The GAS MenDr Srivalli Bhagavatula
Speciality Registrar, MicrobiologyDr Brendan Healy
Consultant Microbiology and Infectious DiseasesDr Albert J Mifsud
Whipps Cross University Hospital
Call from the ward 2 cases returned to theatre 24 hours post operatively for septic shock
Outbreak 1
Case 1 75 yr male, metastatic bowel cancer, partial hepatectomy +
intra‐operative ultrasound scan, severe sepsis 24hrs post op Emergency re‐laparotomy performed, watery discharge found
Case 2 69 yr old male, metastatic bowel cancer on chemotherapy,
partial hepatectomy + intra‐operative ultrasound scan, severe sepsis 24hrs post op
Emergency re‐laparotomy performed with washout
Outbreak 1
Transferred to intensive care and treated with IV piperacillin ‐ tazobactam for sepsis
Peritoneal fluid ‐ GAS isolated after 24 hours
IV benzyl penicillin started, Pip‐Tazo stopped.
Blood cultures ‐ GAS isolated (24 hours after peritoneal fluid result)
Both patients..
Post‐op abdominal focus with secondary bacteraemia
Acute presentation of invasive group A Streptococcal infection post‐operatively
Surgery in the same theatre on the same day
Same surgical team and operating room personnel
Common factors in both patients
Clear epidemiological link between cases
Outbreak declared
Emergency meeting convened
Cases notified
Systematic assessment of the events leading up to the cases was made
Early course
Both operations performed on 17/02/12, one after the other by the same surgical team
No other operations in that theatre on the same day
Team last operated three days previously without incident
Team have not operated since (surgery was carried out on a Friday, culture results positive over the weekend)
Systematic review of Events
Theatre Staff inform the IC team that a visiting surgeon was unwell at the time of the procedure
The IC team understand that the surgeon had been unwell with a sore throat, cough and cold for a period of 3 weeks prior to the incident. He had been self medicating with antibiotics for 24 hours
The visiting surgeon is no longer working at the hospital and is planning to return to his native country in 24 hours time
Further Information
Both patients admitted electively from home
No symptoms of sore throat or any skin lesions in either patient, other patients on the ward or other staff members
No contact between patients prior to the operation
Further information
What would you do now? Who should you swab and how? Would you stop the surgical team from operating? Would you swab the visiting surgeon? Would you swab any other members of the operating team? What rate of carriage might you expect from swabbing
operating team members? How would you manage positive results from members of the
operating team?
The outbreak control team may choose to screen, depending on the circumstances of the outbreak, those with closest contact first
Less than 5% of the adult population are likely to carry GAS in their throat so a positive screening result should be considered as indicative of the likely source of transmission and acted upon accordingly until typing proves otherwise
Carriage rates ‐ guidelines
All HCWs in contact with the patient, either in direct contact or working in the close vicinity (patient’s bed space), should be considered as possible sources of healthcare‐associated GAS.
HCWs in contact with a case of healthcare‐associated GAS should be considered for screening if they have suffered a sore throat or skin infection, or have had skin lesions/dermatitis/eczema, vaginitis or pruritus ani within seven days of the onset of 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 for typing along with patient isolate if not already sent.
The IPCT may decide to screen asymptomatic HCW in certain circumstances
SIGN GRADING D
Who to screen?
Initial HCW screening should include throat and skin lesions
HCWs may need to be examined for skin lesions and dermatitis by an occupational health practitioner
Other sites known to be implicated in transmission are nose, anus, and vagina, and screening of these sites is advised when a HCW is implicated in transmission and throat and skin lesions are negative
SIGN GRADING D
Who to swab and how?
Would you screen / prophylax any other contacts, e.g. Family members etc?
What advice do you give to the visiting surgeon?
Should the visiting surgeon be referred to GMC or equivalent?
Further Questions
Antibiotics should not be routinely administered to all contacts of GAS cases.
The local health protection specialist should be notified of all iGAS infections.
Close contacts of iGAS cases should receive written information and have a heightened awareness of the signs and symptoms of GAS for 30 days after the diagnosis in the index patient.
Close contacts of iGAS cases should seek urgent medical advice if they develop such symptoms within 30 days of a diagnosis in the index case in accordance with previous guidance.
