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Last Updated Sept 2018

Clinical Staff Annually

• Avoid printing this document if possible

• Please ensure you read and complete the multiple choice questions at

the end of the Workbook

• Please email your answers to Infection.prevention@anhst.nhs.uk You must score 8 correct answers to update your mandatory training. If you fail to achieve this, you will be asked to attend the Infection Prevention Level 2 face to face session offered twice a month in the lecture theatre.

Infection Prevention Level 2

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• More serious illness

• Prolonged stay in a health care facility

• Long-term disability

• Excess deaths

• High additional financial burden

• High personal cost on patients and their families

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Introduction

Good infection control is essential to ensure that people who use Health and Social Care Services receive safe and effective care. Effective prevention and control of infection must be part of everyday practice and be applied consistently by everyone.

Good management and organisational processes are crucial to make sure that high standards of infection prevention and control are set up and maintained.

As the regulator of Health and Adult Social Care in England, the Care Quality Commission (CQC) will provide assurance that the care people receive meets essential levels of quality and safety.

The Health and Social Care Act outlines what hospitals in England need to do to ensure compliance with the registration requirement for cleanliness and infection control, and sets out 10 compliance criteria.

1. Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible patients are and any risks that their environment and other patients may pose to them.

2. Provide and maintain a clean and appropriate environment in managed premises that facilitate good hygiene practices.

3. Provide suitable and accurate information on infections to patients and their visitors.

4. Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion.

5. Ensure that people who have/develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.

6. Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.

7. Provide or secure adequate isolation facilities. 8. Secure adequate access to laboratory support as appropriate. 9. Have and adhere to policies designed for the individual’s care and provider

organisations that will help to prevent and control infections. 10. Ensure, so far as reasonably practicable, that care workers are free of and are

protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care. The Health and Social Act 2008

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Infection Prevention The term HCAI (Health Care Associated Infection) covers a wide range of infections. The most well-known include those caused by methicillin resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C.diff) and Escherichia coli (E.coli).

HCAIs cover any infection contracted:

as a direct result of treatment in, or contact with, a health or social care setting as a direct result of healthcare delivery in the community as a result of an infection originally acquired outside a healthcare setting (for

example, in the community) and brought into a healthcare setting by patients, staff or visitors and transmitted to others within that setting (for example, Norovirus).

Infection prevention and control is a key priority for the NHS, and Public Health England (PHE) has a responsibility to advise and support the NHS and others in their efforts to prevent HCAIs and any associated risks to health.

In 2011 and 2016, Airedale hospital took part in the Europe wide point prevalence survey of hospital acquired infection. Our HCAI rate has dropped from 6.8% to 5.5% which is excellent news and which shows that staff are ‘adhering to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.’ (Criteria 9)

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Staphylococcus Aureus Gram positive skin organism

Methicillin (Flucloxacillin) sensitive staphylococcus aureus (MSSA)

All bloodstream infections reported to PHE. Post infection review for hospital acquired cases.

Can cause minor skin infections:

• (pimples, • impetigo, • boils, • cellulitis, • folliculitis, • abscesses

Can cause life-threatening diseases:

• pneumonia • meningitis • osteomyelitis • endocarditis • bacteraemia • Orthopaedic joint infections

Can produce Toxins

Key themes seen:

Staph aureus blood stream infections

Source: unobserved cannulae becoming infected.

Prevention

• Good hand hygiene of staff members and patients. • Encourage patients not to touch invasive devices • Check cannulas twice a day for signs of infection • Encouraging patients to wash or shower every day • Ensuring wounds are clean and covered • Wear aprons for changing bed linen • Don’t sit on beds

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Staphylococcus Aureus

Staphylococcus aureus (S. aureus) is a Gram positive bacterium that commonly colonises human skin and is carried in the nose, throat, axillae, toe webs and perineum without causing infection. Once the bacteria gains access to the body, for example through a cannula site or a surgical procedure, a mild to life-threatening infection may develop. S. aureus, (whether MSSA or MRSA) is one of the most common culprits associated with orthopaedic implant infections. Patients with an Orthopaedic joint, with a S. aureus bacteraemia may go on to develop an implant infection in around 34% of cases. (Clinical services Journal 2010)

S. aureus can produce toxins which can cause:

Scalded skin syndrome which attacks skin cells, causing them to split causing large red weeping areas. Paediatrics patients and neonates are more at risk.

Toxic shock syndrome causing hypotension, fever, diarrhoea, skin shedding rash.

Enterotoxin causes acute sudden onset gastroenteritis, when food is contaminated with S. Aureus, by interfering with electrolyte imbalance in the gut.

Panton-Valentine Leukocidin (PVL) is a toxin that destroys white blood cells and causes extensive tissue necrosis and severe infection. It is carried by < 2% of isolates of S. aureus, (See Management of PVL associated Staphylococcus aureus infections (PVL-SA) Guideline on Aireshare)

Preventing the spread of infection Therefore good hand hygiene of both staff members and patients is needed to prevent transferring the germ around the ward/ hospital.

