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The Role of Wound Care in 2 Group A Streptococcal Outbreaks in a Chicago Skilled Nursing Facility, 2015‒2016

The Role of Wound Care in 2 Group A Streptococcal Outbreaks in a Chicago Skilled Nursing... Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 Open Forum Infectious Diseases BRIEF REPORT cleaning. The CDPH recommended changing soiled diapers/ e R Th ole of Wound Care in 2 Group linen before dressing changes and use of facemasks for irri- A Streptococcal Outbreaks in a Chicago gation, although no issues were apparent. Aer 3 n ft ew cases Skilled Nursing Facility, 2015‒2016 occurred in March 2016, the CDPH and the Centers for Disease 1 2 3 4 Control and Prevention (CDC) conducted an investigation to Sana S. Ahmed, Kasey E. Diebold, Jacob M. Brandvold, Saadeh S. Ewaidah, 4 5 6 5 Stephanie Black, Abimbola Ogundimu, Zhongya Li, Nimalie D. Stone, and review specific wound care practices, identify unrecognized Chris A. Van Beneden infection control gaps, and halt the outbreak. Communicable Diseases, Lake County Health Department and Community Health Center, Waukegan, Illinois; Division of Foodborne, Waterborne, and Environmental Diseases, Atlanta, METHODS Georgia; College of Veterinary Medicine, Washington State University, Pullman, Washington; Communicable Diseases Program, Chicago Department of Public Health, Chicago, Illinois; To identify additional GAS cases, we reviewed resident admis- 5 6 7 Division of Health Quality and Promotion, Group A Streptococcus Laboratory, and Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia sions to local hospitals, facility records, and staff absentee logs from August through December 2015. Staff contact with cases Two consecutive outbreaks of group A  Streptococcus (GAS) was identified by reviewing staff room and wound care nurse infections occurred from 2015–2016 among residents of a floor assignments. We reviewed case bed assignments to iden- Chicago skilled nursing facility. Evaluation of wound care prac- tify shared rooms. tices proved crucial for identifying transmission factors and We defined an invasive case as illness in a SNF resident or implementing prevention measures. We demonstrated shed- staff member with GAS cultured from a normally sterile site ding of GAS on settle plates during care of a colonized wound. (eg, blood) during the outbreak period (July 17, 2015–March Keywords. group A  Streptococcus; healthcare-acquired 31, 2016). A noninvasive case was defined as illness in a resident infection; outbreak; wound infection; vacuum-assisted closure. or staff member with GAS detected from a throat or wound by culture or rapid antigen detection. We defined colonization as detection of GAS from a throat or skin swab of an asymptom- Residents of skilled nursing facilities (SNFs), particularly those atic person. with wounds or receiving wound care, are vulnerable to group We conducted 2 colonization surveys: December 2015– A  Streptococcus (GAS) infections [1, 3, 4], infections spread January 2016 and March 21–31, 2016. Swabs were cultured for by respiratory droplets or direct contact with ill or colonized GAS using standard methodology [7]. persons [2]. Whether this increased risk is caused by residents’ We conducted a matched case–control study among residents contact with potentially ill or colonized sta, co ff ntaminated with wounds to identify infection risk factors. Each case resi- wound care tools, or exposure to specific wound care practices dent was matched to 3 residents without GAS infection or col- is typically unknown [3–5]. onization (controls) by age (<20 years from case resident’s age) In August 2015, the Chicago Department of Public Health and timing of facility stay (overlapping with case residence by at (CDPH) reported an invasive GAS infection and death in a res- least 1 day in the 15 days before case culture). Demographic and ident of a 228-bed, postsurgical/acute rehabilitation SNF. The clinical data were abstracted from medical charts. We calculated facility specializes in wound care and orthopedics. Active sur- matched odds ratios using conditional logistic regression and veillance identified 3 additional GAS infections from December used t tests to compare continuous variables. Multivariable ana- 2015 to January 2016. All infected residents had wounds; 3 lysis to identify independent risk factors was precluded by small received therapy with wound vacuum-assisted closure devices numbers. (VACs), foam dressing attached to a pump providing negative We observed staff performing hand hygiene, point-of-care pressure to promote healing [6]. In December, the CDPH vis- testing, disinfection of shared equipment, wound care activities ited the facility to observe wound care and noted poor wound (eg, dressing changes, wound VAC management), and personal protective equipment (PPE) use. Using a standardized employee survey, we evaluated self-reported infection control practices in Received 4 April 2018; editorial decision 14 June 2018; accepted 22 June 2018. comparison with observed practices. Correspondence: S.  