December 2022
Jonathan Pearce, CEO, Antibiotic Research UK
Infections – a cause for concern and a need to understand
The current Strep A deaths and the justifiable concerns facing millions of families with young school-age children shine a bright light on the levels of public understanding around infections, antibiotics and antimicrobial resistance (AMR). They also emphasise the difficult decisions GPs and other healthcare professionals deal with every day around antibiotic prescribing. These are complex, multi-factorial issues. It immediately highlights the need for rapid, reliable high-quality diagnostic testing to support these treatment/non-treatment decisions. We’ve all become used to the idea of PCR and lateral flow tests for Covid-19. There needs to be shift in practice for other infectious diseases, particularly in a world with increasing AMR.
Education and awareness
Underneath all this, though, is the need for greater education and awareness. People should know about what is involved with infections such as Strep A, the role antibiotics play in treating them and in disease management generally. In the case of Strep A it is only natural that parents and carers will worry about their children’s health. As such, it’s important to be aware of the key symptoms and understand that the vast majority of infections are mild. We must also be clear about what represent worrying signs, symptoms or developments. Knowing when to seek medical advice is vital. See Antibiotic Research UK’s website – for more information on these aspects.
It’s crucial to understand that the real risk here is contact with someone with invasive GAS (iGAS, for invasive Group A Strep) rather than simply contact with any person or patient with a Strep A infection or symptoms. As such prevention of infection has an important role to play in the management of the Strep A risks. Preventions include:
- Good hand hygiene can make a huge difference to the spread of infection.
- Isolation of anyone receiving treatment for GAS for the first 24 hours to prevent spreading the disease.
- Within household, reducing/preventing spread by not sharing fabrics (eg, towels, bedding, clothing, etc) and not preparing food while infected.
- Mask-wearing will prevent the spreading of infection through droplets – while not everyone may be able to wear them, in settings such as a schools where there is a risk of infection, mask-wearing should be encouraged for those who can and who are symptomatic.
Antibiotic-prescribing
As noted, while parents and carers will be naturally concerned. They should be reminded not to seek out antibiotics for chemoprophylaxis (i.e. for use to prevent disease/infection). But, they should seek medical advice if someone develops signs or symptoms of GAS infection. This is particularly important if the person’s condition is worsening or spreading further.
While UK guidelines state that chemoprophylaxis can be offered to individuals and household/close contacts in limited situations, there is no reliable or strong evidence showing that chemoprophylaxis is effective in schools. However, the UK Health Security Agency’s local health protection units will review invasive GAS and scarlet fever outbreaks on a case-by-case basis and may offer chemoprophylaxis based on other risk factors being present or not (see UKHSA guidelines here).
Of course, underlying all these facts and approaches is the reality of the dealing with the situation on the ground. Parents and families will continue to be concerned. The signs and symptoms of scarlet fever resemble many other, generally benign or non-threatening infections, particularly at this time of year; GPs and primary care services are already overworked and overwhelmed; and it’s difficult enough already for many patients to get timely GP access. These are political, systemic and financial issues as much as anything else. Infection outbreaks like this only serve to highlight problems. It exposes the fragility of our healthcare systems and the health security risks that we face.
Shortages
Add the lack of fast, accurate and reliable diagnostic tests for infections and the potential shortage of some key antibiotics, and you can see how easy it is for the situation to escalate. Penicillin is the preferred choice for GAS treatment, with fewer side effects. Shortages will be problematic, although there are other antibiotics that can be used, but supplies of those will also be under pressure. In addition, oral solutions/suspensions will be hard to find, and this will cause difficulties for some families – and as result new guidance has just been released on manipulating solid dosage forms (and how parents/carers can help children to swallow tablets where liquid antibiotics may not be available)
Antimicrobial resistance (AMR)
Unusually GAS hasn’t developed resistance to penicillin, despite other closely-related infections having developed resistant strains (see here for an interesting Twitter thread on this by Tony Breu, Harvard Medical School). Therefore, experts believe the overuse of penicillin is unlikely to contribute to penicillin resistance in GAS on a wide scale, but there will be an impact on the human microbiome as an unintended consequence (see, for example, here).
Conclusion
If anything, the current situation reminds us of the precious resource that antibiotics are. They underpin the effectiveness of modern medicine. We desperately need a bigger investment in and roll-out of rapid, effective diagnostic tests available at the point of care. This will ensure get the right treatment, including antibiotics, where they are needed. It will help avoid prescribing antibiotics where they aren’t needed). We also need a much higher level of public awareness around infection management, antibiotic usage and AMR. There needs to be more support for doctors, pharmacists and other healthcare professionals, including those in accident and emergency services/urgent care. This will help to manage questions from families. They can provide information and support to help explain and understand decisions around treatment and non-treatment.
Email: jonathan.pearce@antibioticresearch.org.uk
LinkedIn: https://www.linkedin.com/in/jonathan-pearce-4173a29/
Twitter: @JPearceCEO
With thanks to Antibiotic Research UK’s Science and Public Engagement and Patient Support Committees for their insight and input. In particular Professor Angharad Davies, Dr Ryan Hamilton, Professor Joe Standing, Cathy Tralau-Stewart and Rebecca Harmston.