• Staff should wear clean clothes or uniforms daily.

• Staff should wear an apron for changing bed linen to prevent skin cells getting on their uniform and should dispose of used linen straight into a linen skip at the bed side, to prevent skin cells from becoming airborne. Hand gel should be applied between beds.

• Staff should cover any cuts or abrasion with waterproof plasters to prevent themselves from getting wound infections from germs found in the hospital

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environment. (Contamination injury)

• Staff and visitors should not sit on patients beds to prevent the transfer of organisms to or from the patient.

Methicillin (Flucloxacillin) resistant

Staphylococcus Aureus (MRSA) Rising numbers of mupirocin resistance

Screening Programme (Acute and some elective patients)

Management of cases/expectations

All bloodstream infections reported to PHE

Post infections reported to PHE

Post infection review for Hospital Acquired Cases

Staphylococcus aureus that are resistant to Flucloxacillin are called MRSA as Methicillin was the previous antibiotic used before Flucloxacillin came on the market. MRSA can vary in resistance to other antibiotics. Our bacteraemia (or blood stream infection) target is Zero MRSA Blood stream infections.

Screening Programme All acute admissions to hospital get screened for MRSA and some elective patients. This is due to a DoH study that found that only 1% of elective admissions were MRSA colonised. The exceptions are patients coming for elective orthopaedic operations, pacemaker insertion and breast reconstruction surgery as the surgery is considered a high risk of infection.

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Mupirocin resistant

Since January 2017 we have seen a large increase in Mupirocin (Bactroban) resistant MRSAs. This is partly due to the germ becoming more resistant and the lab using more sensitive testing equipment that picks up more cases than we would through the agar plate method that was previously used. When the germ is resistant to Mupirocin (Bactroban) we have a second line treatment that should be used.

Management of cases/expectations

If a patient is found to be colonised from a nasal screen or infected from a swab/sample, they should be isolated (gold standard) or nursed in a bay with other low risk patients who have no wounds, catheters or cannulas. The patient is prescribed 5 days of nasal antibiotic cream and 5 days of antiseptic body wash which supresses the MRSA present on the skin and allows healthy skin flora to take its place. (NB: Naseptin (used for pregnant mums) nasal cream is a 10day course.) The MRSA patient information leaflet explains how to correctly apply the suppression. Medical staff will decide treatment of any positive swab (e.g. wound) or sample (e.g. urine) with the microbiologist. The MRSA carepathway (Infection prevention Aireshare page) informs you of all the necessary actions that are needed to prevent further spread of infection whilst caring for the patient.

Post Infection Reviews

Any MRSA blood stream infection will have a post infection review (PIR), where nursing and medical staff meet to look at how the patient got the infection, whether it was preventable or unpreventable and lessons learned.

MRSA Alert symbol! The yellow IC triangle symbol above the patients name on the SystmOne ward board identifies that the patient as having a history of MRSA colonisation or infection. For more information, see MRSA Management Guideline’ on AireShare.

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MRSA Screening Patient groups to be screened:

• All adult general acute admissions

• Patients admitted to/attending high risk areas as per individual departmental

protocols

• Elective orthopaedic, pacemaker insertion and breast implant patients at pre-

assessment.

MRSA colonistion suppression to be started on:

• Patients found to be MRSA positive on screening

• All patients admitted from a nursing/residential home

• All acute orthopeadic patients on admission if over 65 years of age

Please remember to screen any invasive device that the patient has insitu on admission for MRSA, aswell as their nasal screen. MRSA may be colonising these sites (as it is a skin organism) but may precede to cause an infection if staff are not aware.

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Winning the Battle Against MRSA

Invasive devices can be an entry point for infection. Preventing a Catheter associated urine infection

• Urinary catheters bypass the body’s natural defence of the flushing action of

urine. • They are frequently responsible for hospital acquired urinary tract infections

and are the most common source of bloodstream infections here at Airedale. • Germs can enter the urinary tract due either to poor aseptic technique on

insertion, as a result of contamination by staff members’ hands during handling of the device, poor personal hygiene of the patient, lack of post insertion

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catheter care or simply the catheter bag touching the floor thus allowing germs access to the device.

Please ensure that the Urinary Catheter Monitoring Bundle is correctly filled in daily. It also conatins

Monitoring peripheral cannulae/central lines for signs of infection

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Peripheral Vascular Catheter (PVC) Infection There are four possible pathways leading to peripheral vascular catheter (PVC) infection.

First: Migration of microbes down the catheter tract i.e. through the ‘wound’ created to insert the catheter. These microbes may be from the patient’s skin, or contaminated disinfection or the healthcare worker’s hands. The process may happen on insertion if the catheter is contaminated and then introduced into the patient or via microbiologic migration at any time while the catheter is in situ. The insertion of a PVC provides a portal or entry for bacteria to cross from an unsterile external environment to the normally sterile blood.

