Policy on Precautions to be Observed when Caring for
Patients Colonised or Infected with AmpC/
Extended Spectrum Beta-Lactamase Producing
Organisms (ESBL)
V4.0
19th November 2015
Flow Chart outlining the process for caring for patients
Colonised or Infected with AmpC/ESBL
AmpC or ESBL Flag/Result
Is the AmpC or ESBL result
within 2 years?
Yes
No
Isolation not required
Is this result on current
admission?
No
Yes
ISOLATE
Risk Assess
If patient has:
 Diarrhoea
 urinary incontinence
 discharging wounds
 urinary catheter
 open wounds
 following bowel
surgery
ISOLATE
If not, isolation is not required
unless a high risk area i/.e
ITU, Haematology/ Oncology
Ward, Renal Unit where
isolation is advised
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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Table of Contents
Flow Chart outlining the process for caring for patients Colonised or Infected with
AmpC/ESBL ......................................................................................................................... 2
1.
Introduction ................................................................................................................... 4
2.
Purpose of this Policy/Procedure .................................................................................. 4
3.
Scope ........................................................................................................................... 4
4.
Definitions / Glossary .................................................................................................... 4
5.
Ownership and Responsibilities .................................................................................... 4
5.1.
Role of Divisional Managers .................................................................................. 4
5.2.
Role of Ward Sisters/Departmental Managers ...................................................... 5
5.3.
Role of Divisional Directors ................................................................................... 5
5.4.
Role of the Hospital Infection Prevention and Control Committee ......................... 5
5.5.
Role of the Infection Prevention and Control (IPAC) Team ................................... 5
5.6.
Role of Individual Staff ........................................................................................... 5
6.
Standards and Practice ................................................................................................ 5
6.1.
Treatment .............................................................................................................. 5
6.2.
Patient Risk Group ................................................................................................ 5
6.3.
Transmission and Prevention ................................................................................ 5
6.4.
Infection Control Measures .................................................................................... 6
6.5.
Maintaining Standards of Care .............................................................................. 6
6.6.
Transferring of patients .......................................................................................... 7
6.7.
Transportation by Ambulance or Care ................................................................... 7
7.
Dissemination and Implementation ............................................................................... 7
8.
Monitoring compliance and effectiveness ..................................................................... 7
9.
Updating and Review.................................................................................................... 7
10.
Equality and Diversity ................................................................................................ 7
10.2.
Equality Impact Assessment .............................................................................. 8
Appendix 1. Governance Information .................................................................................. 9
Appendix 2. Initial Equality Impact Assessment Form ....................................................... 12
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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1. Introduction
1.1. General Information.
The prevalence of multidrug-resistant Gram-negative bacteria has increased
continuously over the past few years, and bacterial strains producing AmpC betalactamases and/or extended-spectrum beta-lactamases (ESBLs) are of particular
concern.
ESBL’s are enzymes produced by certain bacteria that confer resistance to extended
spectrum cephalosporins e.g. ceftazidime and cefotaxime. They can also confer
resistance to penicillin’s and are often linked with resistance to a number of other
antibiotics thus limiting the choice for treatment. ESBLs were first described in the
1980s and first reported in the UK in 2000 affecting hospital klebsiellae, a type of
gram negative bacteria. In 2003, a strain of Escherichia coli (E. coli), highly resistant
to cephalosporins was reported in this country.
1.2. Significance.
The bacterial pathogen E. coli is the commonest cause of urinary tract infection and
the second most common agent causing bacteraemia (HPA, 2005). The majority of
AmpC/ESBL related infections are of the urinary tract and 19.7% of all hospital
acquired infections are related to the urinary tract (Hospital Infection Society 2007).
The majority of patients with AmpC or ESBL will have no obvious clinical infection
and are colonised in a site such as the gut or have asymptomatic bacteriuria.
However symptomatic infection, including septicaemia can occur.
1.3. This version supersedes any previous versions of this document.
2. Purpose of this Policy/Procedure
This policy provides details for clinical staff to enable them to understand the
principles of the precautions that need to be observed when caring for patients
colonised or infected with AmpC/Extended Spectrum Beta Lactamase (ESBL)
producing organisms within healthcare settings.
3. Scope
This policy applies to all staff working in The Royal Cornwall Hospitals NHS Trust.
4. Definitions / Glossary
Definitions are contained within the text.
5. Ownership and Responsibilities
5.1. Role of Divisional Managers
Divisional Managers/clinical leads must ensure that resources are available for health
care workers to undertake effective standard and isolation precautions.
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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5.2. Role of Ward Sisters/Departmental Managers
Wards Sisters/Charge Nurses and departmental managers are responsible for
ensuring that staff are aware of this guidance and that the guidance is implemented.
5.3. Role of Divisional Directors
Divisional Directors are responsible for ensuring that medical staff comply with this
policy.
5.4. Role of the Hospital Infection Prevention and Control
Committee
The Hospital Infection Prevention and Control Committee is responsible for:
 Approving this policy.
 Overseeing the implementation and monitoring of the policy.
5.5. Role of the Infection Prevention and Control (IPAC) Team
The Infection Prevention and Control team are responsible for undertaking the
surveillance of AmpC/ESBL and will initiate investigation in the event of a cluster or
outbreak with these infections.
5.6. Role of Individual Staff
Each individual has a clinical and ethical responsibility to carry out effective Infection
prevention and control procedures and to act in a way, which minimises risk to the
patient.
6. Standards and Practice
6.1. Treatment
A clinical judgement is required as to whether the AmpC/ESBL is causing significant
infection. In many instances antibiotic therapy is not required. Where treatment is
indicated, options may be very limited. Advice can be obtained from the local duty
medical microbiologist.
6.2. Patient Risk Group
Patients who are most at risk from infections due to AmpC/ESBLs are those who are
Neutropenic, who have undergone organ transplantation, premature neonates and
older persons. Other patients who are at risk include those who have received
prolonged and extensive antibiotic therapy and those who have undergone
gastrointestinal surgery.
6.3. Transmission and Prevention
Transmission of AmpC/ESBL producing organisms occurs due to poor hand hygiene
and the use of contaminated items in the clinical setting.
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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6.4. Infection Control Measures
6.4.1. Isolation

