General Reading iGAS Guidelines - Published January 2012
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Educational Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease. Health Protection Agency, Workshops 2012 Group A Streptococcus Working Group. Communicable Disease and Public Health 2004; 7(4):354-361.
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Keynote Presentation: Diagnosis and Complicated infections of skin and skin structures: when the infection is more than skin deep. DiNubile MJ, Lipsky, B. Journal of treatment Antimicrobial Chemotherapy, 2004, 53, Suppl. S2, ii37-ii50 of skin and soft CLICK HERE Practice guidelines for the diagnosis and management of skin and tissue infections soft tissue infections. Stevens DL et al. Clinical Infectious Disease 2005; 41:1373–1406
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Infections of skin and soft tissue: Outcomes of a classifi cation scheme. Eron J. Clinical Infectious Diseases 2000;31:287(A432).
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Occurrence and antimicrobial susceptibility patterns of pathogens isolated from skin and soft tissue infections: report from the SENTRY READING Antimicrobial Surveillance Program (United States and Canada, 2000). Rennie RP et al. Diagn Microbiol Infect Dis. 2003 Apr; 45(4):287-293. LIST CLICK HERE Comparison of community and health care associated methicillin resistant Staphylococcus aureus infection. Naimi TS, et al. JAMA 2003; 290: 2976-2984
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Methicillin resistant S. aureus infections amoung patients in the emergency department. Moran GJ et al. The New England Journal of Medicine 2006
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HPR 2011;5(7): News CLICK HERE
Polyclonal multiply antiobiotic-resistant methicillin-resistant Staphylococcus aureus with Panton-Valentine leucocidin in England. JAC 2009; doi: 10.1093/jac/dkp386; CLICK HERE
Eff ect of antibiotics on Staphylococcus aureus producing panton- valentine leukocidin. Dumitrescu O, et al. Antimicrobial Agents and Chemotherapy. 2007, 1515–1519 CLICK HERE
Centers for Disease Control and Prevention, Skin & Soft Tissue Infections in Returned Travelers - Chapter 5 - 2012 Yellow Book - Travelers’ Health CLICK HERE Fever and the returning traveller. N Kumar, DJ Lewis. BMJ Gottlieb SL, Kretsinger K, Tarkhashvili N, et al. 2012;344:e2400 Published April 2012 Long-term outcomes of 217 botulism cases in CLICK HERE the Republic of Georgia. Clin Infect Dis 2007; 45:174 Severity assessment of skin and soft tissue infections: CLICK HERE cohort study of management and outcomes for hospitalised patients. Marwick et al. Journal of Botulism, Sobel J. Clin Infect Dis 2005 October Antimicrobial Chemotherapy, doi:10.1093/jac/dkq362, 15;41(8):1167-73 2010 CLICK HERE CLICK HERE The GAS men Guidelines for UK practice for the diagnosis and The prevalence of beta-haemolytic streptococci management of methicillin-resistant Staphylococcus in throat specimens from healthy children and aureus (MRSA) infections presenting in the community. adults. Scand J Prim H Care 1997, 15: 149
Nathwani D, Morgan M, Masterton R, Dryden M, CLICK HERE Cookson B, French G, Lewis D. Journal of Antimicrobial Chemotherapy. 2008 doi:10.1093/jac/dkn096 “Cloud” health-care workers. Sherertz RJ. CLICK HERE (Emerging Infectious Diseases 2001, 7:241) CLICK HERE Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome--a comparative observational study. Cellulitis case report Kaul R, McGeer A, Norrby-Teglund A, Kotb M, Schwartz B, Intravenous immunoglobulin G therapy in streptococcal toxic O’Rourke K, Talbot J, Low DE. Clinical Infectious Diseases shock syndrome: a European randomised, double blind, placebo 1999 Apr;28(4):800-7. controlled trial. CID 2003;37:333-340
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Diagnosis and management of cellulitis, Phoenix G et al, Necrotizing fasciitis. Bellapianta JM, Ljungquist K, Tobin E, Uhl R. J Am BMJ 2012;345:e4955 Acad Orthop Surg 2009 17(3):174-82
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An infected insect bite? Group A streptococcus peri-partum infection- following the Health Protection Agency Centre for Infections, Duty guidelines Doctor Botulism Protocol, November 2011 Global emm type distribution of group A streptococci: systematic
CLICK HERE review and implications for vaccine development. Steer AC et al. Lancet 2009;9:611-16 Werner SB, Passaro D, McGee J, et al. Wound botulism in CLICK HERE California, 1951-1998: recent epidemic in heroin injectors. Clin Infect Dis 2000; 31:1018 Painful calf
CLICK HERE Streptolysin S and necrotising infections produced by group G strep- tococcus. Humar, D., V. Datta, D. J. Bast, B. Beall, J. C. De Azavedo, and Passaro DJ, Werner SB, McGee J, et al. Wound botulism V. Nizet. 2002. Lancet 359:124-129. associated with black tar heroin among injecting drug CLICK HERE users. JAMA 1998; 279:859 CLICK HERE Invasive group A, B, C and G streptococcal infections in Denmark 1999–2002: epidemiological and clinical aspects, Ekelund, K., P. Sam AH, Beynon HL. Images in clinical medicine: Wound Skinhoj, J. Madsen, and H. B. Konradsen. Clinical Microbiology and botulism. N Engl J Med 2010; 363:2444 Infection 2005 11:569-576.
