Case Definitions: Reportable Streptococci DRSP, GBS, GAS

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Case DefinitionsReportable Streptococci
(DRSP, GBS, GAS)

• Maria del Rosario, MD, MPH
• WVDHHR/BPH/IDEP
• IDEP Training - February 2008

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Objectives

• To distinguish S. pneumoniae, Group A
  streptococci (GAS) and Group B streptococci (GBS)
  from each other and the disease they cause.
• To describe how to ascertain reportable diseases
  due to S. pneumoniae, GAS, and GBS.
• To illustrate how to complete missing information
  necessary to ascertain a case.

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Definition of Terms (1)

• Sterile site
• Parts of the human body are colonized by various
  microorganisms. There are parts of the body that
  are normally sterile (no microorganisms). If
  there is a defect or a breach in the defenses,
  organisms can gain entry into these sites.
• e.g. brain, spinal fluid, blood, tissues, organ
  systems
• Invasive Disease
• Disease signs and symptoms due to the presence of
  the organism in normally sterile site/s.
• e.g. meningitis, septicemia (blood infection)

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Definition of Terms (2)

• Antimicrobial susceptibility
• Microorganisms are tested to identify the
  antimicrobial agents that they are susceptible
  to. This information is used to help
  appropriately treat the patient.
• Susceptible organism is vulnerable to the
  antimicrobial
• Intermediate organism is somewhat affected by
  the antimicrobial (i.e. at high doses, combo
  drugs)
• Resistant (nonsusceptible) organism is
  unaffected by the antimicrobial
• Isolate organism

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The Streptococci

• Gram-positive bacteria that grow in beadlike
  chains
• Many types but only a few cause disease in man
• 3 types of strep that are of interest
• Non ?-hemolytic streptococci
• Streptococcus pneumoniae
• ?-hemolytic streptococci
• Group A streptococci
• Group B streptococci

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3 Types of Strep
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Streptococcal Diseases Reporting (1)

• When and what to report
• Immediately for outbreaks
• Report all cases
• e.g. 2 or more cases occuring in a facility
  within a short period of time
• Within 1 week of diagnosis for sporadic cases
• i.e. Invasive disease (refer to slide 6 and 7 for
  details)
• Who should report
• Providers, labs, health departments, etc.
• WVEDSS Forms at IDEP website use for disease
  reporting
• For details see WV rule at http//www.wvdhhr.org/i
  dep/PDFs/IDEP/Reportable20Diseases_20Conditions_
  20Events_07.pdf

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Streptococcal Diseases Reporting (2)

• A. Streptococcus pneumoniae
• Streptococcus pneumoniae, Drug-Resistant Invasive
  Disease (DRSP)
• Invasive Disease Non-Drug Resistant, in Children
  Less Than 5 Years of Age (Invasive Pneumococcal
  Disease, IPD)
• Invasive Disease Non-Drug Resistant, among those
  5 years of age and older

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Streptococcal Diseases Reporting (3)

• B. Streptococcus pyogenes
• Invasive Group A Streptococcal (GAS) Disease
• Streptococcal Toxic Shock Syndrome (STSS)
• C. Streptococcus agalactiae
• Invasive Group B Streptococcal (GBS) Disease
• Organism isolated from placenta and/or amniotic
  fluid with fetal demise

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Streptococcus pneumoniae (1)

• Drug-resistant S. pneumoniae (DRSP)
• Report in WVEDSS as Drug Resistant Streptococcus
  pneumoniae

Case Definition
Clinical description Invasive disease
(meningitis, bacteremia, etc.) at any age

Lab criteria 1 Isolation of S. pneumo from a
normally sterile site (blood, CSF, joint, pleural
fluid, etc.)

