Long procedure leads to strep transmission in OR

Surgical workers may need to be followed

In an unusual case with no obvious breaches in infection control, Group A Streptococcus was transmitted to a surgeon and scrub nurse after they performed a prolonged debridement procedure on a patient with necrotizing fascitis.

In light of the case, infection control professionals may want to conduct surveillance follow-up on health care workers who perform procedures on patients with necrotizing fascitis caused by Group A strep, said Rebecca Chandler, MD, infectious disease fellow at Oregon Health & Science University in Portland.

"If we were in a similar situation again — if we had health care workers who were in a prolonged procedure — it might be worthwhile to screen those health care workers for symptoms," she said.

"Whether they should receive a streptococcal rapid screen, I don’t know. But if we have a similar situation again, we are probably going to want to contact the surgeons just to see how they are doing after the procedure," Chandler said.

Epidemiologists were tipped off on the case because the surgeon made the connection between a subsequent sore throat and having worked on the patient in a four-hour debridement procedure. After the procedure, the patient was admitted to the intensive care unit, but died about three hours later.

"[The surgeon] called her chief resident and said, I think I have strep throat, and I think I got it from that patient,’" Chandler added. "Both [the surgeon] and the scrub nurse received antibiotics, and both of them did not see patients for 24 to 48 hours."

According to the Centers for Disease Control and Prevention, Group A Streptococcus has been transmitted from infected patients to health care personnel after contact with infected secretions, and the infected personnel have subsequently acquired a variety of strep-related illnesses (e.g., toxic shock-like syndrome, cellulitis, lymphangitis, and pharyngitis).

Health care personnel who were strep carriers also have been linked to sporadic outbreaks of surgical site, postpartum, or burn wound infections.1

Chandler recently presented her investigation in San Diego at the annual meeting of the Infectious Disease Society of America.2

Chandler and colleagues began the investigation after the surgeon reported the apparent occupational infection. They identified all health care workers who cared for the index patient and collected oropharyngeal swabs for rapid streptococcal screening and/or cultures. Strep isolates were characterized by emm typing and pulsed field gel electrophoresis (PFGE).

Overall, 103 health care workers had some level of contact with the patient. Specimens were collected from 89 (86%). Four had positive rapid streptococcal tests, but only the surgeon and nurse matched the patient strain.

Among 34 operating room contacts, only those two were present for the entire four-hour debridement procedure.

The infected workers reported total compliance with standard surgical barrier precautions and infection control measures. There were no infections among 56 health care workers whose contact occurred outside the OR, despite the fact that only routine, standard precautions were employed, she said. Since the two infected workers were in full barrier precautions, the route of transmission is a mystery.

"The patient did have a positive, rapid streptococcal screen of his pharynx, but our scrub nurse was never in anyway in contact with the patient without him being intubated and without her having a mask on," Chandler explained. "So that is a little curious because she was in her full surgical protective equipment before the patient arrived in the OR."

The bacteria may have become aerosolized during the procedure on the patient’s necrotized wound, but the most compelling factor appears to be the prolonged contact with the patient.

"He was intubated prior to his entry into the operating room," she said. "He wasn’t coughing at the time he came in, either. So what seemed to be more interesting — rather than his pharynx [as the source] — was that those two actually had contact with his wound longer than anyone else. Whether . . . it was aerosolized from the wound, I don’t know."

Since infection control measures were being followed, the best way to protect health care workers may be to simply follow them after such procedures.

"I can’t think of any way other way to try and protect these health care workers; but maybe in these type of cases, there should be surveillance cultures," Chandler told Hospital Infection Control. "I don’t know if they would be candidates for prophylactic therapy; I know that has been ruled out for close contacts of patients with necrotizing fascitis."


1. Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. Guideline for infection control in health care personnel, 1998. Am J Infect Control 1998; 26:289-354.

2. Chandler RE, Lee Le, Post MT. Transmission of Group A Streptococcus to health care workers in the operating room. Abstract 559. Presented at the Infectious Disease Society of America. San Diego; Oct. 9-12, 2003.