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Critical Care |

Community Outbreak of Severe Invasive Group A Streptococcal (GAS) Disease With a High Incidence of Toxic Shock and Death – Rochester, New York

Rachel Karmally, MD; Todd Sheppard, MD; Maryrose Laguio, MD
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Rochester General Hospital, Rochester, NY


Chest. 2015;148(4_MeetingAbstracts):204A. doi:10.1378/chest.2250031
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Abstract

SESSION TITLE: Critical Care Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM

INTRODUCTION: Invasive infections caused by GAS carry a mortality reported to be as high as 80%. However, it is infrequent in the US with an incidence of 3.5/100,000 population/year of primary cases.1 We will describe 7 cases of invasive GAS presenting to our hospital between February and March 2015.

CASE PRESENTATION: Ages ranged from 43-76 years, 4 being male. The primary source was identified as skin/soft tissue infection (SSTI) in 4 cases and pneumonia in 3. All had at least one identified risk factor for invasive disease including age >50 years, recent trauma or wound, diabetes, or alcoholism. All 4 SSTI required surgical debridement, 3 of which had necrotizing fasciitis (NF) (Img.1) and positive operative cultures and 2 of which had positive blood cultures for GAS. All 3 cases of pneumonia required intubation and had positive respiratory cultures for GAS. All 7 cases required ICU care, 2 developed ARDS (Img.2), 4 developed toxic shock syndrome (TSS), multi-organ failure, and died, and 1 remains hospitalized. Two cases were household contacts and reported to the New York State Department of Health (DOH). The DOH identified a relative as the index case and 2 other household contacts with GAS pharyngitis. The GAS isolates for all 5 were tested by pulse-field gel electrophoresis (PFGE) and found to be identical. All close household contacts screened received either treatment or prophylaxis.

DISCUSSION: Clusters of invasive GAS in close community settings such as day-cares, schools, and military settings have been reported, but this remains relatively uncommon. As mentioned, it is rare for primary cases of invasive GAS to occur. Other than the two household cases, no common exposure has yet been identified between the other 5 cases. With help from the DOH, we will attempt to investigate if a common link exists, and do PFGE testing. Additionally, the CDC recommends droplet precautions for TSS and droplet and contact precautions for skin lesions for 24 hours after implementation of antibiotics.2 Also, guidelines recommend chemoprophylaxis for high-risk household contacts, but not as a routine measure for all, including health care workers.3 Given the rarity of invasive GAS disease at our hospital in the past, our infection control practices and chemoprophylaxis recommendations were assessed on a case-by-case basis.

CONCLUSIONS: Invasive GAS is a rare, but fatal disease. Therefore, it is important to observe infection control methods, report outbreaks, and identify virulent strains of GAS. Additionally, it may be appropriate to provide chemoprophylaxis to close contacts.

Reference #1: Bennett, JE, Dolin, R, & Blaser, MJ. Principles and Practice of Infectious Disease.2014;2:2298.

Reference #2: Centers for Disease Control and Prevention. Guideline for Isolation Precautions.2007.

Reference #3: Centers for Disease Control and Prevention. Prevention of Invasive Group A Streptococcal Disease among Household Contacts of Case Patients and Postpartum and Postsurgical Patients. Clin Infect Dis.2002;35(8):950-959.

DISCLOSURE: The following authors have nothing to disclose: Rachel Karmally, Todd Sheppard, Maryrose Laguio

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