Ahmed, MD, Lake County Health Department and Community Health Center, 3010 Grand Avenue, Waukegan, IL 60085 (sahmed@lakecountyil.gov). To assess GAS shedding from infected or colonized wounds Open Forum Infectious Diseases during wound care, we placed nonselective and selective Published by Oxford University Press on behalf of Infectious Diseases Society of America 2018. (containing colistin and nalidixic acid) blood agar plates dir- This work is written by (a) US Government employee(s) and is in the public domain in the US. DOI: 10.1093/ofid/ofy145 ectly below and adjacent to the wounds (with unknown GAS BRIEF REPORT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 colonization status) of 5 residents either currently or recently wounds with saline pods without wearing facemasks. Wound receiving wound VAC therapy. Residents were positioned in a nurses failed to don PPE before entering rooms of residents on lateral decubitus or recumbent position, based on wound loca- contact precautions and stored used gloves in their pockets. tion. Plates remained in place until dressing removal, wound However, no obvious breaches in infection control practices cleaning, and application of new dressings were complete. during use of wound care products (eg, antimicrobial ointment) GAS isolates were sent to the CDC’s Streptococcus laboratory were noted. Stool leakage was noted under a wound VAC dress- for emm typing [8]. ing seal that did not trigger a system alarm; the nurse needed prompting to clean the fecal-contaminated wound before reap- RESULTS plying the dressing. Appropriate hand hygiene was reported by 92% of 132 sur- From July 2015 to March 2016, we identified 7 GAS cases (6 veyed employees but observed in only 62% (13/21). Only 1–8 invasive  and 1 noninvasive) in residents with postsurgical alcohol-based hand rub dispensers were available on each floor. wounds or decubitus ulcers and 5 GAS cases (all pharyngitis) in Staff did not consistently clean and disinfect shared equipment staff members (Supplementary Figure  1). Review of sick leave (eg, chair scales) before subsequent use. requests and employee surveys identified 2 probable staff cases Two settle plates placed below 1 resident’s sacral wound dur- (physician-diagnosed illness). More than 40% (436/1080) of ing wound VAC dressing change (which included irrigation SNF residents had wounds during the outbreak period. Three with saline pods) grew GAS emm89. Aer o ft bserving fecal con- teams (including a wound VAC management team) were dedi- tamination of the wound upon removal of the wound VAC, rec- cated to wound care. tal and wound swabs were obtained and grew the same strain. e Th first colonization survey (December 2015‒January No GAS grew on settle plates of the remaining 4 residents. 2016)  targeted all staff and residents; GAS was cultured from the oropharynx of 3 of 354 (0.8%) sta. A ff mong 158 residents’ DISCUSSION oropharyngeal swabs, none grew GAS. The wounds of 3 (9.7%) of 31 residents suspected of infection (ie, erythema, drainage, Wounds are a well-known risk factor for GAS infections [9]. warmth) grew GAS. The second colonization survey (March This investigation was the first to document shedding of GAS 21‒31, 2016)  targeted staff epidemiologically linked to March from a colonized wound during wound care. Although the ini- 2016 resident cases and residents with wounds or potentially tial introduction of GAS into this facility may have occurred infected percutaneous devices. GAS was cultured from 4 sta ff via staff working while ill with GAS pharyngitis or residents (4 oropharyngeal cultures from 99 staff; 0 swabs of skin breaks admitted to the facility while colonized or ill, we hypothesize from 7 staff ) and 2 residents (2 cultures of wounds or percuta- that saline irrigation of GAS-colonized or infected wounds con- neous device sites of 64 residents). One staff member was GAS- tributed to continued transmission through dispersal of GAS- positive in both surveys with the same strain (not an outbreak laden droplets. In this context, any breaches in infection control strain). may have enabled intrafacility disease transmission indirectly All GAS cultured from 4 infected and 3 colonized residents to residents through contaminated hands of staff or directly to before January 31, 2016, were emm87; GAS isolated from 3 col- staff providing wound care without