Exposure of healthcare workers to patients with rapidly fatal infections invariably raises concerns regarding the risk of occupational acquisition. We describe acquisition of Streptococcus pyogenes by 2 nurses from a patient with fatal pneumonia and review previously reported cases of transmission of bacterial pathogens from patients with pneumonia to healthcare workers

Baba, Hisashi

Hasegawa, Tadao

Hasegawa, Yoshinori

Iinuma, Yoshitsugu

Imaizumi, Kazuyoshi

Ohta, Michio

Paterson, David L.

University of Queensland eSpace

Transmission of Bacterial Infections to Healthcare Workers during Intubation and
Respiratory Care of Patients with Severe Pneumonia • 
Author(s): Hisashi Baba, MD, PhD; Yoshitsugu Iinuma, MD, PhD; Kazuyoshi Imaizumi, MD, PhD;
Yoshinori Hasegawa, MD, PhD; Tadao Hasegawa, MD, PhD; Michio Ohta, MD, PhD;
David L. Paterson, MD, PhD
Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 10 (October 2009), pp. 1019-
1021
Published by: Cambridge University Press on behalf of The Society for Healthcare Epidemiology of
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infection control and hospital epidemiology october 2009, vol. 30, no. 10
c o n c i s e c o m m u n i c a t i o n
Transmission of Bacterial Infections
to Healthcare Workers during Intubation
and Respiratory Care of Patients
with Severe Pneumonia
Hisashi Baba, MD, PhD;
Yoshitsugu Iinuma, MD, PhD;
Kazuyoshi Imaizumi, MD, PhD;
Yoshinori Hasegawa, MD, PhD;
Tadao Hasegawa, MD, PhD;
Michio Ohta, MD, PhD;
David L. Paterson, MD, PhD
Exposure of healthcare workers to patients with rapidly fatal infec-
tions invariably raises concerns regarding the risk of occupational
acquisition. We describe acquisition of Streptococcus pyogenes by 2
nurses from a patient with fatal pneumonia and review previously
reported cases of transmission of bacterial pathogens from patients
with pneumonia to healthcare workers.
Infect Control Hosp Epidemiol 2009; 30:1019-1021
Large outbreaks of severe acute respiratory syndrome (SARS)
in healthcare settings, as well as the potential for pandemic
influenza, highlight the threat of transmission of respiratory
pathogens to healthcare workers (HCWs).1,2 Aerosol-gener-
ating procedures (eg, endotracheal intubation or suctioning)
increase the risk of HCW infection substantially.1 Even out-
side the setting of SARS or influenza, patients with life-threat-
ening pneumonia raise concerns for HCWs regarding the
potential for acquisition of pathogenic organisms. In this re-
port, we describe suspected transmission of Streptococcus py-
ogenes from a patient with severe pneumonia to HCWs and
review published cases of transmission of bacterial infec-
tions to HCWs that occurred during care of patients with
pneumonia.
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 imme-
diately initiated cardiopulmonary resuscitation. Although the
physician who performed endotracheal intubation wore a sur-
gical mask, all nurses assisting in this procedure and subse-
quent 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 pa-
tient, we recognized that 2 of the 3 nurses involved in the
resuscitation had sore throat and fever. Therefore, we ob-
tained 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 amox-
icillin with no clinical sequelae.
discussion
We describe the presumed transmission of S. pyogenes from
a patient with fatal pneumonia to HCWs. Most likely, trans-
mission occurred while HCWs performed resuscitation and
placement of endotracheal tubes without wearing a mask.
Given this occurrence, we reviewed previously published lit-
erature 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 tuber-
culosis, Bordetella pertussis, and Corynebacterium diphtheriae
is well documented. To our knowledge, transmission of in-
fection to HCWs following care of patients with severe pneu-
monia has been documented with only a small number of
other bacterial pathogens—S. pyogenes, Neisseria meningitidis,
Acinetobacter baumannii, and possibly Haemophilus influen-
zae (Table).
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 in-
fection. 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
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1020 infection control and hospital epidemiology october 2009, vol. 30, no. 10
table. Published Cases of Healthcare Worker (HCW) Acquisition of Bacterial Pathogens from Patients with Severe
