Between November 1984 and April 1985, a long-term care geropsychiatric ward experienced an apparent outbreak of group A streptococcal infections. These infections continued to occur in the patient population during the outbreak period despite the high level of suspicion for case identification that was aroused in the nursing and medical staff. Cases were given prompt and appropriate antibiotic treatment as each case was noted, but this did not stop the outbreak.
This article describes a frustrating problem, and the hard work and efforts of the nursing and medical staff. Initial and logical strategies employed to control the outbreak did not work. Only the simultaneous antibiotic treatment of all the patients on the ward seemed to resolve the situation.
Large epidemics of disease due to this organism no longer occur perhaps because of changing prevalence of the various strains and because of effective antibiotic therapy. Epidemics, however, in unique closed populations still occur. The institutionalized geropsychiatric setting is a unique closed population since, due to mental status, the patients cannot safely leave the ward unattended.
They are therefore usually confined together for extended periods of time with varying degrees of crowding. There may be difficulties with ensuring the personal hygiene of these patients. Certainly, there is difficulty with such "taken-for-granted" hygiene measures as handwashing after toileting and covering coughs and sneezes.
Group A streptococcal infections are largely droplet airborne, but there is no doubt that in many cases direct contact is of considerable significance. The role of inanimate environmental hand-contact objects in outbreaks of Group A strep has been previously judged to be insignificant to transmission.1 Nevertheless, geropsychiatric wards present unique problems for infection surveillance and control.2-3 Behavior may make the environmental fomites more significant to the spread of disease. In a study of a serratia pneumonia outbreak , Laxson et al4 found potential modes of transmission by environmental culturing. Shared items (electric razors, etc.) were found to harbor the organism.
There are many difficulties in controlling streptococcal disease. Many infections are either exceedingly mild or inapparent, and persons with subclinical infections can disseminate streptococci. The geropsychiatric patients involved in this outbreak seldom complained of discomfort due to pharyngitis, for example. Age-related changes often make the febrile response weak andVor undetectable, and vital signs are not generally taken routinely in this type of an ambulatory population so a normal temperature baseline is not known.
Infection depends, to a large degree, on the host resistance. Elderly patients are more prone to infection and do not always respond as do younger people due to underlying diseases and degeneration of skin, urogenital, respiratory, and immunological systems. In the elderly, changes in the central nervous system may cause a reduction in the sensation of pain, so that complaints are not made. This normal aging coupled with symptoms of various dementias make symptom recognition very difficult. Often in these patients, the only early recognizable symptom of an infection may be worsening behavior, confusion, restlessness, or lethargy. Caregivers often do not correlate these behaviors with possible physical illness.
GROUP A STREPTOCOCCAL ISOLATES (INDIVIDUAL PATIENTS) (NOV. '84 THROUGH APRIL '85)
Overcrowding can allow the explosive spread of Streptococcal disease. During these epidemics, it has long been accepted5 that prophylactic antibiotic therapy be given to all those at high risk (such as in boarding schools, orphanages, and military camps) in which infection has become endemic.
Prophylactic therapy was considered fairly early in the recognition of this outbreak, but was not used because of the potential for allergic reactions in clients who are poor historians for medication sensitivities. The ward staff and the infection control team initially felt that a high level of suspicion by the caregivers, coupled with early culturing of suspicious throats and wounds and early appropriate antibiotic treatment, would be preferable to mass antibiotic prophylaxis.
Population Characteristics and Microbiologie Methods
This outbreak occurred in a 23-bed long-term care chronic geropsychiatric ward of a Veterans Administration Medical Center. The 28 patients were male, ambulatory and demented. Dementias were from various causes including head trauma, brain syndromes, and chronic schizophrenia. Twenty-one patients (75%) were between the ages of 58 and 70 years, but seven patients (25%) were younger, debilitated ambulatory clients. Sharing of personal items such as razors was not practiced, but patients shared cigarettes, cigarette butts and often ate and drank after each other.
As with all demented patients, personal hygiene was a problem even though the patients were assisted with showering at least four to five times weekly. Nevertheless, patients generally do not handwash after toileting and they seldom cover their mouths if coughing or sneezing.
The ward consisted of double-occupancy bedrooms, communal bath and shower room, communal restroom, large dayroom, and a smaller smoking room with air exhaust and filtering device. Since most of the patients were smokers, the smalt smoking room was subjected to crowding.
Due to their mental status and for their own safety, patients could not leave the ward unattended. Meals were taken in an adjacent building with patients from other wards. It is interesting to note that no cases of group A Streptococcal disease occurred in patients from other wards with dining room contact to the outbreak group. The census on the outbreak ward remained at maximum of 23 during the outbreak period. In all, there were 61 admissions and 64 discharges.