Second: The second route is via the catheter hub, which can become contaminated by healthcare workers’ or patients’ skin flora during connection of fluids, medicine administration or during extraction of blood. Nishikawa reported that bacterial contamination was more common in the hub area than indwelling catheter segments, and the hub seems an important risk in post-insertion care, in addition to adequate aseptic technique on catheter insertion (Nishikawa et al, 2010; Zingg and Pittet, 2009)

Third: The third route is for catheters to be contaminated directly by bacteria circulating in the bloodstream. That is, the patient has an existing bloodstream infection and microbes are able to attach to the catheter as they pass by the device.

Fourth: The fourth is that of contaminated infusate which may occur at the manufacturing stage (intrinsic) or during manipulation by healthcare workers (extrinsic). Research confirms that infusates other than water, including heparin, have great potential to form crystals in the intraluminal surface of PVCs, which can induce bacterial attachment and colonisation. (Nishikawa et al, 2010).

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A microbial attachment on the PVC surface is likely to be followed by biofilm development and maturation and dispersion of microbial cells from the biofilm into blood stream. The most frequently isolated bacteria from PVCs are coagulase-negative staphylococci and staphylococcus aureus. These bacteria can originate from the skin flora of the patient or the hands of healthcare workers and then reach the patient’s tissues and organs via the blood, causing serious infections and high mortality rates. Thus the infectious route for these organisms is likely skin-bloodstream; i.e. the bacteria enter the bloodstream through PVC wounds in the skin and cause subsequent infection in other organs.

The next most common pathogens for PVC related infections are Gram-negative bacilli such as E. coli. These microorganisms are generally acquired from the hospital environment. (Infection risks associated with Peripheral vascular catheters, Zhang et al 1016)

Ensure the point of insertion is visible under the dressing allowing staff to check for sign of phlebitis. Ensure that the dressing is dated with the insertion date and the Visual Infusion Phlebitis (VIP) score and cannula care plan is completed with the name of the person who inserted the cannula. Observations of the cannula site should take place twice a day. If any signs of phlebitis are observed, then the guide below should be followed. Please ensure that AFFs are completed for any phlebitis that scores 2 or above.

The new VIP chart for 2018 has an observation panel on the back. This is so that staff can monitor any areas of phlebitis post cannula removal.

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Phlebitis Score

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Clostridium difficile (C.diff) Often C.diff patients present with confusion, dehydration, acute kidney injury (AKI) due to profuse diarrhoea and possibly even a fall due to dizziness. A stool sample should be sent to rule out colitis caused by C.diff in these patients.

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C.diff is an anaerobic germ which means it thrives in the gut where no oxygen is present but dies when exposed to oxygen. It overcomes this by being able to form a spore, where it wraps itself in a protective layer and lies dormant in the environment, waiting to be picked up on hands and ingested (eaten!). Getting patients to:

Wash their hands with soap and water after opening their bowels will remove any C.diff spores present, thus preventing them from being left in the environment.

Wash their hands before eating will prevent them from ingesting any spores picked up from the environment

Communicating with Ward Domestics or Ward Supervisor (x4102)

Communicate to the Ward Domestics or Ward Supervisor:

if a patient has been using the communal toilets on the ward whilst having diarrhoea so that the toilets can be cleaned with Tristel fuse and spores removed from the environment

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which side rooms contain infected patients so that they can be cleaned twice daily with Tristel fuse.

Infection prevention- It is important to physically separate the symptomatic patient from other vulnerable patients in order to prevent the spread of Clostridium difficile. They should remain isolated in a single room until 48 hours free of symptoms. Please see the Clostridium Management Guideline for advice on treatment options or speak to the Microbiologist. The patient’s side room should ideally have its own toilet and the side room door should remain closed where possible, due to airborne dispersal of spores. The side room should be cleaned twice a day with Tristel fuse and the commode should be cleaned after each use. Allocate where possible specific equipment for the infected patient e.g. moving and handling slings, wash bowl, single patient use blood pressure cuff and tourniquet. These must be decontaminated after use.

Contact precautions- Non-sterile disposable gloves and plastic aprons should be put on outside the patient’s room and worn when in contact with the patient, with any body fluids or their environment. Before leaving the sideroom, gloves should be removed first (without contaminating your hands); then your apron (breaking the neck strap first and then your hands must be thoroughly washed with warm water and liquid soap and dried with paper towels. Hygienic hand rub must not be used as an alternative as this has no effect on Clostridium difficile spores.

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Winning the Battle against C.difficile

Please ensure all staff know that commodes should only be cleaned with Tristel Fuse.

This is the only solution that kills C.difficile.

Detergent wipes should NEVER be used or even stored in the sluice.

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The Challenge to Reduce Gram Negative Infections

The previous Secretary of State for Health launched an ambitious challenge to reduce healthcare associated Gram-negative (E.coli, Klebsiella and pseudomonas) bloodstream infection by 50% by 2021. Gram-negative bloodstream infection is believed to have contributed to approximately 5,500 NHS patient deaths in 2015.