Patients with an AmpC/ESBL result on the current admission should be
isolated in a single room with dedicated medical equipment (cross
reference Isolation policy). If this is not possible, a risk assessment must
be undertaken. Advice must be sought from Infection Prevention &
Control (IPAC) team.

In the event of a single room not being available, it is important to avoid
nursing other patients in high risk groups in the same area (see above).
This also includes patients who have indwelling urinary catheters as this
increases the risk of urinary tract infection development.

Patients who have had an AmpC or ESBL result within 2 years of the
current admission should have a risk assessment carried out. Those
patients with diarrhoea, urinary incontinence, discharging wounds, urinary
catheter, open wounds following bowel surgery should be isolated. Those
patients who do not have any of the above but are nursed in a high risk
area eg ITU, Renal Unit, Haematology/Oncology wards should be
isolated.

Patients who have had an AmpC or ESBL result in excess of 2 years of
the current admission do not need to be isolated.
6.4.2.
Other Measures

Hand hygiene is of paramount importance and alcohol hand gel is very
effective against AmpC/ESBLs.

Disposable Gloves and aprons must be worn for direct contact with the
patient and their surrounding environment and when dealing with urine
and faeces.

All linen must be treated as infected and handled accordingly.

The adherence to good infection control practice regarding urinary
catheter care and personal hygiene also plays a significant part in
reducing the risk of cross infection.

Once a patient with AmpC or ESBL (positive on this admission or within 2
years of admission) has been discharged, a terminal clean of the
room/bay is required.
6.5. Maintaining Standards of Care
Infection prevention and control measures should not compromise the patient’s care
and should not affect the patient’s freedom to be mobilised or attend other
departments for health care related visits.
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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6.6. Transferring of patients
It is important to make the receiving clinical area aware that the patient has an
AmpC/ESBL positive result with emphasis on good hand hygiene, catheter or urinary
tract management.
6.7. Transportation by Ambulance or Care
Patients with AmpC/ESBL carriage or infections can be transported with other
patients in hospital cars and ambulances. Good infection control practice must be
maintained.
7. Dissemination and Implementation
This policy will be implemented via the following routes:
 Information regarding the policy will be included in the Infection Prevention and
Control newsletter.
 The policy will be included in the Trust’s Document Library
 The policy will be circulated to all Link Practitioners, Ward Sisters/Charge
Nurses and Clinical Matrons
8. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Risk assessment and isolation of patients with AmpC/ESBL
Louise Dickinson, Consultant Nurse/Joint DIPC
Tool
Practice review and audits
Frequency
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
Weekly during ward visits and documented on ICNet.
Reporting to ward sister/Charge nurse on the day if isolation not
carried our appropriately. Report by exception to the Infection
Prevention and Control Steering Group persistent non-compliance
with policy.
Ward Sister to take immediate action where non-compliance with
policy identified.
Required changes to practice will be identified and actioned within
immediately. A lead member of the team will be identified to take
each change forward where appropriate. Lessons will be shared
with all the relevant stakeholders
9. Updating and Review
This document will be reviewed within 3 years.
10. Equality and Diversity
10.1. This document complies with the Royal Cornwall Hospitals NHS Trust
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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service Equality and Diversity statement which can be found in the 'Equality,
Diversity & Human Rights Policy' or the Equality and Diversity website.
10.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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Appendix 1. Governance Information
Document Title
Policy on precautions to be observed when caring
for patients colonised or infected with
AmpC/Extended Spectrum Beta –Lactamase
producing organisms (ESBL’s)
Date Issued/Approved:
Date Valid From:
1st March 2016
Date Valid To:
28th February 2019
Directorate / Department
responsible (author/owner):
Louise Dickinson, Consultant Nurse, Joint
Director Infection Prevention & Control
Contact details:
01872254969
Brief summary of contents
This policy has been developed to provide a
practical document to equip all healthcare staff at
the Royal Cornwall Hospitals NHS Trust with the
necessary information on the precautions to be
observed when caring for patients colonised or
infected with Extend Spectrum Beta-lactamase
producing organisms.
Suggested Keywords:
Extended spectrum, betalactamase, isolation.
Target Audience
RCHT

