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GAS Outbreak Final Report 0913

GAS Outbreak Final Report 0913

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GAS Outbreak Final Report 0913
GAS Outbreak Final Report 0913

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Published by: abc2news on Sep 23, 2013
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11/19/2013

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SUMMARYREPORTOUTBREAK2012-235
September 2013Office of Infectious Disease Epidemiology and Outbreak ResponsePrevention and Health Promotion AdministrationMaryland Department of Health and Mental Hygiene
 
1Outbreak Summary Report 2012-235Outbreak #2012-235 Final Report
INTRODUCTION
On September 17, 2012, the Maryland Department of Health and Mental Hygiene (DHMH) received acall from the infection control department at a large acute care hospital in Baltimore City (Hospital A). Atrauma physician noted three similar cases of severe invasive Group-A Streptococcus (GAS) infection,one fatal, in patients who had recently received liposuction at the same medical spa facility (Facility A)located in Timonium, Baltimore County, MD. Ultimately, cases associated with related facilities in otherstates were identified; however, this report summarizes the joint DHMH – Baltimore CountyDepartment of Health investigation of cases associated with the facility in Maryland.
BACKGROUND
Facility A was a self-described medical spa where patients received elective, self-pay cosmeticprocedures such as laser removal of hair and tattoos, dermal fillers, botulinum toxin injections, andliposuction, a surgical procedure. Unlike other ambulatory surgical centers, which are regulated by theDHMH Office of Healthcare Quality, cosmetic surgical centers, also sometimes called medical spafacilities, were not licensed as healthcare facilities in Maryland if they did not accept payment from aninsurer or other third party payor. The total number of such cosmetic surgical centers in Maryland iscurrently unknown.Liposuction is the removal of excess subcutaneous fat using a suction-assisted aspiration cannula. In2012, there were over 200,000 liposuction procedures performed in the United States
1
. A commonmethod of liposuction is the tumescent method, which involves infusing fluid with lidocaine andepinephrine subcutaneously. Lidocaine provides local anesthesia, epinephrine minimizes surgicalbleeding, and the use of the fluids causes the targeted area to become swollen and firm. An ultrasoundor laser is also used to rupture fat cells prior to suctioning.Liposuction complications are rare, occurring in 0.1-0.5% of procedures
2
. The complication rate of liposuction using the tumescent method is 0.7%
3
. Fatal outcomes have been reported in 1 out of 5,000liposuction procedures
4
. Other complications that have been associated with liposuction include
1
American Society of Plastic Surgeons, 2012 Plastic Surgery Statistics Report.http://www.plasticsurgery.org/Documents/news-resources/statistics/2012-Plastic-Surgery-Statistics/full-plastic-surgery-statistics-report.pdf 
2
Desrosiers A. et al. Don’t try this at home: liposuction in the kitchen by an unqualified practitioner leads todisastrous complications.
Plastic and Resonstr Surg
. 2004:113(1):460-461.
3
Hanke W, Cox SE, Kuznets N, Coleman WP,3rd. Tumescent liposuction report performance measurementinitiative: National survey results. Dermatol Surg. 2004;30(7):967-77; discussion 978. doi: 10.1111/j.1524-4725.2004.30300.x.
4
Grazer FM et al. Fatal outcomes from liposuction: census survey of cosmetic surgeons.
Plast. Reconstr. Surg.
2000; 105:436.
 
2Outbreak Summary Report 2012-235perforation, pulmonary or arterial embolism, hemorrhage, cardiac arrest, shock, pulmonary edema,infection, and sepsis
5
.Group-A
Streptococcus
(GAS) is a gram-positive bacterium that is most often detected in the throat andon the skin. These bacteria are spread through direct contact with mucus from the nose or throat of persons who are infected or through contact with infected wounds or sores on the skin. The bacteriacan also be carried by asymptomatic individuals (called “carriers”) for long periods of time, and whilecarriers are less contagious than those with active infection, they are still capable of transmitting thebacterium that can cause disease. Most GAS infections are relatively mild. The most common GASinfections are “strep throat” and impetigo, a mild skin infection. Occasionally these bacteria can causesevere and even life-threatening diseases when they infect normally sterile body sites, such as blood,muscle, or the lungs, resulting in a condition called “invasive GAS”. Examples of forms of invasive GASare necrotizing fasciitis and streptococcal toxic shock syndrome. Risk factors for invasive GAS includediabetes, drug use, immunosuppression, recent surgery, and traumatic wounds. Mortality rates of invasive GAS are 10-15%. There is approximately a 25% mortality rate associated with invasive infectionresulting in necrotizing fasciitis. Antibiotics can be used to treat both mild and invasive infections. Forthose with invasive disease, treatment in an intensive care unit and surgery to remove damaged tissuemay be necessary. About 9,000-11,500 cases of invasive GAS infections occur each year in the UnitedStates, resulting in 1,000-1,800 deaths annually.
6
Invasive GAS is a reportable condition in Maryland. Upon diagnosis of a case of invasive GAS, cliniciansand/or laboratories submit a report to their local health department for entry into the Marylandnotifiable disease database. Between 2007-2011, there were 946 total cases of invasive GAS inMaryland, and an average of 189 cases of invasive GAS are reported annually.
7
In the healthcare setting, surgical and obstetric patients are most vulnerable to GAS due to the break inmucosal or cutaneous barriers that occurs during these procedures. Group A Strep infection followingsurgery and childbirth is still a very rare occurrence, with GAS being the cause of only 1% of all surgicalsite infections, and 3% of infections after vaginal delivery. Since 1965, there have been at least 15 post-op or post-partum outbreaks of GAS infections attributed to asymptomatic carriage in healthcareworkers.
8
Appropriate infection control measures may help prevent or interrupt transmission from healthcareworker to patient. In addition, per Centers for Disease Control and Prevention (CDC) guidance, once apostsurgical or postobstetrical patient is suspected or identified with GAS, enhanced surveillance andepidemiologic investigation should immediately follow. Screening of all healthcare workers present inthe procedure room, as well as those who had some kind of contact with open wounds, should takeplace. Recommended body sites for screening include the nares, throat, vagina, rectum, and skin.
5
Lehnhardt M et al. Major and Lethal Complications of Liposuction: A Review of 72 Cases in Germany between1998 and 2002, Plastic and Reconstructive Surgery, June 2008, 121(6), 396e-403e.
6
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/groupastreptococcal_g.htm
7
Unpublished DHMH data
8
MMWR Weekly Report, Mar 05, 1999, 48(08): 163-166

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