SIGN GRADING Good practice points
Management of Contacts
HCWs working without appropriate PPE whilst a patient is infectious should be advised about the signs and symptoms of GAS infection for 30 days after the diagnosis in the index patient and if symptomatic seek urgent medical advice.
Any such exposures should be referred to occupational health. Antibiotic prophylaxis should be considered for HCWs who sustain a needlestick injury or direct contamination of mucous membranes or breaks in the skin with potentially infectious material. SIGN GRADING Good practice points
HCW Contacts
Recommendations for chemoprophylaxis should be made by the outbreak control team on a case by case basis.
SIGN GRADING D
Prophylaxis
Symptoms of visiting surgeon not exactly typical for GAS but only symptomatic team member
No other clear source at this stage of the investigation
Transmission can occur through asymptomatic carriage
Risk of delaying surgery versus risk of infection
Issues
Infection probably introduced into the patient’s abdominal cavities during theatre
Visiting surgeon identified as the most likely source and swabs taken
Surgery to proceed as likely source identified and removed (open to debate)
Four people identified as having close contact with the patients during surgery (consultant surgeon, assistant surgeon, junior surgeon and anesthetist) ‐ swabs taken
All operating personnel to be swabbed by Occupational Health All positive cultures to be sent for typing Management of positive results as per guidelines
Conclusions of Local outbreak meeting
Swabs taken from symptomatic surgeon by UK occupational health department to provide throat swabs and swabs of any skin lesions if present
Surgeon advised not to perform any operations whilst the results are outstanding
Surgeon advised to attend OH department at his own hospital on his return.
Management of the visiting surgeon
IPCT should undertake a retrospective analysis of microbiology and surveillance records to identify possible linked cases of healthcare‐associated GAS infection arising in the past 6 months.
IPCT should maintain GAS continuous alert organism surveillance to identify outbreaks which may arise over prolonged periods of time.
Following a case of healthcare‐associated GAS infection the IPCT should consider prospective enhanced surveillance which may include, for example, sampling of infected wounds of patients in the vicinity of the index case or who are being cared for by the same HCWs.
Guidelines
Public Health informed but advised no further action required at present.
Retrospective and prospective surveillance to take place to identify other possible linked cases – (None found)
Decision by Outbreak team
Patients, close contacts and HCWs should be provided with clear, concise information about the outbreak.
Information should be provided to relevant HCWs to encourage heightened awareness of the symptoms of GAS, to take specimens from symptomatic patients, give early treatment where GAS is suspected, and promptly notify the outbreak control team.
Consider active involvement of a press officer to deal with media enquiries. SIGN GRADING Good practice points
Guidelines on communication
None of the health care workers or the patients were given chemoprophylaxis (no evidence of de novo invasion, more in keeping with introduction of organism directly into the abdomen => sepsis)
Patients and close contacts were given information about the outbreak
Hospital communications team was informed to deal with any media enquiries
Round up
The method and frequency of cleaning and decontamination of equipment and relevant ward areas should be reviewed.
Communal facilities such as baths, bidets and showers should be decontaminated between all patients especially on delivery suites, post‐natal wards and other high risk areas, such as burns units.
SIGN GRADING C
What about other sources?
In a possible outbreak environmental sources of transmission should be considered and relevant sampling undertaken. SIGN GRADING D
Environment?
Laryngoscope / Laryngoscope handles?
Ultrasound probe used in both these patients intra‐operatively
Decontamination of the ultrasound probe not possible between each case (expensive piece of equipment that requires Ethylene Dioxide cleaning – needs to be sent to Scotland for decontamination)
Probe washed between cases and probe covered with sterile disposable cover for each operation
Review of other possible sources
GAS isolates from both the patients were analysed at reference laboratory
Same type – Streptococccus pyogenes Lancefield Group A emm st89.0, T‐type 3/13/B3264
Typing results
Symptomatic surgeon’s throat swab – culture negative => sent for PCR ‐ also negative.
Screening throat swabs were done on other operating room personnel by occupational health team – all culture negative
None of the team members had any skin lesions
Screening Results
Case 1 ‐ Discharged from ITU after 4 days. Discharged home one week later
Case 2: Post‐operatively developed multi‐organ failure. 11 day ITU admission. Discharged home a month later.
Patient outcome
Outbreak investigation was closed as no further cases identified
GAS continuous alert organism surveillance to identify future outbreaks in place
Visiting surgeon presumed source although note culture negative. No further testing possible as returned to native country.