use of facemasks. onized staff were other emm types (isolates unavailable from ill All wound teams were observed irrigating residents’ wounds staff). Beginning March 2016, a different strain (emm89) was in a similar fashion without recognizing that spraying sterile identified in 2 infected and 2 colonized residents  and 1 colo- saline may lead to splashing of body fluids. Current infection nized sta. On ff e resident was infected, and 1 staff member colo- control guidelines [10] mention protecting mucous mem- nized with emm87 other emm types of 2 colonized staff: emm81 branes against splashing when managing uncovered wounds or and emm28 and one infected staff: 3.116). when drainage is not contained by dressings. Maragakis et  al. Seven infected residents and 21 matched controls were [11] linked the shedding of Acinetobacter baumannii during enrolled in the case–control study. Infected residents were more low-pressure pulsatile lavage of wounds to a healthcare–asso- oen o ft bese (75% vs 33%, P = undefined) and more frequently ciated outbreak; thereaer ft , use of facemasks by staff was rein- received treatment with antimicrobial ointment (57% vs 5%, forced and a private room used during low-pulsatile lavage to P  =  .03) and wound VACs (86% vs 10%, P  =  undefined) than prevent indirect transmission to residents. controls (once concordant matched pairs were removed, there Similar to an earlier GAS investigation [5], we identified were no cases with normal body mass indexes [BMIs] to com- wound VACs as a risk for GAS infection. However, wound pare with those with abnormal BMIs; similarly, aer r ft emoving VACs and use of antimicrobial cleanser may simply be markers concordant pairs, there were none without wound VACs to for large, deep, poorly healing wounds. compare) (Table 1). Infection control lapses during wound VAC management Lapses in infection control practices were noted during likely contributed to GAS transmission. Staff hand hygiene com- wound care observations. Wound teams routinely irrigated all pliance was low despite awareness of being observed. A resident 2 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 Table 1. A Comparison of Characteristics of GAS-Infected (Invasive and Noninvasive) Case Residents With Wounds and Matched Controls GAS Cases Matched Controls Matched Odds Ratio Characteristics (n = 7) (n = 21) (95% CI) Male, No. (%) 1 (14.3) 7 (33.3) 0.29 (0.03–3.1) Resident age, mean (range), y 65.4 (42.2–89.5) 71.9 (58.0–93.5) — a 2 Resident’s body mass index, kg/m 18.5–29.9 1 (25) 8 (66.7) Ref ≥30 3 (75) 4 (33.3) Undefined Died during admission, No. (%) 1 (14.3) 1 (4.8) 3.0 (0.19–48) Length of stay, mean (range), d 139 (11–708) 57.1 (15–161) 1.4 (0.77–2.4) No. of underlying medical conditions, mean (range) 5 (3–7) 5 (2–11) 1.14 (0.7–1.8) Presence of specific underlying conditions, No. (%) Diabetes 4 (57.1) 13 (61.9) 0.84 (0.17–4.2) Peripheral vascular disease 0 2 (9.5) — Cancer 2 (28.6) 5 (23.8) 1.2 (0.23–6.2) Nonambulatory, No. (%) 4 (57.1) 12 (57.1) 1.0 (0.19–5.3) Incontinence, No. (%) Urine 3 (42.9) 10 (47.6) 0.79 (0.11–5.4) Stool 2 (28.6) 4 (19.1) 1.7 (0.23–13.2) No. of wounds present at time of GAS culture <3 4 (57.1) 18 (85.7) Ref ≥3 3 (42.9) 3 (14.3) 3.7 (0.60–23.0) Antibiotic use 14 d before GAS culture, No. (%) 1 (14.3) 9 (42.9) 0.2 (0.02–2.1) Wound care team, No. (%) Team 1 3 (42.9) 8 (38.1) Ref Team 2 3 (42.9) 12 (57.1) 0.70 (0.12–4.2) Both 1 (14.3) 1 (4.8) 2.4 (0.13–46.5) Wound care from floor staff, No. (%) 3 (42.9) 11 (52.4) 1.6 (0.24–10.3) Wound VAC treatment, No. (%) 6 (85.7) 2 (9.5) Undefined Frequency of wound products used, No. (%) Antimicrobial ointment 4 (57.1) 1 (4.8) 12.0 (1.3–107) Dressing foam 4 (57.1) 4 (19.1) 4.4 (0.77–24.9) Sterile saline 4 (57.1) 14 (66.7) 0.65 (0.11–3.9) Other skin cream 5 (71.4) 7 (33.3) 6.5 (0.69–61.3) Other 4 (57.1) 10 (47.6) 1.4 (0.28–7.0) Physical therapy/occupational therapy 6 (85.7) 18 (85.7) 1.0 (0.10–9.6) Abbreviations: CI, confidence interval; GAS, group A Streptococcus; VAC, vacuum-assisted closure device. Cases: n = 4; controls: n = 12. For every additional 60 days of stay. For every additional comorbid condition. Although we could not quantify the association between treatment with wound VACs and risk for GAS infection because our sample contained no matched pairs discordant on the wound VACS risk factor, we confirmed a statistically significant association between wound VAC and GAS infections by using standard logistic regression on the unmatched sample and adjusting for age and date of GAS culture (the variables used to match controls). with a wound VAC had both rectal and sacral wound GAS col- and training in best practices is paramount. Certain wound care onization, suggesting that