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Postpartum Group A Streptococcus Case Series: Reach Out to Infection Prevention!

Postpartum Group A Streptococcus Case Series: Reach Out to Infection Prevention! A series of postpartum Streptococcus pyogenes infections prompted an investigation to rule out potential transmission by a health care worker. None of the hospital staff screened were colonized. All isolates were determined to be unrelated by molecular methods, including whole genome sequencing. Thus, nosocomial transmission was considered unlikely. Introduction Invasive infections caused by Streptococcus pyogenes (group A streptococcus, GAS), cause significant global morbidity and mortality. For postpartum women, the risk of acquiring Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript invasive GAS is 20-fold higher than in non-pregnant women, resulting in 220 cases/year in the 1,2 United States as of 2002. Although the infection occurs in otherwise healthy women, it carries significant risk of mortality, with a case fatality rate of 3.5% and a 6 to 20-fold increased 1,2 incidence of neonatal death. GAS infections can occur in clusters and may be transmitted by an asymptomatic 1,3,4 healthcare worker (HCW), potentially causing infections up to even more than a year apart. Thus, any case of postpartum GAS warrants investigation to rule out possible transmission by a HCW to prevent potential additional cases. As part of routine surveillance for Caesarean-section surgical site infections (SSI), five cases of postpartum GAS were identified at a large academic medical center, over fourteen months from February 2015 to March 2016. With the identification of the first case, an investigation transpired to ensure cases were not connected through carriage by a HCW. Methods A. Case Definition The 2002 CDC guideline identifies the following as a case of an invasive healthcare associated postpartum GAS infection: isolation, during the hospital stay or within the first seven days after discharge, of GAS from a sterile site or a surgical wound. B. Investigation Methodology For each case the electronic medical record was reviewed using a standardized data collection form to identify demographics, potential risk factors for infection, possible source, Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript clinical course, and treatment. HCWs who had cared for the patients were also identified. Potential patient colonization was assessed by an Ob-Gyn physician who interviewed each patient to identify sick contacts and history of reported skin/soft tissue infections. Patients were screened at non-sterile sites (i.e. oropharynx, vagina and perirectal area) for GAS colonization. The HCWs associated with the first case were also screened for GAS at the same non-sterile sites, and wounds, if present. GAS strains from each patient were retained by the hospital microbiology lab and sent to the Ohio Department of Health for comparison by pulsed field gel electrophoresis (PFGE). Two isolates that were indistinguishable by PFGE were sent to the Department of Pathology and Genomic Medicine, Houston Methodist Hospital for whole genome sequencing (WGS), 6,7 performed as previously described. Case Reports and Results Case 1: In February 2015, a 37 year old female (F) was identified 10 days after a Caesarian delivery with an infected incision that grew GAS. Screening cultures from the oropharynx, vagina and rectum were negative (Table 1), suggesting that she was not colonized with GAS. Blood and urine cultures were not done. An investigation was begun to ensure that no healthcare associated transmission had occurred. Seventeen HCWs who cared for her were identified; none screened positive for GAS carriage at any site. Case 2: A 26 year old F was identified three months after case 1, when she presented with endometritis and GAS bacteremia one day after an uncomplicated vaginal delivery. A urine culture and GAS screening cultures from the oropharynx and vagina were positive, indicating Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript likely colonization prior to delivery. PFGE results (Figure 1) showed case 1 and 2 were different, supporting the hypothesis that HCW transmission had not occurred. No additional staff were screened then. Case 3: Two months after case 2, a 39 year old F presented with vaginal bleeding on post-operative day 20 after a Caesarian-section delivery. A vaginal culture was positive for GAS, and all other screening sites were culture-negative. She was judged to be colonized, rather than having a true infection. Case 4: A 31 year old F re-presented one day after case 3 with septic shock due to GAS bacteremia. She was post-operative day seven from a Caesarian-section delivery. Cultures were positive for GAS from blood, urine and vagina. Her condition quickly improved with antibiotics and supportive care. Further questioning revealed that she had a clitoral ring removed one day prior to delivery. Although