Enterobacteriaceae are a large family of Gram-negative bacteria that includes many of the more familiar pathogens (germs that cause disease), such as Salmonella, Escherichia coli (or E. coli), Yersinia pestis (causes plague), Klebsiella and Shigella, Proteus, Enterobacter, Serratia, and Citrobacter. E. coli is a part of all human and animal gut flora and can be picked up from animals, other humans or through the food chain in uncooked food.

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Ingesting E.coli causes no symptoms (unless the germ produces a toxin as in E.coli 157) as the body does not recognise E.coli as a pathogen. Gut flora are readily shared among family members, in prisons, hospitals, music festivals, anywhere where hand hygiene is poor and the environment is contaminated with these germs.

Trying to achieve this target set by the Secretary of State for Health is likely to be a far harder challenge than previous targets to reduce MRSA blood stream infections (BSI) and C. difficile, and the evidence base around which to develop preventive strategies is presently rather thin. Also, there are no accepted decolonization treatments for people colonized with Gram-negative bacteria. Consequently, the infection control strategies that have been successful in preventing MRSA BSI cannot be expected to work for blood stream infections caused by Gram-negative bacteria. Several guidelines have been published on the prevention and control of multidrug-resistant Gram-negative bacteria; however, there are no guidelines that consider the prevention and control of blood stream infections caused by non-resistant Gram-negative bacteria within healthcare settings. (Journal of Hospital Infection, March 2018).

E.coli bacteraemia or blood stream infections

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Sources of E.coli bloodstream infections

A total of 40,580 cases of E. coli bacteraemia were reported by NHS trusts in England between 1 April 2016 and 31 March 2017. These have been rising year by year; since the year 2000 but numbers of hospital acquired cases (48hrs after admission) have stayed consistent each year at between 20-23%. The majority of cases are community acquired, found in elderly people and occurred primarily through a urinary tract infection that likely originated from their own bowel flora.

A sentinel surveillance study in England looking at risk factors associated with E. coli Bacteraemia found that approximately half of the community-onset cases has some sort of healthcare intervention in the four weeks prior to the bacteraemia onset.

2016/2017 AGH had 132 E.coli bacteraemia; 15 cases were hospital acquired. It is the above 20-23% of hospital acquired cases that we need to reduce.

So how can we do this?

Ensure our patients drink plenty of fluid to aid the natural flushing effect of urine washing bacteria out of the bladder. Dehydrated patients are more prone to urinary tract infections.

Ensure that incontinent patients with pads are checked regularly and are thoroughly cleaned after each episode of incontinence.

Advise patients not to touch their line dressings or urinary catheters unless their hands are clean and they have been shown what to do.

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Criteria for Urine Specimens (Midstream and Catheter) in Suspected Urinary Tract Infections (UTI)

Preventing Urinary Catheter associated Urinary Tract Infection Key recommendations

Patient self-care: Wherever possible the patient must be taught to care for their own urinary catheter. This will help to prevent the risk of infection and will give the patient autonomy. When performing catheter care the nurse must always wear gloves (non- sterile) and wear a disposable apron.

All urinary catheters should be secured to the patient’s leg by a retaining strap; this is to prevent the catheter from sliding up and down the urethra. This could lead to trauma of the urethra, bladder neck and glans of the penis. It also prevents accidental disconnection or removal.

Cleaning the catheter: Using soap and water to clean the catheter is sufficient. This can be done in the shower or bath. Daily bathing should be encouraged (Pratt et al (2001). A disposable wipe can be used to clean the catheter, away from the urethra. Talcum powder or antiperspirants/perfumes are not to be used around the catheter. The glans of the penis can be cleaned using a disposable wipe with soap and water.

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The foreskin, retracted for cleaning, must be replaced to prevent a paraphimosis. Make sure the male patients are aware of this so that they can prevent this from happening.

Infection prevention: A ‘closed system’ is where the catheter stays attached to the leg bag/ valve. The only time the system is broken is when the leg bag/ valve is changed (every 7 days). Attaching a night bag does not break the system. Maintaining a sterile, continuously closed system is essential to the prevention of catheter associated infection. Modern closed systems have significantly reduced the incidence of bacteraemia. Breaches in the closed system, such as unnecessary emptying of the urinary drainage bag or taking a urine sample, will increase the risk of catheter related infection and should be kept to a minimum (Pellowe 2005). The bag should be emptied before it is three quarters full.

Catheter bags must not be allowed to touch the floor. They should be secured to the patient’s leg or set on a specifically designed catheter stand. Bacteria can travel up the catheter system and enter the body causing infection. The drainage bag must be kept below the level of the patient’s bladder at all times, (or emptied before a procedure i.e. turning or physiotherapy). It is essential to always wear gloves/apron and wash hands before and after contact with the catheter bag as it is likely to be contaminated with germs from the urine itself.