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Yuan J, Inami G, Mohle-Boetani J, Vugia DJ. Recurrent Clinical characteristics of necrotizing fasciitis caused by group G wound botulism among injection drug users in California. Streptococcus: Case report and review of the literature. Sharma, M., Clin Infect Dis 2011; 52:862 R. Khatib, and M. Fakih. 2002. Scandinavian Journal of Infectious Diseases 34:468-471. CLICK HERE CLICK HERE Journal of Infection (2012) 64,1e18
www.elsevierhealth.com/journals/jinf
PRACTICE GUIDELINES Guidelines for prevention and control of group A streptococcal infection in acute healthcare and maternity settings in the UK
Jane A. Steer a, Theresa Lamagni b, Brendan Healy c, Marina Morgan d, Matthew Dryden e, Bhargavi Rao b, Shiranee Sriskandan f, Robert George g, Androulla Efstratiou g, Fiona Baker h, Alex Baker i, Doreen Marsden j, Elizabeth Murphy k, Carole Fry l, Neil Irvine m, Rhona Hughes n, Paul Wade o, Rebecca Cordery p, Amelia Cummins q, Isabel Oliver r, Mervi Jokinen s, Jim McMenamin t, Joe Kearney u,v,* a Department of Microbiology, Derriford Hospital, Plymouth, UK b Healthcare-Associated Infection & Antimicrobial Resistance Department, Health Protection Agency, London, UK c Department of Microbiology, Public Health Wales, Cardiff, UK d Department of Microbiology, Royal Devon and Exeter Hospital, Exeter, UK e Department of Microbiology, Royal Hampshire County Hospital, Winchester, UK f Centre for Infection Prevention & Management, Department of Infectious Diseases, Imperial College, London, UK g Respiratory & Systemic Infections Department, Health Protection Agency, London, UK h Infection Prevention & Control Department, North Devon District Hospital, Barnstaple, UK i Communications, Health Protection Agency, London, UK j Lee Spark NF Foundation, Preston, UK k Occupational Health Department, NHS Grampian Occupational Health Service, Aberdeen, UK l Infectious Diseases and Blood Policy, Department of Health, London, UK m Public Health Agency, Northern Ireland, UK n Obstetrics & Gynaecology, Royal Infirmary, Edinburgh, UK o Directorates of Pharmacy and Infection, Guy’s & St. Thomas’ NHS Foundation Trust, London, UK p North East and North Central London Health Protection Unit, Health Protection Agency, London, UK q Essex Health Protection Unit, Health Protection Agency, Witham, UK r Health Protection Agency, South West, Gloucester, UK s Development Department, Royal College of Midwives, UK t Health Protection Scotland, Glasgow, UK u Health Protection Agency, East of England, Witham, UK
Accepted 1 November 2011 Available online 17 November 2011
* Corresponding author. Tel.: þ44 0845 241 2266; fax: þ 44 0 1376 302278. E-mail address: [email protected] (J. Kearney). v On behalf of the GAS Guideline Development Working Group.
0163-4453/$36 Crown Copyright ª 2011 Published by Elsevier Ltd on behalf of The British Infection Association. All rights reserved. doi:10.1016/j.jinf.2011.11.001 2 J.A. Steer et al.