she did not have overt signs of clitoral infection, since she was positive for vaginal colonization, this was considered the most likely source. Notably, her prenatal group B streptococcus (GBS) screen was positive and she had been treated with ampicillin 6 hours prior to delivery. She also received cefazolin perioperatively and for 24 hours after delivery. PFGE showed cases 3 and 4 were distinct from each other and also from the prior two patients. There was no overlap in HCWs caring for these four patients, so healthcare related transmission was thought unlikely. Case 5: Eight months after case 4, in March 2016, a 34 year old F presented with endometritis and GAS bacteremia two days after an uncomplicated vaginal delivery. The patient was culture-positive for vaginal carriage. The PFGE pattern of both her isolates was identical to the strain from case 4, prompting further investigation. A single HCW had cared for both Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript patients, and this HCW screened negative for GAS carriage in the oropharynx, vagina and rectum. Isolates from case 4 and 5 were both type emm3. Whole genome sequencing (WGS) showed that these two isolates differed by 16 single nucleotide polymorphisms. This level of genetic difference strongly argues against HCW-related or a common source transmission. Discussion Cases 1, 2, 4 and 5 met the CDC case definition for invasive postpartum GAS infection. Case 3 presented beyond the seven-day post-discharge window required to be considered as healthcare associated. In addition, this patient was judged to be colonized with GAS rather than truly infected. The index case 1 was not colonized with GAS, so her case was initially concerning for healthcare associated transmission, however, an exhaustive review of HCWs who cared for her did not reveal any colonization. Cases 2, 4 and 5 also met CDC criteria for postpartum invasive GAS, but the isolates from these three patients were genetically distinct from each other as assessed by a combination of PFGE and WGS analysis, and do not appear to have been transmitted by a shared HCW. Other than case 1, all had vaginal carriage of GAS, which likely predisposed them to an invasive GAS infection. No other shared risk factors were identified and all five patients recovered quickly with appropriate treatment. Due to the potentially severe nature of invasive GAS infections, the identification of a single case, especially in an otherwise healthy post-partum patient, mandates a thorough epidemiologic investigation. In this case series there was no evidence indicating that infections were cross- transmitted, hospital acquired, nor associated with a HCW. It is well established that prenatal screening for GBS has dramatically reduced the incidence of neonatal infections, but screening for GAS is not routinely performed. GAS Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript vaginal colonization is a risk factor for developing an invasive infection, although compared to GBS, GAS colonization is far less frequent. A surveillance study performed in 2000 indicated that the rate of GAS colonization late in pregnancy was 0.03% vs 20.1% for GBS, however, in our small series, four of the five patients were colonized with GAS. There were 5,661 deliveries at our institution during the study period, so based on only four positive patients, the rate was 0.071%. This is double the previously reported rate without screening any of the asymptomatic patients, thus we presume our local rate of GAS colonization is much higher. This is supported by surveillance data from the Ohio Department of Health indicating the total rate of invasive GAS has increased 7 fold in the period from 1996 to 2008, although unfortunately the percent of postpartum infections was not specifically quantified. In the last three years in the county where our facility is located, invasive GAS case rates have steadily increased from 3.0 (2014), to 3.8 (2015) and to 4.3 per 100,000 population in 2016. Furthermore, in 2015 there were five community outbreaks of GAS in the county involving 133 total patients, compared to just two outbreaks involving 22 total patients during the preceding three years. Thus, local rates are on the rise and coincided with our cases. With this increase, screening for GAS colonization may be useful, especially if peri-partum antibiotics reduced colonization rates and risk for invasive infection. In our cases, only one patient (case 4) had GBS colonization prior to delivery. This patient was treated with peri-partum ampicillin, but remained colonized with GAS upon presentation with an invasive infection seven days later, suggesting that GAS colonization was not eradicated. In conclusion, although the incidence of GAS vs. GBS remains low, current data show that both community acquired disease and invasive infections are increasing. Additional surveillance data are necessary to confirm rates of vaginal GAS carriage and to assess if targeted Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript peri-partum antibiotic treatment of carriers would alter the risk of postpartum invasive GAS. Given the potential for high morbidity and mortality with GAS infection, it is important for hospital epidemiology programs to remain vigilant. Importantly, no additional cases have been identified through calendar year 2017. Although no HCW transmission was identified in this investigation, Caesarian section SSI surveillance is ongoing. Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Acknowledgments and Notes Financial support: RJO and JMM were supported in part by funds from the Fondren Foundation. Conflict of interest: All authors report no conflicts of interest relevant to this article. A special thanks to Eric Brandt at the Ohio Department of Health for assistance with PFGE. We also thank Mathew Ojeda Saavedra at Houston Methodist Research Institute for assistance with WGS. References 1. Chuang I, Van Beneden C, Beall B, Schuchat A. Population-based surveillance for postpartum invasive group a streptococcus infections, 1995-2000. Clin Infect Dis. 2002;35:665-670. 2. Deutscher M, Lewis M, Zell ER, Taylor TH, Van Beneden C, Schrag S. Incidence and severity of invasive streptococcus pneumoniae, group a streptococcus, and group b streptococcus infections among pregnant and postpartum women. Clin Infect Dis. 2011;53:114-123. 3. Viglionese A, Nottebart VF, Bodman HA, Platt R. Recurrent group a streptococcal carriage in a health care worker associated with widely separated nosocomial outbreaks. Am J Med. 1991;91:3B329S-3B333S. 4. Mastro TD, Farley TA, Elliott JA, et al. An outbreak of surgical-wound infections due to group A streptococcus carried on the scalp. N Engl J Med. 1990;323(14):968-972. Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript 5. Beall B, Besser J, Bisno A, et al. Prevention of invasive group A streptococcal disease among household contacts of case patients and among postpartum and postsurgical patients: recommendations from the Centers for Disease Control and Prevention. Clin Infect Dis. 2002;35:950-959. 6. Olsen RJ, Fittipaldi N, Kachroo P, et al. Clinical laboratory response to a mock outbreak of invasive bacterial infections: A preparedness study. J Clin Microbiol. 2014;52(12):4210-4216. 7. Long SW, Olsen RJ, Eagar TN, et al. Population Genomic Analysis of 1,777 Extended- Spectrum Beta-LactamaseProducing Klebsiella pneumoniae Isolates, Houston, Texas: Unexpected Abundance of Clonal Group 307. MBio. 2017;8(3):1-18. 8. Beres SB, Carroll RK, Shea PR, et al. Molecular complexity of successive bacterial epidemics deconvoluted by comparative pathogenomics. Proc Natl Acad Sci U S A. 2010;107:4371-4376. 9. Verani JR, McGee L, Schrag SJ. Prevention of Perinatal Group B Streptococcal Disease. Morb Mortal Wkly Rep. 2010;59:1-32. 10. Mead PB, Winn WC. Vaginal-rectal colonization with group A streptococci in late pregnancy. Infect Dis Obstet Gynecol. 2000;8:217-219. 11. Ohio Department of Health. Reported Cases of Selected Notifiable Diseases - Ohio, 2008- 2016.; 2017. https://www.odh.ohio.gov/en/healthstats/disease/idann/idann. 12. Columbus Public Health. Annual Summary of Reportable Diseases 2016.; 2017. https://www.columbus.gov/publichealth/programs/Office-of-Epidemiology/Infectious- Disease-Reports/. Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Table 1. Demographics, risk factors, cultures from 5 post-partum females Case 1 Case 2 Case 3 Case 4 Case 5 Age (years) 37 26 39 31 34 Ethnicity White Black White Black White Weight (kg) 65.5 60.9 98.2 88.6 81.8 Smoking Former Current Former Current Former Status GBS Status Not performed Negative Negative Positive Negative Gestational 28w 1d 36w 1d 39w 3d 38w 4d 40w 4d Age at Delivery Delivery C-section Vaginal C-section C-section Vaginal Method Days from 10 1 20 7 2 delivery to GAS culture Days from 6 0 17 4 1 discharge to GAS culture Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Comorbid Chronic kidney Sick contact Congenital Clitoral None illnesses and disease with fever, coagulopathy piercing possible risk sore throat removed 1 factor for GAS day prior to delivery Endometritis No Yes No No Yes Primary Site of C-section Endometritis No clinical Bacteremia Endometritis Infection incisional infection; vaginal colonization only. Blood culture Not performed Positive Not performed Positive Positive Urine culture Not performed Positive Negative Positive Negative Wound culture Positive No wound No wound No wound No wound Oropharyngeal Negative Positive Not performed Negative Negative culture Vaginal culture Negative Positive Positive Positive Positive Perirectal Negative Negative Not performed Negative Negative culture Abbreviations: C-section = Caesarean section Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Figure 1. Pulsed Field Gel Electrophoresis Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Postpartum Group A Streptococcus Case Series: Reach Out to Infection Prevention!