Multi-Resistant Enterobacteriaceae (E.coli Klebsiella and Pseudomonas) 40, 580 cases of E.coli bacteraemia

• Often multi-resistant through ESBL enzyme production • Now becoming resistant to Carbapenems (Meropenem)

There are a number of different ways that germs can be resistant. One of these ways is by producing an enzyme called a beta-lactamase that breaks down the beta-lactam antibiotic family, making it ineffective.

The green IC triangle symbol above the patients name on the SystmOne ward board identifies that the patient as having a history of ESBL colonisation or infection. For more information, see Multi-resistant Organism Management Guideline’ on Aireshare.

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ESBLs

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In 1980, the 3rd generation cephalosporin antibiotic family were introduced (Cefotaxime is one of them) as they had an ‘extended spectrum of activity’ or greater ability to destroy resistant gram negative bacteria. By 1985, bacteria were found to be producing a beta-lactamase enzyme that was resistant to this new antibiotic family. They were then named ‘Extended Spectrum Beta-Lactamases’ or ESBLs.

ESBL producing E.coli, Klebsiella are commonly seen in urinary tract infections but can cause a variety of other infections. The source of the infection is mainly from the

patient’s own gut flora when it is transferred accidently to other parts of their body, such as the bladder. These resistant germs get in the gut either through the food chain or being picked up on hands from the contaminated environment and then eating with unwashed hands.

In those countries with level 3 treatment of sewage, such as the UK, sewage treatment removes E. coli from drinking water (see Yorkshire water website) but a recent study from the Midlands has shown that significant numbers of ESBL producing E. coli in treated effluent are discharged into water courses, where they may then be acquired by people during recreational activity in what appears to be a perfectly clean river, and also by livestock, which may explain the acquisition by dairy herds of ESBL gene CTX-M 14 and 15, the two most prevalent types in humans. ( Multidrug-resistant Gram-negative bacteria: a product of globalization:Journal of Hospital Infection 2015).

Gaze and colleagues measured the presence of third-generation cephalosporin-resistant (ESBL) E. coli in seawater surrounding England and Wales. 11 of 97 sea water samples were found to contain CTX-M ESBL E. coli. While the percentage of ESBL E. coli in bathing waters was low, water users are at risk of ingesting these antibiotic resistant bacteria. (Healio infectious disease, March 31 2015).

The Institute of Soil, Water and Environmental Sciences in Israel, performed a study where E. coli were added into the hydroponic growing medium of maize plants and 48hrs later detected E.coli in the shoot of the plant. This is the first study to demonstrate internalization of E. coli via the root in monocotyledonous plants.

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A study by the London school of Hygiene & Tropical Medicine in 2011, found that 1 in 6 mobile phones grew E.coli from the unwashed hands of their users.

A number of studies have found that these resistant germs may spread extensively amongst family members in the home. (The British Infection Society 2010.) We have seen this in Airedale, where we tested a family (with their permission) of a 5 month old child with a history of multiple ESBL UTI infections. We found that the whole family were gut colonised with the same resistant E.coli. Likewise a study by Rooney et al. (2009) found that nursing homes can act as a reservoir of ESBL E. coli. So how do we look after these patients?

Winning the Battle against Resistant Enterobacteriacea isolation?

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Continent of urine or faeces? - Continent patients pose little risk of infection as the germs pass down the toilet and if good hand hygiene is performed, germs are not carried on the hands.

Incontinent patients pose a risk of infection as the germ can spread into the environment or onto staff members’ hands, thus the need for isolation.

Colonised or Infected?- As we learned earlier, germs can colonise the bladder of elderly patients and cause asymptomatic bacteriuria, therefore staff must observe for clinical symptoms of infection rather than just relying on the MSU result.

Catheterised patients can have resistant bacteria living in the residual volume of urine that remains in the bladder or even in biofilms in the catheter itself.

Hand hygiene– needed by both the patient and staff members is important to prevent carrying the germ on their hands and potentially transferring it on to others.

Patient education- Informing and educating patients puts them at the centre of their care.

Cleaning contaminated equipment- Any equipment used by the patient must be cleaned effectively with Tristel fuse and allowed to dry before use by another patient to prevent onward transmission of the germ. Use the ’I am clean’ labels to assure others you’ve cleaned it.

Cleaning contaminated environment– A research study recovered ESBL producing bacteria in the plug-holes of hospital hand wash sinks (also where pseudomonas is found), around the sinks themselves and on toilet floors. The predominant germs recovered were Klebsiella which have the ability to survive in the environment by producing a biofilm whereas E. coli cannot. ‘ESBL-producing Gram negative organisms in the health care environment’ Journal of Hospital infection 2016 If incontinence care is performed by staff and the water from the wash bowl is poured down the hand wash sink, it contaminates the sink and the plughole. Also the wash- bowl itself will need cleaning and be allowed to dry upside down before storing.

