Streptococcal A so-called “streptococcal” angina is a bacterial angina that can affect children and adults. Usually treated with antibiotics, it can be complicated when the streptococcus moves elsewhere than in the throat. Worrying cases including 3 deaths were reported in France in December.
[Mise à jour le 12 décembre 2022 à 16h05] On the 8 to 9 million tonsillitis occurring every year in Francethe streptococcus A would be involved in approximately a quarter of the cases (10 to 25% in adults25 to 40% in children over 3 years old). Most often, theangina then considered as “bacterial” is benign and treated with antibiotics. In rare but serious cases, it can become complicated. Several pediatric cases of invasive Group A Streptococcal disease “in larger numbers than usual” have been reported in different French regions (Occitanie, Auvergne-Rhône-Alpes, New Aquitaine) over the last 15 days, informs the Directorate General of Health on December 6, mainly among children under 10 years old. These cases led to hospitalization in resuscitation of at least 8 children without identified risk factors, including 2 died. Three adult cases have been reported including 1 died. Streptococcus A is detected by TROD test, usually from the age of 3 years. Faced with the increase in serious cases observed in recent days, doctors must now routinely test every patient with angina, regardless of age and perform a throat swab in case of scarlet fever and negative TROD. “In 99% of cases, there is no difficulty with angina“reassured Didier Couteaud, representative of the Landes Regional Health Agency quoted by France Blue. A 3-year-old girl has died in the area. “In some cases, the disease can degenerate and can affect vital functions. There it was.” An epidemic of scarlet fever and strep throat in the Hautes-Alpes and Bouches-du-Rhône was reported in 2007. Strep A strep throat occurs especially in cold weather as Winter and at springwhich can epidemically affect communities such as schools.
What is strep A strep throat?
Angina is a inflammation of the tonsils or even the entire pharynx. She is most often due to a virus, this is called “viral” angina. More rarely, she is caused by a bacterium, it is then “bacterial”. Among the bacteria responsible for angina, streptococci. There are many bacteria of the genus Streptococcus of which the Streptococcus pyogenes or “Streptococcus A”. “Its habitat is the back of the throat, therefore the pharynx, and it has a rich pathogenic power” explained to us the infectiologist Stéphane Gayet in a previous article. “Strep A remains one of the most common germs in childhood infections including angina like there is no vaccine once morest this germ, unlike, for example, pneumococcus” explains Dr Andréas Werner, pediatrician and President of the French Association of Ambulatory Pediatrics (AFPA). The transmission of streptococcus A is essentially directly by air or skin from a sick person or a healthy carrier (carrier but asymptomatic).
What is the risk of A strep throat in children?
“In children, approximately a third of anginas are due to group A streptococcus (SGA)” explain the French Society of Pediatrics. “This is the germ found in bacterial angina in children. It concerns older children because bacterial angina occurs usually following 3 years, it is very rare that they appear before” continues Dr. Werner. Streptococcus A is usually not systematically sought in the youngest.
What is the risk of Strep A strep throat in adults?
Strep A strep throat is rarer in adults. It would represent 10 to 25% of angina. In adults, a Mac Isaac’s clinical score < 2 a une valeur prédictive négative > 95% to eliminate the streptococcal origin of angina.
Score de Mac Isaac :
- Fever > 38°C +1
- No cough +1
- Sensitive cervical adenopathy +1
- Tonsil damage +1
- Age 15-44 years 0
- ≥ 45 ans -1
What are the symptoms of strep A strep throat?
Strep A strep throat starts abruptly and is manifested by:
- severe pain when swallowing,
- a high fever (more than 38°c),
- intense pharyngeal erythema,
- painful glands,
- swollen tonsils
- no cough
- abdominal pain
Most “there is nothing validated or significant enough to dispense with the sample because bacterial angina cannot be seen” insists Dr. Werner.