Round up
Bold decisions are required whilst information is gathered – guidelines are helpful
Decision to keep operating retrospectively correct but may have been criticised had further cases developed
Decision not to chemoprophylax similarly appropriate Epidemiological analysis of the case is crucial but cases
always difficult to manage as information gathering takes time and is delivered in stages
PCR used but also negative and did not add any further information
Outbreak provided opportunity to review other areas of practice – ultrasound probe.
Learning Points
During routine ITU ward round Index case (IC) was admitted from theatre following extensive debridement for necrotising fasciitis
History of circumcision on 16th May Operative findings: watery / serous discharge Presumptive diagnosis of Group A strep NF made during infection round
20th May circa 14:00
History of invasive post‐op infection in other pt. (P2 TT) ‐ suspicious of Group A strep
Both patients operated on by same surgeon Surgical team contacted while in theatre Despite absence of any symptoms, surgeon withdrawn; list continued by another team.
Two other members of surgical team involved in care of both patients
All three sent to Occupational Health.
20th May (cont.)
Case 2 (P2 TT) post testicular torsion reduction 5th May. Post‐op local infection, re‐operated and testis non‐viable ‐ orchidectomy performed. Swab collected ‐ Group A Strep
Enquiries re further cases: Third patient (P3 N) ‐ Nephrectomy 1st May. Developed severe sepsis within 24hrs post‐op. GAS isolated from blood. Investigated at time. No source identified.
20th May 15:00 to 17:00
Patient 4 (P4 H) ‐ hydrocoele repair 16th May, not discharged due to size of hydrocoele. Co‐amoxiclavstarted 17th May due to suspected ‘atypical infection’. Infection team review, swab collected
Patient 5 (P5 V): Varicocoele repair ‐performed at a private hospital 18th May. Reviewed in OPD 19th May due to pain. No clinical evidence of any problems; started on co‐amoxiclav empirically. Contacted by surgeon and re‐admitted later same day.
20th May (cont.)
Possible outbreak of GAS involving 2 proven cases 3 wks apart plus 1 strongly suspicious case plus 2 possible cases
1 surgeon common to all 2 members of team common to three proven or probable cases
3 theatres involved
20th May: Initial findings
Should you stop the surgeon from operating? Should you stop the other 2 members of the team from operating?
Should you close the theatres? Should you start antibiotics on any of the hospital staff?
Can the Surgeon carry out other duties?
Questions
Medical Director and Lead Exec Director informed Surgeon plus 2 members of team not to perform any invasive work (incl cystoscopies)
Screening swabs collected (Occ H) All to start Amoxicillin As no link with theatres or non‐surgical staff, all lists to continue as normal
20th May: Management (1)
Another surgical team to take over in‐patient care of team
Clinical team may continue non‐invasive OPD work (excluding open wound review)
Detailed investigation to be undertaken
20th May: Management (2)
Clinical cases IC: GAS grown from debrided tissue (16/5/12) P2 TT: GAS grown from swab (5/5/12) P3 N : GAS from blood culture (1/5/12) P4 H: No growth (16/5/12) P5 V: S.aureus (18/5/12)
Screening swabs: Surgeon: GAS from throat & nose; BHS (mixed) from
perineum Other team members: No BHS nose, throat, perineum
21st May
Surgeon: denies any history of URTI or skin infection at any time in last 4 weeks
Surgeon always wears mask during all operations Wife (A) suffers from eczema and she had recent flare up
Children, aged 1 (B) , 5 (C) , 8 (T) yrs recent URTIs Swabs requested from all.
21st May: further information
How would you manage the surgeon now?
When can the surgeon return to work?
When can you stop following up for further cases?
HCW contacts who have been screened and found to be positive for GAS should receive eradication therapy.
Clearance screens should be taken 24 hours after completing treatment, and again at 1, 3, 6, and 12 weeks following the end of treatment
SIGN GRADING D
Who to treat, Clearance screens
Pharyngeal carriage: Treatment options include oral penicillin V (500mg four
times a day for 10 days), amoxicillin (500mg three times a day for 10 days), clindamycin (300mg four times a day for 10 days), or azithromycin (maximum dose of 500mg once a day) for 3 days.
