Reading List 2012.indd - The British Society for Antimicrobial

255 Pages·2012·10.42 MB·English

General Reading
iGAS Guidelines - Published January 2012
CLICK HERE
Educational
Interim UK guidelines for management of close community contacts
Workshops 2012
of invasive group A streptococcal disease. Health Protection Agency,
Group A Streptococcus Working Group. Communicable Disease and
Public Health 2004; 7(4):354-361.
CLICK HERE
Diagnosis and Keynote Presentation:
Complicated infections of skin and skin structures: when the
treatment infection is more than skin deep. DiNubile MJ, Lipsky, B. Journal of
Antimicrobial Chemotherapy, 2004, 53, Suppl. S2, ii37-ii50
of skin and soft
CLICK HERE
tissue infections Practice guidelines for the diagnosis and management of skin and
soft tissue infections. Stevens DL et al. Clinical Infectious Disease
2005; 41:1373–1406
CLICK HERE
Infections of skin and soft tissue: Outcomes of a classifi cation
scheme. Eron J. Clinical Infectious Diseases 2000;31:287(A432).
CLICK HERE
READING Occurrence and antimicrobial susceptibility patterns of pathogens
isolated from skin and soft tissue infections: report from the SENTRY
Antimicrobial Surveillance Program (United States and Canada, 2000).
Rennie RP et al. Diagn Microbiol Infect Dis. 2003 Apr; 45(4):287-293.
LIST
CLICK HERE
Comparison of community and health care associated methicillin
resistant Staphylococcus aureus infection. Naimi TS, et al. JAMA 2003;
290: 2976-2984
CLICK HERE
Methicillin resistant S. aureus infections amoung patients in the
emergency department. Moran GJ et al. The New England Journal of
Medicine 2006
CLICK HERE
HPR 2011;5(7): News
CLICK HERE
Polyclonal multiply antiobiotic-resistant methicillin-resistant
Staphylococcus aureus with Panton-Valentine leucocidin in England.
JAC 2009; doi: 10.1093/jac/dkp386;
CLICK HERE
Eff ect of antibiotics on Staphylococcus aureus producing panton-
valentine leukocidin. Dumitrescu O, et al. Antimicrobial Agents and
Chemotherapy. 2007, 1515–1519
CLICK HERE
Centers for Disease Control and Prevention, Skin & Soft Tissue
Infections in Returned Travelers - Chapter 5 - 2012 Yellow Book -
Travelers’ Health
CLICK HERE
Fever and the returning traveller. N Kumar, DJ Lewis. BMJ Gottlieb SL, Kretsinger K, Tarkhashvili N, et al.
2012;344:e2400 Published April 2012 Long-term outcomes of 217 botulism cases in
the Republic of Georgia. Clin Infect Dis 2007;
CLICK HERE
45:174
Severity assessment of skin and soft tissue infections:
CLICK HERE
cohort study of management and outcomes for
hospitalised patients. Marwick et al. Journal of Botulism, Sobel J. Clin Infect Dis 2005 October
Antimicrobial Chemotherapy, doi:10.1093/jac/dkq362, 15;41(8):1167-73
2010
CLICK HERE
CLICK HERE
The GAS men
Guidelines for UK practice for the diagnosis and The prevalence of beta-haemolytic streptococci
management of methicillin-resistant Staphylococcus in throat specimens from healthy children and
aureus (MRSA) infections presenting in the community. adults. Scand J Prim H Care 1997, 15: 149
Nathwani D, Morgan M, Masterton R, Dryden M,
CLICK HERE
Cookson B, French G, Lewis D. Journal of Antimicrobial
Chemotherapy. 2008 doi:10.1093/jac/dkn096 “Cloud” health-care workers. Sherertz RJ.
(Emerging Infectious Diseases 2001, 7:241)
CLICK HERE
CLICK HERE
Intravenous immunoglobulin therapy for streptococcal
toxic shock syndrome--a comparative observational study. Cellulitis case report
Kaul R, McGeer A, Norrby-Teglund A, Kotb M, Schwartz B, Intravenous immunoglobulin G therapy in streptococcal toxic
O’Rourke K, Talbot J, Low DE. Clinical Infectious Diseases shock syndrome: a European randomised, double blind, placebo
1999 Apr;28(4):800-7. controlled trial. CID 2003;37:333-340
CLICK HERE CLICK HERE
Diagnosis and management of cellulitis, Phoenix G et al, Necrotizing fasciitis. Bellapianta JM, Ljungquist K, Tobin E, Uhl R. J Am
BMJ 2012;345:e4955 Acad Orthop Surg 2009 17(3):174-82
CLICK HERE CLICK HERE
An infected insect bite? Group A streptococcus peri-partum infection- following the
Health Protection Agency Centre for Infections, Duty guidelines
Doctor Botulism Protocol, November 2011 Global emm type distribution of group A streptococci: systematic
review and implications for vaccine development. Steer AC et al.
CLICK HERE
Lancet 2009;9:611-16
Werner SB, Passaro D, McGee J, et al. Wound botulism in CLICK HERE
California, 1951-1998: recent epidemic in heroin injectors.