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References (14)

Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America.
eISSN
2328-8957
DOI
10.1093/ofid/ofy159
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Abstract

A series of postpartum Streptococcus pyogenes infections prompted an investigation to rule out potential transmission by a health care worker. None of the hospital staff screened were colonized. All isolates were determined to be unrelated by molecular methods, including whole genome sequencing. Thus, nosocomial transmission was considered unlikely. Introduction Invasive infections caused by Streptococcus pyogenes (group A streptococcus, GAS), cause significant global morbidity and mortality. For postpartum women, the risk of acquiring Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript invasive GAS is 20-fold higher than in non-pregnant women, resulting in 220 cases/year in the 1,2 United States as of 2002. Although the infection occurs in otherwise healthy women, it carries significant risk of mortality, with a case fatality rate of 3.5% and a 6 to 20-fold increased 1,2 incidence of neonatal death. GAS infections can occur in clusters and may be transmitted by an asymptomatic 1,3,4 healthcare worker (HCW), potentially causing infections up to even more than a year apart. Thus, any case of postpartum GAS warrants investigation to rule out possible transmission by a HCW to prevent potential additional cases. As part of routine surveillance for Caesarean-section surgical site infections (SSI), five cases of postpartum GAS were identified at a large academic medical center, over fourteen months from February 2015 to March 2016. With the identification of the first case, an investigation transpired to ensure cases were not connected through carriage by a HCW. Methods A. Case Definition The 2002 CDC guideline identifies the following as a case of an invasive healthcare associated postpartum GAS infection: isolation, during the hospital stay or within the first seven days after discharge, of GAS from a sterile site or a surgical wound. B. Investigation Methodology For each case the electronic medical record was reviewed using a standardized data collection form to identify demographics, potential risk factors for infection, possible source, Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript clinical course, and treatment. HCWs who had cared for the patients were also identified. Potential patient colonization was assessed by an Ob-Gyn physician who interviewed each patient to identify sick contacts and history of reported skin/soft tissue infections. Patients were screened at non-sterile sites (i.e. oropharynx, vagina and perirectal area) for GAS colonization. The HCWs associated with the first case were also screened for GAS at the same non-sterile sites, and wounds, if present. GAS strains from each patient were retained by the hospital microbiology lab and sent to the Ohio Department of Health for comparison by pulsed field gel electrophoresis (PFGE). Two isolates that were indistinguishable by PFGE were sent to the Department of Pathology and Genomic Medicine, Houston Methodist Hospital for whole genome sequencing (WGS), 6,7 performed as previously described. Case Reports and Results Case 1: In February 2015, a 37 year old female (F) was identified 10 days after a Caesarian delivery with an infected incision that grew GAS. Screening cultures from the oropharynx, vagina and rectum were negative (Table 1), suggesting that she was not colonized with GAS. Blood and urine cultures were not done. An investigation was begun to ensure that no healthcare associated transmission had occurred. Seventeen HCWs who cared for her were identified; none screened positive for GAS carriage at any site. Case 2: A 26 year old F was identified three months after case 1, when she presented with endometritis and GAS bacteremia one day after an uncomplicated vaginal delivery. A urine culture and GAS screening cultures from the oropharynx and vagina were positive, indicating Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript likely colonization prior to delivery. PFGE results (Figure 1) showed case 1 and 2 were different, supporting the hypothesis that HCW transmission had not occurred. No additional staff were screened then. Case 3: Two months after case 2, a 39 year old F presented with vaginal bleeding on post-operative day 20 after a Caesarian-section delivery. A vaginal culture was positive for GAS, and all other screening sites were culture-negative. She was judged to be colonized, rather than having a true infection. Case 4: A 31 year old F re-presented one day after case 3 with septic shock due to GAS bacteremia. She was post-operative day seven from a Caesarian-section delivery. Cultures were positive for GAS from blood, urine and vagina. Her condition quickly improved with antibiotics and supportive care. Further questioning revealed that she had a clitoral ring removed one day prior to delivery. Although she did not have overt signs