title: Invasive group A Streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation.
abstract: OBJECTIVE
  Liposuction is one of the most common cosmetic surgery procedures in the United States. Tumescent liposuction, in which crystalloid fluids, lidocaine, and epinephrine are infused subcutaneously before cannula-assisted aspiration of fat, can be performed without intravenous or general anesthesia, often at outpatient facilities. However, some of these facilities are not subject to state or federal regulation and may not adhere to appropriate infection control practices.
  
  
  OBJECTIVE
  To describe an outbreak of severe group A Streptococcus (GAS) infections among persons undergoing tumescent liposuction at 2 outpatient cosmetic surgery facilities not subject to state or federal regulation.
  
  
  METHODS
  Outbreak investigation (including cohort analysis of at-risk patients), interviews using a standardized questionnaire, medical record review, facility assessment, and laboratory analysis of GAS isolates.
  
  
  METHODS
  Patients undergoing liposuction at 2 outpatient facilities, one in Maryland and the other in Pennsylvania, between July 1 and September 14, 2012.
  
  
  METHODS
  Confirmed invasive GAS infections (isolation of GAS from a normally sterile site or wound of a patient with necrotizing fasciitis or streptococcal toxic shock syndrome), suspected GAS infections (inflamed surgical site and either purulent discharge or fever and chills in a patient with no alternative diagnosis), postsurgical symptoms and patient-reported experiences related to his or her procedure, and emm types, T-antigen types, and antimicrobial susceptibility of GAS isolates.
  
  
  RESULTS
  We identified 4 confirmed cases and 9 suspected cases, including 1 death (overall attack rate, 20% [13 of 66]). One instance of likely secondary GAS transmission to a household member occurred. All confirmed case patients had necrotizing fasciitis and had undergone surgical debridement. Procedures linked to illness were performed by a single surgical team that traveled between the 2 locations; 2 team members (1 of whom reported recent cellulitis) were colonized with a GAS strain that was indistinguishable by laboratory analysis of the isolates from the case patients. Facility assessments and patient reports indicated substandard infection control, including errors in equipment sterilization and infection prevention training.
  
  
  CONCLUSIONS
  This outbreak of severe GAS infections was likely caused by transmission from colonized health care workers to patients during liposuction procedures. Additional oversight of outpatient cosmetic surgery facilities is needed to assure that they maintain appropriate infection control practices and other patient protections.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia2Pennsylvania Department of Health, Harrisburg.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Beaudoin
authors.affiliation: Allegheny County Health Department, Pittsburgh, Pennsylvania.
authors.forename: Lauren
authors.initials: L
authors.lastname: Torso
authors.affiliation: Maryland Department of Health and Mental Hygiene, Baltimore.
authors.forename: Katherine
authors.initials: K
authors.lastname: Richards
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia4Maryland Department of Health and Mental Hygiene, Baltimore.
authors.forename: Maria
authors.initials: M
authors.lastname: Said
authors.affiliation: Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Chris
authors.initials: C
authors.lastname: Van Beneden
authors.affiliation: Pennsylvania Department of Health, Harrisburg.
authors.forename: Allison
authors.initials: A
authors.lastname: Longenberger
authors.affiliation: Pennsylvania Department of Health, Harrisburg.
authors.forename: Stephen
authors.initials: S
authors.lastname: Ostroff
authors.affiliation: Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Joyanna
authors.initials: J
authors.lastname: Wendt
authors.affiliation: Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Dooling
authors.affiliation: Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Matthew
authors.initials: M
authors.lastname: Wise
authors.affiliation: Maryland Department of Health and Mental Hygiene, Baltimore.
authors.forename: David
authors.initials: D
authors.lastname: Blythe
authors.affiliation: Maryland Department of Health and Mental Hygiene, Baltimore.
authors.forename: Lucy
authors.initials: L
authors.lastname: Wilson
authors.affiliation: Pennsylvania Department of Health, Harrisburg.
authors.forename: Mària
authors.initials: M
authors.lastname: Moll
authors.affiliation: Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Perz
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D015187:Lipectomy / Q000009:adverse effects*; D008297:Male; D008396:Maryland / Q000453:epidemiology; D008875:Middle Aged; D010414:Pennsylvania / Q000453:epidemiology; D013290:Streptococcal Infections / Q000453:epidemiology / Q000209:etiology*; D013297:Streptococcus pyogenes / Q000302:isolation & purification / Q000472:pathogenicity*; D013531:Surgicenters / Q000331:legislation & jurisprudence / Q000592:standards; D055815:Young Adult