Clin Infect Dis 2000; 31:1018 Painful calf
Streptolysin S and necrotising infections produced by group G strep-
CLICK HERE
tococcus. Humar, D., V. Datta, D. J. Bast, B. Beall, J. C. De Azavedo, and
Passaro DJ, Werner SB, McGee J, et al. Wound botulism V. Nizet. 2002. Lancet 359:124-129.
associated with black tar heroin among injecting drug
CLICK HERE
users. JAMA 1998; 279:859
Invasive group A, B, C and G streptococcal infections in Denmark
CLICK HERE
1999–2002: epidemiological and clinical aspects, Ekelund, K., P.
Sam AH, Beynon HL. Images in clinical medicine: Wound Skinhoj, J. Madsen, and H. B. Konradsen. Clinical Microbiology and
botulism. N Engl J Med 2010; 363:2444 Infection 2005 11:569-576.
CLICK HERE CLICK HERE
Yuan J, Inami G, Mohle-Boetani J, Vugia DJ. Recurrent Clinical characteristics of necrotizing fasciitis caused by group G
wound botulism among injection drug users in California. Streptococcus: Case report and review of the literature. Sharma, M.,
Clin Infect Dis 2011; 52:862 R. Khatib, and M. Fakih. 2002. Scandinavian Journal of
Infectious Diseases 34:468-471.
CLICK HERE
CLICK HERE
JournalofInfection(2012)64,1e18
www.elsevierhealth.com/journals/jinf
PRACTICE GUIDELINES
Guidelines for prevention and control of group A
streptococcal infection in acute healthcare
and maternity settings in the UK
Jane A. Steera, Theresa Lamagnib, Brendan Healyc, Marina Morgan d,
Matthew Drydene, Bhargavi Rao b, Shiranee Sriskandanf, Robert George g,
Androulla Efstratiou g, Fiona Baker h, Alex Baker i, Doreen Marsden j,
Elizabeth Murphyk, Carole Fryl, Neil Irvine m, Rhona Hughes n, Paul Wade o,
Rebecca Cordery p, Amelia Cummins q, Isabel Oliverr, Mervi Jokinen s,
Jim McMenamint, Joe Kearney u,v,*
aDepartment of Microbiology, Derriford Hospital, Plymouth, UK
bHealthcare-Associated Infection &Antimicrobial ResistanceDepartment, Health Protection Agency,London, UK
cDepartment ofMicrobiology,Public Health Wales,Cardiff, UK
dDepartment of Microbiology,Royal Devon andExeterHospital, Exeter,UK
eDepartment ofMicrobiology,Royal HampshireCountyHospital, Winchester, UK
fCentre forInfection Prevention &Management, Departmentof Infectious Diseases, Imperial College, London, UK
gRespiratory& Systemic InfectionsDepartment, Health Protection Agency,London, UK
hInfection Prevention &Control Department,North Devon District Hospital, Barnstaple, UK
iCommunications,Health Protection Agency, London,UK
jLeeSpark NF Foundation,Preston, UK
kOccupational Health Department,NHS GrampianOccupational Health Service, Aberdeen,UK
lInfectious DiseasesandBlood Policy,Department of Health,London, UK
mPublic Health Agency,Northern Ireland, UK
nObstetrics& Gynaecology,Royal Infirmary,Edinburgh,UK
oDirectorates of PharmacyandInfection, Guy’s& St.Thomas’NHSFoundation Trust,London, UK
pNorth EastandNorth Central LondonHealth Protection Unit, Health Protection Agency,London, UK
qEssex Health Protection Unit, Health Protection Agency,Witham, UK
rHealth Protection Agency,South West,Gloucester,UK
sDevelopmentDepartment, Royal Collegeof Midwives,UK
tHealth Protection Scotland,Glasgow, UK
uHealth Protection Agency,Eastof England, Witham,UK
Accepted 1November2011
Available online 17November2011
* Correspondingauthor.Tel.:þ4408452412266;fax:þ4401376302278.
E-mailaddress:[email protected](J.Kearney).
vOnbehalfoftheGASGuidelineDevelopmentWorkingGroup.
0163-4453/$36CrownCopyrightª2011PublishedbyElsevierLtdonbehalfofTheBritishInfectionAssociation.Allrightsreserved.
doi:10.1016/j.jinf.2011.11.001
2 J.A. Steer etal.
KEYWORDS Summary Hospital outbreaksofgroupA streptococcal(GAS)infectioncanbedevastating
GroupA streptococcus; andoccasionallyresultinthedeathofpreviouslywellpatients.Approximatelyoneintencases
Infectioncontrol; ofsevereGASinfectionishealthcare-associated.Thisguidance,producedbyamultidisciplin-
Midwifery; aryworkinggroup,providesanevidence-basedsystematicapproachtotheinvestigationofsin-
Diseaseoutbreaks; gle cases or outbreaks of healthcare-associated GAS infection in acute care or maternity
GreatBritain settings.