the observed leakage of stool under practices (eg, wound debridement and irrigation) can be sources the dressing seal or inadequate cleaning of the wound increased of cross-contamination. Hand hygiene and appropriate PPE use the risk for spread of organisms from the rectum. education, oer ff ing wound care training by certified sta, a ff nd Recommendations included treating all GAS-infected or col- routine audits may reduce wound care–associated GAS transmis- onized residents and staff with antibiotics and adopting a sup- sion. Early application of recommended infection control prac- portive sick leave policy. Wound teams were advised to wear tices is essential to preventing transmission during outbreaks. facemasks, gowns, and gloves when performing wound dress- ing or wound VAC changes. Supplementary Data Supplementary materials are available at Open Forum Infectious Diseases GAS can be shed from a colonized wound during wound online. Consisting of data provided by the authors to benefit the reader, care; careful review of wound care practices in SNFs is needed the posted materials are not copyedited and are the sole responsibility of to identify unrecognized shedding. Wounds receiving wound the authors, so questions or comments should be addressed to the corre- VAC therapy are vulnerable to GAS infection and colonization, sponding author. BRIEF REPORT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 3. Nelson GE, Pondo T, Toews K, et al. Epidemiology of invasive group A strep- Acknowledgments tococcal infections in the United States, 2005–2012. Clin Infect Dis 2016; We thank medical director Dr. Sarah Kemble, epidemiologists Robynn 63:478–86. Leidig and Shamika Smith, and staff from the Chicago Department of 4. Felkner M, Pascoe N, Shupe-Ricksecker K, Goodman E. The wound care team: Health; Whitney Clegg; and the Illinois Department of Public Health for a new source of group A streptococcal nosocomial transmission. Infect Control participation in this outbreak investigation. We also thank the entire team at Hosp Epidemiol 2005; 26:462–5. the Centers for Disease Control and Prevention Streptococcus laboratory for 5. Deutscher M, Schillie S, Gould C, et al. Investigation of a group A streptococcal the molecular characterization of all clinical and environmental isolates. We outbreak among residents of a long-term acute care hospital. Clin Infect Dis 2011; 52:988–94. also thank the facility’s director and assistant director of nursing, phlebot- 6. Mouës CM, Vos MC, van den Bemd GJ, et  al. Bacterial load in relation to vac- omist, wound care physician and nurses, and all other staff who supported uum-assisted closure wound therapy: a prospective randomized trial. Wound investigative and intervention efforts. Repair Regen 2004; 12:11–7. Financial support. This work was supported by the Respiratory 7. Murray PR, Baron EJ, Jorgensen JJ, et al. Manual of Clinical Microbiology. 8th ed. Diseases Branch of the Centers for Disease Control and Prevention. Washington, DC: ASM Press; 2003. Disclaimer. e fin Th dings and conclusions in this report are those of the 8. Beall B, Facklam R, Thompson T. Sequencing emm-specific PCR products for authors and do not necessarily represent the official position of the Centers routine and accurate typing of group A  streptococci. J Clin Microbiol 1996; for Disease Control and Prevention. 34:953–8. Potential conifl cts of interest. All authors: no reported conflicts of 9. O’Loughlin RE, Roberson A, Cieslak PR, et  al; Active Bacterial Core Surveillance Team. The epidemiology of invasive group A streptococcal infec- interest. All authors have submitted the ICMJE Form for Disclosure of tion and potential vaccine implications: United States, 2000–2004. Clin Infect Potential Conflicts of Interest. Dis 2007; 45:853–62. 10. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control References Practices Advisory Committee. Guideline for Isolation Precautions: Preventing 1. Jordan HT, Richards CL Jr, Burton DC, et  al. Group a streptococcal disease in Transmission of Infectious Agents in Healthcare Settings (2007). Atlanta, GA: CDC; long-term care facilities: descriptive epidemiology and potential control meas- 2015. Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/. ures. Clin Infect Dis 2007; 45:742–52. Accessed 27 August 2017. 2. Center for Disease Control and Prevention. Group A Streptococcal (GAS) Disease. 11. Maragakis LL, Cosgrove SE, Song X, et  al. An outbreak of multidrug-resistant Atlanta, GA: CDC; 2016. Available at: https://www.cdc.gov/groupastrep/index. Acinetobacter baumannii associated with pulsatile lavage wound treatment. html. Accessed 30 August 2017. JAMA 2004; 292:3006–11. 4 • OFID • BRIEF REPORT http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

