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. 2024 May 24;3(1):e000791.
doi: 10.1136/bmjmed-2023-000791. eCollection 2024.

Incidence and treatment of group A streptococcal infections during covid-19 pandemic and 2022 outbreak: retrospective cohort study in England using OpenSAFELY-TPP

Christine Cunningham  1 , Louis Fisher  1 , Christopher Wood  1 , Victoria Speed  1 , Andrew D Brown  1 , Helen Curtis  1 , Rose Higgins  1 , Richard Croker  1 , Ben Fc Butler-Cole  1 , David Evans  1 , Peter Inglesby  1 , Iain Dillingham  1 , Sebastian Cj Bacon  1 , Elizabeth Beech  2 , Kieran Hand  2 , Simon Davy  1 , Tom Ward  1 , George Hickman  1 , Lucy Bridges  1 , Thomas O'Dwyer  1 , Steven Maude  1 , Rebecca M Smith  1 , Amir Mehrkar  1 , Liam C Hart  1 , Chris Bates  3 , Jonathan Cockburn  3 , John Parry  3 , Frank Hester  3 , Sam Harper  3 , Ben Goldacre  1 , Brian MacKenna  1   2
Affiliations

Incidence and treatment of group A streptococcal infections during covid-19 pandemic and 2022 outbreak: retrospective cohort study in England using OpenSAFELY-TPP

Christine Cunningham et al. BMJ Med. .

Abstract

Objective: To investigate the effect of the covid-19 pandemic on the number of patients with group A streptococcal infections and related antibiotic prescriptions.

Design: Retrospective cohort study in England using OpenSAFELY-TPP.

Setting: Primary care practices in England that used TPP SystmOne software, 1 January 2018 to 31 March 2023, with the approval of NHS England.

Participants: Patients registered at a TPP practice at the start of each month of the study period. Patients with missing data for sex or age were excluded, resulting in a population of 23 816 470 in January 2018, increasing to 25 541 940 by March 2023.

Main outcome measures: Monthly counts and crude rates of patients with group A streptococcal infections (sore throat or tonsillitis, scarlet fever, and invasive group A streptococcal infections), and recommended firstline, alternative, and reserved antibiotic prescriptions linked with a group A streptococcal infection before (pre-April 2020), during, and after (post-April 2021) covid-19 restrictions. Maximum and minimum count and rate for each infectious season (time from September to August), as well as the rate ratio of the 2022-23 season compared with the last comparably high season (2017-18).

Results: The number of patients with group A streptococcal infections, and antibiotic prescriptions linked to an indication of group A streptococcal infection, peaked in December 2022, higher than the peak in 2017-18. The rate ratios for monthly sore throat or tonsillitis (possible group A streptococcal throat infection), scarlet fever, and invasive group A streptococcal infection in 2022-23 relative to 2017-18 were 1.39 (95% confidence interval (CI) 1.38 to 1.40), 2.68 (2.59 to 2.77), and 4.37 (2.94 to 6.48), respectively. The rate ratio for prescriptions of first line, alternative, and reserved antibiotics to patients with group A streptococcal infections in 2022-23 relative to 2017-18 were 1.37 (95% CI 1.35 to 1.38), 2.30 (2.26 to 2.34), and 2.42 (2.24 to 2.61), respectively. For individual antibiotic prescriptions in 2022-23, azithromycin showed the greatest relative increase versus 2017-18, with a rate ratio of 7.37 (6.22 to 8.74). This finding followed a marked decrease in the recording of patients with group A streptococcal infections and associated prescriptions during the period of covid-19 restrictions where the maximum count and rates were lower than any minimum rates before the covid-19 pandemic.

Conclusions: Recording of rates of scarlet fever, sore throat or tonsillitis, and invasive group A streptococcal infections, and associated antibiotic prescribing, peaked in December 2022. Primary care data can supplement existing infectious disease surveillance through linkages with relevant prescribing data and detailed analysis of clinical and demographic subgroups.

Keywords: COVID-19; Infectious disease medicine; Primary health care.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the Wellcome Trust, Medical Research Council (MRC), National Core Studies programme, National Institute for Health and Care Research (NIHR), UK Research and Innovation, and Health Data Research UK for the submitted work; BG has received research funding from the Laura and John Arnold Foundation, NHS NIHR, NIHR School of Primary Care Research, NHS England, NIHR Oxford Biomedical Research Centre, Mohn-Westlake Foundation, NIHR Applied Research Collaboration Oxford and Thames Valley, Wellcome Trust, Good Thinking Foundation, Health Data Research UK, Health Foundation, World Health Organization, UK Research and Innovation (UKRI) MRC, Asthma UK, British Lung Foundation, and the Longitudinal Health and Wellbeing strand of the National Core Studies programme; BG has previously been a non-executive director at NHS Digital; BG also receives personal income from speaking and writing for lay audiences on the misuse of science; BM is employed by NHS England working on medicines policy and is the clinical lead for primary care medicines data; EB is regional antimicrobial stewardship lead for NHS England-South West; KH is national pharmacy and prescribing clinical lead for antimicrobial resistance at NHS England; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1
Monthly numbers of patients with scarlet fever, sore throat or tonsillitis, or invasive group A streptococcal infection. Vertical lines represent the start of the covid-19 restriction (April 2020) and recovery (April 2021) periods. Maximum value of each season (September to August) is indicated (x). Gaps indicate data were redacted because of low counts
Figure 2
Figure 2
Monthly numbers of patients with an antibiotic prescription and a record of scarlet fever, sore throat or tonsillitis, or invasive group A streptococcal infection, up to 14 days before or seven days after the prescribing event. Antibiotics were categorised into three groups: phenoxymethylpenicillin (group 1), the first line antibiotic for group A streptococcal infection; macrolides, amoxicillin, and flucloxacillin (group 2), antibiotics recommended if group 1 antibiotics were not available or if patients were allergic to penicillin; and cefalexin and co-amoxiclav (group 3), reserved broad spectrum antibiotics. Vertical lines represent the start of the covid-19 restriction (April 2020) and recovery (April 2021) periods. Maximum values of each season (September to August) are indicated (x)
Figure 3
Figure 3
Monthly rate per 1000 patients with a recorded prescription of phenoxymethylpenicillin and a record of scarlet fever, sore throat or tonsillitis, or invasive group A streptococcal infection, up to 14 days before or seven days after the prescribing event, by age, region, ethnic group, and index of multiple deprivation
Figure 4
Figure 4
Monthly number of codes for sore throat and tonsillitis
See this image and copyright information in PMC

References

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