title: An Outbreak of Severe Group A Streptococcus Infections Associated with Podiatric Application of a Biologic Dermal Substitute.
abstract: OBJECTIVE
  To describe an outbreak of severe Group A Streptococcus (GAS) infections that appeared to be associated with use of a biologic dermal substitute on foot wounds
  
  
  METHODS
  Retrospective cohort study of cases and similar uninfected patients
  
  
  METHODS
  Patients attending the podiatry clinic at a Veterans Affairs Medical Center between July 2011 and November 2011 INTERVENTIONS: Microbiology laboratory data were reviewed for the calendar year, a case definition was established and use of the biologic dermal substitute was discontinued. Staff were cultured to identify potentially colonized employees. A case-cohort study was designed to investigate risk factors for disease. Emm typing and pulsed field gel electrophoresis (PFGE) were performed to identify strain similarity.
  
  
  RESULTS
  In 10 months, 14 cases were identified, and 4 of these patients died. All strains were emm type 28 and were identical according to PFGE. Discontinuation of biologic dermal substitute use halted the outbreak. A prior stroke was more common in the case cohort vs uninfected patient cohorts. The number of patients attending the clinic on 13 probable transmission days was significantly higher than on nontransmission days. We identified 2 patients who were present in the clinic on all but 1 probable transmission day. Surveillance cultures of podiatry clinic staff and cultures of the same lot of retained graft material were negative.
  
  
  CONCLUSIONS
  A carrier was not identified, and we believe the outbreak was associated with inter-patient transmission likely due to lapses in infection control techniques. No additional cases have been identified in >3 years following the resumption of dermal substitute use in May 2012.
authors.affiliation: 1Department of Medicine,University at Buffalo,Buffalo,New York.
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Ibrahim
authors.affiliation: 1Department of Medicine,University at Buffalo,Buffalo,New York.
authors.forename: John A
authors.initials: JA
authors.lastname: Sellick
authors.affiliation: 2VA Western New York Healthcare System at Buffalo,Buffalo,New York.
authors.forename: Elaine L
authors.initials: EL
authors.lastname: Watson
authors.affiliation: 2VA Western New York Healthcare System at Buffalo,Buffalo,New York.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: McCabe
authors.affiliation: 2VA Western New York Healthcare System at Buffalo,Buffalo,New York.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Schoenhals
authors.affiliation: 3Office of Public Health,Veterans Health Administration,Washington, DC.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Martinello
authors.affiliation: 1Department of Medicine,University at Buffalo,Buffalo,New York.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Lesse
mesh_terms: D000368:Aged; D003428:Cross Infection / Q000453:epidemiology*; D004196:Disease Outbreaks; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D016523:Foot Ulcer / Q000382:microbiology / Q000628:therapy*; D006787:Hospitals, Veterans; D006801:Humans; D017053:Infection Control / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009518:New York; D012189:Retrospective Studies; D017768:Skin, Artificial / Q000009:adverse effects*; D013290:Streptococcal Infections / Q000453:epidemiology*; D013297:Streptococcus pyogenes / Q000302:isolation & purification