title: Investigation of a prolonged Group A Streptococcal outbreak among residents of a skilled nursing facility, Georgia, 2009-2012.
abstract: BACKGROUND
  Group A Streptococcus (GAS) is an important bacterial cause of life-threatening illness among the elderly. Public health officials investigated a protracted GAS outbreak in a skilled nursing facility in Georgia housing patients requiring 24-hour nursing or rehabilitation, to prevent additional cases.
  
  
  METHODS
  We defined a case as illness in a skilled nursing facility resident with onset after January 2009 with GAS isolated from a usually sterile (invasive) or nonsterile site (noninvasive). Cases were "recurrent" if >1 month elapsed between episodes. We evaluated infection control practices, performed a GAS carriage study, emm-typed available GAS isolates, and conducted a case-control study of risk factors for infection.
  
  
  RESULTS
  Three investigations, spanning 36 months, identified 19 residents with a total of 24 GAS infections: 15 invasive (3 recurrent) and 9 noninvasive (2 recurrent) episodes. All invasive cases required hospitalization; 4 patients died. Seven residents were GAS carriers. All invasive cases and resident carrier isolates were type emm 11.0. We observed hand hygiene lapses, inadequate infection documentation, and more frequent wound care staff turnover on wing A versus wing B. Risk factors associated with infection in multivariable analysis included living on wing A (odds ratio [OR], 3.4; 95% confidence interval [CI], .9-16.4) and having an indwelling line (OR, 5.6; 95% CI, 1.2-36.4). Cases ceased following facility-wide chemoprophylaxis in July 2012.
  
  
  CONCLUSIONS
  Staff turnover, compromised skin integrity in residents, a suboptimal infection control program, and lack of awareness of infections likely contributed to continued GAS transmission. In widespread, prolonged GAS outbreaks in skilled nursing facilities, facility-wide chemoprophylaxis may be necessary to prevent sustained person-to-person transmission.
authors.affiliation: Respiratory Diseases Branch, National Center for Immunization and Respiratory Diseases.
authors.forename: Kathleen L
authors.initials: KL
authors.lastname: Dooling
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Crist
authors.forename: Duc B
authors.initials: DB
authors.lastname: Nguyen
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bass
authors.forename: Lauren
authors.initials: L
authors.lastname: Lorentzson
authors.forename: Karrie-Ann
authors.initials: KA
authors.lastname: Toews
authors.forename: Tracy
authors.initials: T
authors.lastname: Pondo
authors.forename: Nimalie D
authors.initials: ND
authors.lastname: Stone
authors.forename: Bernard
authors.initials: B
authors.lastname: Beall
authors.forename: Chris
authors.initials: C
authors.lastname: Van Beneden
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D004196:Disease Outbreaks / Q000517:prevention & control / Q000706:statistics & numerical data*; D005260:Female; D005845:Georgia / Q000453:epidemiology; D006801:Humans; D017053:Infection Control; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data; D013290:Streptococcal Infections / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control; D013297:Streptococcus pyogenes / Q000302:isolation & purification*
keywords: Active Bacterial Core surveillance; emm type; group A Streptococcus; infection control; skilled nursing facility