Guidelines for Infection
Prevention and Control in
Primary Care Medical Premises
(Resource Pack)
(Adapted with kind permission from NHS Ashton, Leigh & Wigan)
Name of author:
NHS Cumbria Health Protection Team
Name of responsible
committee:
NHS Cumbria Infection Prevention and Control
Committee
Date issued for publication:
May 2011
Date last Reviewed:
Review Date
May 2013
Expiry date:
Main Author
Clinical Specialist: Infection Prevention
Target audience:
Healthcare personnel involved in the provision and
delivery of care in Primary Medical and Dental
Premises
CHANGE HISTORY
Version
Date
Description
Author
1.0
25/05/2011
Initial draft
Nicola Holland, Clinical Specialist:
Infection Prevention
2
PREFACE
As you are aware the Care Quality Commission (CQC) are making plans to introduce
the registration process for General Practice and it is not too early to begin to assess
how you will meet the requirements of registration in your practice.
The actual registration process will begin in October 2011 with an online enrolment
form. This will request the basic details of the practice including how it is structured
(partnership, Ltd company etc), together with the details of practice locations and
person to contact. All providers must be registered by 1 April 2012
The second phase will require that you validate the details and ensure that they
reflect the correct information.
The third phase will be completion of the application including full details of regulated
activities provided, practice locations and details of the Registered Managers for
each location from which the practice operates. You will also be required to declare
compliance with the Essential Standards of Quality and Safety (ESQS).
It is important that Practices understand fully what declaring compliance means. If
you make this declaration then you are stating in a legal document that you meet all
of the ESQS. Care should be taken when making this declaration because if in reality
you do not, then when the CQC visits you can be found to be in breach of the
regulations. If however you do not comply fully then you must state this and put in
place an action plan to demonstrate how you will become compliant in a reasonable
time frame.
The main areas which are most likely to be tested initially by the CQC during the first
few months of the registration programme are:
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Outcome 4: Care and welfare of the people who use services.
Outcome 8: Cleanliness and infection control.
Outcome 9: Management of medicines.
Outcome 11: Safety, availability and suitability of equipment.
Outcome 16: Assessing and monitoring the quality of service provision
General Practices are required to have systems in place to ensure compliance with
good infection control practice. This Guidance document is based on current
legislation, DOH guidelines and best practice (expected standard) and has been
provided by NHSALW Health Protection Team to support Practices in meeting
Outcome 8 and help prepare Practices for CQC visits.
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INDEX
PAGE
1. Introduction Aims
5
2. Aims
5
3. Hand hygiene
6
4. Personal Protective Equipment
8
5. Disposable gloves
9
6. Disposable plastic aprons
10
7. Surgical face masks and respirators
10
8. Laundry
11
9. Uniform
11
10. Waste Management
12
11. Safe use and disposal of sharps
13
12. Inoculation incidents and human bites
14
13. Spillages
14
14. Clean environment
15
15. Surgical instruments
17
16. MRSA
18
17. Clostridium difficile
19
18. Notification of infectious diseases
21
19. TB referral and management
22
Appendices
Appendix 1
Useful contacts
Appendix 2
Registered medical practitioner notification form template
23
Appendix 3
Colour coding of waste
24
Appendix 4
A to Z cleaning/disinfection for the environment & facilities
25
Appendix 5
National Patient Safety Agencies colour coding
Scheme for cleaning materials and equipment
27
Appendix 6
MRSA decolonisation/eradication procedure
28
Appendix 7
HPA – Guidelines on infection control in schools
& other childcare settings
Appendix 8
30
HPA - Sharps injury/splash – First aid for healthcare
workers
31
Appendix 9
Risk assessment – glove usage
32
Appendix 10
Glove selection guidance
33
Appendix 11
Handwashing poster
34
Appendix 12
Infection Prevention & Control Audit
36
Appendix 13
Fact sheet: Diagnosis of UTI in adults
43
Appendix 14
NHS Cumbria antibiotic guidelines
45
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1. INTRODUCTION
Infection prevention and control in all healthcare settings has attracted heightened
interest in recent years. Because of the throughput of large numbers of patients the
possibility of cross-infection is substantial. Public confidence in general and dental
practices relies upon being, and being seen to be safe places for treatment, and safe
places to work. The need for safe infection prevention and control in primary care is
now more urgent than ever.
