Strep A and the Risks of Delayed Diagnosis
Strep A (group A streptococcus) is a highly contagious bacteria that can cause different infections ranging from minor illness to death in a very small number of cases. Often people can carry the bacteria without developing any illness. Strep A can be prevented though good hygiene but there is no preventative vaccine. The bacteria are often found in the throat and the skin hence it may be caught through close contact and via respiratory droplets.
These bacteria can cause a range of respiratory and skin conditions such as strep throat, scarlet fever, streptococcal toxic shock syndrome and cellulitis. While some of these infections can be treated with simple antibiotics, if the bacteria colonise in areas such as the lungs and blood, it can lead to far more serious complications.
In rare cases, it can develop into a more serious infection which is known as invasive group A streptococcus (iGAS), these are most common in the elderly, the very young and those with underlying health risk factors. It is important then when these symptoms and identified, appropriate escalations and investigations should follow.
Case Study One
A nine-month-old child started to develop a cough which, over a 10-day period, did not subside and had developed into a wheeze. The child was brought to her GP and, following examination, the child was diagnosed with having a chest infection and was prescribed with a week’s worth of antibiotics to help improve her symptoms. After the course of antibiotics, it seemed that she was getting better but the wheeze had persisted.
The child was taken back to the GP and was thought to be norovirus but when examined, she did not have a temperature and was concluded that this was not norovirus.
A week later, the symptoms had continued in the child, and she was unable to keep any food down along with the persistent cough. Taken back to the GP, the GP advised the child’s mother to take her to Accident and Emergency. The child was triaged and shortly after, assessed by a doctor. After discussing the child’s symptoms, the doctor believed that she was suffering from a chest infection and advised if the child’s symptoms worsened, that they should return to the GP practice.
Over the course of a few days, the child’s symptoms had not improved, and her breathing was still not normal. Taken back to her GP, an urgent referral was made to the hospital highlighting that the issue was bacterial. Once in hospital and triaged, the doctors had examined the child but performed no tests. Again, they were discharged and told to monitor the child’s health.
The child started to become less responsive, and her breathing was very noisy. The child’s mother called the emergency services, and a first responder was sent out. The first responder reviewed the child and contacted the hospital to make this matter as urgent as possible when the ambulance came to the hospital.
The child was admitted to the High Dependency Unit and was still having breathing difficulties. She was later transferred to a specialist hospital to continue her treatment. A chest x-ray revealed she had fluid in one of her lungs and was diagnosed with streptococcus pneumonia, empyema, and sepsis. The child remained in hospital for another week until she made a full recovery and was discharged.
It was found that at the initial visit to the hospital, the doctors should have taken more heed of the history provided by the referring GP alongside taking observations and undertaking a chest x-ray considering the identified difficulty in the breathing of the child. The x-ray would have more likely than not identified the fluid in the lungs and treatment would have commenced far sooner than it did.
Case Study Two
A five-year-old child presented to accident and emergency with his mother complaining of a blister on his hand which appeared to be infected. The child’s blister was red and swollen with a with the child experiencing a high temperature and pain. Swabs of the blister were taken. The A&E doctor had decided that the child would require IV antibiotics, however, the paediatric registrar did not consider the possibility of a deep-seated infection. The child was discharged by the paediatric registrar with oral antibiotics and without any follow up or review.
A week later, the mother and child has reattended accident and emergency with symptoms of vomiting, a rash and fever. The doctor diagnosed the child with Streptococcal Toxic Shock Syndrome and initiated IV antibiotics. After a further week in hospital, the child had made a full recovery and was discharged.
The child should have been placed on IV antibiotics at this stage. The microbiology department had also come back with the swab results confirming streptococcus pyogenes, but this was not communicated to the child’s mother, again further delaying the opportunity for earlier treatment.
Recommendations to Help Improve Healthcare Standards and Patient Safety
Take adequate histories and appreciate histories provided by other healthcare staff.
Appropriate safety net measures should be actioned to avoid patients being lost to follow up.
- Undertake appropriate observations.
This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact [email protected] or call +44 (0) 203 355 9796.