomiting. While many of these infections are relatively mild and self-limiting, others – such as scarlet fever – are notifiable diseases; this means that local health protection teams must be informed of suspected cases. Strep A can also lead to serious infections like pneumonia and cellulitis, which can cause significant illness in those affected.
The reason Strep A has been in the news more recently is the incidence of invasive Group A Streptococcus (iGAS) infections. These are rare, and tend to affect those with underlying risk factors, such as having a compromised immune system due to health conditions or medication, or being very young or very old. In cases of iGAS, the bacteria gets deeper into the body, with the potential outcome being a nasty infection – for example, of the bloodstream (bacteraemia), joints (septic arthritis), brain (meningitis) or soft tissue under the skin (necrotising fasciitis).
It is worth remembering that most Strep A infections are relatively mild illnesses that will clear up on their own within a few days. This is also true of many other infections that cause similar symptoms, such as colds; as these are due to viruses rather than bacteria, self-care measures are usually all that is needed, and certainly antibiotics are more than unnecessary – they simply won’t work.
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Serious Shortage Protocols (SSPs) have been issued relating to phenoxymethylpenicillin (also known as penicillin V), which is used to treat Strep A and scarlet fever. The SSPs mean that pharmacists are legally allowed to supply a specific alternative medicine without a new prescription being issued by the prescriber, as would normally be the case.
First choice is an alternative formulation of phenoxymethylpenicillin (note that this is not allowed if the 125mg/ml oral solution (containing sugar) or 250mg tablets have been prescribed). If this is not an option, the preference order for the alternative antibiotics is as follows:
For all prescribing durations in excess of 10 days, erythromycin is the preferred substitution. Solutions, suspensions or solid dosage forms may be supplied, and care must be taken to ensure that the switched product is suitable in terms of formulation, duration, etc.
There is an expectation that if an alternative antibiotic is dispensed, the prescriber should be notified within 24 hours. If the patient does not agree to the alternative, or it is not an appropriate or reasonable switch, the criteria of the SSP will not have been met, and so a supply cannot be made.
SSPs apply to both NHS and private prescriptions and are NHS-wide. The SSP supply must include the identity of the SSP (e.g. “supplied against SSP no. xxx”). Similarly, the prescription endorsement must bear the SSP reference and details of the replacement product that has been dispensed in order for it to be reimbursed correctly.
Full details are available on the PSNC website (psnc.org.uk), along with links to the SSPs, information on how to use them, and guidance published by the Royal Pharmaceutical Society to assist pharmacists in their decision-making (available to members only).
Leyla Hannbeck, chief executive of the Association of Independent Multiple Pharmacies (AIMp), says that pharmacists and their staff are well versed in dealing with stock shortage situations, pointing to problems with the HRT supply chain as an example. In terms of why the difficulties seem more prevalent of late, she states: “The supply of raw ingredients from countries such as India and China has been impacted by Covid, which means manufacturers aren’t able to make products as quickly as they have done in the past.”
However, Dr Hannbeck voices frustration at the ongoing nature of supply chain issues, saying: “Measures should have been put in place to manage what are often predictable changes in demand. For instance, antibiotic prescription volumes started to go up in October, which is in line with the increase in infections we usually see over winter, but the Government hadn’t prepared for it.
“Similarly, as colds and flu became more commonplace and public health messages were issued about the importance of self-care, there wasn’t any contingency planning in terms of ensuring a reliable supply chain of cold remedies, which also ran short – communication to all stakeholders in a logical, thought-out way is needed, but has been missing.”
How to help
Patients – and parents of patients – with Strep A or scarlet fever are likely to be fearful, not just because they are feeling unwell or are concerned about someone who is ill, but also because there is the added worry of not being able to get the medication they have been prescribed.
“It really is out of our control,” says Dr Hannbeck, “but there are a few things that pharmacists and their staff can do… Be sympathetic to their situation, and explain the issues around stock levels so they have an understanding of what is going on.”
Dr Hannbeck adds that it is also imperative to promptly signpost to alternative pharmacies if there is no suitable product available at your own pharmacy.
Signposting should also extend to sources of reliable information, although pharmacy staff should have a sound grasp of red flag symptoms (see box below) and self-care measures.
In terms of self-care for children, it can be helpful to provide advice to caregivers on the suitability and dosing of simple analgesics such as paracetamol and ibuprofen, as well as the importance of rest and of trusting their instincts if they feel that medical attention is warranted.
Additionally, the opportunity to provide preventative advice should not be overlooked: like many infections, relatively simple measures can reduce the rate of transmission of Strep A. Remind customers of the importance of diligent handwashing – chances are, nobody is singing “Happy Birthday” anymore, but this is still good practice – as is covering the mouth and nose when coughing and sneezing, and promptly binning used tissues.
There is a balance to be struck between sensationalist media reporting – which can fuel panic – and providing sensible information. This is where community pharmacy staff really come into their own: by talking to patients in a calm and reassuring way, you can help to raise awareness about important details regarding Strep A, such as the symptoms to watch out for, without triggering high levels of anxiety.
It is important that all members of the pharmacy team are mindful of the signs that medical advice is warranted. Refer any of the symptoms below to the pharmacist:
- Fever, sore throat, swollen glands, difficulty swallowing and headache (these symptoms point towards strep throat, which may require antibiotics)
- A sandpapery rash on the body and a swollen tongue (may indicate scarlet fever, requiring antibiotics and notification to the Public Health Agency)
- High fever, severe muscle aches, localised muscle tenderness, unexplained diarrhoea or vomiting, and increased pain, swelling and redness at the site of a wound ring alarm bells for iGAS (invasive Group A Streptococcus) infections, as do reduced feeding, signs of dehydration such as drowsiness and sunken eyes, and extreme irritability or tiredness in children
- Breathing difficulty, a blue tinge to the skin, tongue or lips, and extreme drowsiness (which may manifest as floppiness in infants) point towards a medical emergency and the need to call 999.