TheguidelinerecommendsthatallcasesofGASinfectionpotentiallyacquiredinhospitalor
through contact with healthcare or maternity services should be investigated. Healthcare
workers,theenvironment,andotherpatientsarepossiblesourcesoftransmission.Screening
ofepidemiologicallylinkedhealthcareworkersshouldbeconsideredforhealthcare-associated
casesofGASinfectionwherenoalternativesourceisreadilyidentified.Communalfacilities,
suchasbaths, bidetsand showers,shouldbecleaned and decontaminated betweenallpa-
tientsespeciallyondeliverysuites,post-natalwardsandotherhighriskareas.Continuoussur-
veillanceisrequiredtoidentifyoutbreakswhichariseoverlongperiodsoftime.GASisolates
fromin-patients,peri-partumpatients,neonates,andpost-operativewoundsshouldbesaved
forsixmonthstofacilitateoutbreakinvestigation.Theseguidelinesdonotcoverdiagnosisand
treatmentofGASinfectionwhichshouldbediscussedwithaninfectionspecialist.
CrownCopyrightª2011PublishedbyElsevierLtdonbehalfofTheBritishInfectionAssocia-
tion.Allrightsreserved.
Introduction associated, most (58%) being post-surgical infections.5 Be-
tween2and11%ofallsevereGASinfectionsareassociated
with recent childbirth, a rate of approximately 0.06 per
Theoverridingtrendoverthelastcenturyhasbeenoneof
1000 births.5e7 Findings from the 2006e08 triennial report
dramatic decline in severe GAS infections. However, the
on maternal deaths identified an increase in the numbers
last three decades have witnessed periodic upsurges in
ofmaternaldeathsassociatedwithGASgenitaltractsepsis
Europeandbeyond.1Thereasonsforthesechangesarenot
fromaround1deathperannumin2000-02to4perannum
understood, but might represent evolutionary shifts in cir-
in 2006e08.8 Several of these deaths were in women with
culatingstrains,drivenbypopulationimmunity.Currentes-
a recent respiratory tract infection or women with family
timates of annual incidence of severe GAS infection range
members with recent history of sore throats. Infection in
from2to5per100,000populationindevelopedcountries,
withcasefatalityratesrangingfrom8to23%.1e4Datacol- the mother carries a further immediate risk of infection
in the baby.9,10
lected in 2003-04 as part of a European project recorded
a rate of 3.33 cases per 100,000 population in England,
Wales andNorthernIreland.5 Outbreaks of GAS in acute care settings
Incidenceofhealthcare-associatedandpostpartum A review of healthcare-associated invasive GAS infections
GAS infection in Ontario between 1992 and 2000 identified one in 10
cases as being linked to an outbreak.6 Hospital outbreaks
of GAS infection can escalate rapidly, be prolonged and
Between 5 and 12% of cases of severe GAS infection are
foundtobehealthcare-associated.1,3e6UKdatain2003-04 result in both patients and healthcare workers (HCWs) be-
inginfected.6 Thenationalreporting systemforsignificant
identified9%ofsevereGASinfectionsasbeinghealthcare-
health protection incidents in England (HPA Incident Re-
porting Information System) identified 10 outbreaks of
the GAS infection in hospital settings during 2008 and
2009 combined. Surgical, obstetrics and gynaecology, and
Glossary
burns units are most commonly involved in hospital out-
breaks, although outbreaks have been seen in a wide
GAS group Astreptococcus
rangeofdifferenthospitalsettings.6Investigationofthese
HPA Health Protection Agency
outbreaks has identified a range of transmission routes:
iGAS invasivegroup Astreptococcus
colonised HCWs to patients, environmental sources to pa-
IPCT infection prevention and control team (or
tients, and patient-to-patient transmission. Patients with
equivalent)
both community and healthcare-associated GAS infection
HCW healthcare worker
have initiated hospital outbreaks with secondary cases
OH OccupationalHealth
typically arising within one month of the index case al-
PPE personalprotective equipment
though longer intervals have been documented.6 In
SIGN ScottishIntercollegiate Guidelines Network
HCWs, throat colonisation is the most common source, al-
STSS streptococcal toxicshock syndrome
thoughskin,vaginalandrectalcolonisationhavealsobeen
SUI serious untoward incident
linked to outbreaks.6,11
UKguidelines onprevention andcontrol of GASin healthcaresettings 3
Methods was made with leading streptococcal researchers across
theworld.Relevantpaperswerereviewedandgradedusing
the Scottish Intercollegiate Guidelines Network (SIGN)
Search strategy
methodbyaminimumoftwoindependentmembersofthe
workinggroup.12Theworkinggroupmaderecommendations
AliteraturereviewwasundertakeninNovember2009which
onthebasisofthisevidence.
