Guideline for the management of Group A Streptococcal Infection (GAS) and Invasive group A Streptococcal Infection (igas)

Transcription

1 Guideline for the management of Group A Streptococcal Infection (GAS) and Invasive group A Streptococcal Infection (igas) Author: Responsible Lead (s) Executive Director: Infection Prevention & Control Team; Health Protection Team Director of Public Health Executive Director of NMAHP Endorsing Body (Bodies): Health protection Committee Governance or Assurance Committee Implementation Date: 15 December 2016 Version Number: V 3.1 Review Date: 15 December 2018 Responsible Person Lanarkshire Infection Control Committee Lanarkshire Infection Control Committee Infection Prevention and Control Department (IPCT) Health Protection Team (HPT) Version No.3.1 Date: December 2016 Page 1 of 14

2 Contents i) Consultation and Distribution Record ii) Change Record 1. Introduction 2. Aim, Purpose and Outcomes 3. Scope 3.1 Who is the Policy Intended to Benefit or Affect 3.2 Who are the Stakeholders? 4. Principle Content 4.1 Invasive group A streptococcus (igas) 4.2 Case definitions 4.3 Investigation Infection prevention and Control Team 5. Roles and Responsibilities 6. Resource Implications 7. Communication Plan 8. Quality Improvement Monitoring and Review 9. Equality and Diversity Impact Assessment 10. Summary of Frequently Asked Questions (FAQ s) 11. References Version No.3.1 Date: December 2016 Page 2 of 14

3 CONSULTATION AND DISTRIBUTION RECORD Contributing Author / Infection Prevention and Control Team Authors Health Protection Team Consultation Process / Stakeholders: General Practitioners Emergency Departments Consultant Microbiologists Infection Control Doctor Chief Nurses Chief Medical Staff Out of Hours Service Infectious Disease Consultant Infection Prevention and Control Team Health Protection Team Distribution: NHS Lanarkshire intranet Firstport NHS Lanarkshire external website Infection Prevention and Control Manual CHANGE RECORD Date Author Change Version No. A.Goodfellow R. Fox Content revised as per review process and new policy template applied HPT, IPCT Content reviewed and updated 3.1 Version No.3.1 Date: December 2016 Page 3 of 14

4 1. Introduction Group A streptococci (GAS) are also known as Streptococcus pyogenes and cause a range of infections. Mild non-invasive infections include sore throats and skin infections such as impetigo are common and highly infectious. Invasive group a streptococcal infections (igas) including necrotising fasciitis (NF) and toxin mediated conditions such as scarlet fever and streptococcal toxic shock syndrome are serious and have significant mortality. This policy should be read in conjunction with chapters one and two of the National Infection Prevention and Control Manual. 2. Aim, Purpose and Outcomes To ensure that Healthcare Workers (HCWs) consider invasive Group A Streptococcal (igas) infection as a possible diagnosis in patients with indicative symptoms. To ensure that all HCWs take appropriate actions to minimise the risk of cross infection to themselves and others by urgent and appropriate referral in line with the guidance developed by the Health protection Agency. To ensure that all HCWs apply appropriate infection prevention and control precautions when providing care for patients with possible, probable or confirmed igas infection. 3. Scope 3.1 Who is the Policy intended to Benefit or Affect? This policy is intended to safeguard patients, staff and the wider public from the risk of igas. 3.2 Who are the Stakeholders? The policy is aimed at all healthcare staff within NHS Lanarkshire 4. Principle Content 4.1 Invasive Group A strep (igas) Invasive Group A Streptococcal disease is a rare but serious illness. The incidence of igas in the UK is around 3.33 per 100,000 population. Asymptomatic carriage of the organism is common. Version No.3.1 Date: December 2016 Page 4 of 14