KEYWORDS Summary Hospital outbreaks of group A streptococcal (GAS) infection can be devastating Group A streptococcus; and occasionally result in the death of previously well patients. Approximately one in ten cases Infection control; of severe GAS infection is healthcare-associated. This guidance, produced by a multidisciplin- Midwifery; ary working group, provides an evidence-based systematic approach to the investigation of sin- Disease outbreaks; gle cases or outbreaks of healthcare-associated GAS infection in acute care or maternity Great Britain settings. The guideline recommends that all cases of GAS infection potentially acquired in hospital or through contact with healthcare or maternity services should be investigated. Healthcare workers, the environment, and other patients are possible sources of transmission. Screening of epidemiologically linked healthcare workers should be considered for healthcare-associated cases of GAS infection where no alternative source is readily identified. Communal facilities, such as baths, bidets and showers, should be cleaned and decontaminated between all pa- tients especially on delivery suites, post-natal wards and other high risk areas. Continuous sur- veillance is required to identify outbreaks which arise over long periods of time. GAS isolates from in-patients, peri-partum patients, neonates, and post-operative wounds should be saved for six months to facilitate outbreak investigation. These guidelines do not cover diagnosis and treatment of GAS infection which should be discussed with an infection specialist. Crown Copyright ª 2011 Published by Elsevier Ltd on behalf of The British Infection Associa- tion. All rights reserved.
Introduction associated, most (58%) being post-surgical infections.5 Be- tween 2 and 11% of all severe GAS infections are associated with recent childbirth, a rate of approximately 0.06 per The overriding trend over the last century has been one of 1000 births.5e7 Findings from the 2006e08 triennial report dramatic decline in severe GAS infections. However, the on maternal deaths identified an increase in the numbers last three decades have witnessed periodic upsurges in of maternal deaths associated with GAS genital tract sepsis Europe and beyond.1 The reasons for these changes are not from around 1 death per annum in 2000-02 to 4 per annum understood, but might represent evolutionary shifts in cir- in 2006e08.8 Several of these deaths were in women with culating strains, driven by population immunity. Current es- a recent respiratory tract infection or women with family timates of annual incidence of severe GAS infection range members with recent history of sore throats. Infection in from 2 to 5 per 100,000 population in developed countries, e the mother carries a further immediate risk of infection with case fatality rates ranging from 8 to 23%.1 4 Data col- in the baby.9,10 lected in 2003-04 as part of a European project recorded a rate of 3.33 cases per 100,000 population in England, Wales and Northern Ireland.5 Outbreaks of GAS in acute care settings
Incidence of healthcare-associated and postpartum A review of healthcare-associated invasive GAS infections GAS infection in Ontario between 1992 and 2000 identified one in 10 cases as being linked to an outbreak.6 Hospital outbreaks of GAS infection can escalate rapidly, be prolonged and Between 5 and 12% of cases of severe GAS infection are e result in both patients and healthcare workers (HCWs) be- found to be healthcare-associated.1,3 6 UK data in 2003-04 ing infected.6 The national reporting system for significant identified 9% of severe GAS infections as being healthcare- health protection incidents in England (HPA Incident Re- porting Information System) identified 10 outbreaks of the GAS infection in hospital settings during 2008 and Glossary 2009 combined. Surgical, obstetrics and gynaecology, and burns units are most commonly involved in hospital out- breaks, although outbreaks have been seen in a wide GAS group A streptococcus 6 HPA Health Protection Agency range of different hospital settings. Investigation of these iGAS invasive group A streptococcus outbreaks has identified a range of transmission routes: IPCT infection prevention and control team (or colonised HCWs to patients, environmental sources to pa- equivalent) tients, and patient-to-patient transmission. Patients with HCW healthcare worker both community and healthcare-associated GAS infection OH Occupational Health have initiated hospital outbreaks with secondary cases typically arising within one month of the index case al- PPE personal protective equipment 6 SIGN Scottish Intercollegiate Guidelines Network though longer intervals have been documented. In STSS streptococcal toxic shock syndrome HCWs, throat colonisation is the most common source, al- SUI serious untoward incident though skin, vaginal and rectal colonisation have also been linked to outbreaks.6,11 UK guidelines on prevention and control of GAS in healthcare settings 3
