Infection Prevention and Control for Invasive Group A Streptococcus Infections in LTCFs

Background

Certain residents in long-term care facilities (LTCFs) have an increased risk of invasive group A Streptococcus (GAS) infections, which can cause serious illness and sometimes death. Residents at higher risk include those who

• Are 65 and older;
• Have underling medical conditions; or
• Have chronic wounds.

GAS is a bacterium that usually spreads between people through respiratory droplets or direct contact. Healthcare personnel (HCP) A working while ill (presenteeism) and lapses in infection control are primary contributors to the spread of these bacteria in LTCFs. Frequently reported infection prevention and control (IPC) gaps involve hand hygiene, cleaning and disinfection of shared medical equipment, wound care practices, and selection and use of personal protective equipment.

Facilitating a response to invasive GAS infections

When invasive GAS is identified in a LTCF, reinforcing core infection control practices among all HCP, including contracted HCP, remains the essential first step.

To rapidly interrupt transmission, LTCFs should engage facility leadership and collaborate with their health department when responding to invasive GAS infections. Engagement with facility leadership ensures allocation of resources to stop transmission and promotes accountability for addressing and monitoring IPC practices among all HCP.

Health departments offer critical prevention and outbreak response expertise by conducting IPC assessments, providing epidemiologic support, and sharing educational resources.

Strategy

Four domains outline a strategy for health departments and LTCFs to respond to reports of invasive GAS infections:

• Respond
• Assess
• Educate
• Escalate

These domains complement other initial response activities for GAS investigations to detect transmission, like identifying symptomatic infections or screening for asymptomatic carriers (colonization) among residents and HCP.

This strategy may also be applied to LTCF outbreaks of infections caused by other invasive groups of β-hemolytic Streptococcus (e.g., group G Streptococcus) infections that have similar clinical presentations and mechanisms of transmission and have also caused outbreaks in LTCFs.1

Respond

• Prevent spread by placing residents with suspected or confirmed GAS infection (or colonization) on Transmission-Based Precautions pending culture results:
  • Wound: Residents with GAS cultured from a wound, ostomy, or device-insertion site should remain on Contact ^[B]and Droplet Precautions^[C]until 24 hours after the initiation of effective antibiotic therapy and any wound drainage stops or can be contained by a dressing.
  • Throat: Residents with GAS cultured from their throat should remain on Droplet Precautions^[C] until 24 hours after the initiation of effective antibiotic therapy.

• Until the outbreak is over, HCP should wear a facemask during all wound care activities for all residents (regardless of GAS infection or colonization) or when handling invasive medical devices (e.g., central vascular catheters, indwelling urinary catheters, tracheostomy tubes). Wound care activities involve any contact with an open wound (e.g., bathing, wound assessments, dressing changes).

• To manage HCP who were exposed, ill, or colonized with GAS adhere to CDC's recommendations for group A Streptococcus infection control in healthcare personnel.

Assess

• Review IPC polices for alignment with CDC's core infection control practices.
  • HCP who work while sick could contribute to the introduction and transmission of GAS in LTCF. To discourage HCP from working while sick, LTCFs should implement non-punitive, flexible policies (e.g., paid leave) to encourage HCP with signs or symptoms of infection to stay home.
  • Contracted HCP may provide care to residents in multiple LTCFs. Whenever possible, LTCFs with contracted HCP should align policies and procedures with the contracting company to ensure HCP do not work while sick.

• Conduct IPC audits to assess how IPC policies are implemented in practice.
  • Prioritize evaluation of hand hygiene, selection and use of personal protective equipment, and cleaning and disinfection of environmental surfaces and reusable medical equipment among all HCP, including contracted HCP. Audits of contracted HCP may need to be tailored based on where and how supplies and equipment are used, stored, transported, or reprocessed. See resources below.
  • Wound care and respiratory care are frequently associated with spread of GAS in LTCFs. Consider reviewing IPC policies and conducting audits for wound care and respiratory care in addition to the above items as a proactive measure, if not already completed.
  • IPC audits of infection control areas beyond those listed above can provide valuable information to identify gaps in the facility's IPC program and HCP practices and should be completed as time permits.

• Provide prompt feedback and develop a plan to correct identified gaps and measure improvement for IPC policies and practices. Consider prioritizing high-yield recommendations that are feasible to implement and have the greatest potential to reduce transmission.

Educate

• Educate HCP, residents, and residents loved ones about the signs and symptoms of GAS infection and how to prevent spread to others.
  • Residents and their loved ones trust their care team as a primary source of health information and appreciate proactive communication about situations (e.g., outbreaks) within the facility, as well as steps being taken to keep residents safe and healthy.
• Educate HCP on the importance of not working while ill.

Escalate

Take additional measures if initial interventions fail to control spread.

• Consider cohorting residents with GAS infection and the HCP caring for these residents, halting new admissions in affected units or floors, expanding screening to identify asymptomatic carriers, or engaging with additional Infection Prevention experts (e.g., corporate Infection Preventionists, consultants, etc.).

• Universal use of facemasks by HCP has been used to limit spread of respiratory infections in healthcare settings. This strategy may be beneficial when there are ongoing challenges with adherence to IPC recommendations, concerns about transmission from HCP to resident, or elevated GAS community transmission or infections (when re-introductions could be a contributing factor).

• In instances where sustained person-to-person transmission is occurring for an extended period (e.g., several months) despite improvements in infection control, expanded use of antibiotic chemoprophylaxis among HCP and residents may be considered to eradicate carriage and interrupt transmission.

Resources

Tools for IPC audits

• Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings
• Module 2: Hand Hygiene
• Module 3: Selection and Use of PPE
• Module 4: Environmental Cleaning
• Module 8: Wound Care