5 4.2 Case definitions Invasive GAS (igas) infection Invasive GAS infection is illness associated with the isolation of GAS from a normally sterile body site, such as blood, cerebrospinal fluid, joint aspirate, pericardial/ peritoneal/ pleural fluids, bone, endometrium, deep tissue or abscess at operation or post mortem. It also includes severe GAS infections, where GAS has been isolated from a normally nonsterile site in combination with severe clinical presentations such as streptococcal toxic shock syndrome (STSS) or necrotising fasciitis. Peri-partum GAS infection Peri-partum GAS infection is defined as isolation of GAS up to seven days post discharge or delivery in the mother associated with clinical infection, such as endometriosis, STSS, wound infection, or isolation from a sterile site. Healthcare-Associated (HAI) GAS Infection Healthcare-associated (HAI) GAS infection is defined as a GAS infection that is neither present, nor incubating at the time of admission but considered to have been acquired following admission to hospital or as a result of healthcare interventions in another healthcare facility. Onset of HAI GAS infection is more than 48 hours after admission, or postoperatively at any time after admission and for up to seven days post discharge. Outbreak An outbreak is considered if there are two or more cases of suspected GAS infection related by person or place. The cases will usually be within a month of each other but the interval may be extended to several months. It should be noted that the intervals between cases in published outbreak reports for GAS has, on occasion, extended to more than a year. Reference laboratory typing from culture-proven cases is needed to confirm that cases are related. Diagnosis The diagnosis of confirmed igas disease is a microbiological diagnosis, which requires culture of GAS bacteria. There are three clinical syndromes which are associated with igas infection: Streptococcal toxic shock syndrome This is a syndrome of hypotension and multi-organ failure frequently including renal and hepatic impairment, adult respiratory distress syndrome, disseminated intravascular coagulation and central nervous system dysfunction. Necrotising fasciitis This is characterised by extensive local necrosis of skin and sub-cutaneous soft tissues. Version No.3.1 Date: December 2016 Page 5 of 14

6 Other infections: igas can also be isolated from a sterile site without an aseptic focus being identified or in association with pericarditis, meningitis, pneumonia, peritonitis, puerperal sepsis, osteomyelitis, septic arthritis, myositis or a wound infection, without fulfilling the definition of toxic shock syndrome or necrotising fasciitis. Toxic shock syndrome can also be caused by Staphylococcus aureus, but in that illness there is more frequently a generalised desquamating rash. Necrotising fasciitis can also be caused by anaerobic streptococci, Staphylococcus aureus, Bacteroides species and mixed anaerobic flora. Therefore the above clinical presentations are not indicative of igas infection in the absence of confirmatory microbiological results. However if GAS is isolated from an appropriate non-sterile site, such as a wound swab, throat swab or vaginal swab and the patient has clinical evidence of toxic shock syndrome or necrotising fasciitis the patient can be regarded as having probable igas infection. The infection control measures and notification procedures described in this guideline should be applied to patients with probable igas infection as well as those with confirmed igas infection. Close contact Close contact is defined as someone who has had prolonged contact (household or kissing contact) with the case during seven days before the onset of the illness. Those who have had transient close contact should only be considered as close contacts if they have been exposed to large droplet particles from the patients respiratory tract (e.g. during intubation), around the time of hospital admission. Work and school colleagues and those who have travelled in the same train, bus or car are not regarded as close contacts. Reporting a case Infection Prevention and Control Team All cases of suspected GAS infection identified in the acute care setting or maternity units and any cases identified within seven days in mother or baby post partum, that could have been healthcare-associated, should be reported to the local Infection Prevention and Control Team. Health Protection Team All igas cases should be discussed and notified to the local Health Protection Team (Mon-Thursday 9am-5pm and Friday 9am-4.30pm on or out of hours , Version No.3.1 Date: December 2016 Page 6 of 14