Methods was made with leading streptococcal researchers across the world. Relevant papers were reviewed and graded using Search strategy the Scottish Intercollegiate Guidelines Network (SIGN) method by a minimum of two independent members of the working group.12 The working group made recommendations A literature review was undertaken in November 2009 which on the basis of this evidence. included case reports, outbreak/cluster investigation re- ports, retrospective and prospective surveillance studies Case definitions and national guidelines. The following sources were searched: Medline (1950 onwards), the Cochrane Library Invasive GAS (iGAS) infection and The National Health Service Centre for Reviews and Invasive GAS infection is illness associated with the iso- Dissemination. Reports from working groups, expert com- lation of GAS from a normally sterile body site, such as mittees and the Royal Colleges were also included. The key blood, cerebrospinal fluid, joint aspirate, pericardial/peri- word search used the following individual terms and com- toneal/pleural fluids, bone, endometrium, deep tissue or bined the terms using AND/OR: infection control, healthcare abscess at operation or post mortem. For the purposes of associated infection; nosocomial; maternity; health care these guidelines it also includes severe GAS infections, workers; clusters; surgical; outbreaks; transmission; puer- where GAS has been isolated from a normally non-sterile peral sepsis; group A, C and G and beta-haemolytic strep- site in combination with a severe clinical presentation, such tococcus; Streptococcus pyogenes; invasive; antibiotic as streptococcal toxic shock syndrome (STSS) or necrotising prophylaxis; carriage. The search was not restricted accord- fasciitis. ing to language of publication; the only restriction was to hu- man studies. Relevant studies identified from the electronic Peri-partum GAS infection search were reviewed for relevance by title and abstract. For the purposes of these guidelines, peri-partum GAS The full text of studies of potential relevance was retrieved. infection is defined as isolation of GAS up to 7 days post All studies identified also had their references checked for discharge or delivery in the mother in association with relevant articles. To identify national guidelines that might a clinical infection, such as endometritis, STSS, wound not be published in the scientific literature, direct contact infection, or isolation from a sterile site.
Algorithm 1 Management of a single case of GAS infection. 4 J.A. Steer et al.
Healthcare-associated GAS infection Initial investigations A healthcare-associated GAS infection is defined as a GAS infection that is neither present nor incubating at the time of Initial investigations should establish if the infection or admission but considered to have been acquired following colonisation with GAS is community or healthcare- admission to hospital or as a result of healthcare interven- associated. It should be established if the patient had tions in other healthcare facilities. Typically, onset of GAS symptoms or signs consistent with GAS infection such as > infection is 48 h after admission, or postoperatively at any sore throat or skin infection on or just prior to admission time after admission and for up to seven days post discharge. or childbirth. Intra-familial spread of GAS is common and enquiries should be made as to whether close personal Outbreak contacts or visitors are suffering from any illness that An outbreak should be considered if there are two or more could be attributable to GAS. Identification of a close cases of suspected GAS infection related by person or place. personal contact with symptoms or signs of GAS infection These cases will usually be within a month of each other but reduces the likelihood that the infection was acquired the interval may extend to several months. It should be noted from a healthcare source. Symptomatic close contacts that the interval between cases in published outbreak reports should seek advice from their GP. The infection should for GAS has, on occasion, extended to more than a year. be considered to be healthcare-associated if symptoms Reference laboratory typing from culture-proven cases is and signs of infection were not present on admission and needed to confirm that cases are related. they have developed during a hospital stay or within 7 days of discharge from hospital or post delivery, with no Infection prevention and control of GAS other obvious source of transmission. In this case, infection screening of HCWs as a possible source should be considered - see Transmission from healthcare worker The successful management of every case of GAS is to patient. important, not only to prevent spread and possible serious Contacts of community-acquired cases of invasive GAS infection should be managed according to the existing infections, but also to investigate if transmission is occur- 9 ring from an ongoing and preventable source. All GAS community guidelines. infections suspected of being healthcare-associated should be investigated further (see Algorithm 1).