included case reports, outbreak/cluster investigation re-
ports, retrospective and prospective surveillance studies Case definitions
and national guidelines. The following sources were
searched: Medline (1950 onwards), the Cochrane Library
InvasiveGAS(iGAS)infection
and The National Health Service Centre for Reviews and
Invasive GAS infection is illness associated with the iso-
Dissemination. Reports from working groups, expert com-
lation of GAS from a normally sterile body site, such as
mitteesandtheRoyalCollegeswerealsoincluded.Thekey
blood,cerebrospinal fluid, jointaspirate,pericardial/peri-
word search used the following individual terms and com-
toneal/pleural fluids, bone, endometrium, deep tissue or
binedthetermsusingAND/OR:infectioncontrol,healthcare
abscess at operation or post mortem. For the purposes of
associated infection; nosocomial; maternity; health care
these guidelines it also includes severe GAS infections,
workers; clusters; surgical; outbreaks; transmission; puer-
where GAS has been isolated from a normally non-sterile
peral sepsis; group A, C and G and beta-haemolytic strep-
siteincombinationwithasevereclinicalpresentation,such
tococcus; Streptococcus pyogenes; invasive; antibiotic
asstreptococcaltoxicshocksyndrome(STSS)ornecrotising
prophylaxis;carriage.Thesearchwasnotrestrictedaccord-
fasciitis.
ingtolanguageofpublication;theonlyrestrictionwastohu-
manstudies.Relevantstudiesidentifiedfromtheelectronic Peri-partum GASinfection
search were reviewed for relevance by title and abstract. For the purposes of these guidelines, peri-partum GAS
Thefulltextofstudiesofpotentialrelevancewasretrieved. infection is defined as isolation of GAS up to 7 days post
Allstudiesidentifiedalsohadtheirreferencescheckedfor discharge or delivery in the mother in association with
relevantarticles.Toidentifynationalguidelinesthatmight a clinical infection, such as endometritis, STSS, wound
notbepublishedinthescientificliterature,directcontact infection, orisolation from asterile site.
Algorithm1 ManagementofasinglecaseofGASinfection.
4 J.A. Steer etal.
Healthcare-associated GASinfection Initial investigations
A healthcare-associated GAS infection is defined as a GAS
infectionthatisneitherpresentnorincubatingatthetimeof
Initial investigations should establish if the infection or
admission but considered to have been acquired following
colonisation with GAS is community or healthcare-
admissiontohospitalorasaresultofhealthcareinterven- associated. It should be established if the patient had
tions in other healthcare facilities. Typically, onset of GAS
symptoms or signs consistent with GAS infection such as
infectionis>48hafteradmission,orpostoperativelyatany
sorethroatorskininfectiononorjustpriortoadmission
timeafteradmissionandforuptosevendayspostdischarge. orchildbirth.Intra-familialspreadofGASiscommonand
enquiries should be made as to whether close personal
Outbreak
contacts or visitors are suffering from any illness that
Anoutbreak should beconsidered if there aretwo ormore could be attributable to GAS. Identification of a close
casesofsuspectedGASinfectionrelatedbypersonorplace.
personalcontactwithsymptomsorsignsofGASinfection
Thesecaseswillusuallybewithinamonthofeachotherbut
reduces the likelihood that the infection was acquired
theintervalmayextendtoseveralmonths.Itshouldbenoted from a healthcare source. Symptomatic close contacts
thattheintervalbetweencasesinpublishedoutbreakreports
should seek advice from their GP. The infection should
for GAS has, on occasion, extended to more than a year.
be considered to be healthcare-associated if symptoms
Reference laboratory typing from culture-proven cases is
andsignsofinfectionwerenotpresentonadmissionand
neededtoconfirmthatcasesarerelated. they have developed during a hospital stay or within 7
days of discharge from hospital or post delivery, with no
Infection prevention and control of GAS other obvious source of transmission. In this case,
infection screening of HCWs as a possible source should be
considered - see Transmission from healthcare worker
to patient.
The successful management of every case of GAS is
Contacts of community-acquired cases of invasive GAS
important,notonlyto preventspreadandpossibleserious
infection should be managed according to the existing
infections, but also to investigate if transmission is occur-
community guidelines.9
ring from an ongoing and preventable source. All GAS
infectionssuspectedofbeinghealthcare-associatedshould
beinvestigatedfurther(see Algorithm1).
Reporting cases Recommendations
AllcasesofsuspectedGASinfectionidentifiedinacutecare (cid:2) IPCTshouldestablishwhetherthecaseiscommunity
settings or maternity units, including stand-alone midwife
or healthcare-associated.
led units, and any cases identified within seven days of (cid:2) Further investigation of potential sources of infec-
discharge or delivery that could have been healthcare-
tion is warrantedfor anycaseof GASinfectioncon-
associated should be reported to the infection prevention
sidered to behealthcare-associated.
andcontrol team(IPCT)orequivalent.
SIGN GRADINGGoodpractice points
InvasiveGASinfectionisanotifiablediseaseinEngland,
Wales and Scotland.13 All iGAS infections should be dis-
cussed with the local health protection specialist so that
contact assessment can be initiated according to existing Prospective and retrospective surveillance
national guidance.9
Outbreaks of GAS infection and deaths in patients with Theintervalbetweenidentifiedcasesinpublishedoutbreak
healthcare-associated GAS infection should be reported as reports for GAS has, on occasion, extended up to one or
seriousuntoward incidents vianormal reporting routes. moreyears,14andassuchtheIPCTshouldmaintainongoing
In the event of a death due to confirmed or suspected GAS infection surveillance where a case of healthcare-
GAS - see Communication with, and advice to, mortuary associated GAS infection has been identified. The IPCT
andpathology staff. should review surveillance records for the past six months
at a minimum to establish if the new case is sporadic or
Recommendations part of a possible outbreak of healthcare-associated GAS
infection.
