Literature Reviews
April 1, 1997 4 minutes read
Weber DJ, Rutala WA, Denny FW. Management of healthcare workers with pharyngitis or suspected streptococcal infections. Infect Control Hosp Epidemiol 1996; 17:753-761.
More than 50 nosocomial outbreaks of group A streptococcus (GAS) have been reported in the past 30 years. GAS can cause pharyngitis, rheumatic fever, streptococcal toxic shock syndrome, and serious skin and soft-tissue infections. For this reason, the authors contend that health care facilities must develop policies for diagnosing and treating symptomatic employees. The article outlines a management strategy for health care workers with pharyngitis or suspected to be the source of streptococci during a nosocomial outbreak.
GAS generally is spread by direct person-to-person contact via saliva droplets or nasal secretions, although airborne transmission has been suggested by some outbreaks. Crowding can increase spread and virulence.
Symptoms associated with acute pharyngitis include sore throat, pain on swallowing, headache, fever, abdominal pain, nausea, and vomiting. Pharyngeal and tonsillar inflammation, often with exudates, are revealed upon examination. Other signs are soft palate petechiae; enlarged, tender anterior cervical lymph nodes; scarlatiniform rash; and red, swollen uvula. One-third to one-half of patients from whom GAS are isolated will be asymptomatic or mildly symptomatic.
Group B streptococcus can cause neonatal sepsis and meningitis and is an etiologic agent in adult infections including skin and soft-tissue infection, bacteremia, urosepsis, pneumonia, and peritonitis. Groups C and G streptococci can cause exudative pharyngitis, cellulitis, wound infection, pyoderma, septic arthritis, osteomyelitis, puerperal infection, and endocarditis.
Most nosocomial GAS outbreaks have involved postpartum women, newborns, postoperative patients, burn patients, or patients in geriatric wards or extended care facilities. Asymptomatic HCWs frequently have been identified as the index case. Sites of colonization or infection have included the pharynx, vagina, rectum, or skin, with the source of infection being family members.
During outbreaks, additional personnel have become colonized by the epidemic strain, and HCWs have developed clinical infections as secondary cases. Typing the epidemic strain has been widely used to delineate extent of outbreaks and to determine whether a colonized HCW could be the index case.
The authors review a number of nosocomial outbreaks, such as a pseudoepidemic of sepsis linked to a phlebotomist with dermatitis and secondary streptococcal infection; environmental sources including a contaminated showerhead, bidets, toilet seats, and multidose medication vials; and ingestion of contaminated food.
HCWs with acute pharyngitis should undergo a history and physical examination to exclude serious infection syndromes, to diagnose GAS rapidly, and to consider other treatable sources of pharyngitis. A commercially available rapid streptococcal diagnostic test should be used. If negative, a throat culture should be obtained.
The authors recommend that a cotton or Dacron swab be rubbed vigorously over both tonsils, the oropharynx, and the nasopharynx posterior to the uvula. The swab then should be rubbed into the media of a portion of the blood agar plate, and the entire plate should be streaked with a wire loop to yield individual colonies. "Several stabs through the agar should be made to permit subsurface growth that will allow the development of hemolysis due to streptolysin O," they state.
Preferred treatment for acute pharyngitis is a single injection of benzathine penicillin G, 1.2 million units intramuscularly, but it is used infrequently because the injection is painful. The most commonly used therapy is penicillin V 500 mg orally two to three times per day for 10 days. An alternative for penicillin-allergic patients is erythromycin, 250 mg orally two to four times per day for 10 days. Although the risk of HCW-to-patient transmission is small, employees with group A strep pharyngitis should be treated and relieved from work for 24 hours.
To evaluate and manage HCWs suspected as sources of nosocomial strep infections, the authors suggest that active surveillance of potential cases be used to determine an epidemic’s extent. "In most instances, a review of outbreak cases should produce only a limited number of personnel who must be evaluated," they state. "However, the urgency of determining whether the outbreak is due to a colonized or infected staff member may require screening a large number of persons."
Potential carriers should be screened for symptomatic infections, especially pharyngitis, skin infections of the hand and scalp, and rectal infections. In symptomatic personnel, cultures should be obtained of the infected site, appropriate therapy should be administered, and they should be relieved from work until asymptomatic.
Both symptomatic and asymptomatic workers associated with an outbreak of postoperative wound infections should have pharyngeal, vaginal, and rectal cultures performed. Pharyngeal cultures should be performed on asymptomatic personnel associated with outbreaks of postpartum, neonatal, or burn wound infections.
Molecular typing of streptococcal isolates from HCWs and patients may assist in identifying the index case and secondarily infected staff, although it will not be available quickly enough to aid in making clinical decisions regarding outbreak interventions. HCWs carrying an epidemic strain should remain off work until post-therapy cultures show elimination of carriage.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content