Intended for healthcare professionals

Rapid response to:

Practice Practice Pointer

Group A beta-haemolytic streptococcal infection in children

BMJ 2024; 385 doi: https://doi.org/10.1136/bmj-2023-077561 (Published 02 April 2024) Cite this as: BMJ 2024;385:e077561

Rapid Response:

GAS: Ten Days to Prevent Rheumatic Heart Disease, A Call to Action

Dear Editor

We read the article by Morgan and colleagues with great interest. This article was opportune in reviving attention on Rheumatic heart disease (RHD). The latter is a severe cardiac condition that develops due to an abnormal immune response following a Group A Streptococcal (GAS) pharyngitis infection. Despite its preventable nature, RHD remains the most prevalent cardiovascular disease among individuals younger than 25 years.

While high-income countries have successfully eliminated RHD through enhanced public health measures and access to penicillin, the disease remains a substantial challenge in low- and middle-income nations, where medical care and screening programs are limited. Recent research indicates that the rise in refugee migration may be contributing to a resurgence of RHD in high-income countries, necessitating further investigation into the disease burden in these regions.

Concerningly, eight of the EU15+ countries have already shown a notable rise in their incidence rates of RHD for both genders (1). The re-emergence of RHD in these countries can be linked to the influx of refugees. Still, it is probable that various factors within the host nations, such as the living conditions of migrants, accessibility to healthcare, and the initial health condition of migrants upon arrival, also play a role in these trends. Furthermore, subclinical GAS or infections for which medical attention is not sought could be frequent among migrants and occur in about one-third of this kind of patients.

These changing circumstances prompt us to emphasize the management of streptococcal infection concerning preventing RHD other than shortening illness duration, obtaining microbiological cures, and reducing the risk of suppurative complications. Thus, it is essential to highlight that there is currently a lack of research in medical literature comparing the efficacy of shorter courses of penicillin in preventing RHD. Therefore, it could be advisable that any GAS infection should be treated with ten days of phenoxymethylpenicillin (amoxycillin because it is more palatable and clarithromycin for children with mild/severe penicillin allergy) (2).

1. Ojha U, Marshall DC, Salciccioli JD, Al-Khayatt BM, Hammond-Haley M, Goodall R, Borsky KL, Crowley CP, Shalhoub J, Hartley A. Temporal trend analysis of rheumatic heart disease burden in high-income countries between 1990 and 2019. Eur Heart J Qual Care Clin Outcomes. 2024 Mar 1;10(2):108-120. doi: 10.1093/ehjqcco/qcac083. PMID: 36477873; PMCID: PMC10904725.
2. Shulman ST, Bisno AL, Clegg HW, et al.; Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Shulman ST, Bisno AL, Clegg HW, et al.; Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov 15;55(10):e86-e102full-text, correction can be found in Clin Infect Dis 2014 May;58(10):1496 , commentary can be found in Clin Infect Dis 2013 Apr;56(8):1194-1195.

Competing interests: No competing interests

04 April 2024
Giovanni Ghirga
Pediatrician
Claudia Orchi, Pediatrician, ISDE, Italy.
International Society of Doctors for the Environment (ISDE, Italy)
Civitavecchia