To ensure all interventions are in place to prevent further spread of infection, please follow the Multi- resistant Organism Care pathway that can be found on the Infection prevention Aireshare page or in the Multi-resistant Organism guideline.

IC

ESBLs

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Carbapenemase Producing Enterobacteriaceae (CPE)

Thanksfully, we have always been able to treat serious (ESBL) infections with an antibiotic called Meropenem (one of the Carbapenem family) which is our ‘last line of defence’ when it comes to antibiotics. Gram negatice bacteria have now been found to produce an enzyme or carbaoenemase that also breaks down Meropenem, making it resistant (in some cases to all, or nearly all) antibiotics. A number of countries across Europe have seen large numbes of these infections (Greece being the highest).

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To identify these patients, the question above has been added to the Triage questions in Emergency Departments (EDs) and in the admission documentation at ‘door ways’ to the hospital.

London and Mancester hospitals have had outbreaks with these resistant germs. Patients that are identified are isolated and are required to have 3 negative stool samples for CPE before they can be nursed on the open bay. Patients that have a history of CPE have this symbol above their name on the ward board.

The orange IC triangle symbol above the patients name on the SystmOne ward board identifies that the patient as having a history of CPE colonisation or infection. For more information, see Multi-resistant Organism Management Guideline’ on Aireshare

Suspected CPE Risk Early isolation and detection

• Isolate in a single room (ensuite if possible) and reinforce strict isolation standard precautions

• Screening is either 3x rectal swabs or faeces samples on alternate days. • If all 3 screens are negative – discontinue • If any screens positive – continue for duration of stay

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Pseudomonas Aeruginosa Risks

• Often multi-resistant to a number of antibiotics • Common cause of urinary tract infections/pneumonia • Often associated with contaminated water and live in moist environments

around the sink • CPE producing P.Aeruginosa was isolated in a sink drain. Patients closest to

the sink were infected with the same germ. Water flowing directly into the plug hole may have caused aerosols across the ward. (Aspeland et al).

• Hand wash sinks should not be used for anything other than hand washing! Safe water in healthcare premsises – DOH

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Antimicrobial Guidance Antimicrobial use (AMU) is a key driver of animicrobial resistance (AMR); understanding the indications, dose used and adherence to guidelines is important in reducing anitbiotic consumption.

Antimicrobials: a Balancing Act • Antibiotic use is a balancing act of risks and

benefits • Use the Start smart:Then focus guide (below) • The right drug, according to local guidance • Within an hour of presentation for IVs • Then focused to the safest, most appropriate choice • Every use of an antibiotic risks increasing resistance rates

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• Infective dose: As little as 10 to 100 virions are required to infect a host

• One single episode of vomiting may generate 300,000 to 3 milliion infectious doses

• Environmental swabbing has shown contamination of common touch surfaces such as door handles, soap dispensers, patient equipment, toilet seats and telephone.

• Tristel fuse is recommended for environmental decontamination.

Ring Infection Prevention Immediately

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Standard Precautions

• Hand hygiene

• Maintain skin integrity

• Personal Protective Equipment (PPE)

• Blood/body substance spillage

• Sharps safety

• Safe handling of clinical waste

• Decontamination of equipment

• Decontamination of environment

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Hand Hygiene It is important to recognise that the hands of health care staff will always carry bacteria, be it their own bacteria or those that have attached as a result of acitivities (e.g. handling equipment, touching surfaces or patients). Remember, the greatest concentration of micro organisms are found beneath your finger nails.

Although it is not possible to sterilise your hands, the number of bacteria present can be reduced significantly through good hand hygience practice.

Situations that pose the greatest risks include, but are not limited to:

• Before patient contact • Before contact with a susceptible patient site (such as an invasive device or

wound) • Before an aseptic task • After exposure to body fluids (blood, vomit, faeces, urine and so on) • After glove removal • After patient contact • After contact with the patient’s immediate environment.

To support compliance with hand hygience in the workplace, health care workers should meet the following standards while working:

Keep nails short, clean and polish free Avoid wearing wrist watches and jewellry Avoid wearing rings with ridges or stones. (A plain wedding

band is acceptable) Do not wear artifical nails or nail extensions Cover any cuts and abrasions with a waterproof dressing Wear short sleeves or roll up sleeves prior to hand hygience Report any skin conditions affecting hands (for example, psoriasis or

dermatities) to Employee Health and Wellbeing for advice.

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Intact Skin Protects You Wet hands transfer micro-organisms more effectively than dry ones, and inadequately dried hands can also be prone to developing skin damage.

Disposable paper hand towels should be used to ensure hands are dried thoroughly. Fabric towels are not suitable for use in health care facilities as these quickly become contaminated with micro-organisms.

Applying liquid soap directly to dry hands can irritate and dry out the skin making it painful to wash Therefore, always wet hands first.

Using moisturiser as you start work, before breaks and as you leave will protect and maintain the skin integrity.

