Needlestick shows risk of necrotizing fasciitis
First reported case caused by 'minor' injury
The case of a Texas health care worker who developed necrotizing fasciitis due to group A streptococcus contracted from a needlestick injury carries a grim warning to other health care providers who are occupationally exposed to bodily fluids.
The disease struck a healthy 27-year-old internal medicine resident working in the emergency room at Hermann Hospital in Houston after she was "scratched" on the dorsal aspect of her left fifth metacarpal-phalangeal joint by a needle used to insert a central venous catheter into a patient. The patient had been admitted to the emergency room with sepsis of unknown cause.
Carin Hagberg, MD, who helped treat the resident, reported that the injury occurred when another health care provider who had removed the used needle from the patient's vein accidentally "grazed" the resident with it.
Hagberg is one of three physicians from the University of Texas-Houston Medical School (with which the teaching hospital is affiliated) who wrote the report.1 According to that report, within 14 hours of the injury the resident developed erythema, induration, and pain in her hand, followed by chills and fever (101.1 degrees F). She initially was treated with nafcillin, but penicillin G and clindamycin were added when it was discovered that the patient had died 12 hours after admission from group A streptococcus sepsis.
Over the next 48 hours, the resident developed leukocytosis, "followed by leukopenia, a prolonged prothrombin time and partial-thromboplastin time, decreased hemoglobin level and platelet count, hypotension, and progression of the area of induration and erythema toward her elbow and axilla." This led to the diagnosis of necrotizing fasciitis due to group A streptococcus.
Surgery to remove the organism and prevent its spread up the arm revealed necrosis of subcutaneous tissue, fascia, and muscle. The resident was discharged after 17 days of treatment and has recovered, although she was left with some disfigurement of the left arm due to a muscle flap that was used to close the wound defect.
Published reports confirm that prompt diagnosis and early, aggressive antibiotic and surgical interventions are necessary to prevent mortality.2-4 Necrotizing fasciitis has been called "one of the most serious infections known to humans,"5 though reports of the disease are relatively rare because of the availability of effective antibiotic treatment. The Houston report notes that group A strep is a "well-known cause of necrotizing fasciitis" and that "recent reports have emphasized the increase in aggressive infections due to this organism."
Despite this increase, and despite the resident's apparently minor injury, rapid infection progression, and need for aggressive therapy, a similar incident involving a health care worker is not likely, says William Trick, MD, an epidemiologist in the hospital infections branch of the U.S. Centers for Disease Control and Prevention.
Nevertheless, Hagberg - an anesthesiologist who participated in the resident's surgery - remains concerned that a two-millimeter long injury similar in appearance and severity to a cat scratch could transmit a life-threatening infection. "It's unbelievable, but it shows just how strong the bug is," she states. "To me, it's almost like a virus. It's that deadly." One reason the resident became infected could be that the source patient was at the "peak" of disease, she adds.
Could it happen again to another health care worker? Yes, says Hagberg. "This is the first report, but I'm sure it has happened before and people weren't aware of it. I'm wondering now that since this report has come out, we might see how many more [reports] come up," she says.
Hagberg advises health care workers to take the same precautions against group A strep that they would for AIDS patients. "It's flesh-eating bacteria, and it seems to be getting more virulent. Fortunately for [the resident], it was recognized, debrided, and they got rid of it. As an anesthesiologist, I am always sticking people. When I'm going to see a patient with necrotizing fasciitis, I'll take the same precautions to protect myself from blood and secretions as I would with a patient with HIV. It's that dangerous," Hagberg says. "There's no doubt."
References
1. Hagberg C, Radulescu A, Rex JH. Necrotizing fasciitis due to group A streptococcus after an accidental needle-stick injury (Correspondence). N Engl J Med 1997; 337:1,699.
2. Majeski J, Majeski E. Necrotizing fasciitis: Improved survival with early recognition by tissue biopsy and aggressive surgical treatment. South Med J 1997; 90:1,065-1,068.
3. Tsai CC, Lin SD, Lai CS, et al. A clinical analysis of necrotizing fasciitis: A review of 54 cases. Kao Hsiung I Hsueh Tsa Chih 1995; 11:673-677.
4. Stone DR, Gorbach SL. Necrotizing fasciitis: The changing spectrum. Dermatol Clin 1997; 15:213-220.
5. Kaul R, McGeer A, Low DE, et al. Population-based surveillance for group A streptococcal necrotizing fasciitis: Clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario group A streptococcal study. Am J Med 1997; 103:18-24.
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