The streptococcus family of bacteria, which happily live on most people without causing infection, can occasionally cause streptococcal infection in humans, ranging from mild localised infections to severe invasive ones.^1,2 Several strains of bacteria can cause these infections, the most common being group A (GAS) and group B streptococcus (GBS.)^1,2 As infants’ immune systems are not fully developed,  they are at greater risk of infection. Without strong immunity, infections can become severe, with GBS being a significant cause of sepsis and meningitis in newborn babies and GAS infections being prevalent in young children.^3,4 Thus, proper infection identification, treatment and management are crucial in vulnerable populations such as infants. This article will examine the different types of infection, signs & symptoms, treatment and prevention. 

Types of infection caused by Streptococcus

Streptococcal infections can cause several diseases with varying severity. Below, we will cover some diseases caused by GAS and GBS.

GAS infections are common and usually mild in severity, with easy treatment. However, when the bacteria become invasive in certain cases, the disease becomes more severe.

GAS causes a range of mild infections at the body surface^1,5 such as:

• Sore throat (also called Strep throat)
• Impetigo (skin infection leading to pus-filled blisters)
• Skin infections
• Tonsillitis (severe throat infection)
• Scarlet fever (an infection that causes a distinctive rash and sore throat 

In addition, GAS can also cause more severe invasive infections,⁵ including:

• Bacteraemia (presence of bacteria in the blood) 
• Streptococcal toxic shock syndrome 
• Tissue death caused by bacterial infection

GBS infections can make infants very ill and can quickly spread from mother to child. GBS can cause a range of diseases,^2,6 such as:

• Pneumonia (inflammation of the lungs)
• Bacteraemia 
• Meningitis (inflammation of the protective layers that surround the brain)
• Endocarditis (infection of the inner lining of the heart)
• Infections of skin and soft tissue 

Signs and Symptoms of Streptococcal Infection in Infants

Symptoms of Streptococcal infection vary. Caregivers know their infants best and can tell if something is wrong. It is important to recognise symptoms as early as possible so that treatment can begin to minimise the risk of lasting damage and complications for the infant. The following symptoms provide an overview of the typical symptoms of Group A and Group B infections to help you identify an infection early.

Most Streptococcus A infections are mild and can be treated easily. According to the NHS, signs of GAS infections in children are commonly associated with sore throat, headache, nausea, vomiting, fever, deep red rash (Scarlet fever), skin pustules that mature to honey-coloured scabs (impetigo) that appear on the extremities and/or face, tender and swollen skin (cellulitis), and severe muscle aches. 

According to the NHS, symptoms of GBS infection can develop up to three months after leaving the hospital. Infants may exhibit respiratory distress, breathe very slowly or rapidly, not respond as normal, lack of appetite, vomiting, elevated heart rate, discoloured or blotchy skin and fever. If you suspect your infant has a GBS infection, the NHS recommends seeking medical attention immediately.

Diagnosis of Streptococcal Infection

Diagnosis of Streptococcal infection typically begins with a physical examination of the symptoms experienced by the infants. However, a physical examination is insufficient for accurately diagnosing streptococcal infection as symptoms overlap with other infectious agent symptoms. Therefore, several methods are used to diagnose a Streptococcus infection. Throat swabs and rapid antigen detection tests can be used to determine whether GAS isolates are present.⁷ Laboratory testing of blood samples can be used to detect sepsis, and a lumbar puncture² (a procedure that involves collecting fluid from the lower spine) is used if meningitis is suspected. Additionally, chest X-rays can be used if pneumonia⁸ is suspected. 

Management and Treatment

If your child is suspected to have a Streptococcal infection, treatment courses will begin with antibiotics.^1,2 Antibiotic treatment will likely begin before the results of laboratory tests are available² to confirm the bacteria present. Antibiotic treatment can be discontinued if the laboratory test results do not support a GAS/GBS infection. Antibiotic courses can be administered at home for mild GAS infections. However, if more severe invasive infection occurs, antibiotics may need to be administered at a hospital. Penicillin and amoxicillin are first choice antibiotics to combat mild GAS infections, and for those allergic to penicillin, alternative antibiotic treatments are available. These antibiotics can be administered orally and, in some instances, injected if required.⁷ For GBS, antibiotic treatment typically begins with ampicillin and gentamicin.²

Other management options can be administered alongside the primary antibiotic treatment.⁷ For example, antipyretics can help to reduce fevers, and some studies have demonstrated the benefits of administering non-steroidal anti-inflammatory drugs^9,10 (such as ibuprofen) to reduce fevers and pain. 

One major complication of GAS infection is acute rheumatic fever¹ (an autoimmune response), which can occur even in mild cases of the disease. Symptoms of acute rheumatic fever include joint pain, joint swelling, chorea (a neurological condition resulting in involuntary movement, changes to the skin, and heart problems. The symptoms are severe and require management through medication such as corticosteroids and antiepileptics. In some instances, surgery may be necessary to restore proper heart function. Complications of GBS infection are life-threatening due to the risk of meningitis and pneumonia.²

Prevention of Streptococcal Infections

Streptococcal bacteria often live harmlessly on our skin's surface. However, this can pose a risk, particularly during pregnancy. In 35 % of healthy patients, GBS bacteria are present in the genital tract,² which poses a risk to the foetus whilst in the uterus or as the baby is born. Therefore, preventative measures should be taken during pregnancy. Screening for GBS during pregnancy can help to prevent the risk of GBS infection for the infant. After screening to determine GBS presence, antibiotics can be administered as a preventative measure during pregnancy to reduce the risk of GBS infection for the infant.

Furthermore, the NHS recommends general good hygiene practices to prevent the spread of Streptococcus bacteria. If you suspect your child has a GAS infection, they should not attend school or nursery until they start a course of antibiotics. You should wash your hands regularly to reduce the spread, cover coughs and sneezes with a tissue and bin the tissue after use. Additionally, limiting close contact with those infected with GAS will help reduce bacterial transmission.

Whilst no vaccination for Streptococcus currently exists, vaccinations for GAS and GBS are under development and will help to reduce the impact of Streptococcus infections. The Strep A Vaccine Global Consortium (SAVAC) aims to produce the world's first Strep A vaccine that is effective, affordable, and safe. Guidance from the WHO recommends that the development of maternal vaccines against GBS should be a priority, as this could prevent GBS infection in newborn babies. 

Summary

Streptococcal infections are common and can cause mild to severe illness. Crucially, the early recognition of symptoms in infants and children is essential to ensure prompt treatment and improved outcomes. Streptococcal infections can be treated with antibiotics prescribed by a healthcare professional, and other medications can also be used to manage symptoms such as fevers. Prevention and management of Streptococcal infections requires a collaborative effort between different healthcare professionals and caregivers to ensure the infant's recovery from the disease