of clitoral infection, since she was positive for vaginal colonization, this was considered the most likely source. Notably, her prenatal group B streptococcus (GBS) screen was positive and she had been treated with ampicillin 6 hours prior to delivery. She also received cefazolin perioperatively and for 24 hours after delivery. PFGE showed cases 3 and 4 were distinct from each other and also from the prior two patients. There was no overlap in HCWs caring for these four patients, so healthcare related transmission was thought unlikely. Case 5: Eight months after case 4, in March 2016, a 34 year old F presented with endometritis and GAS bacteremia two days after an uncomplicated vaginal delivery. The patient was culture-positive for vaginal carriage. The PFGE pattern of both her isolates was identical to the strain from case 4, prompting further investigation. A single HCW had cared for both Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript patients, and this HCW screened negative for GAS carriage in the oropharynx, vagina and rectum. Isolates from case 4 and 5 were both type emm3. Whole genome sequencing (WGS) showed that these two isolates differed by 16 single nucleotide polymorphisms. This level of genetic difference strongly argues against HCW-related or a common source transmission. Discussion Cases 1, 2, 4 and 5 met the CDC case definition for invasive postpartum GAS infection. Case 3 presented beyond the seven-day post-discharge window required to be considered as healthcare associated. In addition, this patient was judged to be colonized with GAS rather than truly infected. The index case 1 was not colonized with GAS, so her case was initially concerning for healthcare associated transmission, however, an exhaustive review of HCWs who cared for her did not reveal any colonization. Cases 2, 4 and 5 also met CDC criteria for postpartum invasive GAS, but the isolates from these three patients were genetically distinct from each other as assessed by a combination of PFGE and WGS analysis, and do not appear to have been transmitted by a shared HCW. Other than case 1, all had vaginal carriage of GAS, which likely predisposed them to an invasive GAS infection. No other shared risk factors were identified and all five patients recovered quickly with appropriate treatment. Due to the potentially severe nature of invasive GAS infections, the identification of a single case, especially in an otherwise healthy post-partum patient, mandates a thorough epidemiologic investigation. In this case series there was no evidence indicating that infections were cross- transmitted, hospital acquired, nor associated with a HCW. It is well established that prenatal screening for GBS has dramatically reduced the incidence of neonatal infections, but screening for GAS is not routinely performed. GAS Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript vaginal colonization is a risk factor for developing an invasive infection, although compared to GBS, GAS colonization is far less frequent. A surveillance study performed in 2000 indicated that the rate of GAS colonization late in pregnancy was 0.03% vs 20.1% for GBS, however, in our small series, four of the five patients were colonized with GAS. There were 5,661 deliveries at our institution during the study period, so based on only four positive patients, the rate was 0.071%. This is double the previously reported rate without screening any of the asymptomatic patients, thus we presume our local rate of GAS colonization is much higher. This is supported by surveillance data from the Ohio Department of Health indicating the total rate of invasive GAS has increased 7 fold in the period from 1996 to 2008, although unfortunately the percent of postpartum infections was not specifically quantified. In the last three years in the county where our facility is located, invasive GAS case rates have steadily increased from 3.0 (2014), to 3.8 (2015) and to 4.3 per 100,000 population in 2016. Furthermore, in 2015 there were five community outbreaks of GAS in the county involving 133 total patients, compared to just two outbreaks involving 22 total patients during the preceding three years. Thus, local rates are on the rise and coincided with our cases. With this increase, screening for GAS colonization may be useful, especially if peri-partum antibiotics reduced colonization rates and risk for invasive infection. In our cases, only one patient (case 4) had GBS colonization prior to delivery. This patient was treated with peri-partum ampicillin, but remained colonized with GAS upon presentation with an invasive infection seven days later, suggesting that GAS colonization was not eradicated. In conclusion, although the incidence of GAS vs. GBS remains low, current data show that both community acquired disease and invasive infections are increasing. Additional surveillance data are necessary to confirm rates of vaginal GAS carriage and to assess if targeted Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript peri-partum antibiotic treatment of carriers would alter the risk of postpartum invasive GAS. Given the potential for high morbidity and mortality with GAS infection, it is important for hospital epidemiology programs to remain vigilant. Importantly, no additional cases have been identified through calendar year 2017. Although no HCW transmission was identified in this investigation, Caesarian section SSI surveillance is ongoing. Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Acknowledgments and Notes Financial support: RJO and JMM were supported in part by funds from the Fondren Foundation. Conflict of interest: All authors report no conflicts of interest relevant to this article. A special thanks to Eric Brandt at the Ohio Department of Health for assistance with PFGE. We also thank Mathew Ojeda Saavedra at Houston Methodist Research Institute for assistance with WGS. References 1. Chuang I, Van Beneden C, Beall B, Schuchat A. Population-based surveillance for postpartum invasive group a streptococcus infections, 1995-2000. Clin Infect Dis. 2002;35:665-670. 2. Deutscher M, Lewis M, Zell ER, Taylor TH, Van Beneden C, Schrag S. Incidence and severity of invasive streptococcus pneumoniae, group a streptococcus, and group b streptococcus infections among pregnant and postpartum women. Clin Infect Dis. 2011;53:114-123. 3. Viglionese A, Nottebart VF, Bodman HA, Platt R. Recurrent group a streptococcal carriage in a health care worker associated with widely separated nosocomial outbreaks. Am J Med. 1991;91:3B329S-3B333S. 4. Mastro TD, Farley TA, Elliott JA, et al. An outbreak of surgical-wound infections due to group A streptococcus carried on the scalp. N Engl J Med. 1990;323(14):968-972. Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript 5. Beall B, Besser J, Bisno A, et al. Prevention of invasive group A streptococcal disease among household contacts of case patients and among postpartum and postsurgical patients: recommendations from the Centers for Disease Control and Prevention. Clin Infect Dis. 2002;35:950-959. 6. Olsen RJ, Fittipaldi N, Kachroo P, et al. Clinical laboratory response to a mock outbreak of invasive bacterial infections: A preparedness study. J Clin Microbiol. 2014;52(12):4210-4216. 7. Long SW, Olsen RJ, Eagar TN, et al. Population Genomic Analysis of 1,777 Extended- Spectrum Beta-LactamaseProducing Klebsiella pneumoniae Isolates, Houston, Texas: Unexpected Abundance of Clonal Group 307. MBio. 2017;8(3):1-18. 8. Beres SB, Carroll RK, Shea PR, et al. Molecular complexity of successive bacterial epidemics deconvoluted by comparative pathogenomics. Proc Natl Acad Sci U S A. 2010;107:4371-4376. 9. Verani JR, McGee L, Schrag SJ. Prevention of Perinatal Group B Streptococcal Disease. Morb Mortal Wkly Rep. 2010;59:1-32. 10. Mead PB, Winn WC. Vaginal-rectal colonization with group A streptococci in late pregnancy. Infect Dis Obstet Gynecol. 2000;8:217-219. 11. Ohio Department of Health. Reported Cases of Selected Notifiable Diseases - Ohio, 2008- 2016.; 2017. https://www.odh.ohio.gov/en/healthstats/disease/idann/idann. 12. Columbus Public Health. Annual Summary of Reportable Diseases 2016.; 2017. https://www.columbus.gov/publichealth/programs/Office-of-Epidemiology/Infectious- Disease-Reports/. Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Table 1. Demographics, risk factors, cultures from 5 post-partum females Case 1 Case 2 Case 3 Case 4 Case 5 Age (years) 37 26 39 31 34 Ethnicity White Black White Black White Weight (kg) 65.5 60.9 98.2 88.6 81.8 Smoking Former Current Former Current Former Status GBS Status Not performed Negative Negative Positive Negative Gestational 28w 1d 36w 1d 39w 3d 38w 4d 40w 4d Age at Delivery Delivery C-section Vaginal C-section C-section Vaginal Method Days from 10 1 20 7 2 delivery to GAS culture Days from 6 0 17 4 1 discharge to GAS culture Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Comorbid Chronic kidney Sick contact Congenital Clitoral None illnesses and disease with fever, coagulopathy piercing possible risk sore throat removed 1 factor for GAS day prior to delivery Endometritis No Yes No No Yes Primary Site of C-section Endometritis No clinical Bacteremia Endometritis Infection incisional infection; vaginal colonization only. Blood culture Not performed Positive Not performed Positive Positive Urine culture Not performed Positive Negative Positive Negative Wound culture Positive No wound No wound No wound No wound Oropharyngeal Negative Positive Not performed Negative Negative culture Vaginal culture Negative Positive Positive Positive Positive Perirectal Negative Negative Not performed Negative Negative culture Abbreviations: C-section = Caesarean section Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript Figure 1. Pulsed Field Gel Electrophoresis Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofy159/5047440 by Ed 'DeepDyve' Gillespie user on 17 July 2018 Accepted Manuscript

Journal

Open Forum Infectious DiseasesOxford University Press

Published: Jul 2, 2018

There are no references for this article.