Primary care for the first time has been made subject to the same infection
prevention and control regulations as other parts of the Health Service; it therefore
needs to ensure that procedures are compliant with the extensive agenda of
legislation and regulations governing safe practice.
Finally we hope the users of this resource pack will find both the content and the
format suitable for their needs. We are aware that, frequently, the material in
guidance such as this is superseded by new information between writing and
publication. The Health Protection Team will review the resource pack every 2 years
or if new national guidelines are published.
2. AIMS
A diverse range of documents provides the foundation on which communicable
disease and infection prevention and control procedures are built. No single
publication considers all of the issues relating to infection prevention and control in
primary care.
This resource pack document will be particularly useful to GP’S, practice/dental
nurses and practice managers, as well as other healthcare professionals working in
general and dental practices. It seeks to review all relevant issues, and provide a
framework upon which, audit can be undertaken to improve infection prevention and
control. It will help healthcare professionals identify and minimise risks to staff and
patients and create a safer working environment.
The information contained within this document addresses the issues that are most
likely to impact on health and communicable disease control in primary care which
are:
Standard (Universal) Precautions
 Hand hygiene
 Protective clothing and Equipment (PPE)
 Laundry management, uniform.
 Waste management and spillages
 Clean clinical environment
 Decontamination of equipment
 Management of exposure to blood or body fluids
DH (2001) EPIC project: Developing national evidence based guidelines for preventing healthcare-associated
infection. Journal of Hospital Infection 47 (Supplement)
National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and
Community Care. Clinical Guideline2 (2003) suppliment1
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3. HAND HYGIENE
Good hand hygiene is essential to reduce the transmission of infection in healthcare
settings and is a critical element of standard infection prevention and control
precautions.
3.1 WHO 5 moments hand hygiene
The World Health Organisations publication 5 moments for hand hygiene is now the
global benchmark of WHEN to perform Hand Hygiene It is your professional
responsibility to follow this guidance.
See also appendix 12 for poster
3.2 Choice of handwashing method
In the community and home setting, choosing a method of hand decontamination will
be heavily influenced by the assessment of what is practically possible, the available
resources in the care setting (particularly patients own homes), what is appropriate
for the episode of care, and, to some degree, personal preferences based on the
acceptability of preparations or materials.
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Soap and Water - Effective handwashing with a non-medicated liquid soap
will remove transient micro-organisms and render the hands socially clean.
This level of decontamination is sufficient for general social contact and
most clinical care activities.
Surgical hand disinfection - Using an antiseptic soap preparation such as
‘hibiscrub’ will reduce both transient organisms and resident flora, and result
in hand antisepsis. This should be reserved for operating theatres or before
invasive procedures.
Hygienic handrubs (alcohol) – eliminate transient micro-organisms and
have the advantage that a source of water is not required for their use,
Hygienic hand rubs offer a practical and highly acceptable alternative to
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handwashing when hands are not grossly soiled and are recommended for
routine use.
3.3 Hand decontamination using liquid soap
An effective handwashing technique involves three stages: preparation, washing and
rinsing and drying.
 Preparation requires wetting hands under tepid running water before applying
liquid soap.
 The hand wash solution must come into contact with all of the surfaces of the
hand. The hands must be rubbed vigorously together for a minimum of 10 –
15 seconds, paying particular attention to the tips of the fingers, the thumbs
and the areas between the fingers (See below & appendix 11) as these are the
areas most commonly missed.
 Hand drying has been shown to be a critical factor in the hand hygiene
process, in particular removing any remaining residual moisture that may
facilitate transmission of microorganisms. Hands that are not dried properly
can become dry and cracked, leading to an increased risk of harbouring
microorganisms on the hands that might be transmitted to others
Handwashing
1
2
3
Palm to palm.
4
Backs of fingers to opposing palms
with fingers interlocked.
Right palm over left dorsum
and left palm over right dorsum.
5
Palm to palm
fingers interlaced.
6
Rotational rubbing of right thumb
clasped in left palm and vice versa.
Rotational rubbing, backwards and forwards
with clasped fingers of right hand in left palm
and vice versa.
5.3
3.4 Hand decontamination using hygienic handrubs (alcohol)
When decontaminating hands using an alcohol hand rub, hands should be free of dirt
and organic material.
