Invasive Group A Streptococcus
Invasive group A streptococcus (iGAS) can cause severe, life-threatening illness among the elderly, particularly long-term care (LTC) residents.1-4 The incidence of iGAS infection is higher among long-term care residents than among community members of the same age, and residents who develop iGAS infections have significant morbidity and mortality risk due to advanced age, close living conditions, and comorbidities (e.g., diabetes, cardiovascular disease).1,4,5 Outbreaks of iGAS in LTC facilities in the United States and Canada have mortality rates of 8% to 40%.2
Because of the potential severity of illness, even a single case of iGAS requires public health action.4 Healthcare practitioners and healthcare facilities in Pennsylvania are required to report positive group A streptococcus cultures from invasive sites (e.g., blood, synovial fluid) through the Pennsylvania National Electronic Disease Surveillance System (PA-NEDSS) within five days of identification.6 In fall 2012, the Bureau of Epidemiology at the Pennsylvania Department of Health started tracking reports of iGAS in LTC facilities.7 To identify LTC-associated infections reported through PA-NEDSS, the Department of Health staff ask the following question: "Is the patient a resident of a nursing home or other chronic care facility, or were they recently transferred from such a facility?"7 If the answer is yes, then the case is counted as an LTC-associated case. Reports of iGAS in current or recent LTC residents increased from 25 reports in PA-NEDSS in 2013 to 63 reports in 2016.7
Since 2009, Pennsylvania LTC facilities have reported healthcare-associated infections through the Pennsylvania Patient Safety Authority's Pennsylvania Patient Safety Reporting System (PA-PSRS). PA-PSRS reports of LTC-associated infections are based on different criteria from PA-NEDSS and comprise a subset of the PA-NEDSS reports.
To further understand the differences between iGAS reporting in the two systems, Authority analysts compared the number of iGAS cases identified through PA-NEDSS with the number of iGAS cases identified through PA-PSRS during the same period. Authority analysts queried the PA-PSRS database for any reports potentially indicative of iGAS (e.g., mention of streptococcus or strep) submitted from January 2013 through December 2016, and selected reports with documentation of group A streptococcus or Streptococcus pyogenes, based on culture results or notification by the hospital receiving the patient in transfer. Analysts identified 18 reports (Figure).
Although fewer LTC-associated iGAS events were reported through PA-PSRS than through PA-NEDSS, both databases contain an increase in event reports over time. It is unknown whether this increase is a true increase in the number of illnesses or a result of improved awareness and reporting.7
Group A streptococcus infection may present as pharyngitis or skin infections, including impetigo or cellulitis, and can cause severe infection including pneumonia and bacteremia.5 iGAS is spread by droplet or contact transmission with an infected person.5 Fomite transmission (such as contaminated clothing or equipment) is unlikely.5 In LTC settings, healthcare workers with active streptococcal skin infections, pharyngitis, or asymptomatic carriage have been known to transmit the bacteria to residents.5
Effective surveillance, monitoring, and adherence to infection prevention practices can help identify iGAS cases early and help prevent outbreaks.1,2,4,5 Please see "Infection Prevention Strategies for One Culture-Confirmed iGAS Infection," below, for more guidance.
- Jordan HT, Richards CL, Burton DC, Thigpen MC, Van Beneden CA. Group A streptococcal disease in long-term care facilities: descriptive epidemiology and potential control measures. Clin Infect Dis. 2007 Sep 15;45(6):742-52. Also available: http://dx.doi.org/10.1086/520992. PMID: 17712760.
- Section 4-1. Management of Group A Streptococcus (GAS). In: Peel Public Health - Take Control Guide 2011. Mississauga (ON): Peel Public Health.
- Centers for Disease Control and Prevention (CDC). Invasive group A streptococcus in a skilled nursing facility--Pennsylvania, 2009-2010. MMWR Morb Mortal Wkly Rep. 2011 Oct 28;60(42):1445-9. PMID: 22031216.
- Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Atlanta (GA): Centers for Disease Control and Preventin (CDC); 2007 Feb 15. 209 p. Also available: https://www.cdc.gov/infectioncontrol/guidelines/isolation/.
- Grota P, et al. APIC text of infection control and epidemiology. 4th ed. Arlington (VA): Association for Professionals in Infection Control and Epidemiology, Inc.; 2014.
- 28 Pa. Code § 27.21 (2002). Available: https://www.pacode.com/secure/data/028/chapter27/028_0027.pdf.
- Kinsey CB. (Epidemiologist, Healthcare-Associated Infections, Bureau of Epidemiology, Pennsylvania Department of Health). Personal communication. 2017 May 23.
- Nanduri SA, Arwady MA, Edens C, Lavin MA, Morgan J, Clegg W, Beron A, Albertson JP, Link-Gelles R, Ogundimu A, Gold J, Jackson D, Beall B, Stone N, Van Beneden C, Fleming-Dutra K. Prolonged outbreak of invasive Group A Streptococcus among nursing home residents - Illinois 2015. In: 65th Epidemic Intelligence Service Conference; 2016 May 2-5; Atlanta (GA).
- Rainbow J, Jewell B, Danila RN, Boxrud D, Beall B, Van Beneden C, Lynfield R. Invasive group A streptococcal disease in nursing homes, Minnesota, 1995-2006. Emerg Infect Dis. 2008 May;14(5):772-7. Also available: http://dx.doi.org/10.3201/eid1405.070407. PMID: 18439360.
Infection Prevention Strategies for One Culture-Confirmed iGAS Infection*
Because of the potential severity of iGAS infection, even one case should be investigated by the facility and the Department of Health.
Infection Control—Staff Education and Monitoring Includes Employees and Contracted Staff
Report any cases of invasive group A streptococcus (iGAS) infection through the Pennsylvania National Electronic Disease Surveillance System (PA-NEDSS). If you are unsure whether a case from your facility has been reported, or if you are seeking guidance, call your local district office or state health center. You may also call 1-877-PA-HEALTH to be directed to the correct office.2,6,7
- Place residents who have iGAS infection on the appropriate precautions, as follows4,5,8
- Standard precautions for skin or wound infection if a dressing covers and contains drainage
- Standard, contact, and droplet precautions if no dressing is present or the dressing does not adequately contain drainage
- Droplet and standard precautions for pharyngitis or pneumonia (through the first 24 hours of antimicrobial therapy)4
- Droplet and standard precautions for invasive disease (through the first 24 hours of antimicrobial therapy)4
- Provide education on proper hand hygiene and respiratory etiquette to staff, residents, and visitors.1,5,7,9
- Provide education on wound care and dressing changes.8
- Provide education on environmental cleaning, with a focus on high-touch areas.5
- Provide education on equipment cleaning, reinforcing the importance of cleaning and disinfecting equipment that is shared between residents; or use dedicated equipment, if possible.4
- Monitor compliance with hand hygiene, respiratory etiquette, standard and transmission-based precautions, personal protective equipment, usage, and cleaning practices.5
Surveil to Identify Additional Cases
- Perform retrospective review of all resident cultures for the previous month for culture-confirmed infections.2,7
- Maintain active symptom surveillance for invasive and noninvasive cases for four months after the onset of the most recent infection.7
- Check residents daily for symptoms of iGAS infection and order a culture for anyone who is symptomatic7
- Survey staff for symptoms of iGAS and order a culture for any staff member who is symptomatic; refer staff with positive cultures to a physician for treatment7
- Provide staff education on recognition of iGAS infections, the importance of basic hygiene, and not working while ill.1,6,8
Identification of Potential Carriers
- In consultation with the Department of Health Bureau of Epidemiology, you may be asked to order cultures for people (e.g., family, friends, healthcare workers) who come into close contact with residents who have iGAS infections.7
* Additional actions and recommendations might be necessary if more than a single case is identified.