Interestingly, employees on the ward during the epidemic were not affected. Early in the outbreak, they were encouraged to report to the employee health department for culture and treatment of sore throats and wounds. None were positive at that time nor in mid-April toward the end of the outbreak when ail direct care employees were throatcultured.
Specimens for culture during the outbreak were collected in media-containing swab culturettes and were processed by the medical center's own microbiology laboratory using standard microbiologie techniques.6 Two patient isolates, including one from bacteremia, were sent for special typing to the reference streptococcus laboratory at the Centers for Disease Control. The two were identical T-types, but because M-types were not done and because only two isolates were sent, it is impossible to say with certainty that the outbreak resulted from a single strain. Also, the environmental surface isolates obtained during the outbreak investigation are not known to be the same strains as the patient isolates.
The Outbreak and Control Measures
Beginning in November 1984 and continuing until early April 1985, the ward experienced a much higher than expected frequency of infections caused by group A streptococcus. The patients' ward cumulative incidence rate for the organism during the epidemic period was 30%, and the average monthly ward infection incidence rate was 10% compared to 2% for the expected previous baseline rate.
Contacts and exposures between cases and noncases on the ward were essentially the same since all patients used ail facilities. But the majority of the cases occurred in patients who carried a diagnosis of chronic schizophrenia with long-term phenathiazine drug therapy (68%).
The cases were varied: pharyngitis, exudative tonsillitis, minor wound infections, cellulitis, and one bacteremia following a cellulitis. None of these cases were judged to be simply colonizations since the wounds were purulent and the throats were either red, exudative, or with swollen cervical lymph nodes (see Figure 1).
The index case may have been a physically active younger schizophrenic with exudative tonsillitis. His symptoms may not have been recognized early because he did not complain of discomfort and his vital signs were not monitored. However early in November, three days before his tonsillitis was discovered, he began to have violent verbal outbursts and increased hostility. This behavior change may have been the earliest detectable symptom of physical illness.
Four days later, another more elderly patient was noted to have reddened, draining blisters on both hands. Culture revealed the group A streptococcus as the cause of this pyoderma. Later on in the month, three more throat cultures on other patients revealed the organism. Two of these patients were complaining of sore throat and the third had a behavior change, becoming somnolent after which temperature elevation was noted. At the same time, a patient with a chronic foot ulcer was noted to have more swelling and drainage and was culture positive for group A streptococcus.
At this point, the suspected outbreak was definitely identified. All the cases had been treated appropriately as they were identified via culture results with oral penicillin. The ward nursing and medical staff were advised by the infection control committee to maintain a high level of suspicion for symptomatic patients and employees.
Even though it could be argued that the high frequency of "strep" isolates may have resulted from aggressive cuituring rather than actual disease, all the cases subsequently identified were symptomatic in that the wounds were purulent and the throats were either red, exudative, or with swollen cervical lymph nodes.
All throats were cultured as soon as a patient or employee expressed a sore throat complaint, or if a noncommunicative patient displayed a behavior change or a temperature elevation. Temperatures of all the patients were taken twice daily, morning and evening.
It is interesting to note that none of the employees became ill or complained of sore throats during the outbreak. All draining wounds were cultured when noted and possible cases of cellulitis were promptly reported to the ward physician for early evaluation and treatment.
Attempts to isolate or to cohort these patients were not generally successful because of psychiatric behaviors and the inability of staff to stay one-on-one with a patient in order to keep him confined to a private room. Efforts were directed instead to early case detection and treatment, since with appropriate antibiotic treatment, transmissibility is generally terminated within 24 hours. Efforts to encourage good patient hygiene were intensified and daily showers with a nursing employee in attendance were used not only for hygiene, but for skin inspection and general assessment. Patients were assisted and encouraged with handwashing after toileting and before meals. Efforts were increased to ensure good ward sanitation, particularly the daily cleaning of multi-use dayroom furniture and bathroom fixtures. Electric razors had never been shared on this ward.
Despite these measures, cases continued to occur, four sore throats in December and three wound infections in January. There was still reluctance on the part of the staff to carry out prophylactic antibiotic therapy of all patients. So in late February, after two more minor wounds, one cellulitis and one pharyngitis, surveillance for casefinding and hygiene education was increased.
Random patient and employee cultures were taken as an adjunct to handwashing classes for employees and patients. Of 18 hand cultures done, only two (11%) were positive for the organism. Both of these were from severely demented patients who had not been previously known cases. Subsequent throat exams and cultures of these two showed injected tonsillar pillars and positive group A streptococcus.