 The amount/volume used to provide adequate coverage of the hands should
be indicated in the manufacturers’ instructions. This is normally around 3 ml.

The steps to perform hand hygiene using alcohol based hand rub are the
same as when performing hand washing (see Appendix 11)
 The time taken to perform hand hygiene using alcohol based hand rub is at
least 20seconds (20-30 seconds is adequate). Manufacturers’ instructions
should be followed (a number of these recommend rubbing for 30 seconds)
 If the solution has not dried by the end of this process allow hands to dry fully
before any patient/client procedures are undertaken.
NB. The use of antimicrobial impregnated wipes has been considered for use in the
hand hygiene process, however, it has been shown that such wipes are not as
effective as hand washing or the use of alcohol based hand rub, therefore these are
not considered a substitute. However as a last resort in the absence of appropriate
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hand hygiene facilities in the home environment they may be used followed by the
application of a alcohol hand rub prior to undertaking any care procedures.
3.5 Hand cream
An emollient hand cream should be applied regularly to protect the skin from the
drying effects of regular hand decontamination. If a particular soap or alcohol product
causes skin irritation the Occupational Health Team should be consulted.
3.6 Nails
It has been shown that nails, including chipped nail polish, can harbour potentially
harmful bacteria. Caring for nails helps prevent the harbouring of microorganisms,
which could then be transmitted to those who are receiving care.
 Nails must be natural, kept short and clean.
 Nail polish should not be worn
 Artificial fingernails/extensions should not be worn when providing care
 Nail brushes should not be used
The steps included in the hand hygiene process must be followed in order to ensure
nail areas are cleaned properly (Appendix 11)
3.7 Jewellery
It has been shown that jewellery, particularly rings with stones and/or jewellery of
intricate detail, can be contaminated with microorganisms, which could then spread
via touch contact and potentially cause infection.
Wrist and hand jewellery should be removed before care is provided. Where there
will be close personal contact with patients/clients this is essential.
3.8 Occupational health
Any member of staff experiencing a skin problem should refer themselves to the
Occupational Health Department, where a full history will be taken and a discussion
will take place to agree a suitable care plan. The manager may need to be informed
of the outcome where changes in work practice are required, in line with health and
safety requirements.
References and sources of Information
National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and
Community Care. Clinical Guideline2 (2003) suppliment1
World Health Organisation (WHO): Your 5 moments for hand hygiene. May 2009
Department of Health: Uniforms & workwear: Guidance on uniform and workwear policies for NHS employers (2010)
4. PERSONAL PROTECTIVE EQUIPMENT (PPE)
Personal protective equipment is used to protect both the patient and the healthcare
worker from the potential risks of cross infection. Uniform is not classed as PPE.
Gloves, aprons, masks goggles/visors, and in certain situations hats and footwear
are classed as PPE.
Practices should base their selection of PPE on an assessment of the risk of
transmission of micro-organisms to the patient, and the risk of contamination of the
healthcare practitioners clothing and skin by contact with the patient. If there is a risk
of contact with blood, body fluids, secretions or excretions, additional precautions
may be required.
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Following a risk assessment, staff may also require PPE for contact with hazardous
chemicals and certain pharmaceuticals.
5. DISPOSABLE GLOVES
Hands have a key role in the transmission of infection and gloves can reduce the
number of micro-organisms acquired. However hands should still be washed when
gloves are removed.
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Gloves must be worn for invasive procedures, contact with sterile sites and
non-intact skin or mucous membranes, and all activities that have been
assessed as carrying a risk of exposure to blood, body fluids, secretions or
excretions, or sharp or contaminated instruments.

Gloves that are acceptable to healthcare personnel and conform to European
Community (CE) standards on safety and performance must be available.
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Neither powdered gloves nor polythene gloves should be used in healthcare
activities.
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Gloves must be worn as single-use items and should never be washed,
disinfected or re-sterilised. They must be put on immediately before an
episode of patient contact or treatment and removed as soon as the activity is
completed. Gloves must be changed between caring for different patients,
and between different care or treatment activities for the same patient.

Gloves must be disposed of as clinical waste and hands decontaminated after
the gloves have been removed.

