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Strep A: Why battling against antimicrobial resistance isn't futile

Strep A clearly didn't get the memo that it is unwelcome this festive season. However, in the words of Lance Corporal Jones, “don't panic!” Dr Toni Hazell explains why

“Good morning doctor, would you mind seeing little Johnny? He’s had a sore throat for the last hour and I’m really worried that he’s got this strep thing. Yes of course I can bring him in, I’ll just go and get him – he’s climbing a tree in the garden at the moment.”

Panic, panic, panic. The world seems to be panicking about invasive group A streptococcus (iGAS). As a parent I completely get it – headlines about children dying give me the shivers. But as a healthcare professional, I do wonder where this is going to end. Absolute increases in the number of cases of iGAS are tiny, less than two extra cases per 100,000 children when compared to pre-COVID-19 levels.

But demand is overwhelming, with NHS 111 calls increasing by 60%.

Official guidance suggests that we should lower our threshold for prescribing and give antibiotics to children who have a FeverPAIN score of three or more, even though a score of two to three is only usually associated with a 34-40% likelihood of isolating streptococcus.

While this percentage may be increased due to the higher prevalence, it’s still a lot more antibiotics being given than we normally would.

In the FeverPAIN score you get a point for presenting within three days. This is meant to indicate severe illness. However, at the moment probably just due to worry, most children with a sore throat, fever and no cough will trigger the magic number three and get their antibiotics.

It is understandable why this has been done, because the death or serious illness of any child is a tragedy, but you have to wonder at what point we will have gone too far.

Read more: Strep A and scarlet fever: What pharmacists should know and advise

There are several concerns. The first is that in the huge melee of well children clamouring for our attention, we will miss those who are really sick. If little Johnny has to be brought down from tree climbing, he isn’t that ill.

I like to go out to the waiting room to get patients rather than use the tannoy. If a child has to be caught, because they are zooming around pretending to be an aeroplane, they aren’t sick.

Conversely, I might spot that the tenth child on my list is lying listless and dehydrated in Mum’s arms and decide that they need to be seen first.

How much meningitis, measles, rubella, COVID-19 and Kawasaki’s disease are we going to miss while demand is so high?

Secondly, we’re prescribing an awful lot of antibiotics. They are being given out by doctors and by other clinicians who can prescribe including advanced nurse practitioners and pharmacists.

We are all under huge pressure to prescribe for children who really don’t need it.

As an experienced GP, I’m happy to say no to antibiotics when they aren’t needed though I will of course abide by the reduced threshold at the moment.

Read more: Strep A: A frontline perspective from a community pharmacist

I’ll have a conversation with the parent, explain that childhood illness is a normal part of growing up, that their child has no symptoms or signs to suggest serious illness, that antibiotics won’t help, and do they really want the diarrhoea side-effect along with the cough – and that if they overuse antibiotics then resistance might mean that they don’t work when really needed.

I can offer sensible safety-netting advice and in some cases will give a review appointment, which can be cancelled if the child improves.

I know that in my practice, we all sing from the same hymn sheet when it comes to antibiotics, and that I will be rigorously defended in the event of a complaint regarding a non-prescription.

It worries me that some colleagues, whether doctor or other professional, might for a variety of reasons be less happy to have this robust discussion. I’m not trying to criticise my colleagues – there are all sorts of reasons why someone might feel that they might have to prescribe.

Maybe they’ve had a couple of vexatious complaints lately, haven’t felt well supported, and don’t feel up to dealing with another one. Maybe they’ve seen a sick child, or have known one who has been very ill, and they feel nervous about missing things.

Maybe they are on their 70th patient of the day, haven’t eaten, drunk anything, or gone to the toilet for 10 hours and have just lost the will to live.

Whatever the reasons, antibiotic use has shot up, with predictable shortages and the introduction of new serious shortage protocols (SSP).

Read more: Strep A: Serious Shortage Protocols issued for three penicillin medicines

If one good thing comes out of this, it might be increased government acceptance of the wisdom of allowing pharmacists to use their skills to adapt prescriptions.

Under the SSP, if penicillin isn’t available, the pharmacist can choose from a variety of alternatives including amoxicillin, clarithromycin and cefalexin.

Why can’t this be the case all the time? It’s highly insulting that it isn’t the case for antibiotics, and for other medicines often in short supply, such as transdermal hormone replacement therapy.

Read more: Pharmacy bodies ‘press’ government for greater powers to amend prescriptions

We might also find that this generation of children don’t grow into adults who have never learnt tablets, as some parents who can’t get hold of liquid will have to follow official advice and teach their children to take tablets.

With COVID-19 still around and the NHS on its knees, a new infectious agent was not the Christmas present that we were looking for.

Let’s hope that this one is more short-lived than the last one and that we can soon go back to sensible antibiotic stewardship and an acknowledgment that most respiratory tract infections are viral and self-limiting.

 

Toni Hazell is a GP based in a practice in London

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Pharmacist Manager
Barnsley
£30 per hour

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