Lab criteria 2 "Nonsusceptible" isolate (i.e.,
intermediate- or high-level resistance of S.
pneumoniae isolate to at least 1 antimicrobial
agent currently approved for use in treating
pneumococcal infection) Lab criteria 2a
determined by oxacillin screening Lab criteria
2b determined by quantitative MIC method
NCCLS recommends that all invasive S. pneumoniae
isolates found to be possibly resistant to
beta-lactams (i.e., an oxacillin zone size of
less than 20 mm) by oxacillin screening should
undergo further susceptibility testing by using a
quantitative MIC method acceptable for
penicillin, extended-spectrum cephalosporins, and
other drugs as clinically indicated.
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Streptococcus pneumoniae (2)

• Drug-resistant S. pneumoniae (DRSP)
• Case classification
• Probable a clinically compatible case caused by
  laboratory-confirmed culture of S. pneumoniae
  identified as "nonsusceptible" (i.e., an
  oxacillin zone size of less than 20 mm) when
  oxacillin screening is the only method of
  antimicrobial susceptibility testing performed
  (lab criteria 1 and 2a only)
• Confirmed a clinically compatible case that is
  laboratory confirmed (lab criteria 1, 2a, 2b)

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Streptococcus pneumoniae (3)

• Invasive Pneumococcal Disease (IPD), non-drug
  resistant among
• Case definition

Clinical description Invasive disease
(meningitis, bacteremia, etc.) in children
years of age

Lab criteria 1 Isolation of S. pneumo from a
normally sterile site (blood, CSF, joint, pleural
fluid, etc.)

Lab criteria 2 S. pneumo is drug-susceptible or
susceptibility not available
Report in WVEDSS as Streptococcus pneumoniae in
children less than age 5.
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Streptococcus pneumoniae (4)

• Invasive Pneumococcal Disease (IPD) non-drug
  resistant among
• Case classification
• Confirmed a clinically compatible case in a
  child less than five years of age caused by
  laboratory-confirmed culture (lab criteria 2) of
  S. pneumoniae from a normally sterile site (lab
  criteria 1)

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Streptococcus pneumoniae (5)

• Invasive Pneumococcal Disease (IPD) non-drug
  resistant among 5 years old
• Case definition

Clinical description Invasive disease
(meningitis, bacteremia, etc.) in children 5
years of age

Lab criteria 1 Isolation of S. pneumo from a
normally sterile site (blood, CSF, joint, pleural
fluid, etc.)

Lab criteria 2 S. pneumo is drug-susceptible or
susceptibility not available
Report in WVEDSS as Streptococcus pneumoniae,
all other
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Example 1 S. pneumoniae report
Background On 01/16/08, VAMC ICP calls to let
you know that shes faxing you a lab report on
Mr. Seek. Mr. Seek is diagnosed with pneumonia,
currently on respiratory support and is on
multiple antibiotics may have sepsis. The
specimen was from a sputum sample.
Beckley VAMC Laboratory Microbiology Name
Seek, Barry Age 85 years old Collection Date
Jan. 1, 2008 Completed Jan. 14, 2008 Provider
Dr. Will Treat Collection sample
sputum Result - Growth of Streptococcus,
possible Strep. pneumoniae
What next ?
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Example 1 S. pneumoniae report

• Clinical description
• Invasive disease? Pneumonia, sepsis
• Lab Result
• Organism S. pneumo
• Type of test Culture
• Source of specimen sputum
• ?
• What next
• Review the protocol. Investigate ?
• Pending additional information (labs)? NO ?
  STOP, not reportable
• ? YES
• Lab Result
• Blood culture S. pneumo (collected 1/8/2008,
  completed 01/17/08)
• ?
• What next
• Investigate - Clinical information, etc.
• Additional info
• Susceptibility available? NO ? Strep pneumo, All
  Other (IPD5 years)

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Example 1 S. pneumoniae report
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Example 1 S. pneumoniae report
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Example 1 S. pneumoniae report
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Example 1 S. pneumoniae report

• Lab Result
• Bacterial sensitivities Streptococcus pneumoniae
  (blood)
• Type of Test Oxacillin disk diffusion
• Result Oxacillin zone size 15 mm (reference
  20 mm)
• ?
• What next
• Investigate ?
• Pending additional information (labs)? NO ?
  DRSP, probable
• ? YES
• Lab Result
• Bacterial sensitivities Streptococcus pneumoniae
• Type of Test E-test
• Result
• Levofloxacin 0.75 susceptible
• Penicillin 0.1 intermediate ? DRSP,
  confirmed
• Vancomycin 0.38 susceptible

• What next
• Complete investigation
• Send isolate to OLS for further testing
  (serotyping)

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Example 1 S. pneumoniae report
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Example 1 S. pneumoniae report

• Complete the Investigation
• Review and edit WVEDSS form as needed

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Streptococcus pyogenes (1)

