IPPOL30 Management of Group A Streptococcal Infection in Community Settings V2 by Provide Community

Management of Group A Streptococcal Infection in Community Settings

Version: V2

Ratified by: Quality & Safety Committee

Date ratified: 03/11/2023

Job Title of author: Specialist Infection Prevention Nurse

Reviewed by Committee or Expert Group Infection Prevention Group

Equality Impact Assessed by: Specialist Infection Prevention Nurse

1. Introduction

Group A Streptococcus (GAS) is a bacterium often found in the throat and on the skin. Strep A is also known as Streptococcus pyogenes. GAS usually causes mild infections such as sore throats or a ‘strep’ throat (tonsillitis). It is also responsible for skin infections such as impetigo, cellulitis and respiratory infections including scarlet fever

GAS bacteria can spread from person to person through contact with respiratory droplets from a person with strep throat. These droplets may spread when a person with strep throat coughs or sneezes. If you are exposed to those droplets then touch your mouth or rub your eyes you could become infected. The bacteria can also spread as a result of direct contact with an infected individual. Impetigo can be caused by GAS.

On rare occasions, GAS, can cause more serious infections This is called invasive GAS or iGAS. iGAS occurs when the bacterium gets into parts of the body where it is not usually found, such as the muscles, lungs or blood. It does this by getting past the defences of the person who is being infected. This can be through sores or breaks in the skin which allow the bacteria to invade deep into tissues or blood stream.

Some strains of GAS are more easily able to cause severe disease than others Invasive Group A streptococcal (iGAS) infections can cause life-threatening, infections such as:

• bacteremia, (blood stream infection)

• cellulitis

• pneumonia

• meningitis

• puerperal sepsis

• septic arthritis

• less commonly, necrotizing fasciitis and Streptococcal Toxic Shock Syndrome (STSS)

Two of the most severe, but rare, forms of invasive GAS disease are necrotising fasciitis which is a deep tissue infection with tissue destruction requiring surgery and Streptococcal Toxic Shock Syndrome which is an illness with some of the following: high fever, low blood pressure, confusion, rash as in scarlet fever, diarrhoea and vomiting, difficulty in breathing, kidney or liver damage and blood clotting problems.

GAS can cause outbreaks of infection in healthcare settings including community, acute, maternity, residential and nursing home settings. Outbreaks may occur over prolonged, periods of time and can affect patients in a wide geographic area. They can involve spread from colonised staff to patients, patient to patient and as a result of contamination of medical devices, towels and bedding and occasionally via food if prepared by someone with the infection.

GAS is usually diagnosed by microbiological culture of the affected site. GAS isolates from patients with healthcare-associated infections should be stored locally for a minimum of 6 months.

As with many infections, a person is more vulnerable to GAS if they have a poor or inadequate immune system as their ability to fight infection is impaired.

Invasive GAS (iGAS) infection and scarlet fever are both notifiable diseases requiring notification to the local Health Protection Team at UK Health & Security Agency (UKHSA).

2. Purpose

The purpose of this policy is to ensure prompt diagnosis and treatment of patients which is essential to reduce the morbidity and mortality associated with all GAS infections.

3. Definitions

Group A Streptococcal Infections (GAS)

Streptococcus pyogenes also known as (GAS) is the most common bacterium in the streptococcus group. Under a microscope, streptococcus bacteria look like a twisted bunch of round berries. It can cause a multitude of illnesses.

GAS infection is illness associated with GAS, it may be clinically likely from signs and symptoms or microbiologically confirmed.

Infection of GAS may spread through direct contact with respiratory secretions (mucus) or sores on the skin. GAS infections can cause over 500,000 deaths per year, despite the emergence of antibiotics as a treatment for streptococcus infection GAS is becoming an increasing problem, with a rapid increase in cases affecting children at the end of 2022 attributed largely to increased socialising post-pandemic.

