JSTOR

Case Report

A 71‐year‐old man presented to the hospital complaining of respiratory distress. A chest radiograph showed right lower lobe consolidation. He was admitted to the hospital with a presumptive diagnosis of community‐acquired pneumonia. His general condition quickly worsened, leading to asystolic cardiac arrest. A physician and 3 nurses in the ward immediately initiated cardiopulmonary resuscitation. Although the physician who performed endotracheal intubation wore a surgical mask, all nurses assisting in this procedure and subsequent endotracheal suctioning did not wear a mask (because of a low perceived risk of acquisition of pathogens). Despite their efforts, the patient was dead 4 hours after his arrival in the hospital.

A sputum sample from the patient was cultured, and the isolate found was identified as S. pyogenes. As a result of our investigation into HCWs who had had contact with the patient, we recognized that 2 of the 3 nurses involved in the resuscitation had sore throat and fever. Therefore, we obtained throat swab samples from the 14 HCWs who had had any contact with the patient. S. pyogenes was recovered from cultures of the throat samples from the 2 symptomatic nurses; the throat swab samples of the remaining 12 HCWs were negative for S. pyogenes. The genotype of the isolates from the symptomatic nurses and the index patient was determined to be emm type 1 by means of sequencing of the emm gene, and all isolates showed an identical pattern in pulsed‐field gel electrophoresis. Both infected nurses lacked any regular contact with children. The infected nurses were given amoxicillin with no clinical sequelae.

Discussion

We describe the presumed transmission of S. pyogenes from a patient with fatal pneumonia to HCWs. Most likely, transmission occurred while HCWs performed resuscitation and placement of endotracheal tubes without wearing a mask. Given this occurrence, we reviewed previously published literature in which transmission of bacterial infections to HCWs as a result of the respiratory care of patients with severe pneumonia has been documented. Healthcare‐associated transmission of the respiratory viruses Mycobacterium tuberculosis, Bordetella pertussis, and Corynebacterium diphtheriae is well documented. To our knowledge, transmission of infection to HCWs following care of patients with severe pneumonia has been documented with only a small number of other bacterial pathogens—S. pyogenes, Neisseria meningitidis, Acinetobacter baumannii, and possibly Haemophilus influenzae (Table).

Table.  Published Cases of Healthcare Worker (HCW) Acquisition of Bacterial Pathogens from Patients with Severe Pneumonia

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There are several cases in which transmission of S. pyogenes to HCWs has been described,^3‐5^,9,10 including a number in which the acquisition was from patients with respiratory infection. Daneman et al reported 20 hospital outbreaks in a prospective study that involved a 9‐year period of surveillance for invasive S. pyogenes infections in Ontario, Canada.⁹ They found 6 cases of secondary transmission to HCWs in 13 outbreaks in which the colonization status of HCWs was investigated. Four of these 6 outbreaks included patients with respiratory infection (eg, pneumonia or tracheostomy site infection) as a possible source of the transmission.

Patients with pneumonia due to S. pyogenes have also been involved in 3 other reports of occupational acquisition by HCWs.^3‐5 The largest outbreak among HCWs, in which 24 HCWs were infected from a single patient, was reported by Kakis et al.⁵ All 16 HCWs who responded to the authors’ questionnaire answered that they had cared for the patient without wearing a surgical mask.⁵

Numerous cases of laboratory‐acquired and healthcare‐acquired N. meningitidis infection have been described, but, to our knowledge, just a single case report exists of HCW acquisition during care of a patient with meningococcal pneumonia.⁶ In this case, a nurse died of meningococcal meningitis after caring for a patient who was admitted to the intensive care unit with meningococcal pneumonia. It is not known whether the nurse wore a mask while caring for the patient.

A single case of presumed transmission of H. influenzae type b from an intensive care unit patient with pneumonia to a HCW has been described.⁷ A physical therapist caring for the patient became ill with pharyngitis, fever, and rigors. H. influenzae type b with the same biotype was isolated from culture samples of the physical therapist’s blood. Molecular typing was not performed, so it is impossible to be certain that there was truly acquisition by the HCW from the patient. The report does not comment on use of a face mask or other precautions.

Recently, occupational transmission of multidrug‐resistant A. baumannii to a HCW was also reported.⁸ The HCW developed severe Acinetobacter pneumonia (necessitating mechanical ventilation) after providing respiratory care including endotracheal suctioning to a patient with A. baumannii in the sputum. She was reported not to have worn a mask while providing respiratory care. Genotypically, her isolate and the patient’s isolate were identical.

Our case and these published cases have common backgrounds and can suggest important lessons. First, transmission of bacterial pathogens from patients with severe pneumonia to HCWs is extremely rare. We can find no documented reports of patient‐to‐HCW transmission of the most common cause of community‐acquired pneumonia, Streptococcus pneumoniae. Second, HCWs who acquired infection from patients did not comply with standard precautions (Table). Current Centers for Disease Control and Prevention guidelines recommend protection of the eyes, nose, and mouth, in addition to the wearing of a gown and gloves, during the performance of aerosol‐generating procedures such as endotracheal intubation and open suctioning of the respiratory tract.²

Should additional precautions (eg, droplet or airborne precautions) be used for care of patients with severe pneumonia? Droplet precautions are indicated during the first 24 hours of antimicrobial therapy in patients with N. meningitidis or S. pyogenes infections.² However, apart from suggestive evidence from Gram stain of respiratory secretions, it is typically impossible to be certain of these diagnoses within 24 hours of the patient's presentation at the hospital. Transmission‐based precautions are sometimes used when conditions carry a sufficiently high risk to warrant their use empirically while the results of confirmatory tests are pending.² For example, the presence of cough, fever, and upper lobe infiltrate mandates use of airborne precautions in addition to contact precautions, because of the risk of tuberculosis.² At the present time, given the lack of adherence to standard precautions in documented cases of infections acquired by HCWs, there is insufficient data to recommend that additional precautions be routinely used in the care of patients with severe pneumonia (Figure).

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Figure.  Prevention strategies for healthcare workers who encounter patients with severe pneumonia recommended in Siegel et al.² HIV, human immunodeficiency virus.

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Further study should focus on adherence, determinants of adherence, and evaluation of strategies and interventions to enhance adherence to standard precautions. Such studies could allow practical recommendations to be made that would facilitate increased adherence to these measures. In addition, it would be appropriate to perform well‐conducted prospective studies to assess the true risks of acquisition by HCWs of pathogenic bacteria from patients with severe pneumonia. In the meantime, adherence to standard precautions is the most important means of prevention of patient‐to‐HCW transmission of bacteria that cause severe pneumonia.