The Role of Wound Care in 2 Group A Streptococcal Outbreaks in a Chicago Skilled Nursing Facility, 2015‒2016

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Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 Open Forum Infectious Diseases BRIEF REPORT cleaning. The CDPH recommended changing soiled diapers/ e R Th ole of Wound Care in 2 Group linen before dressing changes and use of facemasks for irri- A Streptococcal Outbreaks in a Chicago gation, although no issues were apparent. Aer 3 n ft ew cases Skilled Nursing Facility, 2015‒2016 occurred in March 2016, the CDPH and the Centers for Disease 1 2 3 4 Control and Prevention (CDC) conducted an investigation to Sana S. Ahmed, Kasey E. Diebold, Jacob M. Brandvold, Saadeh S. Ewaidah, 4 5 6 5 Stephanie Black, Abimbola Ogundimu, Zhongya Li, Nimalie D. Stone, and review specific wound care practices, identify unrecognized Chris A. Van Beneden infection control gaps, and halt the outbreak. Communicable Diseases, Lake County Health Department and Community Health Center, Waukegan, Illinois; Division of Foodborne, Waterborne, and Environmental Diseases, Atlanta, METHODS Georgia; College of Veterinary Medicine, Washington State University, Pullman, Washington; Communicable Diseases Program, Chicago Department of Public Health, Chicago, Illinois; To identify additional GAS cases, we reviewed resident admis- 5 6 7 Division of Health Quality and Promotion, Group A Streptococcus Laboratory, and Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia sions to local hospitals, facility records, and staff absentee logs from August through December 2015. Staff contact with cases Two consecutive outbreaks of group A  Streptococcus (GAS) was identified by reviewing staff room and wound care nurse infections occurred from 2015–2016 among residents of a floor assignments. We reviewed case bed assignments to iden- Chicago skilled nursing facility. Evaluation of wound care prac- tify shared rooms. tices proved crucial for identifying transmission factors and We defined an invasive case as illness in a SNF resident or implementing prevention measures. We demonstrated shed- staff member with GAS cultured from a normally sterile site ding of GAS on settle plates during care of a colonized wound. (eg, blood) during the outbreak period (July 17, 2015–March Keywords. group A  Streptococcus; healthcare-acquired 31, 2016). A noninvasive case was defined as illness in a resident infection; outbreak; wound infection; vacuum-assisted closure. or staff member with GAS detected from a throat or wound by culture or rapid antigen detection. We defined colonization as detection of GAS from a throat or skin swab of an asymptom- Residents of skilled nursing facilities (SNFs), particularly those atic person. with wounds or receiving wound care, are vulnerable to group We conducted 2 colonization surveys: December 2015– A  Streptococcus (GAS) infections [1, 3, 4], infections spread January 2016 and March 21–31, 2016. Swabs were cultured for by respiratory droplets or direct contact with ill or colonized GAS using standard methodology [7]. persons [2]. Whether this increased risk is caused by residents’ We conducted a matched case–control study among residents contact with potentially ill or colonized sta, co ff ntaminated with wounds to identify infection risk factors. Each case resi- wound care tools, or exposure to specific wound care practices dent was matched to 3 residents without GAS infection or col- is typically unknown [3–5]. onization (controls) by age (<20 years from case resident’s age) In August 2015, the Chicago Department of Public Health and timing of facility stay (overlapping with case residence by at (CDPH) reported an invasive GAS infection and death in a res- least 1 day in the 15 days before case culture). Demographic and ident of a 228-bed, postsurgical/acute rehabilitation SNF. The clinical data were abstracted from medical charts. We calculated facility specializes in wound care and orthopedics. Active sur- matched odds ratios using conditional logistic regression and veillance identified 3 additional GAS infections from December used t tests to compare continuous variables. Multivariable ana- 2015 to January 2016. All infected residents had wounds; 3 lysis to identify independent risk factors was precluded by small received therapy with wound vacuum-assisted closure devices numbers. (VACs), foam dressing attached to a pump providing negative We observed staff performing hand hygiene, point-of-care pressure to promote healing [6]. In December, the CDPH vis- testing, disinfection of shared equipment, wound care activities ited the facility to observe wound care and noted poor wound (eg, dressing changes, wound VAC management), and personal protective equipment (PPE) use. Using a standardized employee survey, we evaluated self-reported infection control practices in Received 4 April 2018; editorial decision 14 June 2018; accepted 22 June 2018. comparison with observed practices. Correspondence: S.  