In the child, no clinical sign or score has predictive value positive or negative sufficient to determine the streptococcal origin of the angina. “The McIsaac score is not useful in pediatrics” says Dr. Werner. The doctor must perform a rapid screening test (RDT) dedicated to angina to confirm streptococcal angina. “We insert the cotton swab in the back of the throat and we have the result in 3 minutes” explains Dr. Werner who recalls that normally “Any angina requires a sample before the prescription of antibiotics to check if it is bacterial”. Or “currently, a majority of doctors do not order this free test from Health Insurance and prescribe antibiotics without taking the test“. This test is usually recommended from the age of 3 as “bacterial angina is rare before” reminds the pediatrician.
The shortage of amoxicillin complicates the situation.
In 2018, a study French research by Dr Nicolas Nodet seeking to assess the prevalence of strep throat in children 12-35 months showed that the streptococcus A was responsible for 26% of angina acute of these children. For this doctor,a bacterium is not so rare and the generalization of the diagnostic test “would make it possible to better manage the symptoms and the pain of many children, while effectively preventing the occurrence of loco-regional complications”. This generalization was recorded on December 6, 2022 over there DGS following the increase in serious cases occurring in children under 10 years of age in France. Physicians must currently perform a Streptococcus A Rapid Diagnostic Orientation Test (TROD) in the event of angina and a throat swab before a clinical picture of scarlet fever, in the event of a negative TROD.
What are the treatments for strep A strep throat?
In the event of a positive test for group A strep throat, the doctor will prescribe antibiotics: amoxicillin is recommended by the High Authority of Health. This antibiotic is currently in short supply in France: “We don’t have many left, which makes the situation very special” testifies Dr. Werner. On December 12, the DGS reminded doctors that “antibiotic therapy is only recommended in case of positive angina TROD”. It should not be automatic because there is a suspicion of angina.
What are the complications of strep throat?
Group A strep throat may be responsible for rare but serious complications. Streptococcus can invade other areas of the body: “In classic angina, the streptococcus is found in the throat. When the infection is invasive, this same germ will be found everywhere and lead to meningitis, pneumonia, otitis…” explains Dr. Werner. Strep A strep throat may also be responsible for renal complications (acute glomerulonephritis), cardiac (acute articular rheumatism (AAR)) or neurological (Sydenham’s chorea) “but these complications are less and less present in France as the virulence of the germ has decreased“. An invasive streptococcal A infection imposes a hospitalisation.
“A child who has a systemic streptococcal A infection is doing very badly”
What are the signs of angina complications?
“A child who has a systemic streptococcal A infection is a child who is really bad” emphasizes Dr. Werner. “Any deterioration in the general condition of the child should be cause for concern, when the child is very badly, there is no improvement following the start of treatment, you have to consult once more” he explains. Thestreptococcus A is a germ very sensitive to antibioticsit has little resistance. “The antibiotic acts quickly, following 24 to 36 hours, the child is no longer contagious and he is better, there is a marked improvement in pain” argue le Dr Werner.
What advice for prevention?
To limit the risk of transmission, it is advisable to adopt the same barrier gestures used once morest winter viruses:
- Hand washing,
- Wearing a mask for people with respiratory infections,
- Sneeze or cough into the bend of the elbow
- Ventilate the room,
- Thoroughly clean the child’s nose regularly
- Avoiding the community for fragile children
- Make the recommended vaccinations for children
- Avoid large surfaces for the youngest children.
Thanks to Dr Andréas Werner, pediatrician, President of the French Association of Ambulatory Pediatricians (AFPA) and editor for the Mpedia site.
Sources
Resurgence of invasive streptococcal A infections, DGS, December 6, 2022
Invasive Group A Streptococcal Infection (IISGA): update as of December 6, 2022, Public Health France.
Epidemic of scarlet fever and strep throat Hautes-Alpes and Bouches-du-Rhône, 2007. Health monitoring institute.
Angina, Marseille University Hospitals, AP-HM
Streptatest, BioSynex, URPS Pharmacists.
Prevalence of strep throat in children aged 12 to 35 months in pediatric emergencies: intermediate results of the Pasteur Nicolas Nodet study. OpenScience. 2018