Following a case of healthcare-associated GAS infec-
(cid:2) AllcasesofsuspectedGASinfectionidentifiedinthe
tion the IPCT should consider prospective enhanced
acutecaresettingormaternityunitsandstandalone
surveillance which may include, for example, sampling
midwifeledunitsandanycasesidentifiedwithinseven
infected wounds of patients in the vicinity of the index
days of discharge or delivery that could have been
case or who are being cared for by the same HCWs. In
healthcare-associatedshouldbereportedtotheIPCT.
addition, the IPCTshould be informed of any cases which
(cid:2) All iGAS cases should bediscussed with andnotified
may be caused by GAS, e.g. cases of puerperal sepsis
tothelocalhealthprotectionspecialistbytherele-
treated empirically. Post-discharge surveillance, if re-
vantclinicianandmicrobiologist.
quired, would help identify healthcare-associated cases
SIGN GRADINGGoodpractice points
presenting after discharge.
UKguidelines onprevention andcontrol of GASin healthcaresettings 5
Personal protective equipment (PPE)
Recommendations
Whilstthepatientisconsideredinfectious,HCWsmustuse
(cid:2) IPCTshouldundertakearetrospectiveanalysisofmi- personal protective clothing including disposable gloves
crobiologyandsurveillancerecordstoidentifypossi- and aprons when in contact with the patient and their
ble linked cases of healthcare-associated GAS equipment or immediate surroundings. Facial protection,
infectionarisingin the past6months. such as a fluid repellent surgical mask and eye shield or
(cid:2) IPCTshouldmaintainGAScontinuousalertorganism visor, is recommended where a risk of transmission from
surveillance to identify outbreaks which may arise droplets is identified; examples include bronchoscopy,
overprolonged periodsof time. suctioning or dressing wounds that are producing a large
(cid:2) Followingacaseofhealthcare-associatedGASinfec- amount of exudate. Fluid repellent surgical masks with
tion the IPCTshould consider prospective enhanced visors must be used at operative debridement/change of
surveillance which may include, for example, sam- dressings for cases of necrotising fasciitis. If an HCW has
pling of infected wounds of patients in the vicinity any break in skin integrity e.g. a cut or skin lesion, this
of the index caseor who arebeing caredfor by the mustbecoveredwithawaterproofdressing.Intheevent
sameHCWs. of failure to comply with PPE or needlestick injury - see
SIGNGRADING Goodpracticepoints Transmission from patient to healthcare worker.
Visitors must be given information about how to pre-
vent the transmission of infection, and shown how to use
appropriatePPE whenvisiting the affected individual. The
Patient isolation
PPE required by visitors will depend on risk assessment of
the factors affecting transmission (e.g. if there is a high
Patients diagnosed with or clinically suspected of having
risk of droplet transmission) and also the visitor’s level of
GAS infection should be isolated in a single room, with
direct contact and involvement in the affected person’s
a self contained toilet and its own hand basin. Breast
care.
feeding should be supported where possible. Mother and
baby should not be separated unless the mother or baby
requires admission to an ICU. Notes and charts should be
kept outside the room and patients should have dedicated Recommendations
equipment wherepossible.
It is frequently cited that isolation should continue for
24e48 h after commencement of appropriate antibiotic (cid:2) HCWs should wear PPE including disposable gloves
andapronswhenincontactwiththepatientortheir
therapy. Studies suggesting that exclusion for 24 h of
equipmentandtheir immediatesurroundings.
effective therapy is appropriate, have primarily been
(cid:2) Breaksintheskinmustbecoveredwithawaterproof
performed in children with pharyngitis or scarlet fever
dressing.
(Padfield,personalcommunication).However,casereports
(cid:2) Fluid repellent surgical masks with visors must be
showthatGAScanbeisolatedfromsuperficialsitesbeyond
used at operative debridement/change of dressings
24hofantibiotictreatment,includingthedryingumbilical
cord.14,15Inarecentcasereportoftransmissionfromapa- of necrotising fasciitis and for procedures where
droplet spreadis possible.
tientwithnecrotisingfasciitistoanHCW,thisoccurred50h
after initiation of appropriateantimicrobial therapy.16 (cid:2) Visitors should be offered suitable information and
relevant PPE following a risk assessment of the visi-
The working party felt that although there were some
tor’s level of direct contact/involvement in the af-
instances when patients should be isolated until culture
fectedperson’scare.
negative,24hofeffectivetherapywasappropriateforthe
SIGNGRADING Goodpracticepoint
majority of cases seen in hospitals; examples include
necrotising fasciitis where there is significant discharge of
potentially infectious body fluids, patients with infected
eczemawherethereisahighriskofshedding,mothersand
neonateson maternity units,andpatients on burnsunits. Hand hygiene
Semmelweis identified the importance of hand washing in
Recommendations preventing the spread of puerperal sepsis on maternity
units.17HCWsmustadheretostricthandhygienepolicyus-
inganeffectivetechniquei.e.handwashingwithsoapand
(cid:2) Patients with GAS should be placed in isolation for
waterordecontaminationwithalcoholhandrubbeforeand
a minimumof 24hof effective antibiotictherapy.
