Group A strep prophylaxis may be required for HCWs
CDC advisors consider new guidelines
Guidelines for investigating group A Streptococcus outbreaks in hospitals may include employee health provisions for postexposure chemoprophylaxis for workers exposed to patients with the often deadly infection.
The Hospital Infection Control Practices Advisory Committee (HICPAC) of the federal Centers for Disease Control and Prevention (CDC) in Atlanta is updating hospital guidelines that could include a recommendation for health care worker chemoprophylaxis with rifampin, penicillin, or some other drug, says William R. Jarvis, MD, chief of the investigation and prevention branch in the CDC's hospital infections program.
Limited surveillance data indicate there are between 10,000 and 15,000 cases of invasive streptococcal disease each year in the United States, with recent increases in the severity and incidence of illness. An increasing proportion of cases are presenting with streptococcal toxic shock syndrome. Typical mortality rates are between 5% and 15%, but can exceed 60%, with illness progressing rapidly to shock and organ system failure within 24 to 48 hours.
The CDC does not maintain surveillance data on the number of patient-to-HCW transmissions, Jarvis says, but some episodes of transmission have been noted in a small group of facilities.
In one outbreak at a hospital in Ontario, Canada, reported last year at the annual conference of the Society for Healthcare Epidemiology of America in San Diego, three patients died and six HCWs developed pharyngitis infections. The outbreak was uncovered when the pathogen was cultured from the blood of a patient who died of sepsis. The patient's hospital roommate, who also died, had group A strep in a chronically draining leg infection. The third patient, who had been in the same unit as the others, died with pneumonia and cellulitis.
Staff members may have been infected through droplet transmission. Although they were using universal precautions, they were not wearing masks because the patients were not known to have strep.
Surgeon infected by peritoneal fluid
In other unpublished reports, an outbreak in an intensive care unit of a Denver hospital began with a patient who died of septic toxic shock syndrome and necrotizing fasciitis. Two other intensive care patients developed pneumonia with uremia caused by group A strep, and two nurses who cared for the patients developed pharyngitis. Another case involved a surgeon who operated on a woman with peritonitis and developed bullous cellulitis after some of the infected peritoneal fluid splashed on his surgical gown.
In another case, streptococcal toxic shock syndrome was transmitted directly to an emergency medical worker who developed the syndrome within 24 hours of resuscitating an infected child.1
"We're not sure how generalizable [those cases] are to other facilities," Jarvis notes. "One of the complicating factors with this is that group A strep certainly isn't limited to people in the hospital. It is more often in the community than in the hospital, and secondary transmission from household contacts or children in day care may be affecting health care workers as often or more often than patients are."
Most hospital-acquired infections are HCW-to-patient transmissions, but nosocomial transmission in general is rare, Jarvis says.
"When it does occur, our attitude is one case is an epidemic and you should be investigating it. A number of outbreaks have been traced to colonized and/or infected health care workers, with colonization being in any number of sites -- pharynx, rectum, vagina, behind the ears, all over the place. In some of those cases, it has been very difficult to identify exactly what was going on."
New draft due this month
In addition to the rarity of nosocomial transmission, another matter to be considered regarding the need for chemoprophylaxis is primary vs. secondary transmission of group A strep, "and if you implemented a policy or a practice of instituting chemoprophylaxis, whether you would identify the individuals soon enough to actually have an effect," Jarvis adds.
The employee health issue was suggested to HICPAC by Ben Schwartz, MD, chief of the CDC's childhood and vaccine preventable disease epidemiology section of the childhood and respiratory diseases branch at a meeting last fall. The advisory group is considering the measure and is expected to release revised draft guidelines at another meeting this month.
"The initial response from HICPAC was they didn't feel that prophylaxis was really necessary and that further data need to be developed to determine what would be the benefit," Schwartz tells Hospital Employee Health. "[HICPAC's] emphasis was on using appropriate infection control practices, particularly barriers such as gloves and wearing a mask when coming into contact with infected patients."
Schwartz says he wants postexposure chemoprophylaxis to be considered "in a manner comparable to the prophylaxis for folks who are in contact with someone who has meningococcal illness. When health care workers have secretion exposure to meningococcal meningitis, they get rifampin prophylaxis. What I suggested is that we consider something similar for group A Streptococcus, but I think the members of the committee felt that we would be asking for a lot of intervention when the risk is really not as clear as in the case of meningococcus."
Because no active surveillance is in place for nosocomial group A strep infection, the risk to HCWs cannot be quantified, he adds.
Julie Garner, RN, MN, a nurse consultant in the CDC's hospital infections program and executive secretary of HICPAC, says the revised guidelines are still in development and will be discussed at the group's June meeting.
"We will look at prevention of transmission of infections in hospitals, both to prevent transmission to patients from personnel and to personnel from patients," she says. "It will be a very comprehensive document."
Reference
1. Valenzuela TD, Hooton TM, Kaplan EL, et al. Transmission of "toxic strep" syndrome from an infected child to a firefighter during CPR. Ann Emerg Med 1991; 20:90-92. *
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