Invasive Group A Streptococcal Infections (iGAS)

Invasive GAS (iGAS) is illness associated with isolation of GAS from blood or a normally sterile site. It also includes severe disease including necrotising fasciitis (NF) or Streptococcal Toxic Shock Syndrome (STSS) where the GAS was isolated from a normally non-sterile site- e.g. skin.

Community Setting

Community setting refers to the services Provide CIC provide to patients in their own homes or Residential Home

Incidence of iGAS

An incidence of iGAS refers to one diagnosed case, which must be reported to local Health Protection team.

Outbreak of iGAS

An outbreak of iGAS is where there are two or more cases of infection linked by person or place. These cases will usually be within a month of each other, but the interval may extend to six months especially if detected due to typing of isolates over an extended period. Where an outbreak is identified this must be reported to local Health Protection Unit.

Personal Protective Equipment PPE

PPE refers to items of equipment that are worn by the healthcare worker to protect from injury, hazardous material or spread of infection. These items include use of aprons/long sleeve gowns, gloves, eye protection such as goggles or visor and types of facial masks. The correct use of PPE can prevent transmission of contaminants from blood, body fluids, or respiratory secretions.

Standard Infection Control Precautions

Standard infection control precautions (SICPs) are the basic infection prevention measures necessary to reduce the risk of transmission of infectious agents from both recognised and unrecognised sources of infection.

Standard infection control precautions (SICPs) are to be used by all staff, in all care settings, at all times, for all patients whether infection is known to be present or not. This is to ensure the safety of those being cared for, staff and visitors in the care environment.

Carrier of GAS

An individual who harbors the specific GAS organism without manifestation of symptoms and is capable of transmitting the infection to others; the condition of such an individual is referred to as the ‘carrier’ state.

4. Duties

All clinical staff must work within this procedure and be familiar with associated documentation which supports best practice in managing GAS infection and preventing transmission.

The Chief Executive has the responsibility to:

• ensure that infection prevention and control is a core part of clinical governance and patient safety programme.

• Promote staff compliance with infection prevention policies, procedures in order to prevent Healthcare Associated Infections (HCAI)

• Awareness of legal responsibilities to identify, assess and control the risk of infection.

Group Chief Nurse and Group Chief Operations Director/Director of Infection Prevention and Control (DIPC)

• Oversee infection prevention policies, procedures, guidance and their implementation.

• Reports directly to the Chief Executive and Board members.

Infection Prevention and Control Team (IPCT) is responsible for:

• Acting as a resource for best practice for clinical staff, which includes training where required for staff to be familiar with this procedure.

• Investigating cases of GAS when notified and undertaking appropriate immediate measures to prevent spread of GAS.

• Alert appropriate clinical and operational staff should a potential outbreak of GAS be detected.

• If outbreaks of GAS are detected the IPCT will be actively involved as members of the Outbreak Control Team see IPPOL16 Management and control of an Outbreak of infection policy

Consultant Microbiologists

Either working for UKHSA or local laboratories consultant microbiologists are responsible for advising on the provision of appropriate antimicrobial therapy to Clinicians/GP and staff. Consultants may also be members of the Outbreak Control Team.

Assistant Directors

• Support managers by providing resources for implementation of specific measures associated with management of GAS infections.

• Support managers and infection prevention link practitioners in the auditing and monitoring of levels of compliance with measures that prevent GAS infection and reduce the risk of transmission, i.e. SICP, hand hygiene, decontamination resources such as cleaning of medical equipment, wound care, and cleanliness of environment.

• To assist managers to ensure that staff have the correct equipment to help prevent the spread of GAS in wound care.

• To ensure that robust escalation procedures are in place relating to wound deterioration and sepsis.

Line Managers

• Have responsibility for ensuring all staff are up to date with mandatory infection prevention training.

• To contribute to outbreak investigations, including staff screening and control measures as necessary, such as providing a list of ‘contacts’ when a case of iGAS is known.

• Ensuring staff with GAS infections are referred to Occupational Health and do not work while potentially infectious.

• To ensure that staff are proactively swabbing suspected infective wounds and refer to the CGU16 wound management guideline.