Non-latex hypo-allergenic gloves must be available for use by staff with latex
allergy. Sensitivity to natural rubber latex in patients, carers and healthcare
personnel must be documented, and alternatives to natural rubber latex
gloves must be available. (nitrile or neoprene gloves)

Oil can weaken and degrade latex, reducing the glove's protection. Avoid
using oil-based lotions and moisturisers (e.g. those that contain lanolin,
mineral oil, petroleum, coconut oil or palm oil as main ingredients). If you are
uncertain about compatibility, check with the lotion manufacturer.

Gloved hands should not be washed or alcohol applied in order to
decontaminate them, they must be removed after single use.
For glove selection also see appendix 10
Copolymer gloves
Vinyl gloves
Latex gloves
Are more likely to burst under pressure because of weakness in
the welded seams.
Are more permeable to viruses than latex products and are more
likely to split than latex. They are not the product of choice when
exposure to blood or body fluids is a risk or when high levels of
manual dexterity are required.
Are made from natural products & contain proteins. Frequent
users may develop allergies, which can be severe. The
cornstarch powder picks up allergens in the rubber and distributes
them via the skin or into the air. This increases the risk of
sensitisation to patients as well as staff. Low protein powder-free
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latex gloves provide the best protection.
Latex free
In cases of latex allergy, latex free gloves without allergenic
hypo-allergenic gloves additives can be used. (nitrile or neoprene gloves)
6. DISPOSABLE PLASTIC APRONS
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Disposable plastic aprons should be worn when there is a risk that clothing
may be exposed to blood, body fluids, secretions or excretions, with the
exception of sweat.
Plastic aprons should be worn as single-use items, for one procedure or
episode of patient care, and then discarded and disposed of as clinical waste.
Full-body fluid repellent gowns must be worn where there is a risk of
extensive splashing of blood, body fluids, secretions, with the exception of
sweat, onto the skin or clothing of healthcare practitioners.
7. SURGICAL FACE MASKS
Should be worn when there is a risk of blood, body fluids, secretions, excretions or
chemicals splashing into the face.
During an outbreak of Pandemic Influenza surgical masks may also be worn to
protect the wearer from the transmission of influenza by respiratory droplets. The
mask should be fluid repellent and should be worn by the healthcare workers for any
close contact with patients with influenza symptoms (i.e. within approximately one
metre). The mask will provide a physical barrier and minimise contamination of the
nose and mouth by droplets.
When pandemic influenza patients are cohorted in one area and several patients
must be visited over a short time or in rapid sequence, it may be more practical for
staff to put on a surgical mask on entry to the area and to keep it on for the duration
of the activity or until the surgical mask requires replacement (i.e. when it becomes
wet or damaged).
Surgical masks should:
 Cover both nose and mouth
 Not be allowed to dangle around the neck after or between each use
 Not be touched once put on
 Be changed when they become moist or damaged
 Be worn once and then discarded as clinical waste – hand hygiene must be
performed after disposal.
Respirator masks
During an outbreak of Pandemic Influenza a disposable respirator providing the
highest possible protection factor available (i.e. an EN149:2001 FFP3 disposable
respirator) should be worn by healthcare workers when performing procedures that
have the potential to generate infectious aerosols
Fitting the respirator correctly is critically important for it to provide proper protection.
Every user should be fit tested and trained in the use of the respirator. In addition to
the initial fit test carried out by a trained fitter, a fit check should be carried out each
time a respirator is worn.
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A good fit can only be achieved if the area where the respirator seals against the skin
is clean shaven. Beards, long moustaches and stubble may cause leaks around the
respirator.
Disposable respirators should be replaced after each use and changed if breathing
becomes difficult, the respirator is damaged or distorted, the respirator becomes
obviously contaminated by respiratory secretions or other body fluids, or if a proper
face fit cannot be maintained.
References and Sources of Information
National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and
Community Care. Clinical Guideline 2 (2003) suppliment1
The Personal Protective Equipment at Work Regulations, 1992 (Statutory Instrument 1992 no2966) London HMSO
DoH. The epic project: Developing national evidence-based guidelines for preventing healthcare associated
infections. Journal of Hospital Infection (2001); 47: S1 – S82.
NHS Ashton, Leigh and Wigan. Handwashing Policy April 2010
DoH. Pandemic (H1N1) 2009 Influenza: A summary of guidance for infection prevention & control in healthcare
settings
8. LAUNDRY
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If used linen should be laundered after every patient contact.
Curtains should be washed at least every 6 months or when visibly soiled.