7 4.3 Investigation 4.31 Infection Prevention and Control Team The Infection Prevention and Control Team should establish whether the case is community or healthcare-associated Establish if patient had symptoms consistent with GAS on or just prior to admission or childbirth (and if household contacts are suffering from illness that could be attributable to GAS) Further investigation of potential sources of infection is warranted for any case of GAS infection considered to be healthcare-associated Infection Prevention and Control Team should check for possible linked cases of healthcare-associated GAS infection arising in the past 6 months. The Infection Prevention and Control Team should maintain GAS continuous alert organism surveillance to identify outbreaks which may arise over prolonged periods of time. Following a case of healthcare-associated GAS infection the Infection Prevention and Control Team should consider prospective enhanced surveillance. This may include sampling of infected wounds of patients in the vicinity of the index case or who are being cared for by the same healthcare worker, including visiting clinicians and Bank staff. Contacts of community-acquired cases of igas infection should be followed up by the Health Protection Team Infection Control Precautions Standard Infection Control precautions / Transmission-based Precautions. Isolation Patients must be nursed in a single room, under neutral or negative pressure. If not available, contact the IPCT for advice. Isolation is required for a minimum of 24 hours from commencement of appropriate antibiotic therapy. Cases of necrotising fasciitis and other cases where there is significant discharge of potentially infected body fluids or high risk shedding, mothers and neonates on maternity units and patients on burns units, should be isolated until culture negative. Specimens Patient care equipment Hand hygiene As clinically indicated. If there is no clinical improvement with 48 hours of appropriate antimicrobials the Microbiologist should be consulted. Take only that equipment which is necessary into the room. Ensure any shared equipment is decontaminated using a chlorine based detergent. Strict adherence to hand hygiene guidelines, hands must be decontaminated before and after each direct patient episode Patients and Visitors should be offered guidance on appropriate hand hygiene. Refer to NIPCM chapter 1 SICP s (1.2) Version No.3.1 Date: December 2016 Page 7 of 14

8 Linen Personal Protective Equipment (PPE) Change bed linen daily. Linen should be treated as infected linen. Removing and bagging linen should be performed so as to minimise dispersal of GAS from the bed linen and clothes. The patient s own clothes should be sealed securely in a plastic bag and relatives should be requested to wash the clothes at home at the highest temperature that will not damage the fibre. They should dispose of the plastic bag in a Waste bin. Refer to NIPCM (SICP chapter 1 (1.7) Healthcare workers should wear PPE including single use gloves and aprons when in contact with the patient or patient care equipment and the surrounding environment. Breaks in the skin must be covered with a waterproof dressing Fluid repellent surgical masks with visors must be used during operative debridement/ change of dressings of necrotising fasciitis and for procedures where droplet spread is possible. Visitors should be offered suitable information and relevant PPE following a risk assessment of the visitor s level of direct contact/ involvement in the affected person s care. Refer to NIPCM (chapter 1 SICP s (1.4) Environmental Decontaminaton Daily environmental and equipment cleaning must be undertaken with a solution of 1,000ppm available Chlorine releasing agent. Dedicated equipment clean as above after each use. Additional cleaning may be advised by the IPCT. Terminal clean Remove all of the following from the vacated single room: healthcare waste and any other disposable items (bagged before removal from the room); bedding/bed screens/curtains and manage as infectious linen (bagged before removal from the room); and reusable non-invasive care equipment (decontaminated in the room prior to removal). Disposal of waste The room should be decontaminated using either: a combined detergent disinfectant solution at a dilution (1,000ppm av.cl.); or a general purpose neutral detergent clean in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.. The room must be cleaned from the highest to lowest point and from the least to most contaminated point. All clinical waste should be discarded into designated clinical Version No.3.1 Date: December 2016 Page 8 of 14

9 waste bag or sharps container (where sharps are used). Household waste should be disposed of in a clear bag Refer to NIPCM (SICP chapter 1 (1.9) Disposal of body fluids Moving between ward / departments Procedure after death Disposable bedpan shells and urinals can be macerated. The solid bedpan base should be decontaminated using a chlorine based detergent. Patients should only be transferred if unavoidable or essential for patient care. Details of infection risk should be communicated to the ambulance service, receiving facility, Infection Prevention and Control Team and if appropriate, the referring hospital. In the event of a death, hospital mortuary staff should be informed of the risk of infection and transmission routes. Healthcare (HCW s) workers During outbreaks of infection screening of HCW s may be required. The Occupation Health Service / SALUS and Infection Prevention and Control Team will advise. Version No.3.1 Date: December 2016 Page 9 of 14

