Pseudo Outbreak of Group A Strep (GAS)

at Concord HospitalA Collaborative Review

Review Participants IP, ID, Lab, Micro, QA, Materials Management, Lean, DHHS

Presented by Lynda Caine, Infection Prevention Officer

Agenda

• Background• Reviews Conducted– Line Listing– Process and Observation– Product Review– Case Studies and Lab Data Correlation with

Timeline• DHHS Reports

Background• 8 cases of Group A Strep were identified in

blood cultures over several weeks in April-May• In 2013, 5 cases of GAS were reported for the

entire year• This could be a serious finding as GAS in the

blood is a serious infection and can be fatal• Occurrences are reportable to DHHS• Note: all 8 cases were present on admission

Background continued

• This is a higher number of positives than our usual or expected number

• Concern of whether this represented a possible pseudo outbreak

• Decision to review all cases and blood culture process

• Decision to contact the State for possible assistance• Were we dealing with a contamination issue or was

it a coincidence?

Pseudo outbreak

• Type: Term

Pronunciation: sū-dō-out brāk′Definitions:1. Episode of increased disease incidence due to enhanced surveillance or other factor not related to the disease under study

Line Listing

• 8 symptomatic patients seen in the ED between 4/1/14 and 5/3/14

• No common links were identified – except all blood cultures were drawn in the ED– No community commonalities were identified– Different room locations in ED – Different Phlebotomists drew blood– No illness of ED and Phlebotomy Staff– Patients received antibiotics after blood draw

Process Observation

• Reviewed Lab Policy• Looked at all supplies used for a blood draw• Looked at all of the steps in a blood draw• Created a flow map of laboratory blood culture

collection and processing steps• One simulated blood draw observation was

conducted• No discrepancies identified between stated and

observed practices

Product Review

• Micro conducted testing on all lots of current blood culture bottles as well as chlorhexidine swabs – with no positive results

• Collected a sample of all supplies used for blood culture collection

• Materials Management compiled a list of vendors and manufacturers – although no further action was needed at this time

CH Case Timeline

Plotted:• Blood Culture Collection Time• Antibiotic Administration• Blood Culture Result Time

Finding: blood cultures were obtained prior to antibiotic administration

Lab Data Correlation

• Medical record review supported intermittent bacteremia or septicemia present on admission– Symptoms: including fever– Lab results: WBC, Lactic Acid, Absolute

Neutrophils, etc.

• NOTE: Group A strep is not a typical blood culture contaminate

Community Data from CH Micro: Positive Group A Strep Throat Cultures

DHHS: Group A Strep by Age Group

DHHS: Group A Strep Rate and Cases by Age Group

DHHS: Group A Strep Cases by Sex and Year

DHHS: Group A Strep Cases by County and Year

DHHS: Group A Strep Rate by County and Year

DHHS: Group A Strep Rate by County and Year

DHHS: Group A Strep Rate by County

DHHS: Group A Strep Rate by Month

DHHS: Group A Strep Rate and Cases by Year

Summary

• No further cases have been identified• Increased incidence of group A Strep noted in

Concord and in other New Hampshire communities• DHHS was not concerned but reviewed NH data• Continue to monitor for new incidence• Save future isolates for PFGE testing at the State

Lab through June 1, 2014• Re-emphasize to Staff to not come to work when ill

Special THANKS to DHHS!!!