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Personal Protective Equipmement (PPE) A selection of PPE must be based on an assessment of the risk of transmission of micro-organisms to the patient or carer, and the risk of contamination of the healthcare practitioner’s clothing and skin by the patient’s blood, secretions or excretion. The risk assessment should include:

• Who is at risk • Whether sterile or non sterile gloves should be worn • Exposure to blood or body fluids • Contact with non-intact skin or mucus membranes • Exposure to hazadous substances.

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Personal Protective Equipmement (PPE)

Aprons: Disposable plastic aprons must be worn when it is likely that body substance will soil clothing. Plastic aprons must be worn during all close patient contact including bed making. Plastic aprons afford more protection to uniforms/own cloths than cloth gowns because they are water repellant, impervious to microial contamination and can prevent the transmission of

micro organisms from uniforms/clothes to patients.

Plastic aprons must be worn as single use items for one procedure or episode of patient care and then discarded and disposed of as clinical waste.

Gloves: There are two main indications for the use of gloves in preventing healthcare associated infection, to protect the hands from contamination with organic matter and micro organisms and to reduce the risks of transmission of micro-organisms to both patients and staff.

A risk assessment should be made of the type of procedure to be undertaken and the related risks to the patient and health care worker in order to establish whether gloves should be worn.

Gloves should be worn as single use items. They should be put on immediately before an episode of patient care and removed as soon as the activitity is completed. Gloves must be changed between caring for different patients, or between different carers for the same patient. Gloves must be disposed of as clinical waste and hands decontaminated, ideally by washing with soap and water. Hand gel should never be applied to gloves.

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Personal Protective Equipmement (PPE)

Eye/Mouth Protection: Should be worn where there is a risk of blood or body fluids splashing into the mouth or eyes. This is to protect you from acquiring a blood borne virus or a bacterial infection. A surgical mask is waterproof and will prevent this from happening. Goggles over spectacles or visors will protect your

eyes from spashes. If you receive a spash to your eye, use saline to gently irrigate your eye, washing from the inner side of your eye (closest to your nose) allowing the saline to flow over your eye. If you receive a splash to your mouth or broken skin, rinse/cleanse thoroughly with water and then contact Infection Prevention via the switchboard. When this happens, it is called a contamination issue. Surgical masks should be worn when caring for patients with Flu but changed to an FFp3 Respirator when performing aerosol generating procedures.

FFP3 Respirators: are designed to protect the wearers from breathing in small airborne particles which might contain viruses or Tuberculosis. Staff need to perform a Fit check before carrying out any procedures. Please see Flu Guidance on Infection Prevention’s Aireshare page on how to perform a fit check. If a sucessful fit check cannot be achieved, remove and refit the respirator. If you still cannot obtain a sucessful fit check, try the cone shape respirators. If a sucessful fit check cannot be achieved, please contact Infection Prevention. FFp3 Respirators should be worn when performing aerosol generating procedures with patients suspected of having Flu or worn when in contact with a patient with suspected or known Mycobacterium Tuberculosis.

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Safe Handling of Spillages Blood Spillage (Hep B, C &HIV risk)

• Clean spillages promptly

• Soak up fluid with paper towels & discard in orange bag

• Disinfect the area using Hypochlorite solution 10, 000ppm

Body Fluid Spillage • Clean spillage promptly

• Soak up fluid with paper towels & discard in

orange bag

• Disinfect the are using Tristel fuse 1,000ppm

Deal with any blood/body fluid spllage immediately.

Blood Spillage: Wear PPE to protect your hands and uniform (and a surgical mask if there is a risk of spashing). Use paper towels to absorb the fluid, then clean with hot water and detergent followed by 10,000ppm hypochlorite solution. Ensure a window is opened as the chlorine smell is very strong.

Urine, faeces and vomit: Wear PPE (gloves and apron) and use paper towels to absorb the fluid. Clean with hot water and detergent followed by 1,000ppm

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hypochlorite solution or an agent that contains both: e.g. Tristel fuse. Dispose of the paper towels in a clinical waste bag.

Sharps Safety Safe disposal of contaminated sharps

This is classified as healthcare waste and must be disposed of in a rigid sharps container that complies with UN3291 and BS7329 standards. Refer to Prevention and Management of contamination Injuries Policies on Aireshare.Ensure that sharps bin lids are firmly clicked down on assembling and the label is completed. When sharps containers are ¾ full they must be closed securely and the person closing must complete and sign the label on the container. The bin must be placed for collection in the clinical waste area and must not be placed inside a clinical waste bag,When a sharps bin is not in use, pull the lid half way across (see picture). This is called ‘temporary closure’ and will prevent sharps from falling out of the bin if it is accidently dropped.

Tips for prevention of sharps injuries:

Never re-sheath needles Use safety devices where possible Always use point of use sharpes bin Do not overfill sharps bin Do not use sharps bin for objects other than sharps Disposing of needle and syringe as a unit reduces risk

of injury Wearing gloves can remove up to 80% of blood from

a needle in the event of an injury Make sure lighting and space to perform the

procedure is adequate

If a sharps bin is full Do not use it. Close it up and start a new one. This is the responsibility of all clinical staff.