Ahmed, MD, Lake County Health Department and Community Health Center, 3010 Grand Avenue, Waukegan, IL 60085 (sahmed@lakecountyil.gov). To assess GAS shedding from infected or colonized wounds Open Forum Infectious Diseases during wound care, we placed nonselective and selective Published by Oxford University Press on behalf of Infectious Diseases Society of America 2018. (containing colistin and nalidixic acid) blood agar plates dir- This work is written by (a) US Government employee(s) and is in the public domain in the US. DOI: 10.1093/ofid/ofy145 ectly below and adjacent to the wounds (with unknown GAS BRIEF REPORT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 colonization status) of 5 residents either currently or recently wounds with saline pods without wearing facemasks. Wound receiving wound VAC therapy. Residents were positioned in a nurses failed to don PPE before entering rooms of residents on lateral decubitus or recumbent position, based on wound loca- contact precautions and stored used gloves in their pockets. tion. Plates remained in place until dressing removal, wound However, no obvious breaches in infection control practices cleaning, and application of new dressings were complete. during use of wound care products (eg, antimicrobial ointment) GAS isolates were sent to the CDC’s Streptococcus laboratory were noted. Stool leakage was noted under a wound VAC dress- for emm typing [8]. ing seal that did not trigger a system alarm; the nurse needed prompting to clean the fecal-contaminated wound before reap- RESULTS plying the dressing. Appropriate hand hygiene was reported by 92% of 132 sur- From July 2015 to March 2016, we identified 7 GAS cases (6 veyed employees but observed in only 62% (13/21). Only 1–8 invasive  and 1 noninvasive) in residents with postsurgical alcohol-based hand rub dispensers were available on each floor. wounds or decubitus ulcers and 5 GAS cases (all pharyngitis) in Staff did not consistently clean and disinfect shared equipment staff members (Supplementary Figure  1). Review of sick leave (eg, chair scales) before subsequent use. requests and employee surveys identified 2 probable staff cases Two settle plates placed below 1 resident’s sacral wound dur- (physician-diagnosed illness). More than 40% (436/1080) of ing wound VAC dressing change (which included irrigation SNF residents had wounds during the outbreak period. Three with saline pods) grew GAS emm89. Aer o ft bserving fecal con- teams (including a wound VAC management team) were dedi- tamination of the wound upon removal of the wound VAC, rec- cated to wound care. tal and wound swabs were obtained and grew the same strain. e Th first colonization survey (December 2015‒January No GAS grew on settle plates of the remaining 4 residents. 2016)  targeted all staff and residents; GAS was cultured from the oropharynx of 3 of 354 (0.8%) sta. A ff mong 158 residents’ DISCUSSION oropharyngeal swabs, none grew GAS. The wounds of 3 (9.7%) of 31 residents suspected of infection (ie, erythema, drainage, Wounds are a well-known risk factor for GAS infections [9]. warmth) grew GAS. The second colonization survey (March This investigation was the first to document shedding of GAS 21‒31, 2016)  targeted staff epidemiologically linked to March from a colonized wound during wound care. Although the ini- 2016 resident cases and residents with wounds or potentially tial introduction of GAS into this facility may have occurred infected percutaneous devices. GAS was cultured from 4 sta ff via staff working while ill with GAS pharyngitis or residents (4 oropharyngeal cultures from 99 staff; 0 swabs of skin breaks admitted to the facility while colonized or ill, we hypothesize from 7 staff ) and 2 residents (2 cultures of wounds or percuta- that saline irrigation of GAS-colonized or infected wounds con- neous device sites of 64 residents). One staff member was GAS- tributed to continued transmission through dispersal of GAS- positive in both surveys with the same strain (not an outbreak laden droplets. In this context, any breaches in infection control strain). may have enabled intrafacility disease transmission indirectly All GAS cultured from 4 infected and 3 colonized residents to residents through contaminated hands of staff or directly to before January 31, 2016, were emm87; GAS isolated from 3 col- staff providing wound care without use of facemasks. onized staff were other emm types (isolates