Reporting cases Recommendations
All cases of suspected GAS infection identified in acute care IPCT should establish whether the case is community settings or maternity units, including stand-alone midwife or healthcare-associated. led units, and any cases identified within seven days of Further investigation of potential sources of infec- discharge or delivery that could have been healthcare- tion is warranted for any case of GAS infection con- associated should be reported to the infection prevention sidered to be healthcare-associated. and control team (IPCT) or equivalent. SIGN GRADING Good practice points Invasive GAS infection is a notifiable disease in England, Wales and Scotland.13 All iGAS infections should be dis- cussed with the local health protection specialist so that contact assessment can be initiated according to existing Prospective and retrospective surveillance national guidance.9 Outbreaks of GAS infection and deaths in patients with The interval between identified cases in published outbreak healthcare-associated GAS infection should be reported as reports for GAS has, on occasion, extended up to one or serious untoward incidents via normal reporting routes. more years,14 and as such the IPCT should maintain ongoing In the event of a death due to confirmed or suspected GAS infection surveillance where a case of healthcare- GAS - see Communication with, and advice to, mortuary associated GAS infection has been identified. The IPCT and pathology staff. should review surveillance records for the past six months at a minimum to establish if the new case is sporadic or Recommendations part of a possible outbreak of healthcare-associated GAS infection. Following a case of healthcare-associated GAS infec- All cases of suspected GAS infection identified in the tion the IPCT should consider prospective enhanced acute care setting or maternity units and stand alone surveillance which may include, for example, sampling midwife led units and any cases identified within seven infected wounds of patients in the vicinity of the index days of discharge or delivery that could have been case or who are being cared for by the same HCWs. In healthcare-associated should be reported to the IPCT. addition, the IPCT should be informed of any cases which All iGAS cases should be discussed with and notified may be caused by GAS, e.g. cases of puerperal sepsis to the local health protection specialist by the rele- treated empirically. Post-discharge surveillance, if re- vant clinician and microbiologist. quired, would help identify healthcare-associated cases SIGN GRADING Good practice points presenting after discharge. UK guidelines on prevention and control of GAS in healthcare settings 5
Personal protective equipment (PPE) Recommendations Whilst the patient is considered infectious, HCWs must use IPCT should undertake a retrospective analysis of mi- personal protective clothing including disposable gloves crobiology and surveillance records to identify possi- and aprons when in contact with the patient and their ble linked cases of healthcare-associated GAS equipment or immediate surroundings. Facial protection, infection arising in the past 6 months. such as a fluid repellent surgical mask and eye shield or IPCT should maintain GAS continuous alert organism visor, is recommended where a risk of transmission from surveillance to identify outbreaks which may arise droplets is identified; examples include bronchoscopy, over prolonged periods of time. suctioning or dressing wounds that are producing a large Following a case of healthcare-associated GAS infec- amount of exudate. Fluid repellent surgical masks with tion the IPCT should consider prospective enhanced visors must be used at operative debridement/change of surveillance which may include, for example, sam- dressings for cases of necrotising fasciitis. If an HCW has pling of infected wounds of patients in the vicinity any break in skin integrity e.g. a cut or skin lesion, this of the index case or who are being cared for by the must be covered with a waterproof dressing. In the event same HCWs. of failure to comply with PPE or needlestick injury - see SIGN GRADING Good practice points Transmission from patient to healthcare worker. Visitors must be given information about how to pre- vent the transmission of infection, and shown how to use appropriate PPE when visiting the affected individual. The Patient isolation PPE required by visitors will depend on risk assessment of the factors affecting transmission (e.g. if there is a high Patients diagnosed with or clinically suspected of having risk of droplet transmission) and also the visitor’s level of GAS infection should be isolated in a single room, with direct contact and involvement in the affected person’s a self contained toilet and its own hand basin. Breast care. feeding should be supported where possible. Mother and baby should not be separated unless the mother or baby requires admission to an ICU. Notes and charts should be kept outside the room and patients should have dedicated Recommendations equipment where possible. It is frequently cited that isolation should continue for 24e48 h after commencement of appropriate antibiotic HCWs should wear PPE including disposable gloves therapy. Studies suggesting that exclusion for 24 h of and aprons when in contact with the patient or their effective therapy is appropriate, have primarily been equipment and their immediate surroundings. performed in children with pharyngitis or scarlet fever Breaks in the skin must be covered with a waterproof (Padfield, personal communication). However, case reports dressing. show that GAS can be isolated from superficial sites beyond Fluid repellent surgical masks with visors must be 24 h of antibiotic treatment, including the drying