10 4.33 Health Protection Team; Managing Community Contacts and Cases The HPT or on-call Consultant in Public Health Medicine (CPHM) must be informed, as soon as possible, by the medical staff in charge of any patient presenting with severe infection in whom GAS is isolated from a normally-sterile body site by microbiology. It is the responsibility of the HPT (or on call CPHM) to discuss the case with the clinical doctor and agree whether the case fits the case definition for igas. The HPT will identify whether any contacts require prophylaxis. If appropriate, the hospital will provide prophylaxis to hospital contacts, on request from a member of the HPT. Decisions on prophylaxis for HCWs, who may consider themselves as contacts, should be made by the HPT or Occupational Health (OH), in conjunction the IPCT. Antibiotics can successfully eradicate GAS from the upper respiratory tract. In theory antibiotics could prevent the development of igas in persons who have newly acquired GAS colonisation. Antibiotics could also prevent the spread of GAS from established carriers who could transmit the organism to others. However, it is not known whether a policy of giving antibiotics to contacts of GAS patients actually does prevent igas. Due to this, the current UK policy is to provide antibiotic prophylaxis only to those in the highest risk category for the development of igas infection as indicated in table 1. Version No.3.1 Date: December 2016 Page 10 of 14

11 Table 1 Management of close contacts of patients with igas infection Individuals Requiring Antibiotic Prophylaxis A mother whose baby develops igas infection during the first 28 days of life A neonate whose mother develops igas infection during the first 28 days after giving birth. Close contacts who develop symptoms suggestive of GAS infection such as sore throat, fever or skin infection Individuals Requiring a Contact Information Letter and Q&A Leaflet Those with prolonged close contact in a household setting who do not have symptoms suggesting GAS infection. HCWs who have been exposed to droplet particles from the patient s respiratory tract (e.g. during intubation). Injecting drug users following a case occurring in a local injecting drug user. Close contacts who are not in the highest risk category should be given a GAS information leaflet. They should be advised to seek immedicate medical attention via the Accident and Emergency Department if they become unwell with symptoms of invasive disease e.g. high fever, severe muscle aches or localised muscle tenderness. A heightened index of suspicion for igas infection should be maintained for 30 days after the diagnosis is made in the index patient. The on-call CPHM will determine if anyone requiresantibiotic prophylaxis Chemoprophylaxis Appropriate prophylaxis consists of a 10 day course of Penicillin V mg qds. For those with penicillin allergy, a suitable alternative is five days of azithromycin 12mg/kg/day (maximum 500mg/day). If azithromycin is used then susceptibility to erythromycin/azithromycin in the index case should be confirmed Managing contacts in care homes or hospital wards Several outbreaks of GAS infection have been reported in care home residents. If a single case of igas infection occurs in a care home or hospital ward, close contacts should only be given antibiotic prophylaxis if they have symptoms suggestive of GAS infection, unless otherwise advised by the Infection Control Doctor /CPHM, for example if an extremely virulent strain is circulating. If close contacts have symptoms suggesting igas infection they will need immediate hospital assessment. If more than one case of igas occurs in a care home, the CPHM will assess and determine whether it is necessary to set up a Problem Assessment Group (PAG)/Outbreak Control Team (OCT). If more than one case of igas occurs in a ward setting, suggesting the possibility of hospital transmission, the Infection Control Doctor will assess the need to set up a hospital PAG/OCT. Version No.3.1 Date: December 2016 Page 11 of 14