after contact with the patient and/or their environment,
(cid:2) Cases of necrotising fasciitis and other cases where
regardless of the use of gloves and other protective
there is significant discharge of potentially infected
measures.18
bodyfluidsorhighriskofshedding,mothersandne-
Whereappropriatethepatientandtheirvisitorsmustbe
onates on maternity units and patients on burns
offered suitable information and facilities to encourage
units,should beisolated untilculturenegative.
theirownadherencetostandardinfectioncontrolpractice
SIGN GRADINGD/Good practicepoints
including effectivehand hygienepractice.
6 J.A. Steer etal.
facilityisnotrecommendedunlessunavoidableoressential
Recommendations
fortheindividual’sclinicalcare.Isolationdictatesthatthe
movement of patients for non-clinical reasons should be
(cid:2) HCWsmust adhereto strict handhygienepolicy. minimised. Details of the risk of infection must be effec-
(cid:2) Visitors should be offered suitable information and tivelycommunicatedtotheambulanceservice,thereceiv-
facilities to be able to adhere to standard infection ing ward/department or facility, and the receiving IPCT
control practice,including goodhandhygiene. must be informed using the inter-healthcare transfer
SIGN GRADINGGoodpractice points form. If it isfound thata caseof GAScould have acquired
the infection in another hospital, that information should
berelayed to the referringhospital.
Environmental cleaning
The isolation room, furniture and equipment must be
cleaned daily as a minimum and terminal cleaning un- Recommendations
dertaken.Detergentandwaterfollowedbyhypochloriteat
1000 ppm, ora combinedproduct, is recommended for all
(cid:2) Transfer only if unavoidable or essential for the pa-
environmental and equipment cleaning where a patient is
tient’scare.
known to have an infection, healthcare associated or
(cid:2) Details of the risk of infection must be effectively
otherwise.19,20
communicatedtotheambulanceservice,thereceiv-
Communal facilities such as baths, bidets and showers
ing facility, IPCT and if appropriate, the referring
should normally be cleaned and decontaminated between
hospital.
patients irrespective of whether they are known to be
SIGN GRADINGGoodpractice points
infected or not. In the case of delivery suites and early
post-natalcarethisisparticularlyimportantbecauseofthe
high risk of blood and body fluid contamination, the
exposed nature of episiotomy wounds and the supporting Infections occurring in mothers and babies
evidence that these communal utilities have acted as the
source of outbreaks - see Environment as source of
Althoughperi-partumGASinfectionistypicallyacquiredat
outbreak.21e23
the time of or after childbirth from both exogenous and
endogenoussources,28,29pregnantwomenwhoarefoundto
Recommendations beinfectedwithorcarryingGASearlierinpregnancyshould
betreatedatthetimeandhavethisclearlydocumentedin
(cid:2) Theisolationroom,furniture,andequipmentshould the maternity notes.30
Babies born to infected or colonised mothers may
becleanedwithdetergentandwaterfollowedbyhy-
become colonised and this can be detected by swabbing
pochloriteat1000ppmdaily(orcombineddetergent
oftheumbilicus,earsandnose.Occasionallythebabymay
hypochlorite product).
(cid:2) Communal facilities such as baths, bidets and develop infection including invasive disease.31e36 Maternal
and neonatal infection tend to be closely related in terms
showersshouldbe cleaned anddecontaminated be-
oftiming.Motherandbabyshouldnotbeseparatedunless
tween all patients especially on delivery suites,
the mother orbaby requiresadmission toanICU.
post-natal wards and other high risk areas, such as
Following the identification of infected motherebaby
burnsunits.
pairsintheUK,interimguidancefortheirmanagementwas
SIGN GRADINGD/Good practicepoints.
published in 2004.9 Antibiotics should be administered to
motherandbabyifeitherdevelopssuspectedorconfirmed
Linen and waste
invasiveGASdiseaseintheneonatalperiod(first28daysof
life).Ofnote,oneneonatalsepsisandonenecrotisingfas-
Whilstthepatientisconsideredinfectious,linenandwaste ciitis of the scalp have been reported in association with
mustbehandled ashazardous.24e27 the use of foetalscalpelectrodes.37
Recommendation Recommendations
(cid:2) Whilstthepatientisconsideredinfectious,linenand (cid:2) Antibiotics should be administered to mother and
wastemust behandledashazardous. baby,ifeitherdevelopssuspectedorconfirmedinva-
SIGN GRADINGGoodpractice points siveGASdiseaseintheneonatalperiod(first28days
of life).
SIGNGRADINGC
(cid:2) Pregnant women infected or colonised with GAS
Transferring patients
prior to admission should be treated and have this
clearly documented inthe maternity notes.