• Managers must ensure that staff have the correct equipment to help prevent the spread of GAS wound infection, these include:

1. Maceratable bowls for leg cleansing and cloths

2. Large disposable floor covering for staff to use when kneeling

3. Single use scissors

4. Long sleeve plastic aprons

5. Hand wipes if homes are unsuitable for hand hygiene to take place

6. Hand hygiene equipment (alcohol gel and paper towel)

7. Hand wash soap

8. Plastic boot boxes for storage of equipment

9. Sterile dressing packs

10. Doppler leg coverings

11. BP arm coverings

12. Replacement doppler canvas carry cases

13. Detergent/disinfectant wipes

14. Formulary dressings

15. New IT technology to help improve wound management

• To ensure that robust escalations are in place for the deterioration of wounds and sepsis.

• To ensure that where a patient has complex wound needs the patient is referred to appropriate services such as Tissue Viability or podiatry.

• To ensure all infected patients have a HCAI form completed and sent to the IP team.

• Items of medical equipment must be cleaned after each use. Items used off site i.e. in the patient’s home should, in addition be thoroughly cleaned weekly in a designated decontamination room in line with IPPOL 09 Decontamination of medical equipment policy.

• To actively swab suspected/infected wounds and action results

• To ensure staff datix results that are not actioned, or if results are not returned within 72hrs-96hrs.

• To ensure a datix is completed if results are delayed longer than 96hrs.

• To support managers and infection prevention link practitioners in the auditing and monitoring levels of compliance using the ward with measures that prevent GAS infection and reduce the risk of transmission.

• To ensure that staff wear correct uniform and have adequate items of uniform (dress/shirt etc.) to enable regular change/laundering.

• Ensure that staff risk assess the suitability of the patient home environment prior to performing wound care.

• To ensure that ICT bases are clean.

• To ensure that office spaces are not used for storing consumables.

• To ensure that storerooms are cleaned weekly and open supplies are stored in lidded, wipeable containers on shelving and off the floor.

The Occupational Health Service – currently Medigold is responsible for:

• If appropriate or agreed with UKHSA and Provide CIC, Occupational Health are responsible for providing advice to staff about exposure to GAS and providing antimicrobial prophylaxis under appropriate clinical/medical guidance.

• Investigating and treating staff with known carriage of GAS as referred to by line manager and under appropriate clinical/medical guidance.

• Contributing to outbreak investigations including staff screening when it is determined to be appropriate.

• In some circumstance where staff screening is required and occupational health provider cannot accommodate screening, alternative arrangements with external agencies will be made.

UK Health & Security Agency (UKHSA) are responsible for:

• Providing advice to contacts of cases of GAS and iGAS in the community.

• Identifying significant contacts of community cases of iGAS. Significant contacts defined as >24hours continuous exposure as this increases risk of GAS colonisation.

• Contributing to (and on occasions, leading on) outbreak investigations of community GAS.

All Clinical Staff are responsible for:

• Maintaining standards of hygiene and use of Personal Protective Equipment (PPE) for the prevention of transmission of infection

• To ensure that if they are known to have GAS infection or are symptomatic with temperature and sore throat or wound infection, they take appropriate measures to seek advice and obtain treatment from their GP.

• Informing Occupational Health and an appropriate senior manager if aware that they may be infected or colonized with GAS.

• Contributing to outbreak investigations including cooperating with staff screening and other control measures as necessary

5. Consultation and Communication

This policy has been developed by the IP team in consultation with members of the Infection prevention group for comment and approval. In development this policy has been guided by the latest to date national resources available from NHS England, UKHSA and National Institue for health and care excellence (NICE).

6. Monitoring

In the event of planned change in the process(es) described within this document either by UKHSA or at local level, or an incident involving the described process(es), this policy will be reviewed and revised as necessary to maintain its accuracy and effectiveness.

7. Infection Prevention and Control

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 reusable medical equipment, towels or bedding.

