Dr. Thomas Vescio was reading lab reports in his office at Evanston Hospital early on the morning of Thursday, August 2, when he received an urgent call from the intensive care unit. A woman who’d delivered her first baby by cesarean section two days earlier had developed a high fever Wednesday night, along with pain in her belly. She’d been prescribed a broad-spectrum antibiotic, one effective against a wide range of infections, but she showed no improvement. Then, within hours, her blood pressure dropped sharply and her heart began beating erratically. Her breathing became difficult as her lungs began to stop absorbing oxygen, and her kidneys started to shut down.
The long horizontal abdominal incision is the most obvious point of infection in a postcesarean mother. To Vescio, the woman’s looked healthy, showing no inflammation and exuding no pus. In fact, that’s consistent with toxic shock, when bacteria produce toxins that kill the white blood cells that produce those symptoms. A surgical resident removed a few staples from the corner of her incision so Vescio could get a closer look. “The fluid that was inside there was clearly abnormal,” he says. “If you open a normal wound, it should bleed and the blood should be red. Her blood was brown and it didn’t clot the way it should.” He swabbed the inside of the wound and prepared a slide, rushing it to the hospital’s microbiology lab. Within 15 minutes his fears were confirmed. “We saw tons of bacteria classic for GAS.”
Infections, disease clusters, and epidemics occur in hospitals all the time. That’s why they staff epidemiologists like Vescio. But outbreaks of invasive Group A streptococci are uncommon occurrences inside a modern one such as Evanston. When one does occur–in geriatric wards or burn units, for example–it’s usually spread via physical contact between health-care workers and patients. In the aftermath, the Illinois Department of Public Health and other regulatory bodies investigate, and the hospital better have a good explanation of why it happened and what it’ll do to prevent it in the future.
For a variety of reasons, Semmelweis’s doctrine was misunderstood and ridiculed for years, and women continued to die by the thousands. It wasn’t until the latter part of that century that he was vindicated by the work of surgeon Joseph Lister and bacteriologist Louis Pasteur. By then he was dead–from a self-inflicted strep infection by some accounts. Says one biographer, he was “a martyr to the world’s stupidity.”
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Because of its rarity, and in spite of the media attention it receives, an invasive infection like necrotizing fasciitis is easily misdiagnosed. Frequently the point at which the bacteria invades the body is a barely noticed scratch or bruise. Later an infected person may complain of flulike symptoms: fever, sore throat, nausea, diarrhea, chills, or aches. Disproportionate soreness may be felt around the wound. If the patient reports to an emergency room he or she might be sent home with orders to take aspirin and rest. Meanwhile, the bacteria are rapidly multiplying along the fascia, the deep layers of skin and fatty tissue that separate the upper layers from the muscles. They produce enzymes that destroy tissue cells and stop clotting. As the necrosis spreads, the blood vessels that irrigate the fascia are destroyed, preventing blood, oxygen, and antibiotics from reaching the infected area.
Estimates of the mortality rate of patients with necrotizing fasciitis–which can also be caused by other bacteria–vary from 25 to 80 percent. If the patient goes into toxic shock, as Vescio’s did, it is around 50 percent. Survivors face a long and difficult recovery, negotiating secondary infections, extended wound care, painful scarring or amputations, physical therapy, plastic surgery, and emotional trauma.
Nowadays Vescio is most interested in HIV, but as a student he had heard of the handful of reports written on surgical-wound outbreaks of invasive GAS in the medical literature. Because of the high mortality rate of such cases and the speed at which they can develop into outbreaks, they tend to be cited in textbooks. “In infectious disease, when you’re in training,” says Vescio, “you learned that one case of Group A strep is reason for concern.” But few doctors have ever had to manage an outbreak, something Vescio discovered on August 2 when he called some of his older colleagues for advice.
