IPC 3.3 Group A Streptococcus

Contents

1.0 Introduction
2.0 Mode of transmission
2.1 Risk factors
2.2 Signs and symptoms - clinical indications
2.3 Screening
3.0 Antimicrobial treatment guidance
4.0 Infection prevention and control principles
4.1 Isolation
4.2 Hand hygiene
4.3 Respiratory / Cough hygiene 
4.4 Personal protective equipment
4.5 Equipment
4.6 Environmental cleaning
4.7 Linen
4.8 Body fluids
4.9 Waste standard
4.10 Occupational exposure
5.0 Surveillance
6.0 Outbreaks
7.0 References/Source documents
Appendix 1 - Patient leaflets
Record of changes

1.0 Introduction

Organism 

Group A Streptococcus (GAS; Streptococcus pyogenes) is a bacterium which can colonise the throat, skin and anogenital tract. It causes a diverse range of skin, soft tissue, and respiratory tract infections, including tonsillitis, pharyngitis, scarlet fever, impetigo, erysipelas, cellulitis, and pneumonia.

GAS can occasionally cause infections that are extremely severe: this is referred to as invasive Group A Streptococcus (iGAS).

Incubation period

The Incubation period is one to three days.

Period of communicability 

There is a high level of communicability in patients who are symptomatic, until treated with appropriate antibiotics for 48 hours or for longer until showing definite clinical signs of improvement.

Individuals at risk 

The general population.

Notifiable disease 

Invasive GAS infection is a notifiable disease.

Informing IPC team 

Invasive GAS must be reported via Ulysses.

The IPC Team can provide advice and information on the IPC precautions for suspected/ known cases of GAS.

Group A Strep to wounds must be reported via Ulysses. 

2.0 Mode of transmission 

• GAS is spread by close contact between individuals through:
  • respiratory droplets
  • direct skin contact
• It can also be transmitted environmentally, through:
  • contact with contaminated objects, such as towels or bedding
  • ingestion of food inoculated by a carrier
• Healthcare workers’ hands can also be a source of transmission.

2.1 Risk factors

Invasive disease most commonly occurs in adults, while non-invasive disease is common in children.

People at increased risk for sporadic iGAS include those aged over 65 years of age; those who have recently been infected with varicella virus; those with HIV infection, diabetes, heart disease or cancer; and those using high-dose steroids or intravenous drugs.

2.2 Signs and symptoms - clinical indications

GAS causes a diverse range of skin, soft tissue, and respiratory tract infections, including:

• tonsillitis
• pharyngitis
• scarlet fever
• impetigo
• erysipelas
• cellulitis
• pneumonia

In rare cases, patients may go on to develop post-streptococcal complications, such as:

• rheumatic fever
• glomerulonephritis

Invasive GAS Infection (iGAS) - Illness associated with the isolation of GAS from a normally sterile body site e.g., bloodstream. Examples of iGAS include

• Bacteraemia
• Sepsis
• Bacterial meningitis
• Endocarditis

Patients may have sterile wounds that become infected post-surgery. iGAS can also include severe GAS infections, where GAS has been isolated from a normally nonsterile site in combination with a severe clinical presentation, such as:

• streptococcal toxic shock syndrome (STSS)
• necrotising fasciitis.

2.3 Screening

IPC 4.1 Obtaining a clinical sample

• Routine screening of patients or staff for GAS is not currently required. However, if a wound is present on admission this must be swabbed and sent to the laboratory for culture and sensitivity as per clinical assessment, including offender health sites.
• GAS is diagnosed by taking a swab of the patient’s throat or wound and sending it to microbiology, who will culture for the bacteria.
• If iGAS is suspected, blood cultures can confirm whether there are bacteria in the blood. Other samples may be required.
• It is important to send the appropriate clinical specimens for culture and sensitivity to the laboratory in any patient with a suspected infection.

3.0 Antimicrobial treatment guidance 

Patient treatment

Refer to local primary care antimicrobial stewardship guidelines (The page is available from the 'Antimicrobial Stewardship and Guidelines' page on the Connect site)

Discuss all severe or invasive infections with a Medical Microbiologist.

Staff treatment

4.0 Infection prevention and control principles

4.1 Isolation

Inpatient areas and Intermediate Care Units

• Patients diagnosed with or clinically suspected of having GAS infection should be isolated in a single room with their own toilet and hand washing facilities. Close monitoring of physical observations is crucial to identify any early signs of deterioration - use NEWS 2

4.2 Hand hygiene 

All staff must strictly adhere to the Hand Hygiene guidelines:

• 1.2 Hand hygiene (NHS England)
• Best Practice: How to hand wash step by step images
• Alcohol gel is effective against bacteria including Streptococci and can be used if hands are not visibly soiled (NHS England).