9. UNIFORM
Not all staff need to wear uniforms, and it seems unlikely that uniforms are a
significant source of cross-infection. Nevertheless, the way staff dress will send
messages to the patients they care for, and to the public. It is sensible for Practices
to consider what messages they are trying to convey, and to advise on dress codes
accordingly. Both infection prevention and control and public confidence should
underpin a Practices uniform policy, but the two are not necessarily interchangeable.
Examples of expected standards as described by the Department of Health Include
 Dress in a manner which is likely to inspire public confidence
 Change into a clean uniform at the start of each shift
 Change immediately if uniform or clothes become visibly soiled or
contaminated
 Wear short-sleeved shirts/blouses and avoid wearing white coats when
providing patient care
 Cover uniform completely when travelling to and from work
 Wear clear identifiers (uniform and/or name badge)
 Tie long hair back off the collar
 Wash uniforms at the hottest temperature suitable for the fabric. (Practices
may also wish to take in to account the ‘washable’ nature of clothing when
making purchasing decisions e.g. are items which are ONLY capable of being
washed at low temperatures or which are ‘dry-clean’ only suitable?).
 Keep finger nails short and clean
References and Sources of Information
Department of Health: Uniforms & workwear: Guidance on uniform and workwear policies for NHS employers (2010
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National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and
Community Care. Clinical Guideline2 (2003) suppliment1
10. WASTE MANAGEMENT
Health care organisations and the individuals that work within these organisations,
have a legal and moral duty to dispose of waste properly in accordance with statutory
‘duty of care’ requirements.
Changes to legislation governing the management of waste, its storage, carriage,
treatment and disposal meant previous guidance on clinical waste provided in the
Health Service Advisory Committee (HSAC) publication Safe disposal of clinical
waste (1999) required revision, and in December 2006 it was replaced by the
Department of Health’s Health technical memorandum 07-01: Safe management of
health care waste.
The Safe management of health care waste memorandum 2006 introduces some
key changes, specifically:



The removal of the old ‘clinical waste group A to E’ definitions
The introduction and definition of new identification terms (health care waste,
infectious waste, medicinal waste and offensive waste)
A revised colour-coded system for the disposal of waste.
While the advice and courses of action contained within the memorandum aren’t
mandatory, the memorandum advises that health care organisations must take steps
to ensure compliance with relevant legislation, to ensure compliance with all
regulatory requirements – from production through to transport and finally disposal.
Employers are responsible for developing and making available an appropriate
health care waste management policy which clearly outlines written instructions on
the way waste should be managed.
NHS Cumbria’s waste management policy covers the production, handling,
movement and disposal of healthcare waste produced by its staff. Those
independent contractors providing services on behalf of the PCT may if they
wish use this document which is available on the intranet to form the basis for
developing their own waste management policies and procedures.
However national guidance clearly states that the existence of a policy should
not be assumed to be an indication of good practice and that employers are
responsible for monitoring practice within their organisation through the
implementation of robust audit procedures.
10.1 Waste segregation
Segregating waste at the point of production is critical to the safe management of
health care waste. Segregation not only helps control the management costs
associated with waste, but ensures the correct pathways are adopted for the storage,
transport and ultimate disposal of waste.
For segregation to work effectively the Safe management of health care waste (2006)
advises that staff must be provided with colour-coded and labelled waste receptacles
and sack holders. These should be positioned in locations as close to the point of
production as possible and replaced when three-quarters full, securely tied and
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appropriately labelled. Liquid or solidified waste should be placed in a rigid, leakproof container.
10.2 The national colour-coding system (appendix 3)
The (2006) Safe management of health care waste memorandum recommends
adopting the national, colour-coded waste segregation system with immediate effect.
A new national colour-coded system for waste streaming is now recommended for
the segregation of health care waste into streams that are linked to an appropriate
disposal path. This means that waste should be identified and segregated on the
basis of its waste classification, which in turn determines its waste management
option.
Adopting this new best practice segregation system will ensure standardisation
across the UK.
10.3 Waste audits
Waste auditing is a legal requirement, and not just best practice. Waste audits play
an essential role in demonstrating compliance with regulatory standards and should
be undertaken by the waste producer at least every year
Environment Agency – Safe Management of Healthcare Waste March 2011)
11. SAFE USE AND DISPOSAL OF SHARPS
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

All sharps must be disposed of safely and correctly immediately after use.