Inordertominimisetheriskofcross-infection,thetransfer
SIGN GRADINGGoodpractice points
of any patient with an infection to another healthcare
UKguidelines onprevention andcontrol of GASin healthcaresettings 7
Transmission from patient to close personal antibiotics. The working party recommends HCWs receive
contacts a 3 day course of amoxicillin (500 mg, orally, three times
aday)intheseinstances,unlessthereisevidenceofactive
infectioninthe HCW, whereafull courseshouldbegiven.
Antibioticsshouldnotberoutinelyadministeredtocontacts
ofGAScases.Closepersonalcontactsofacaseofinvasive
GAS infection should receive written information outlining Recommendations
the signs and symptoms of invasive GAS infection and ad-
visedtoseekmedicalattentioniftheydevelopsuchsymp-
(cid:2) HCWs working without appropriate PPE whilst a pa-
toms within 30 days of a diagnosis in the index case in
tient is infectious should be advised aboutthe signs
accordancewithpreviousguidance.9Thisistheresponsibil-
and symptoms of GAS infection for 30 days after
ityofthelocalhealthprotectionspecialist,although,local
thediagnosisintheindexpatientandifsymptomatic
arrangementsshouldbemadesothatpatientinformationis
seekurgentmedical advice.
availableandcanbegiventotherelativesintheacutecare
(cid:2) Any such exposures should be referred to occupa-
setting - see Appendix 3. Close personal contacts are de-
tionalhealth.Antibioticprophylaxisshouldbeconsid-
fined as the same as for meningococcal disease, that is
ered for HCWs who sustain a needlestick injury or
sharing a household or kissing contacts within the seven
directcontaminationofmucousmembranesorbreaks
daysprior to theonset of the illness.38
intheskinwithpotentiallyinfectiousmaterial.
SIGNGRADINGGoodpracticepoints
Recommendations
Transmission from patient to patient
(cid:2) Antibiotics should not be routinely administered to
all contactsof GAScases.
(cid:2) Thelocalhealthprotectionspecialistshouldbenoti- Transmission from patient to patient is minimised with
isolationandfullcompliancewithstandardprecautionsfor
fiedof all iGAS infections.
(cid:2) Close contacts of iGAS cases should receive written infectionpreventionandcontrol.TheIPCTshouldestablishif
other recent cases are connected. Patients with both
information and have a heightened awareness of
community and healthcare-associated GAS infection and
the signs and symptoms of GAS for 30 days after
colonised and infected HCWs have seeded hospital out-
the diagnosisinthe index patient.
(cid:2) ClosecontactsofiGAScasesshouldseekurgentmed- breaks.6 Antibiotics should not be routinely administered
to contacts of GAS except in exceptional circumstances -
icaladviceiftheydevelopsuchsymptomswithin30
seeUseofchemoprophylaxis.Considerationshouldbegiven
days of a diagnosis in the index case in accordance
toprovidinginformationtopatientsinclosecontactwiththe
with previous guidance.
indexcaseiftherehasbeensignificantclosecontactpriorto
SIGNGRADING Goodpracticepoints
infectioncontrolproceduresbeinginstituted-seeCommuni-
cationwith,andadviceto,closecontactsandAppendix3.
Transmission from patient to healthcare worker
Transmission from healthcare worker to
patient
TransmissionfrompatienttoHCWhasbeenmostfrequently
described in the context of necrotising fasciitis where
multiple contacts may become infected or colonised.39,40 Althoughmanyhealthcare-associatedGASinfectionswillbe
One HCW with dermatitis developed cellulitis of the arm duetoendogenous flora,somepatients willhaveacquired
within48hofnursingapatientwithoutgloves.41Transmission their infection from a HCW - see Healthcare workers as
hasalsobeendescribedduringapostmortem-seeCommu- source of outbreak. Depending on the circumstances of
nicationwith,andadviceto,mortuaryandpathologystaff.42 the case in question, and where there is no other obvious
Appropriate PPE should be worn - see Personal protec- source of transmission, the IPCTshould consider screening
tive equipment (PPE). HCWs who have performed direct HCWsin contact withthe patient.
physical procedures on a patient with GAS infection, e.g. Forasinglecaseofhealthcare-associatedGAS,allHCWs
mouth-to-mouth resuscitation, should be advised by the in contact or working in close proximity to the patient
IPCTonthesignsandsymptomsofGASdiseaseandadvised (patient’s bed space, theatre, delivery room) should be
to seek medical advice if they develop such symptoms considered as possible sources of healthcare-associated
within 30 days of a diagnosis in the index case.9 Any such GAS. The HCWs most likely to have transmitted GAS are
exposedHCWshould bereferred to occupational health. those with direct contact with the patient within seven
Antibiotic prophylaxis should be considered for HCWs daysoftheonsetoftheinfection.Inparticular,thefollow-
whosustainaneedlestickinjuryordirectcontaminationof inggroups should beconsidered for screening:
mucous membranes or breaks in the skin with material
potentiallyinfectedwithGAS.Thedecisiontotreatshould (cid:2) thosepresentintheatreandperformingpost-operative
be made on a case-by-case basis after discussion between dressingchangesfor surgical cases6,43
a microbiologist or other infection specialist and an (cid:2) those performing vaginal examinations or dealing with
occupational health practitioner, taking into account the episiotomies and those present at delivery for mater-
typeofexposureandlengthoftimethepatienthasbeenon nitycases6
8 J.A. Steer etal.
TheIPCTmaywishtotakeastep-wiseapproachtotheir
Recommendations
investigationsaccordingly.TheIPCTshouldconsiderasking
HCWstopresenttoOccupationalHealthforscreeningifthey
havebeensymptomaticwithasorethroatorskininfection, (cid:2) In the event of death, the hospital mortuary staff
or have had skin lesions/dermatitis/eczema or vaginitis or shouldbeinformedoftheriskofinfectionandroutes
pruritusaniduringtheweekpriortotheindexpatient’son- of transmission.
