Jan 4, 2023 Strep Update

doctor checking patient for strep

Uzma Hasan, MD Uzma Hasan, MD
Division Director Pediatric Infectious Diseases,
Cooperman Barnabas Medical Center

Doug DeStefano, PharmDDoug DeStefano, PharmD
Corporate AVP, Pharmacy Operations

During the respiratory viral surge, an increase in invasive group A Strep disease is being reported, both in the US and in the UK. The WHO and UK Health Security Agency recently put out an advisory to alert clinicians re: rise in Gp A Strep (Strep Pyogenes infections) including fatalities. 15 pediatric deaths have been reported in the UK since September 2022.

On Dec 22, 2022, the CDC issued a health alert network health advisory to inform clinicians of an increase in pediatric invasive group A Streptococcal infections in many states in the US, including Colorado, Texas and Arizona.

Group A Strep (Streptococcus pyogenes) typically causes sore throat/pharyngitis, can cause skin/soft tissue infections, and rarely necrotizing pneumonias, sepsis, toxic shock syndrome, and necrotizing fasciitis. Those with influenza or chicken pox illness are at increased risk of invasive group A Strep infection. Also at risk for invasive group A Strep infections are those above age 65, residents of long term facilities, those who are immunosuppressed, those who are homeless or IV drug users.

Peak age for group A Strep pharyngitis is 5-15 years. Spread is via respiratory route, with peak spread being December through April. Spread can also via direct contact with infected skin.

The diagnosis of Group A Strep pharyngitis is via a rapid antigen detection, which is less sensitive than throat culture or molecular based assays.

Penicillin is the drug of choice for treatment of Group A Strep infections, and the bacteria is uniformly susceptible to Betalactams. Of note macrolide/Clindamycin resistance has been reported.

Please note there is currently an amoxicillin and cephalexin shortage being reported nationally, particularly in suspension, chewable tablets and low dose capsules.

  • FDA approved commercial dosage forms:
    • Penicillin V, oral suspension (125mg/5ml or 250mg/5ml in 100ml or 200ml bottle)
    • Penicillin V, oral tablet (250mg or 500mg)
    • Amoxicillin, oral suspension (125mg/5ml in 80ml, 100ml or 150ml bottle)
    • Amoxicillin, oral suspension (200mg/5ml in 50ml, 75ml, 80ml or 100ml bottle)
    • Amoxicillin, oral suspension (400mg/5ml in 50ml, 75ml or 100ml bottle)
    • Amoxicillin, oral chewable tablet (125mg or 250mg)
    • Amoxicillin, oral capsule (125mg, 250mg or 500mg)
    • Benzathine Penicillin G, intramuscular (600mu/ml, 1.2mmu/2ml, 2.4mmu/4ml syringe)
    • Cephalexin, oral suspension (125mg/5ml or 250mg/5ml in 100ml or 200ml bottle)
    • Cephalexin, oral capsule (250mg, 500mg or 750mg)
    • Cefadroxil, oral suspension (250mg/5ml or 500mg/5ml in 100ml bottle)
    • Cefadroxil, oral capsule (500mg) or tablet (1gm)
    • Clindamycin, oral suspension (75mg/5ml in 100ml bottle)
    • Clindamycin, oral capsule (75mg, 150mg or 300mg)
    • Azithromycin, oral suspension (100mg/5ml in 15ml or 200mg/5ml in 15ml, 22.5ml, 30ml bottle)
    • Azithromycin, oral tablet (250mg, 500mg or 600mg)
    • Clarithromycin, oral suspension (125mg/5ml or 250mg/5ml in 50ml or 100ml bottle)
    • Clarithromycin, oral tablet (250mg or 500mg)
  • Of note an increase in necrotizing pneumonias secondary to Streptococcus Pneumoniae is also being reported nationally.
  • Children who are behind on their vaccination series must be caught up on their vaccines, including varicella, influenza and pneumococcal vaccines.

Sources

https://emergency.cdc.gov/han/2022/han00484.asp
https://www.who.int/europe/news/item/12-12-2022-increase-in-invasive-group-a-streptococcal-infections-among-children-in-europe--including-fatalities
https://www.nature.com/articles/d41586-022-04403-y
https://publications.aap.org/redbook/book/347/chapter/5756422/Group-A-Streptococcal-Infections

The ASP, representing pediatric providers, including pediatric infectious disease specialists and pharmacists, exchange ideas, discuss case management strategies and develop and implement guidelines to be shared system wide, as well as serve as a resource for community physicians.

For more educational information, research and best practices from the Children’s Health Network at RWJBarnabas Health, visit rwjbh.org/childrenshealthresearch.