• ingestion of food contaminated by an individual carrier of the bacteria.

Signs and Symptoms of GAS Infection

Invasion and presentation of infection occurs 1-3 days after initial colonisation and can include the following:

• Tonsillitis, sore throat

• Pharyngitis

• Fever

• Scarlet fever characterised by a rash, red and swollen tongue and flushed cheeks.

• Impetigo

• Enlarged lymph nodes in the neck.

• Rash

• Cellulitis

• Pus collections on the tonsils, tiny red spots on the palate, headache, abdominal pain.

Precautions for Prevention of Transmission

Hand Hygiene

As part of SICP hand hygiene is one of the most important factors in preventing transmission of infection. All HCWs must adhere to Provide hand hygiene policy. On identification of patient with GAS infection it is also important to assist and encourage the patient to use hand hygiene. Where access to handwashing facilities is prohibitive in the home, then handwipes must be used, followed by alcohol hand sanitiser.

PPE

Minimum PPE for healthcare workers when in contact with infectious GAS patients consists of disposable gloves and aprons. A fluid repellent surgical mask and or eye protection is not required unless there is a risk of exposure to droplets i.e. change of dressings, care of necrotising fasciitis and procedures likely to generate droplets. In the event of an outbreak it may be necessary to wear a plastic long sleeved gown.

Health care workers with breaks in their skin must cover lesions with a waterproof dressing. If they become infected, they must inform their manager, Medigold or seek help from their own GP.

Decontamination of Equipment

Medical equipment that is designated as reusable and used in the community setting must be managed and decontaminated following the designated guidance in the decontamination of medical equipment policy IPPOL09. i.e. decontaminated after each use and weekly in the designated decontamination areas. In the event of an outbreak this will be increased to daily cleaning. Car boots should be cleaned weekly and monitored by senior staff.

When a case is known or in the event of an outbreak or period of increased incidence the monitoring of decontamination standards will be reviewed with relevant service managers and outbreak group to agree whether an increase in audit frequency is required. Increased auditing of decontamination of equipment is performed via the ward app and any variances actioned.

If possible and where a case is confirmed with GAS any reusable equipment should be designated for that patient to prevent potential spread. If this is not possible, guidance must be sought from the Infection Prevention team prior to any re-use on another patient.

Community Visits

Community staff should, if possible, visit a known case of GAS last on morning/afternoon list and staff should avoid taking non-essential equipment into the patient’s home. Kneeling mats must be used, maceratable bowls, single use doppler leg covers etc.

Community staff must ensure hand washing and use of a hand sanitizing gel takes place before and on completion of the visit. (See Hand Hygiene Policy). During an outbreak staff may be asked to wash their hands up to their elbows.

Uniform

All staff should be bare below the elbows on visiting patients. Outdoor clothing such as coats and cardigans should be removed prior to entering patient’s home. A clean uniform must be worn each day. Uniforms must be washed at highest temperature for that material according to the fabric label.

8. Management of Cases

Reporting One Case

All cases of iGAS are notifiable to local Health protection team. Within Provide CIC cases of iGAS will have been confirmed from the local laboratory. For all cases of GAS and iGAS that nurses or healthcare workers become of aware they must inform the infection Prevention team as a priority and complete the Healthcare associated Infection Alert form on the intranet and send to mailto:provide.infectionpreventionteam@nhs.net

Reporting Two Cases

Where two cases are identified linked by person or place (these cases will usually be within a month of each other, but the interval may extend to six months especially if detected due to typing of isolates over an extended period), these will meet definition of outbreak and local Health protection team must be informed. The Infection prevention team will undertake this in consultation with Consultant Microbiologist and directorate during working hours. Outside these hours the notification will be undertaken by assistant director.

During an outbreak it may be considered necessary to cohort nursing teams on a caseload or working in a team. All advice will be taken in consultation with the local Health Protection Team.

An outbreak must have a datix completed, and patients GP(s) or clinician(s) informed. Follow the outbreak policy.

