Dr. Sheila Fallon Friedlander discusses recent upticks of invasive Group A Streptococcus in children, including why dermatologists should be aware, be willing to culture, and act quickly to treat.
Sheila Fallon Friedlander, MD, Scripps Clinic, San Diego, and Professor Emeritus, Dermatology Department, University of California San Diego Medical Center, San Diego, California
“In December, the CDC issued a statement that they were concerned about a possible uptick in group A invasive strep disease, particularly in children,” said Sheila Fallon Friedlander, MD, who presented an update on group A Streptococcus disease as part of the Infectious Disease Update panel at Maui Derm Hawaii 2023.1
The CDC noticed an increase the six months prior to its statement. While some might attribute it to masks coming off, which may be part of the story, it doesn’t explain why strep is showing up unusually early in the season, said Dr. Fallon Friedlander.
“Group A strep is a disease that most commonly occurs in December through April—in the winter and spring months. In addition, it appeared to be increasingly associated with viral infections, including respiratory syncytial virus (RSV), which is a childhood disease that we see a lot of but now we’re seeing it in adults as well as influenza and COVID-19.”
The World Health Organization also released an alert in December about an increase in invasive group A strep disease in five European countries, including the U.K., Ireland, and France, said Dr. Fallon Freidlander.2
“Everybody paid attention because we want to get ahead of things. We’re willing to accept normal strep, which lives on the surface of our throat and in our skin, but in invasive group A strep, the bug goes deeper and causes more severe disease. We find it superficially in cellulitis occasionally in strep throat, and we find it in impetigo, but it is more of a concern when it is found in necrotizing fasciitis, deep-seated infections, in pneumonias, and sepsis. That is when we refer to it as invasive group A strep.
A Wolf in Sheep’s Clothing
Dr. Fallon Friedlander describes invasive group A strep as “a wolf in sheep’s clothing.”
“Initially you could say it looks like regular cellulitis or regular impetigo but then it gets worse. Or maybe someone has a sore throat and then gets sicker. There isn’t one specific sign of what to look for but rather a constellation of things. What’s most important is to not write it off as a virus.”
One of the problems is that clinicians are less likely to think about strep because of COVID-19, she said.
“But what do we do for COVID? We don’t give antibiotics.”
“It’s important now that we realize that not only is COVID-19 still around (although not as much), but we might be seeing more group A strep.”
Invasive group A strep may be occurring more frequently with other viral infections because once tissue has been damaged from COVID-19, or influenza… it’s more susceptible, said Dr. Fallon Friedlander.
Diagnosis and Treatment
If there’s any doubt in your mind about whether a patient has group A strep, “culture, culture, culture,” she said.
“Many pediatric offices can quickly do a strep antigen test.”
This is not time to think twice about using antibiotics, said Dr. Fallon Friedlander.
“If you’re suspicious about strep, try to document it and then treat. Don’t sit around waiting.”
“This is a case where [antibiotic treatment] can be lifesaving. The wonderful thing about this particular form of strep is that it is sensitive to the kitchen sink. If it’s group A strep, it is sensitive to penicillin for the most part.”
For pediatric patients, who might not take penicillin because of its terrible taste, the next best thing is amoxicillin, said Dr. Fallon Friedlander.
“There is a shortage of amoxicillin suspension. So, the CDC, FDA, and others have listed in guidelines that you can take an amoxicillin tablet, crush it up and put it in apple sauce. That’s one way to deal with it. You can also use cephalosporins. The great thing about cephalosporins is that sometimes we as dermatologists are not sure if it’s staph or strep. Oftentimes, cephalosporins will cover both, although it won’t cover methicillin-resistant Staphylococcus aureus (MRSA).”
Clinicians should emphasize good hygiene to those who have been around people with group A strep or impetigo, said Dr. Fallon Friedlander.
“For impetigo it’s really important that everybody washes their hands and that the lesions we treat locally with compresses (or some people use mupirocin) don’t make it easy for this bug to spread.”
Being aware of group A strep is important for pediatric and adult dermatologists alike, she said.
“Guess what? Older people, particularly those who are immunosuppressed, in nursing homes, or who have drug problems, are at increased risk for strep.”
The bottom line is to think about strep as well as COVID-19 in the “new world,” said Dr. Fallon Friedlander.
References:
- CDC. Increase in Pediatric Invasive Group A Streptococcal Infections. CDC Health Alert Network. December 22, 2023. Accessed February 27, 2023. HAN Archive – 00484 | Health Alert Network (HAN) (cdc.gov)
- World Health Organization. Increased incidence of scarlet fever and invasive Group A Streptococcus infection – multi-country. Disease Outbreak News. December 15, 2022. Accessed February 28, 2023. Increased incidence of scarlet fever and invasive Group A Streptococcus infection – multi-country (who.int)