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I am delighted that this article has not made the knee-jerk suggestion that every case of group A streptococcal (GAS) disease should require antibiotic treatment or antibiotic chemoprophylaxis of contacts.[1]
I have commented previously, questioning the logic of national guidelines that mandate the use of such chemoprophylaxis following the identification of cases of invasive GAS disease (iGAS).[2 After all, these bacteria are endemic in the community, with (usually seasonal) variations in prevalence, and people infected can be asymptomatic or have usually mild disease. A proportion of cases do have more serious iGAS. It seemed reasonable to assume that:
* The bacteria causing iGAS are the same as those causing the less serious forms of infection;
* There are many less serious infections - cases with severe disease are only a small percentage of all the cases of GAS infection;
* People with less serious infections are just as infectious (possibly more so) as people with iGAS; and
* Very widespread use of antibiotics for chemoprophylaxis not only poses a huge burden on stretched healthcare staff, but will also have unintended adverse consequences (adverse drug reactions, increased antimicrobial resistance, etc.)
If these assumptions are correct, there seems to be no medical logic for giving chemoprophylaxis to contacts of iGAS cases, but not to contacts of mild or asymptomatic disease. After all, there are many more of the latter, who are equally likely to spread the bacteria, so why just give chemoprophylaxis to iGAS contacts. (Unless this is based on the assumption that they will be anxious, and that this will reassure them – in which case we should still be explicit about this, and be as sure as we can be that the benefits justify the costs.)
This editorial does provide a little more evidence that there may be differences in the strains of GAS that cause iGAS, in which case there may be a case for considering more widespread chemoprophylaxis, as long as there are not large numbers of mild or asymptomatic cases caused by the same strains.
This is why good surveillance is important, not just of severely ill cases, but also of the background rates of infection with different strains.
We must maintain a population based approach, and be wary of calls for prevention from tertiary care specialists who only see the most serious cases, and are less aware of the very large numbers of minor or asymptomatic cases in the community, and the consequent imbalance of harms and benefits.
Re: Resurgence of group A streptococcal disease in children
Dear Editor
I am delighted that this article has not made the knee-jerk suggestion that every case of group A streptococcal (GAS) disease should require antibiotic treatment or antibiotic chemoprophylaxis of contacts.[1]
I have commented previously, questioning the logic of national guidelines that mandate the use of such chemoprophylaxis following the identification of cases of invasive GAS disease (iGAS).[2 After all, these bacteria are endemic in the community, with (usually seasonal) variations in prevalence, and people infected can be asymptomatic or have usually mild disease. A proportion of cases do have more serious iGAS. It seemed reasonable to assume that:
* The bacteria causing iGAS are the same as those causing the less serious forms of infection;
* There are many less serious infections - cases with severe disease are only a small percentage of all the cases of GAS infection;
* People with less serious infections are just as infectious (possibly more so) as people with iGAS; and
* Very widespread use of antibiotics for chemoprophylaxis not only poses a huge burden on stretched healthcare staff, but will also have unintended adverse consequences (adverse drug reactions, increased antimicrobial resistance, etc.)
If these assumptions are correct, there seems to be no medical logic for giving chemoprophylaxis to contacts of iGAS cases, but not to contacts of mild or asymptomatic disease. After all, there are many more of the latter, who are equally likely to spread the bacteria, so why just give chemoprophylaxis to iGAS contacts. (Unless this is based on the assumption that they will be anxious, and that this will reassure them – in which case we should still be explicit about this, and be as sure as we can be that the benefits justify the costs.)
This editorial does provide a little more evidence that there may be differences in the strains of GAS that cause iGAS, in which case there may be a case for considering more widespread chemoprophylaxis, as long as there are not large numbers of mild or asymptomatic cases caused by the same strains.
This is why good surveillance is important, not just of severely ill cases, but also of the background rates of infection with different strains.
We must maintain a population based approach, and be wary of calls for prevention from tertiary care specialists who only see the most serious cases, and are less aware of the very large numbers of minor or asymptomatic cases in the community, and the consequent imbalance of harms and benefits.
1. Bamford A, Whittaker E. Resurgence of group A streptococcal disease in children. BMJ 2023;380:p43. (https://www.bmj.com/content/bmj/380/bmj.p43.full.pdf).
2. English PMB. Strep A: GPs are put on alert as cases and deaths rise- Rapid Response. BMJ 2022; Updated 07 Dec 2022; Accessed: 2022 (07 Dec 2022): (https://www.bmj.com/content/379/bmj.o2941/rapid-responses).
Competing interests: No competing interests