• Invasive Group A Streptococcal (GAS) disease
• Case definition
• Report in WVEDSS as
• Streptococcal Disease, Group A Invasive

Invasive disease (e.g. pneumonia,
bacteremia/sepsis, myositis or necrotizing
fasciitis, meningitis, peritonitis,
osteomyelitis, septic arthritis)

Isolation of group A Streptococcus by culture
from a normally sterile site (e.g. blood or
cerebrospinal fluid, joint, pleural, or
pericardial fluid)

• Case Classification
• Confirmed - a case that is laboratory confirmed

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Streptococcus pyogenes (2)

• Streptococcal Toxic Shock Syndrome (STSS)
• Case definition
• Clinical manifestations occurring within the
  first 48 hours of illness or hospitalization
• Hypotension, AND
• Multi-organ involvement characterized by 2 or
  more of the following
• Renal impairment
• Coagulopathy
• Liver involvement
• Acute respiratory distress syndrome
• A generalized erythematous macular rash that may
  desquamate
• Soft-tissue necrosis (necrotizing fasciitis,
  myositis, gangrene)
• Isolation of group A Streptococcus (S. pyogenes)
  by culture from a normally sterile site (blood,
  CSF, joint, pleural, or pericardial fluid).
• Report in WVEDSS as Streptococcal Toxic Shock
  Syndrome.
• ______________
• See details at http//www.cdc.gov/epo/dphsi/case
  def/streptococcalcurrent.htm

• Case Classification
• Confirmed - a case that is laboratory confirmed

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Example 2 Group A strep report

• Background
• Provider calls about a child with chickenpox for
  5 days. Has had sore throat for a few days
  still has fever. Generalized numerous pox
  lesions. Now right leg is red, tender and
  swollen, with one draining pox lesions. Provider
  faxes the lab to you. Child has been on
  Erythromycin X 1 day.

CAMC Laboratory Microbiology Name Bubu,
Mai Age 6 years old Collection Date Jan. 2,
2008 Completed Jan. 8, 2008 Provider Dr. Babe
E. Dock Collection sample throat swab Culture
Result - Heavy growth of Streptococcus
pyogenes
Whats next ?
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Example 2 Group A strep report

• Clinical description
• Invasive disease?
• Lab Result
• Organism S. pyogenes
• Type of test Culture
• Source of specimen throat swab
• ?
• Whats next?
• Review protocol. Investigate ?
• Pending additional information (labs)? NO ?
  STOP, not reportable
• ? YES
• Lab Result?
• Blood culture Streptococcus pyogenes
• ?
• Streptococcal Disease, Invasive Group A

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Example 2 Group A strep report
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Example 2 Group A strep report
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Example 2 Group A strep report
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Example 2 Group A strep report
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Example 2 Group A strep report
Complete the investigation. Review the form and
make changes accordingly.
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Streptococcus agalactiae (1)

• Invasive Group B Streptococcal (GBS) disease

Manifest as invasive disease (sepsis, pneumonia,
meningitis, osteomyelitis, septic arthritis,
amnionitis, urinary tract infection) and
stillbirth
Isolation of group B Streptococcus from a
non-sterile site such as placenta and/or amniotic
fluid with fetal demise

Isolation of group B Streptococcus by culture
from a normally sterile site (blood or CSF,
joint, pleural, or pericardial fluid, surgical
aspirate, bone, joint fluid, or internal body
site )

• Report in WVEDSS as
• Streptococcal Disease, Group B Invasive
• Case Classification
• Confirmed - a case that is laboratory confirmed

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Example 3 Group B strep report
Background Laboratory report mailed to your
health department
LabCorp Dublin, OH Name Brown, Ann Age 28
years old Collection Date Dec. 21,
2007 Completed Dec. 2 8, 2008 Provider Dr.
Smith Collection sample placenta Culture
Result - Streptococcus agalactiae
Whats next ?
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Example 3 Group B strep report

• Lab Result
• Organism S. agalactiae
• Type of test Culture
• Source of specimen placenta
• ?
• Whats next?
• Review protocol. Investigate ?
• What additional information do you need to
  ascertain a case?
• Clinical description fulfilled? NO ? STOP, not
  reportable
• ? YES
• Streptococcal Disease, Invasive Group B
• ?
• What next?

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Example 3 Group B strep report
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Example 3 Group B strep report
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References