Clindamycin (300mg four times a day for 10 days) should be used for eradication of throat carriage in cases where first‐line therapy with penicillin has been unsuccessful.
SIGN GRADING D
Treatment recommendations
Non‐pharyngeal carriage: Penicillin treatment alone may not be sufficient. Treatment options include clindamycin 300mg four times a day for 10 days, or azithromycin 12mg per kg per day (maximum 500mg once a day) for 5 days with some limited reports in literature of combining with oral rifampicin or oral vancomycin.
SIGN GRADING D
Treatment non pharyngeal
HCWs with symptomatic GAS pharyngitis should stay away from clinical work until at least 24 hours of appropriate therapy and resolution of symptoms has occurred. Asymptomatic HCWs should stay away from work until 24 hours of appropriate therapy.
A longer period of time may be required for HCWs with skin lesions or in other circumstances where carriage has been linked to an outbreak or confirmed transmission. This should be at the discretion of the IPCT team in liaison with the occupational health practitioner and discussed on a case‐by‐case basis after a risk assessment.
Return to work
“Some of these outbreaks may evolve over several months. Twenty‐eight cases of GAS infection, including four cases of iGAS infection and three deaths over a nine‐month period, occurred in patients being cared for by a wound care team. Longitudinal surveillance by the IPCT is important.”
Guidelines
Investigation of GAS cases by ICT is routine ‐ no cases linked with surgery recorded (apart from P3)
All GAS isolates downloaded from LIMS (previous 3 months)
No additional cases identified from in‐patients linked with surgery
All non‐throat cases (incl A&E, GP) checked for recent admissions ‐ none found
21st May: results search
Summary: 3 proven cases, 2 possible Review of theatres ‐ no commonality identified Surgeon
to restrict all clinical activities to continue Amoxicillin 10 days to return to OccH at Day 5, 11, 12, 13
Other team members to return to normal duties; antibiotics stopped.
Look back considered ‐ decided against Discussed with RSIL, CfI
21st May: outbreak meeting
Positive Son (T): T,P neg. Nose ‐ GAS Son (B): P neg. Nose and Throat ‐ GAS
Negative Wife (A): N, T, P ‐ negative Daughter (C): N,T,P ‐ negative
Family follow‐up
Original swabs (20/5) N, T ‐ GAS; Perineum ‐ GBS 26/5, 28/5, 1/6, 2/6, 3/6 ‐ No BHS Surgeon returned to full clinical work 5/6 (2 week
exclusion) Surgeon followed up 3 mo for 1 year
Surgeon follow‐up
Outbreak of Group A Strep wound infection 3 proven cases over 3 weeks (plus 2 possible) Epidemiological information key Source: asymptomatic surgeon Family members colonised / infected Postulated that surgeon was colonised intermittently from family members
Believed to have been unavoidable
Summary
Outbreaks of GAS well described Asymptomatic carriage in children well described (to 20%)
Adult carriage: 2‐4% (Scand J Prim H Care 1997, 15: 149; Acta Pathol Micro Immunol Scand B 1985, 93: 347)
Outbreaks due to airborne transmission (cloud carriers) rare (EID 2001, 7:241)
Management of GAS outbreaks discussed Importance of epidemiological information highlighted
Management of colonised staff discussed
Conclusions
3 Scopes in use ‐ ETO decontamination takes place when possible Other times ‐manual wash with endozime detergent, followed by decontamination in a washer/ disinfector using tristel. The
probe is then handled as a sterile instrument, handled with sterile gloved hands placed between sterile towels on a clean trolley. Taken to theatres, a sterile sheath is placed on the probe by the scrub nurse prior to placement in the sterile field.
The decontamination process is prior to use within three hours of surgery. The probe is decontaminated (as above) post use. The scope is transported between the theatre and Endoscopy room in the same tray pre and post use. Documentation poor, no individual scope numbers recorded. Decontaminations not recorded. Records of ETO decontamination in SSU/HSDU, but no records/monitoring of individual probe turnaround. Potential of
single scope ETO decontamination only.
Recommendations Each probe to have an individual decontamination record. Actioned 27/02/12. SOP put into place. Actioned 27/02/12. Theatre 8 Scope serial numbers requested from HSDU. Actioned 02/03/12. ETO probe turnaround documentation system to be put in place. A review of scope decontamination procedures throughout theatres.
Further Information re Scope disinfection