PCH
CFT
KCCG
Executive Director responsible
for Policy:
Nurse Executive
Date revised:
19th November 2015
This document replaces (exact
title of previous version):
Policy on precautions to be observed when caring
for patients colonised or infected with Extended
Spectrum Beta –Lactamase producing organisms
(ESBL’s)
Approval route (names of
committees)/consultation:
Hospital Infection Prevention and Control
Committee
Divisional Manager confirming
approval processes
Louise Dickinson
Name and Post Title of additional
signatories
Not Required
Signature of Executive Director
giving approval
Publication Location (refer to
Policy on Policies – Approvals
and Ratification):
{Original Copy Signed}
Internet & Intranet

Intranet Only
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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Document Library Folder/Sub
Folder
Clinical / Infection Prevention & Control
Links to key external standards
CQC outcome 8. Health and Social Care Act.
Related Documents:
Department of Health (2009) The Health and
Social Care Act. DoH London
HPA. (2005). Investigations into multi-drug
resistant ESBL producing Escherichia coli strains
causing infections in England. Health Protection
Agency. Available at:
http://www.hpa.org.uk/hpa/publications/esbl
Health Protection Agency (2012) English national
point prevalence survey on healthcare associated
infections and antimicrobial use 2011. HPA:London
Clinical Microbiology 2011 Aug: 49(8): 2924-2932
doi: 10.1128/JCM.00091-11
PMCID: PMC3147753
Detection of AmpC Beta-Lactamase in Escherichia
coli: Comparison of Three Phenotypic Confirmation
Assays and Genetic Analysis. S.Peter-Getzlaff,
S.Polsfuss, M.Poledica, M.Hombach, J.Giger,
E.C.Bottger, R.Zbinden and G.V.Bloemberg.
Training Need Identified?
No
Version Control Table
Date
Version
No
01 Jan 08 V1.0
Summary of Changes
Initial Issue
IPAC Team
11 Mar 10 V2.0
Revised and updated
17 Jan 13 V3.0
Revised and re-formatted. Isolation of
patients updated.
19 Nov 15 V4.0
Changes Made by
(Name and Job Title)
Revised and updated
Louise Dickinson
Consultant Nurse
Infection Prevention
and Control
Louise Dickinson
Consultant Nurse
Infection Prevention
and Control
Jean James
CNS, Infection
Prevention and Control
All or part of this document can be released under the Freedom of Information
Act 2000
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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Appendix 2. Initial Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to
as policy): Policy on Precautions to be observed when caring for patients colonised or infected
with AmpC/Extended Spectrum Beta-Lactamase producing organisms (ESBL)
Directorate and service area:
Is this a new or existing Policy?
Clinical/Infection Prevention and Control
Existing
Name of individual completing
Telephone: 01872 254969
assessment: Louise Dickinson
1. Policy Aim*
To provide staff with the necessary information and knowledge to
Who is the strategy /
effectively reduce the risk of AmpC and ESBL introduction to the
policy / proposal /
Trust, and to put in place systems to control and contain cases of
service function
AmpC and ESBL as and when they occur.
aimed at?
2. Policy Objectives*
To provide clinical staff with guidelines for management of patients
with AmpC/ESBL producing organisms and to identify strategies for
the prevention and control of cross infection to other patients, staff and
visitors.
3. Policy – intended
Outcomes*
To reduce the risk of transmission of infection.
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
Monitoring compliance with the policy will be via auditing, practice
review and carrying out work place inspections.
b) If yes, have these
*groups been
consulted?
Yes
C). Please list any
groups who have
been consulted about
this procedure.
Hospital Infection Prevention and Control Committee
All staff and patients.
Yes
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Yes
No

Rationale for Assessment / Existing Evidence
Infections may affect any age
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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
Infections may affect any gender
Race / Ethnic
communities /groups

Infections may affect any groups.
Disability -

Infections may affect all regardless of disability
Religion /
other beliefs

Infections may affect any religion
Marriage and civil
partnership

Infections may affect all people – married or
otherwise
Pregnancy and maternity

Sexual Orientation,

Infections may affect any pregnant woman. Pregnant
members of staff may need to take additional
precautions depending on the organism involved.
Infections may affect all regardless of sexual
orientation
Sex (male, female, transgender / gender
reassignment)
Learning disability, physical
disability, sensory impairment
and mental health problems
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
8. Please indicate if a full equality analysis is recommended.
Yes
No 
9. If you are not recommending a Full Impact assessment please explain why.
None of the equality strands have been identified in the initial impact assessment.
Signature of policy developer / lead manager / director
Louise Dickinson
Names and signatures of
members carrying out the
Screening Assessment
Date of completion and submission
1. Louise Dickinson
2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site.
Signed _______________
Date ________________
Policy on precautions to be observed when caring for patients colonised or infected with AmpC/Extended Spectrum Beta-lactamase
producing organisms (ESBL)
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