setof infection-see exampleletterAppendix 4.The IPCT (cid:2) Pathologystaffshouldbeinformedwhenunfixedtis-
maydecidetoscreenasymptomaticHCWsincertaincircum- suefromacaseofnecrotisingfasciitisissentforex-
stances e.g. screening theatre staff following a post- amination.
operativecaseofnecrotizingfasciitis.TheHCWsshouldbe SIGN GRADINGGoodpractice point
seenandscreenedbyanoccupationalhealthpractitioner.
Few studies of GAS throat carriage in the healthy adult
Communication with, and advice to, close
populationhavebeenundertaken,butofthoseconducted,
contacts
carriageratesof5%orlessarereported,withmoststudies
reportingcarriageinlessthan1%.44e47Similarly,studiesof
GASvaginalandrectalcolonisation,restrictedtopregnant It is important that suitable and accurate information is
women, report carriage rates of 1% or less.48,49 As such, communicatedtoanypatientwithiGASinfectionandtheir
a positive screening result should be considered as indica- close personal contacts by the responsible consultant or
tive of likely source of transmission and dealt with as amemberoftheirteam-see,Appendices2and3.Thelocal
suchwhilstawaitingtypingresults.PleaserefertoScreen- health protection specialist in liaison with the IPCTshould
ing of healthcare workers for further advice on HCW ensurerelevantinformationisgiveninwrittenformtoclose
screening and section Management of colonised and in- personal contacts in accordance with existing community
fected healthcare workers for management of GAS colon- guidancee see Appendix 2 and Transmission from patient
isedor infectedhealthcarestaff. toclosepersonalcontacts.AllHCWsshouldbefullyinformed
athandoverofshiftssothatcommunicationwiththepatient
andtheirfamilyisconsistent,accurate,anddocumented.
Recommendations
Recommendations
(cid:2) AllHCWsincontactwiththepatient,eitherindirect
contact or working in the close vicinity (patient’s (cid:2) Suitable and accurate information should be pro-
bedspace),shouldbeconsideredaspossiblesources
vided promptly to the patient and close personal
ofhealthcare-associated GAS.
contacts foriGAS infections.
(cid:2) HCWs in contact with a case of healthcare- (cid:2) Effective hand over between health care teams
associated GAS should be considered for screening
should ensure communication with the patient with
iftheyhavesufferedasorethroatorskininfection,
iGAS infection and their close personal contacts is
orhave had skinlesions/dermatitis/eczema, vagini-
consistent, accurateanddocumented.
tis or pruritus ani within seven days of the onset of
SIGN GRADINGGoodpractice points
the infection in the patient. If so, the HCW should
be seen and relevant swabs taken by occupational
health. Isolates from positive swabs should be sent Management of an outbreak of GAS infection
for typing along with the patient isolate if not al-
readysent.
The investigation and control of single cases of GAS also
(cid:2) TheIPCTmaydecidetoscreenasymptomaticHCWin
applies to cases inoutbreaks.
certaincircumstances.
SIGN GRADINGD
Formation of outbreak control team
When a suspected or confirmed outbreak of GAS has been
Communication with, and advice to, mortuary
identified, interventions to prevent further transmission
and pathology staff
and further cases should be put in place immediately (see
Algorithm2).TheDirectorofInfectionPreventionandCon-
There are reports of invasive streptococcal infections trol, infection control doctor or deputy should set up an
acquired by healthcare workers from patients, including outbreak control team. The make-up of the team will de-
acaseofnecrotisingfasciitisfollowingneedlestickinjuryin pendonthenatureoftheoutbreak,butmayincludeinfec-
amortician.42,50Intheeventofapatientdeaththemortu- tioncontrolnurses,aconsultantmicrobiologist,consultant
ary staff should be informed of the risk of infection and from the specialty involved, occupational health adviser,
routesoftransmission suchthatthe necessaryprecautions local health protection specialist, local commissioning
canbeundertaken.Acadaverbagshouldbeused.Thebody lead, cleaning manager, bed manager, appropriate health-
can be viewed, but no embalming or other preparation of care manager and communications adviser. A member of
the body should take place.51 Pathology staff should also theIPCTshouldsupervisethedailymanagementoftheout-
beinformedwhenunfixedtissuefromacaseofnecrotising break and oversee the immediate implementation of pre-
fasciitisis sentforexamination. ventative measures.