Discard sharps personally – do not rely on others to do this for you.
Sharps must not be passed from hand to hand, and handling should be kept
to a minimum.
Needles must not be recapped, bent, broken or disassembled before use or
disposal. Discard needle & syringe as one unit directly into sharps container.
Used sharps must be discarded into a sharps container (conforming to
UN3291 and BS7320 standards) at the point of use by the user. These must
not be filled above the mark that indicates that they are full.
Containers must be assembled correctly according to manufacturer’s
instructions i.e. ensuring that the lid is secure.
Containers should be kept in a safe location out of the reach of children e.g.
on a flat surface, below eye level, but not on the floor (free wall and trolley
brackets are available from sharps bin manufacturers). This will reduce the
risk of injury to patients, visitors and staff.
When not in use the temporary closing mechanism on sharps containers must
be activated
Full containers should not be allowed to accumulate. They must be sealed
and labelled/identification tag attached before disposal by the licensed route.
Needle safety devices must be used where there are clear indications that
they will provide safer systems of working for healthcare personnel.
Under no circumstances should items be retrieved from a sharps box.
Under no circumstances should sharps or sharps boxes be put in yellow bags
for disposal.
Under the Health and Safety Act (1974) it is the personal responsibility of the
individual using a sharp to dispose of it safely, the exception being in
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situations where it may be necessary to delegate this responsibility to another
named person (e.g. during surgical procedures)
12. INOCULATION ACCIDENTS
include:
 Skin prick or laceration by a sharp instrument or needle contaminated with
blood.
 Blood splashes onto an abrasion or cut.
 Contamination of mucous membranes of eyes or mouth with blood.
 Human bites.
Treatment of inoculation accidents:
 If it is a small wound, encourage bleeding by squeezing area, do not suck
wound. Wash area thoroughly with soap and running water, and then cover
with a waterproof dressing if necessary.
 If the eyes/mouth are involved irrigate with copious amounts of clean water.
 Following skin exposure, wash the affected area thoroughly with soap and
water.
 Report the incident immediately to your manager.
(Appendix 8 for poster/flow chart)

Arrange with your manager for immediate referral either to Occupational
Health (or A&E if Occupational Health is closed); Take with you a completed
accident/incident form – so that an urgent risk assessment can be
undertaken.
Human Bites:
 If a bite does not break the skin, clean with soap and water and record
incident no medical intervention necessary.
 If a bite does break the skin, clean immediately with soap and water and
arrange with your manager for immediate referral to Occupational Health
(or A&E if Occupational Health is closed); take with you a completed
accident/incident form.
13. SPILLAGES
Treating spills of blood or body fluid may expose the healthcare worker to bloodborne
viruses or other pathogens. The task can be carried out more safely if any pathogens
in the spill are first destroyed by disinfectant. Disposable gloves should always be
worn when cleaning possible contaminated spills. If there is a risk of contaminating
clothing, a disposable plastic apron should also be worn.
13.1 Methods of treating body fluid spills
Chlorine-releasing granules*
 Put on disposable gloves and apron
 Cover fluid completely with chlorine granules
 Leave for 2 minutes
 Remove granules and discard into infectious waste stream
 Wash the area with detergent and water
Hypochlorite solution*
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




Put on disposable gloves and apron
Cover spill with disposable paper towels
Pour hypochlorite (10,000 ppm available chlorine) over the towels i.e. half
strength Milton 2 diluted with water, HAZ Tabs or other propriety product
sufficiently diluted.
Leave for 2 minutes
Remove towels and discard into infectious waste stream
Wash the area with detergent and water
Detergent and water
 Put on disposable gloves and apron
 Soak up spill with disposable towels
 Discard towels into infectious waste stream
 Wash the area with detergent and water
* Do not use for large spills of urine
References and Sources of Information
Health Technical Memorandum 07-01: Safe Management of Healthcare Waste 2006
Fraise, A.P. Bradley, C. (2009) Ayliffe’s Control of healthcare-Associated Infection. 5th ed, London, Hodder Arbnold,
National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and
Community Care. Clinical Guideline 2 (2003) suppliment1
14. CLEAN ENVIRONMENT
The cleanliness of any health care environment is important to support infection
prevention and control and ensure patient confidence. In August 2010 the National
Patient Safety Agency (NPSA) published ‘The national specifications for cleanliness
in the NHS: A framework for setting and measuring performance outcomes in primary
medical and dental care premises ’along with a self audit tool. It is recommended that
this audit tool and guidance is adopted by care providers where it is applicable to the
services provided as this would contribute to demonstrating how they ensure they
meet the registration requirement to maintain appropriate standards.