Contacts

On notification of iGAS the local Health Protection team will investigate all close contacts, and this may include Provide CIC Health care workers that have cared for a patient in the home or nursing/residential setting. Where this is required, line managers will need to ensure they can provide a contact list of staff that fulfil the criteria requested by the local health protection team.

Prophylaxis

All prophylaxis and treatment of staff who have either infection or carriage must be discussed with the local Health Protection team and Consultant Microbiologist and if involved, IPC staff at the Integrated Care System

Where Occupational Health have agreed to treat and screen staff, line managers will be informed by the IPT.

9. Training

All staff will continue to receive training in SICP as part of induction and mandatory training requirements. Staff may receive specific training in relation to this procedure where it is identified as part of a post outbreak or incident requirement, or as an individual appraisal development need.

10.References

NHS England (2023) IPC A to Z of pathogens resource (draft) https://www.england.nhs.uk/publication/national-infection-prevention-and-control/

UKHSA (2023) UK guidelines for the management of contacts of invasive group A streptococcus (iGAS) infection in community settings

Invasive group A streptococcal disease: managing close contacts in community settings - GOV.UK (www.gov.uk)

UKHSA (2023) Group A Streptococcus: Information and guidance on group A streptococcal infections

Group A Streptococcus - GOV.UK (www.gov.uk)

Appendix 1: Patient Information Leaflet

Information for Patient’s: Group A Streptococcus

What is Group A Streptococcal infection?

Group A Streptococcus (GAS) are bacteria (germs) which can be found in the nose, throat or on the skin without causing harm or infection. Sometimes these bacteria can get into parts of the body where they are not usually found, such as the blood, muscles or the lungs, and this can cause infection.

How do I get GAS infection?

GAS is spread mainly by droplets in the respiratory tract (nose and throat) of an infected person when they cough, sneeze or kiss. The bacteria can also be spread by hands that have not been washed into wounds or breaks in the skin.

How do I know if I am infected with GAS?

A healthcare worker (nurse or doctor) will take a swab of the infected site and send this to a laboratory to test if you have an infection. You may feel unwell and have symptoms such as fever, sore throat or swollen glands. How serious is the infection?

Infections caused by GAS can range from mild to severe. Most infections are mild, for example a sore throat or skin infection. A small number of people may get a more serious infection called invasive Group A Streptococcus, or iGAS. This happens when the bacteria release poisons that spread to other sites in the body such as the blood, muscles or lungs. The infection caused can vary greatly and sometimes needs medical interventions such as surgery (an operation)

How will I be treated if I get a GAS infection?

Most people with a GAS infection will only need antibiotics (medicine) from their GP (family doctor) to treat their infection. If you are in hospital you might need to stay in a single room for a few days to stop the infection spreading to others until the antibiotics have treated the infection. The staff caring for you will always perform correct hand hygiene, wear gloves and an apron, and will wear a mask if you have respiratory symptoms. Staff will tell your friends and relatives to perform correct hand hygiene using soap and water or an alcoholbased hand rub before and after visiting. If you have an iGAS infection the treatment you need might include other medical interventions. Staff will always discuss these with you and your family.

What can I do to stop the infection spreading to my friends and family?

Most people who come into contact with someone with GAS do not get the infection. Make sure you wash your hands thoroughly with soap and warm water, particularly after coughing or sneezing or touching wounds or breaks in the skin. If your friends or family develop any of the signs or symptoms below, they should get in touch with their GP (family doctor) to say that they have come into contact with someone who has a GAS infection. • Sore throat • High fever • Aching or tender muscles • Redness around wounds

Taken from NHS National Services Scotland Health Protection Scotland

Appendix 2: Patient Information Leaflet

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Management of Group A Streptococcal Infection in Community Settings

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Policy for the Management of Group A Streptococcal Infection in Community Settings

Project/Policy Manager: Infection Prevention Nurse Date: 03/11/2023

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Neutral

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/a

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

N/a

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

N/a

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/a

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/a

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

N/a

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age