4.3 Respiratory / Cough hygiene

National infection prevention and control manual (NIPCM) for England

4.4 Personal protective equipment

Facial protection such as a fluid repellent surgical mask and eye shield or visor, is recommended when there is a risk of body fluid splash to the eyes, nose or mouth, e.g., during chest suctioning or dressing wounds that are producing a large amount of exudate.

Personal protective equipment (PPE): fluid-resistant surgical masks (FRSM) and respiratory protective equipment (RPE)

Appendix 5b: Personal protective equipment (PPE) when applying transmission based precautions (TBPs)

Appendix 6: Putting on and Removing Personal Protective Equipment (PPE)

4.5 Equipment

Safe management of patient care equipment in an isolation room/cohort area

Appendix 7: Decontamination of reusable non-invasive care equipment

4.6 Environmental cleaning

Safe management of the care environment

4.7 Linen

Safe management of linen

Appendix 8: Best Practice - Linen Bagging and Tagging 

4.8 Body fluids

Safe management of blood and body fluid spillages

Appendix 9: Management of blood and body fluid spills

4.9 Waste standard

Safe disposal of waste (including sharps)

4.10 Occupational exposure

Occupational safety: prevention of exposure (including sharps injuries)

Appendix 10: Best practice - management of occupational exposure incidents

5.0 Surveillance 

On identification of a single case of GAS, the IPCT should establish whether the case is likely to be community acquired or healthcare associated.

For contacts of cases of iGAS, clinical teams should contact the UK Health Security Agency (UKHSA) and refer to the guidelines for management of close community contacts of invasive Group A Streptococcal disease (iGAS) (UKHSA 2023)

If the case is likely to be healthcare acquired then the IPCT may consider prospective enhanced surveillance. This can include sampling of infected wounds of patients in the vicinity of the index case or who are being cared for by the same healthcare workers (HCWs).

Screening of healthcare workers may be undertaken in conjunction with microbiology, UKHSA and Occupational Health advice, e.g., swabs of throat or skin lesions even if asymptomatic.

A review of surveillance records for possible linked cases identified retrospectively may also be undertaken.

Inform UK Health Security Agency (UKHSA) of any iGAS or healthcare associated cases.

6.0 Outbreaks

If an outbreak of GAS is declared (two or more acquired cases within the same area) the IPCT will review and convene an outbreak meeting if required. The UKHSA should be informed. The Incident investigation process will be undertaken where required by the trust. The outbreak should be reported via the trust incident reporting system.

For any outbreak, initial control will involve the same measures as would be taken for an individual healthcare acquired case. This includes identification of cases, treatment and isolation, and management of contacts.

In addition, to controlling and identifying the source of an outbreak the IPCT will undertake epidemiological surveillance, environmental audits, and screening of patients and asymptomatic HCWs as deemed necessary by the outbreak meeting.

7.0 References/Source documents

Brouwer, S. et al. (2023) 'Pathogenesis, epidemiology and control of Group A Streptococcus infection'. Nature Reviews Microbiology, 21, pp. 431-447. doi: 10.1038/s41579-023-00865-7

Department of Health and Social Care (2015) Health and Social Care Act 2008: code of practice on the prevention and control of infections. (Accessed: 01 February 2024).

Loveday, H.P. et al. (2014) 'epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England'. Journal of Hospital Infection, 86, pp. S1-S70. doi:10.1016/S0195-6701(13)60012-2.

UK Health Security Agency (2023) UK guidelines for the management of contacts of invasive group A streptococcus (iGAS) infection in community settings. (Accessed: 01 February 2024). 

HM Government (2019) Group A Streptococcal Disease Important information for people in prison. (Accessed: 01 February 2024).

Public Health England (2019a) Group A streptococcal infections: guidance and data 

Public Health England (2019b) Management and Prevention of bacterial wound infections in prescribed places of detention: Guidelines for healthcare, custodial staff and responding health protection services. (Accessed: 01 February 2024).

Steer, J. et al. (2012). Guidelines for prevention and control of group a streptococcal infection in acute healthcare and maternity settings in the UK. Journal of Infection. 64. 1-18. doi: 10.1016/j.jinf.2011.11.001

Appendix 1 - Patent leaflets 

TBC

Record of changes