NPSA guidance is available at: tp://www.nrls.npsa.nhs.uk/resources/type/guidance/?entryid45=75241
The Revised Healthcare Cleaning Manual is available at: www.nrls.npsa.nhs.uk/resources/?Entryld45=61830
14.1 Cleaning
Cleaning is a process that removes contaminates including dust, soil large numbers
of micro-organisms and the organic matter that shields them. Disinfection kills some
micro-organisms but does not leave surfaces and equipment completely free of
contamination and is only effective if the equipment or surface is thoroughly cleaned
with detergent solution before hand. In most situations, thorough cleaning and rinsing
with a freshly prepared solution of detergent and water is adequate and additional
disinfection is wasteful. (appendix 4)
14.2 Colour coding of cleaning materials (appendix 5)
Most healthcare organisations already have a colour coding scheme for cleaning
materials and equipment. However, there is presently no consistency across the
NHS. It has been estimated that there are as many as 50 different schemes currently
in use, mostly revolving around the same core colours but with their specific meaning
15
varying. Sometimes, for historical reasons (for example, as a result of mergers), even
hospitals within the same trust have different schemes in place.
This presents a potential risk when domestic staff move from organisation to
organisation, or even in some cases from practice to practice within the same
consortium. A standardised code will mitigate the risk of possible crosscontamination.
The National Patient Safety Agency (NPSA) has developed a National Colour Coding
Scheme for cleaning materials (appendix 5). The recommendation is that all NHS
organisations adopt this code as standard in order to improve the safety of cleaning,
ensure consistency and provide clarity for staff.
14.3 Choice of cleaning products
 Select and use a good quality detergent.
 Detergents classed as anionic and non-ionic have the best detergent activity
(e.g. good quality washing up liquid).
 Detergents classed as cationic (e.g. quaternary ammonium compounds
(QACs) such as Roccal, Dettol ED and Cetavalon have some antimicrobial
properties, but they are usually less efficient detergents.
 Check product labels before use.
14.4 Cleaning
Practices should have a regular planned and written cleaning schedule available that
details items and environments to be cleaned;
 Before and after each clinic session
 Daily
 Weekly
 Monthly
 Annually
14.5 Cleaning Equipment
 Cleaning equipment should be stored clean and dry in a designated lockable
area
 Use different colour-coded equipment for cleaning different areas. This avoids
any risk of cleaning equipment being used inappropriately, for example in
both toilet and clinical areas.
 Do not use brooms as they raise dust.
 Cleaning cloths must be single-use.
 After cleaning, surfaces should be dried using paper towels.
14.6 Domestic cleaning staff
Cleaning staff should receive induction and ongoing training in the following:
 Basic cleaning skills and schedules
 Cleaning blood and body fluid spills (if included in job description)
 Safe handling of sharps bins and waste bags
 Care of cleaning equipment
 Safe and correct storage of consumables including disinfectants
 Standard precautions including hand hygiene and use of personal protective
equipment
 Actions to be taken as a result of a sharps injury
All staff should know and understand the importance of thorough cleaning. A clean
environment reduces the cumulative risk of cross-infection posed by micro-organisms
16
in the environment. Hands are in contact with surfaces all the time and, if unwashed,
will transfer any organisms present. This risk is always present but will increase if
cleaning is neglected.
15. SURGICAL INSTRUMENTS
Practices must comply with current national legislation and regulatory requirements
for the sterilisation and decontamination of medical devices. If they have not done so
already, practices will need to take steps to ensure that they are in compliance.
Ultimately, it is the responsibility of individual practices to ensure that they are
compliant with current legislation.
There has been a change in legislation affecting PCTs, who are now obliged to
ensure that organisations from which they commission healthcare services are in
compliance with current legislation – hence in recent years, letters to practices
informing them of “new decontamination regulations”.