unavailable from ill All wound teams were observed irrigating residents’ wounds staff). Beginning March 2016, a different strain (emm89) was in a similar fashion without recognizing that spraying sterile identified in 2 infected and 2 colonized residents  and 1 colo- saline may lead to splashing of body fluids. Current infection nized sta. On ff e resident was infected, and 1 staff member colo- control guidelines [10] mention protecting mucous mem- nized with emm87 other emm types of 2 colonized staff: emm81 branes against splashing when managing uncovered wounds or and emm28 and one infected staff: 3.116). when drainage is not contained by dressings. Maragakis et  al. Seven infected residents and 21 matched controls were [11] linked the shedding of Acinetobacter baumannii during enrolled in the case–control study. Infected residents were more low-pressure pulsatile lavage of wounds to a healthcare–asso- oen o ft bese (75% vs 33%, P = undefined) and more frequently ciated outbreak; thereaer ft , use of facemasks by staff was rein- received treatment with antimicrobial ointment (57% vs 5%, forced and a private room used during low-pulsatile lavage to P  =  .03) and wound VACs (86% vs 10%, P  =  undefined) than prevent indirect transmission to residents. controls (once concordant matched pairs were removed, there Similar to an earlier GAS investigation [5], we identified were no cases with normal body mass indexes [BMIs] to com- wound VACs as a risk for GAS infection. However, wound pare with those with abnormal BMIs; similarly, aer r ft emoving VACs and use of antimicrobial cleanser may simply be markers concordant pairs, there were none without wound VACs to for large, deep, poorly healing wounds. compare) (Table 1). Infection control lapses during wound VAC management Lapses in infection control practices were noted during likely contributed to GAS transmission. Staff hand hygiene com- wound care observations. Wound teams routinely irrigated all pliance was low despite awareness of being observed. A resident 2 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 Table 1. A Comparison of Characteristics of GAS-Infected (Invasive and Noninvasive) Case Residents With Wounds and Matched Controls GAS Cases Matched Controls Matched Odds Ratio Characteristics (n = 7) (n = 21) (95% CI) Male, No. (%) 1 (14.3) 7 (33.3) 0.29 (0.03–3.1) Resident age, mean (range), y 65.4 (42.2–89.5) 71.9 (58.0–93.5) — a 2 Resident’s body mass index, kg/m 18.5–29.9 1 (25) 8 (66.7) Ref ≥30 3 (75) 4 (33.3) Undefined Died during admission, No. (%) 1 (14.3) 1 (4.8) 3.0 (0.19–48) Length of stay, mean (range), d 139 (11–708) 57.1 (15–161) 1.4 (0.77–2.4) No. of underlying medical conditions, mean (range) 5 (3–7) 5 (2–11) 1.14 (0.7–1.8) Presence of specific underlying conditions, No. (%) Diabetes 4 (57.1) 13 (61.9) 0.84 (0.17–4.2) Peripheral vascular disease 0 2 (9.5) — Cancer 2 (28.6) 5 (23.8) 1.2 (0.23–6.2) Nonambulatory, No. (%) 4 (57.1) 12 (57.1) 1.0 (0.19–5.3) Incontinence, No. (%) Urine 3 (42.9) 10 (47.6) 0.79 (0.11–5.4) Stool 2 (28.6) 4 (19.1) 1.7 (0.23–13.2) No. of wounds present at time of GAS culture <3 4 (57.1) 18 (85.7) Ref ≥3 3 (42.9) 3 (14.3) 3.7 (0.60–23.0) Antibiotic use 14 d before GAS culture, No. (%) 1 (14.3) 9 (42.9) 0.2 (0.02–2.1) Wound care team, No. (%) Team 1 3 (42.9) 8 (38.1) Ref Team 2 3 (42.9) 12 (57.1) 0.70 (0.12–4.2) Both 1 (14.3) 1 (4.8) 2.4 (0.13–46.5) Wound care from floor staff, No. (%) 3 (42.9) 11 (52.4) 1.6 (0.24–10.3) Wound VAC treatment, No. (%) 6 (85.7) 2 (9.5) Undefined Frequency of wound products used, No. (%) Antimicrobial ointment 4 (57.1) 1 (4.8) 12.0 (1.3–107) Dressing foam 4 (57.1) 4 (19.1) 4.4 (0.77–24.9) Sterile saline 4 (57.1) 14 (66.7) 0.65 (0.11–3.9) Other skin cream 5 (71.4) 7 (33.3) 6.5 (0.69–61.3) Other 4 (57.1) 10 (47.6) 1.4 (0.28–7.0) Physical therapy/occupational therapy 6 (85.7) 18 (85.7) 1.0 (0.10–9.6) Abbreviations: CI, confidence interval; GAS, group A Streptococcus; VAC, vacuum-assisted closure device. Cases: n = 4; controls: n = 12. For every additional 60 days of stay. For every additional comorbid condition. Although we could not quantify the association between treatment with wound VACs and risk for GAS infection because our sample contained no matched pairs discordant on the wound VACS risk factor, we confirmed a statistically significant association between wound VAC and GAS infections by using standard logistic regression on the unmatched sample and adjusting for age and date of GAS culture (the variables used to match controls). with a wound VAC had both rectal and sacral wound GAS col- and training in best practices is paramount. Certain wound care onization, suggesting that the observed leakage of stool under practices (eg, wound debridement