Notes from the Field: Invasive Group G β-Hemolytic Streptococcus Outbreak at a Long-Term Care Facility — Pennsylvania, 2024

Investigation and Outcomes

Patient Characteristics

Both patients, women aged >85 years, had underlying medical conditions. Patient A, a resident at the facility since 2021, had long-term bladder catheter use and cellulitis; after her hospitalization, she returned to the facility. Patient B, living at the facility since October 2024, had heart failure, multiple myeloma, chronic deep vein thrombosis, and cellulitis; patient B died 1 day after her acute hospital admission.

Assessment of IPC Practices

Review of facility IPC policies and practices and observation of wound care and hand hygiene identified numerous protocol breaches. The facility’s hand hygiene policy did not specify a preference for use of alcohol-based hand sanitizer in a majority of clinical situations, which differs from CDC guidance. Successful hand hygiene^† was observed during 22 (50%) of 44 instances during which hand hygiene was indicated. Observation of wound care among 13 residents identified infection control breaches^§ during all 13 occurrences, including not preparing a clean field before a procedure, improper handling^¶ of multidose topical medications, and moving from dirty to clean tasks without performing hand hygiene. PADOH provided written IPC and surveillance recommendations, based on experience with and guidelines for investigating and controlling GAS infections in LTCFs (3).

Identification of Colonization

In January 2025, using GAS guidelines (3), all residents receiving wound care (12 [17%] of 70, excluding patient A, who had returned to the facility) were screened for GGS colonization; throat swabs were collected from all 12 residents, and 15 wound swabs were collected from nine residents.** Throat swabs were also collected from the two staff members who provided wound care. Culture-based testing by the state public health laboratory identified two colonized patients through positive wound swab culture results; all throat swab test results were negative. In response to CDC and PADOH recommendations for GAS decolonization (3), a 10-day course of oral cephalexin was provided to the colonized residents. Repeat testing 30 days after starting antibiotics remained positive for both residents; one resident received a 10-day course of oral ampicillin, the second received a 10-day course of oral ciprofloxacin. Wound cultures were negative for both on subsequent testing.

Whole Genome Sequencing of Isolates

Four isolates (two blood culture isolates from patients A and B and two obtained from resident wound colonization screening) were sent to CDC for emm typing^†† and whole genome sequencing. All were emm type 2574.3 and previously uncharacterized multilocus sequence type 525; the high relatedness of the strains (1–2 single nucleotide polymorphism differences) suggests a common source.

Preliminary Conclusion and Actions

In an English-language literature search of PubMed using keywords “group G Streptococcus,” “Streptococcus dysgalactiae subsp. equisimilis,” and “long-term care facility,” no previous reports of an outbreak of invasive GGS at a LTCF in the United States were identified. High genomic relatedness among clinical and colonization isolates suggests intrafacility transmission, likely resulting from suboptimal IPC practices. The epidemiologic characteristics, outcomes, and patient risk factors identified in this investigation were similar to those observed in GAS outbreaks, including advanced patient age, chronic comorbidity, the presence of wounds, colonization of residents who share health care staff members, and severe outcomes among infected patients (3,5). In the absence of established guidance for GGS outbreak response in LTCFs, PADOH followed GAS guidance (3). No additional GGS infections have been reported by the facility. Jurisdictions might consider including GGS clusters in routine surveillance protocols. The public health response tools for GAS can likely be applied to outbreaks involving other groups of β-hemolytic Streptococcus in LTCFs.