Scarlet fever

Advise patients, or their parents/guardians, to:

• Stay home from work or school until they are afebrile AND at least 12 hours have passed after initiation of appropriate antibiotic therapy. This is to minimize the potential spread of scarlet fever-causing strains of Streptococcus pyogenes to other people.[10]Centers for Disease Control and Prevention. Scarlet fever: information for clinicians. Jun 2022 [internet publication]. https://www.cdc.gov/groupastrep/diseases-hcp/scarlet-fever.html [65]Schwartz RH, Kim D, Martin M, et al. A reappraisal of the minimum duration of antibiotic treatment before approval of return to school for children with streptococcal pharyngitis. Pediatr Infect Dis J. 2015 Dec;34(12):1302-4. http://www.ncbi.nlm.nih.gov/pubmed/26295745?tool=bestpractice.com ​ However, although the Centers for Disease Control and Prevention recommends staying home for at least a 12-hour period after initiation of antibiotics, there is evidence that most patients who are being treated with an antibiotic for 24 hours or longer are generally no longer infectious after this time.[21]McGuire E, Li A, Collin SM, et al. Time to negative throat culture following initiation of antibiotics for pharyngeal group A streptococcus: a systematic review and meta-analysis to inform public health control measures [preprint]. medRxiv. 2022 Nov 8 [Epub ahead of print]. https://www.medrxiv.org/content/10.1101/2022.11.08.22282068v1 Note that individual schools and daycare centers may have their own policies.

• Complete the fully prescribed course of antibiotics, currently recommended for 10 days for penicillin V and amoxicillin.[2]Shulman ST, Bisno AL, Clegg HW, et al. 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):e86-102. [Erratum in: Clin Infect Dis. 2014 May;58(10):1496.] https://academic.oup.com/cid/article/55/10/e86/321183 http://www.ncbi.nlm.nih.gov/pubmed/22965026?tool=bestpractice.com [43]Holm AE, Llor C, Bjerrum L, et al. Short- vs. long-course antibiotic treatment for acute streptococcal pharyngitis: systematic review and meta-analysis of randomized controlled trials. Antibiotics (Basel). 2020 Oct 26;9(11):733. https://www.mdpi.com/2079-6382/9/11/733 http://www.ncbi.nlm.nih.gov/pubmed/33114471?tool=bestpractice.com

• Keep their nails cut short to minimize the risk of scratching and introducing a secondary bacterial infection.

• Expect the skin affected by the rash to start peeling (called desquamation) starting 3-4 days after scarlatiniform rash. This is the part of the natural course and evolution of the illness and does not represent a worsening or relapse of the infection.

• Watch out for any symptoms that might suggest complications (e.g., persistent high fever, cellulitis, joint pain and swelling) and to seek medical help immediately.[49]Drug and Therapeutics Bulletin. Managing scarlet fever. BMJ. 2018 Aug 30;362:k3005. http://www.ncbi.nlm.nih.gov/pubmed/30166279?tool=bestpractice.com

Advise close contacts to be vigilant of scarlet fever symptoms and its complications.[49]Drug and Therapeutics Bulletin. Managing scarlet fever. BMJ. 2018 Aug 30;362:k3005. http://www.ncbi.nlm.nih.gov/pubmed/30166279?tool=bestpractice.com

• Be aware that household contacts have been found to have an increased risk of invasive group A streptococcal infection in the 2 months after scarlet fever onset, although the risk is relatively low (35.3 cases/100,000 person-years).[16]Watts V, Balasegaram S, Brown CS, et al. Increased risk for invasive group A streptococcus disease for household contacts of scarlet fever cases, England, 2011-2016. Emerg Infect Dis. 2019 Mar;25(3):529-37. https://wwwnc.cdc.gov/eid/article/25/3/18-1518_article http://www.ncbi.nlm.nih.gov/pubmed/30602121?tool=bestpractice.com See Complications.