Employees were encouraged to assist patients with handwashing. For convenience, waterless handwashing agents were made available for dayroom and lunchroom use. In addition to handwashing classes, personnel were reminded to continue close surveillance for signs of infection in patients (behavior changes, complaints of sore throat, wounds visualized during showering, and temperature monitoring).
To stress the importance of environmental sanitation to housekeepers and nursing employees, classes were held and environmental cultures taken. Despite the clean appearance of the ward, group A streptococci were found on mouth contact, multiuse items (the water foundation spigot, smoking room ashtrays, and the wide rim of the smoking room waste can). Cleaning twice each day instead of once with a fresh detergent solution began.
Despite these diligent efforts, February brought three more wound and cellulitis cases and one pharyngitis. In early March, five sore throats and one bacteremia occurred. The bacteremia was in a previously detected and treated facial cellulitis case. No further cases occurred for three weeks. Then in midApril, one sore throat and one more wound infection were noted.
If the treatment team and infection control committee had been reluctant to give massive antibiotic therapy to all the patients on the ward because of possible drug allergy, these reservations were now put aside. For now, despite the fact that well-planned reasonable and cost-effective efforts had been taken, the outbreak was continuing unabated. It was clear that all the patients in the relatively closed environment should be given a course of antimicrobial therapy in an attempt to eradicate the organism from human carriers.
Despite the additional cost, prior to antibiotic therapy, cultures were done on all the exposed patients. Throats and obvious lesions were cultured. This culturing was out of curiosity to know the actual prevalence of the organism during the outbreak period. Cultures taken on the patients revealed six infected throats (26%). All patient-care and frequently visiting employees were throat cultured. None of these showed the organism.
Patients who were not allergic were offered a choice of either long-acting benzathine penicillin, 1,200,000 units one dose intramuscularly, or oral penicillin, 500 mgm four times daily for ten days. Those six patients currently affected with pharyngitis opted for the one injection. Nine patients were alleged to be allergic and were given instead erythromycin 500 mgm four times daily for ten days.
During this treatment period, all admissions and transfers into the ward were curtailed (ten days). After this tenday interval, all employees and patients were recultured two weeks after the last day of oral antibiotic treatment. All of these cultures were negative. In the following weeks and months, there was no further apparent "strep" activity.
Widespread antibiotic therapy was probably responsible for stopping the outbreak. Containment of the outbreak was unsuccessful in the initial program (aggressive case-finding for symptomatic cases, hygiene, and sanitation). Isolation and cohorting were not done after a few unsuccessful attempts so it is not known what effect this measure might have had if staffing had been adequate to enforce it with the demented patients.
Contamination of the environment was felt to have pìayed a role in the outbreak, but this was not substantiated by experience or the literature. Whenever an infected person is present, organisms can be isolated from the environment. Microbiological surveillance may trace Streptococcal outbreaks to a recognizable source.7
Outbreaks in geropsychiatric institutions may go unnoticed for extended periods of time. Indeed, even individual patient illnesses are often unnoticed until they reach a level of severity. This is apparently due to patients' behavior, their inability to communicate symptoms, the subtlety of symptoms in the aged, and the lack of awareness of these things on the part of the healthcare staff.
Perhaps this outbreak description will alert others to the potential for outbreaks, the desirability of early prophylactic widespread antibiotic therapy, and the value of educating caregivers to the subtlety of infection symptoms in the geropsychiatric client, and to the need for careful monitoring of vital signs and behavioral clues.
- 1. Rafferty KM. Pancoasl SJ: Bacteriological sampling of telephones and hospital staff hand-contact objects. Infect Control 1984; 4(11):535.
- 2. Brooks B: Infection control guidelines: Mental health unit in general hospital. Am J Infect Control 1983: 2(5).
- 3. Cramer P: Infection control for mental institulions. Hospital Infection Control 1979; 166.
- 4. Laxson L, Bloser M, Wang WL: Role of shared objects in an outbreak of tobramycm resistant serrana marcescens pneumonia. Presented at the APIC Educational Conference in Las Vegas, Nevada. 1986.
- 5. Braude AI, DavisCE, Fierer J: Infectious Diseases and Medial Microbiology. Philadelphia. WB Saunders Co, 1986, 242-244.
- 6. Fackiam RR: Streptococci and verococci. Manual of Clinical Microbiology, ed4. Washington, DC, American Society for Microbiology, 1985 pp 154-176.
- 7. Denys GA, et al: Brief report: Possible prevention of an outbreak of group A streptococcal infection by a prospective epidemiology approach. Infect Control 1986; 7(1):30-31.