and irrigation) can be sources the dressing seal or inadequate cleaning of the wound increased of cross-contamination. Hand hygiene and appropriate PPE use the risk for spread of organisms from the rectum. education, oer ff ing wound care training by certified sta, a ff nd Recommendations included treating all GAS-infected or col- routine audits may reduce wound care–associated GAS transmis- onized residents and staff with antibiotics and adopting a sup- sion. Early application of recommended infection control prac- portive sick leave policy. Wound teams were advised to wear tices is essential to preventing transmission during outbreaks. facemasks, gowns, and gloves when performing wound dress- ing or wound VAC changes. Supplementary Data Supplementary materials are available at Open Forum Infectious Diseases GAS can be shed from a colonized wound during wound online. Consisting of data provided by the authors to benefit the reader, care; careful review of wound care practices in SNFs is needed the posted materials are not copyedited and are the sole responsibility of to identify unrecognized shedding. Wounds receiving wound the authors, so questions or comments should be addressed to the corre- VAC therapy are vulnerable to GAS infection and colonization, sponding author. BRIEF REPORT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy145/5045441 by guest on 16 October 2019 3. Nelson GE, Pondo T, Toews K, et al. Epidemiology of invasive group A strep- Acknowledgments tococcal infections in the United States, 2005–2012. Clin Infect Dis 2016; We thank medical director Dr. Sarah Kemble, epidemiologists Robynn 63:478–86. Leidig and Shamika Smith, and staff from the Chicago Department of 4. Felkner M, Pascoe N, Shupe-Ricksecker K, Goodman E. The wound care team: Health; Whitney Clegg; and the Illinois Department of Public Health for a new source of group A streptococcal nosocomial transmission. Infect Control participation in this outbreak investigation. We also thank the entire team at Hosp Epidemiol 2005; 26:462–5. the Centers for Disease Control and Prevention Streptococcus laboratory for 5. Deutscher M, Schillie S, Gould C, et al. Investigation of a group A streptococcal the molecular characterization of all clinical and environmental isolates. We outbreak among residents of a long-term acute care hospital. Clin Infect Dis 2011; 52:988–94. also thank the facility’s director and assistant director of nursing, phlebot- 6. Mouës CM, Vos MC, van den Bemd GJ, et  al. Bacterial load in relation to vac- omist, wound care physician and nurses, and all other staff who supported uum-assisted closure wound therapy: a prospective randomized trial. Wound investigative and intervention efforts. Repair Regen 2004; 12:11–7. Financial support. This work was supported by the Respiratory 7. Murray PR, Baron EJ, Jorgensen JJ, et al. Manual of Clinical Microbiology. 8th ed. Diseases Branch of the Centers for Disease Control and Prevention. Washington, DC: ASM Press; 2003. Disclaimer. e fin Th dings and conclusions in this report are those of the 8. Beall B, Facklam R, Thompson T. Sequencing emm-specific PCR products for authors and do not necessarily represent the official position of the Centers routine and accurate typing of group A  streptococci. J Clin Microbiol 1996; for Disease Control and Prevention. 34:953–8. Potential conifl cts of interest. All authors: no reported conflicts of 9. O’Loughlin RE, Roberson A, Cieslak PR, et  al; Active Bacterial Core Surveillance Team. The epidemiology of invasive group A streptococcal infec- interest. All authors have submitted the ICMJE Form for Disclosure of tion and potential vaccine implications: United States, 2000–2004. Clin Infect Potential Conflicts of Interest. Dis 2007; 45:853–62. 10. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control References Practices Advisory Committee. Guideline for Isolation Precautions: Preventing 1. Jordan HT, Richards CL Jr, Burton DC, et  al. Group a streptococcal disease in Transmission of Infectious Agents in Healthcare Settings (2007). Atlanta, GA: CDC; long-term care facilities: descriptive epidemiology and potential control meas- 2015. Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/. ures. Clin Infect Dis 2007; 45:742–52. Accessed 27 August 2017. 2. Center for Disease Control and Prevention. Group A Streptococcal (GAS) Disease. 11. Maragakis LL, Cosgrove SE, Song X, et  al. An outbreak of multidrug-resistant Atlanta, GA: CDC; 2016. Available at: https://www.cdc.gov/groupastrep/index. Acinetobacter baumannii associated with pulsatile lavage wound treatment. html. Accessed 30 August 2017. JAMA 2004; 292:3006–11. 4 • OFID • BRIEF REPORT

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