umbilical used at operative debridement/change of dressings cord.14,15 In a recent case report of transmission from a pa- of necrotising fasciitis and for procedures where tient with necrotising fasciitis to an HCW, this occurred 50 h droplet spread is possible. after initiation of appropriate antimicrobial therapy.16 Visitors should be offered suitable information and The working party felt that although there were some relevant PPE following a risk assessment of the visi- instances when patients should be isolated until culture tor’s level of direct contact/involvement in the af- negative, 24 h of effective therapy was appropriate for the fected person’s care. majority of cases seen in hospitals; examples include SIGN GRADING Good practice point necrotising fasciitis where there is significant discharge of potentially infectious body fluids, patients with infected eczema where there is a high risk of shedding, mothers and neonates on maternity units, and patients on burns units. Hand hygiene
Semmelweis identified the importance of hand washing in Recommendations preventing the spread of puerperal sepsis on maternity units.17 HCWs must adhere to strict hand hygiene policy us- ing an effective technique i.e. hand washing with soap and Patients with GAS should be placed in isolation for water or decontamination with alcohol hand rub before and a minimum of 24 h of effective antibiotic therapy. after contact with the patient and/or their environment, Cases of necrotising fasciitis and other cases where regardless of the use of gloves and other protective there is significant discharge of potentially infected measures.18 body fluids or high risk of shedding, mothers and ne- Where appropriate the patient and their visitors must be onates on maternity units and patients on burns offered suitable information and facilities to encourage units, should be isolated until culture negative. their own adherence to standard infection control practice SIGN GRADING D/Good practice points including effective hand hygiene practice. 6 J.A. Steer et al.
facility is not recommended unless unavoidable or essential Recommendations for the individual’s clinical care. Isolation dictates that the movement of patients for non-clinical reasons should be HCWs must adhere to strict hand hygiene policy. minimised. Details of the risk of infection must be effec- Visitors should be offered suitable information and tively communicated to the ambulance service, the receiv- facilities to be able to adhere to standard infection ing ward/department or facility, and the receiving IPCT control practice, including good hand hygiene. must be informed using the inter-healthcare transfer SIGN GRADING Good practice points form. If it is found that a case of GAS could have acquired the infection in another hospital, that information should be relayed to the referring hospital. Environmental cleaning
The isolation room, furniture and equipment must be cleaned daily as a minimum and terminal cleaning un- Recommendations dertaken. Detergent and water followed by hypochlorite at 1000 ppm, or a combined product, is recommended for all Transfer only if unavoidable or essential for the pa- environmental and equipment cleaning where a patient is tient’s care. known to have an infection, healthcare associated or Details of the risk of infection must be effectively otherwise.19,20 communicated to the ambulance service, the receiv- Communal facilities such as baths, bidets and showers ing facility, IPCT and if appropriate, the referring should normally be cleaned and decontaminated between hospital. patients irrespective of whether they are known to be SIGN GRADING Good practice points infected or not. In the case of delivery suites and early post-natal care this is particularly important because of the high risk of blood and body fluid contamination, the exposed nature of episiotomy wounds and the supporting Infections occurring in mothers and babies evidence that these communal utilities have acted as the source of outbreaks - see Environment as source of 21e23 Although peri-partum GAS infection is typically acquired at outbreak. the time of or after childbirth from both exogenous and endogenous sources,28,29 pregnant women who are found to Recommendations be infected with or carrying GAS earlier in pregnancy should be treated at the time and have this clearly documented in 30 The isolation room, furniture, and equipment should the maternity notes. be cleaned with detergent and water followed by hy- Babies born to infected or colonised mothers may pochlorite at 1000 ppm daily (or combined detergent become colonised and this can be detected by swabbing of the umbilicus, ears and nose. Occasionally the baby may hypochlorite product). 31e36 Communal facilities such as baths, bidets and develop infection including invasive disease. Maternal showers should be cleaned and decontaminated be- and neonatal infection tend to be closely related in terms tween all patients especially on delivery suites, of timing. Mother and baby should not be separated unless post-natal wards and other high risk areas, such as the mother or baby requires admission to an ICU. e burns units. Following the identification of infected mother baby SIGN GRADING D/Good practice points. pairs in the UK, interim guidance for their management was published in 2004.9 Antibiotics should be administered to mother and baby if either develops suspected or confirmed Linen and waste invasive GAS disease in the neonatal period (first 28 days of life). Of note, one neonatal sepsis and one necrotising fas- Whilst the patient is considered infectious, linen and waste ciitis of the scalp have been reported in association with e must be handled as hazardous.24 27 the use of foetal scalp electrodes.37
Recommendation Recommendations