Pneumonia
Reference Pathogen Infected HCW(s) Possible risky procedure(s) HCW(s) wore mask
[3] Streptococcus pyogenes 2 nurses Respiratory care in ICU No
[4] S. pyogenes 6 nurses (3 definitive
and 3 possible cases)
Unknown Unknown
[5] S. pyogenes 24 HCWs in ED or ICU Intubation and respiratory care
in ED or ICU
No, 16; unknown, 8
PR S. pyogenes 2 nurses Resuscitation and assistance in
intubation
No
[6] Neisseria meningitidis 1 nurse Unspecified care of patient with
meningococcal pneumonia
Unknown
[7] Haemophilus influenzae 1 physiotherapist Physiotherapy for patient in ICU Unknown
[8] Acinetobacter baumannii 1 nurse Respiratory care including endo-
tracheal suctioning in ICU
No
note. ED, emergency department; ICU, intensive care unit; PR, present report.
figure. Prevention strategies for healthcare workers who encounter patients with severe pneumonia recommended in Siegel et al.2 HIV,
human immunodeficiency virus.
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-ac-
quired N. meningitidis infection have been described, but, to
our knowledge, just a single case report exists of HCW ac-
quisition during care of a patient with meningococcal pneu-
monia.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 de-
veloped severe Acinetobacter pneumonia (necessitating me-
chanical ventilation) after providing respiratory care includ-
ing 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 back-
grounds and can suggest important lessons. First, trans-
mission 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 in-
fection from patients did not comply with standard precau-
tions (Table). Current Centers for Disease Control and Pre-
vention 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
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bacterial transmission to hcws 1021
such as endotracheal intubation and open suctioning of the
respiratory tract.2
Should additional precautions (eg, droplet or airborne pre-
cautions) 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 evi-
dence 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 man-
dates use of airborne precautions in addition to contact pre-
cautions, 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 pneu-
monia (Figure).
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 fa-
cilitate 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 transmis-
sion of bacteria that cause severe pneumonia.
acknowledgments
Potential conflicts of interest. All authors report no conflicts of interest rel-
evant to this article.
From the Department of Infectious Diseases, Nagoya University Hospital
(H.B.), the Departments of Respiratory Medicine (K.I., Y.H.) and Molecular
Bacteriology (M.O.), Nagoya University Graduate School of Medicine, and
the Department of Bacteriology, Nagoya City University Graduate School of
Medical Sciences (T.H.), Nagoya; the Department of Clinical Laboratory
Medicine, Kyoto University Graduate School of Medicine, Kyoto (Y.I.), Japan;
the University of Queensland Centre for Clinical Research (H.B., D.L.P.),
and the Centre for Healthcare Related Infection Surveillance and Prevention
(D.L.P.), Brisbane, Queensland, Australia.
Address reprint requests to Hisashi Baba, University of Queensland Centre
for Clinical Research, Level 8, Building 71/918 Royal Brisbane and Women’s
Hospital Campus, Herston, QLD 4029, Australia (hibab@med.nagoya-u.ac
.jp).
Received April 8, 2009; accepted May 12, 2009; electronically published
August 31, 2009.
 2009 by The Society for Healthcare Epidemiology of America. All rights
reserved. 0899-823X/2009/3010-0015$15.00. DOI: 10.1086/606043
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Transmission of bacterial infections to healthcare workers during intubation and respiratory care of patients with severe pneumonia

Hisashi Baba

Yoshitsugu Iinuma

Kazuyoshi Imaizumi

Yoshinori Hasegawa

Tadao Hasegawa

Michio Ohta

David L. Paterson

Crossref

Transmission of Bacterial Infections to Healthcare Workers during Intubation and Respiratory Care of Patients with Severe Pneumonia

http://espace.library.uq.edu.au/view/UQ:198625/UQ198625_OA.pdf

Transmission of bacterial infections to healthcare workers during intubation and respiratory care of patients with severe pneumonia

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