12 4.36 Managing contacts in intravenous drug using populations Injecting drug users are at increased risk of igas. If igas infection occurs in an intravenous drug user, local addictions/harm reduction teams should be notified of this. Information regarding the symptoms of igas infection should be circulated among injecting drug users. General practitioners and Accident and Emergency Departments should be alerted to the occurrence of outbreaks of igas infection among injecting drug user populations Clusters of igas infection If two or more cases of igas occur in the same household within a 30-day period, then the entire household should receive chemoprophylaxis. Clusters of igas infection in the community are difficult to define due to uncertainties regarding appropriate temporal and geographic boundaries. It will be the responsibility of the HPT or on-call CPHM to determine when an outbreak control group is required to determine the appropriate public health response. 5. ROLES AND RESPONSIBILITIES Who Roles & Responsibilities NHS Board Endorse and support the implementation of this Policy Infection Prevention & Control Team Senior Charge Nurse (Ward Manager) / Team Leader Senior Nurses Heads of Departments Health Care Workers (HCWs) Keep this policy up-to-date Provide education opportunities on this policy. Ensure that staff are aware of the content of this policy. Support HCWs and IPCTs in following this policy. Ensure that all staff comply with this policy. Support HCWs and IPCTs in following this policy. Support the IPCT with the implementation of this policy Follow this policy. Inform a member of the Infection Prevention and Control Team (IPCT) if this policy cannot be followed. Ensure the quick reference guide is used. Clinicians Follow the policy for treatment and management of a case of GAS. Health protection Team Salus Occupational Health & Safety Keep this policy up-to date Manage community cases and contact tracing Support staff screening during an investigation / outbreak Version No.3.1 Date: December 2016 Page 12 of 14

13 6. RESOURCE IMPLICATIONS There are no resource issues 7. COMMUNICATION PLAN Staff brief Electronic launch through dissemination by Medical Director, Associate Medical Director, Divisional Nurse Director and Chief Pharmacist to medical, nursing and pharmacy staff The policy will be available on the Policies section on FirstPort and NHS Lanarkshire external website 8. QUALITY IMPROVEMENT MONITORING AND REVIEW Compliance of this policy will be monitored by the Health protection Team and Infection Prevention and Control team. The IPCT will undertake monitoring of SICPs, TBPs, Hand Hygiene and Environmental Cleanliness within clinical areas. Results will be discussed with the Senior Charge Nurse and fed back to the Senior Nurse and Site Hygiene Teams where actions will be discussed and areas for improvement identified. This policy should be reviewed by the Infection Prevention and control Team every 2 years ensuring all sources of evidence are accessed to provide best evidence for practice. 9. EQUALITY AND DIVERSITY IMPACT ASSESSMENT This policy meets NHS Lanarkshire s EDIA. A completed copy has been sent to hina.sheikh@lanarkshire.scot.nhs.uk (tick box) 10. Summary of Frequently Asked Questions (FAQ s) If you have any questions about this policy or how to implement it, please contact the Health Protection Team or Infection Prevention and Control team to discuss your query. 11. References Heymann D.L. Control of Communicable Diseases in Man Manual. 19th Edition Ayliffe GAJ. Fraise AP. Geddes AM. Mitchell K. Control of Hospital Infection (4th ed). Oxford University Press. USA/UK, Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases (6th ed). Churchill Livingstone. USA Health Protection Agency, Group A Streptococcus Working Group, Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease, Commun Dis Public Health (2004); 7: Version No.3.1 Date: December 2016 Page 13 of 14

14 Interim UK guidelines for the management of close community contacts of invasive group A streptococcal disease. Communicable Disease and Public Health, (4): p Steer J.A et al, (2012) Guidelines for the prevention and control of group A streptococcal infection in acute healthcare and maternity settings in the UK Journal of Infection 64 pp National Infection Prevention and Control Policy Manual Public Health Act. Steer JA et al. Guidelines for prevention and control of group A streptococcal infection in acute healthcare and maternity settings in the UK. Journal of Infection (2012); 64: Version No.3.1 Date: December 2016 Page 14 of 14