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Prevention and Management of Contamination Injuries

• First Aid Treatment (Bleed) • Wash the wound • Inform Infection Prevention

Team • Inform Employee Health and

Wellbeing (EHWB) • Complete documentation • Appropriate blood

specimens will be recommended

Ensure you dispose of your waste correctly

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Decontamination of Equipment One study showed that frequently touched articles in the patients’ environment such as cardiac monitors, infusion pumps and bed rails were grossly contaminated with micro organisms. Any piece of equipment that is used by or on a patient should be cleaned before being used on another patient. Therefore, members of staff need to be aware of their individual responsiblitiy for practising and promoting decontamination of reusable medical devices to ensure the safety of the patient, themselves and the environment.

Equipment such as commodes need to be decontaminated with the correct cleaning solution. Three patients had the same strain of Clostridium difficile on one ward. The commodes were swabbed and

the same strain of Clostridium difficile spores were found. The commodes had been cleaned with detergent wipes which do not remove C.diff spores instead of Tristel fuse which kill C.diff spores. Refer to:

Medical Devices:Process for Decontamination, Cleaning and Disinfection.

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Safe disposal of linen contaminated with body substances

Linen skips should be taken to the bedside and used linen should be carefully placed in them, to prevent dispersal of skin cells and micro organisms into the air, to then settle in the environment. Hand gel should be applied after handling used linen and before handling clean linen to prevent the spread of skin cells.Aprons should be worn for bed making.

Linen heavily contaminated with body substances must be placed into a water soluble

bag to protect laundry staff from avoidable risk. When handling soiled linen, gloves and apron must be worn.

The Clinical environment A dirty or contaminated clinical environment is one of the factors that may contribute to HCAIs. Exposure to environmental contamination with spores of C.difficile is one example of occasions when the environment contributes to the development of infection. Many micro-organisms can be identified from the patient’s environment and these usually reflect bacteria carried by patients or staff ( in the case of S.aureus). Contact with the immediate patient of a contaminated environmenr by the hands of staff can also be a route for transmission of micro organisms. High standards of cleanliness will help to reduce the risk of cross-infection and are aesthetically pleasing to patients and the public . Mattress Checks After a patient has been discharged, please unzip the mattress cover. If staining is present on either the underside of the cover or on the mattress core then please follow and complete a mattress audit form (can be found on the Aireshare Infection prevention page). Please attach the form to the mattress and ask porters to swap it or a clean mattress. The dirty mattress needs taking by porters to the dirty mattress store on ward 11.

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Clinical Workbook Level 2- Questions

All the answers to the questions below are found in this workbook. Please write your answers on this sheet and email to the Infection Prevention group email address: Infection.prevention@anhst.nhs.uk

You will need to get 8 answers correct to complete your update. The questions will be marked and your record will be updated by the Training dept. If you do not achieve the pass rate you will need to attend an Infection Prevention session in the lecture theatre. You will be contacted by email.

1. What is the name of the toxin that ‘destroys white blood cells and causes extensive tissue necrosis and severe infection’?

A) Enterotoxin

B) Toxic shock syndrome

C) Panton Valentine Leucocidin

2. Patients admitted from ……… are commenced on MRSA suppression?

A) Home

B) Hospitals abroad

C) Nursing homes

3. What management of a patient found to be positive for MRSA is considered Gold standard?

A) Isolation

B) MRSA suppression

C) A post infection review

4. What is the 2nd route of infection via, in regards to peripheral vascular catheter (PVC) infection?

A) Migration of microbes down the catheter tract

B) Contamination by bacteria circulating in the blood stream C) The catheter hub

Clinical Workbook Level 2- Questions (Cont)

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5. What are the next most common pathogens for PVC-related infections?

A) Coagulase negative staphylococci

B) Staphylococcus aureus

C) Gram-negative bacilli such as E. coli

6. How can we prevent C.diff spores form being ingested by patients?

A) Wash their hands with soap and water before eating

B) Eating uncooked food

C) Using alcohol hand gel before eating

7. Dehydrated patients are more prone to………?

A) Wrinkles

B) UTIs

C) Headaches

8. Gaze and colleagues measured the presence of third-generation cephalosporin-resistant (ESBL) E.coli in what?

A) Drinking water

B) Sea water

C) River water

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Clinical Workbook Level 2- Questions (Cont.)

9. How often should nebulisers be washed?

A) Weekly

B) Between use

C) Daily

10. Where is the greatest concentration of microorganisms found on your hands?

A) On your thumbs

B) Under your fingernails

C) Under your ring

11. How often should gloves be changed?

A) Between patients

B) Between different cares for the same patient

C) When they are visibly dirty

12. How full should sharps bins be before they are securely closed?

A) Completely full B) 1/2 full C) 3/4 full