Full compliance with current national decontamination standards which would enable
practices to continue to use in-house facilities is not a practical or cost effective use
of resources. However, a number of alternative options are available. These include:
 Switch to single use instruments
 Send instruments for sterilisation to an off-site location that is compliant with
current standards (for example, a local hospital CSSD or super-CSSD site).
 Use a combination of the above options
Each option has its advantages and disadvantages, and practices will need to
carefully consider which approach will be the most suitable for their needs.
15.1 Single-use items
If an item is marked for single-use, it means that you must only use it on a single
occasion and then discard it. You should never use a single-use device on multiple
occasions on a single patient or on different patients. Equipment marked with the
following with must not be re-used
If a medical device is marked for single patient use, you can use the item for
multiple uses on one patient and then you must discard it. Examples of single patient
use devices include nebulizer masks and suction tubing. Some form of reprocessing
may be necessary between uses on the same patient. Always make sure you follow
the manufacturer’s instructions.
17
16. MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
16.1 Control of MRSA in community settings
The risk of MRSA transmission in residential care homes, where residents are
generally more healthy and have fewer invasive devices than hospital patients, is
much lower. Spread of MRSA between residents may occur but is associated with
colonisation rather than infection. Isolation of residents with MRSA is not necessary
and they should be able to use communal areas with other residents. They may
share a bedroom, provided neither occupant has open lesion, invasive devices or
catheters. Standard (universal) precautions such as hand hygiene and the use of
disposable gloves and apron for contact with body fluids, dealing with wounds or
invasive procedures as described earlier should be sufficient to prevent spread.
Advice to the home is available from the Infection Prevention and Control Team
(See contact list appendix 1 for Infection Prevention and Control)
16.2 Control of MRSA in hospitals
Attempts to control the spread of MRSA are essential to both retain options for
antimicrobial therapy and protect vulnerable patients. Current guidelines for the
control of MRSA in hospitals recommend targeting the approach to infection
prevention and control according to level of risk and clinical area affected.
16.3 Decolonisation
Since Staphylococcus aureus commonly colonises the skin, it is an important cause
of post operative surgical wound infection. Decolonisation prior to elective surgery is
therefore performed as recommended by the DH and is mandatory for all emergency
admissions by 2011. For your information the full decolonisation regime used by
Community Healthcare on colonised patients is included in the appendices of this
document
See contact list appendix 1 for advice/referral and Appendix 6 for decolonisation regime
18
17. CLOSTRIDIUM DIFFICILE INFECTION (CDI)
Clostridium difficile infection (CDI) is associated with antimicrobial use. Prescribing
antimicrobials wisely can reduce the incidence.
Clostridium difficile infection (CDI)
 C. difficile is a bacterium present in the gut flora in some people.
 Antimicrobials disturb the balance of the gut flora, allowing C. difficile to
multiply and cause infection.
 Symptoms of CDI can vary from mild diarrhoea to fatal bowel inflammation.
 C. difficile spores are shed in the faeces. The spores can survive for long
periods in the environment. If ingested, they can transmit infection to others.
17.1 Prudent antimicrobial prescribing
 Only prescribe antimicrobials when indicated by the clinical condition of the
patient or the results of microbiological investigation.
 Do not prescribe antimicrobials for sore throat, coughs and colds in patients
at low risk of complications.
 Consider delayed prescriptions in case symptoms worsen or become
prolonged.
 If an antimicrobial is required, follow local guidelines.
 Choose a narrow-spectrum agent where possible and prescribe a short
course.
 Generally, no more than 5-7 days’ treatment is required.
 Three-day courses are appropriate in some cases.
 Broad-spectrum antimicrobials should be reserved for the treatment of
serious infections when the pathogen is not known.
17.2 Which patients are most at risk of CDI?
Patients are more at risk of CDI if they are:
 Elderly
 Suffering from severe underlying diseases
 Immunocompromised
 In an environment where they are in close contact with one another (e.g. in a
care home), particularly if hygiene is lacking.
Other factors that increase the risk of CDI are:

Use of antimicrobials

Recent gastrointestinal procedures

Presence of a nasogastric tube
The use of proton pump inhibitors (PPIs) might increase the risk of CDI. Only
prescribe PPIs when indicated.
17.3 Antimicrobials to avoid where possible
The antimicrobials most strongly associated with CDI are:
 Second and third generation cephalosporins: cefaclor, cefuroxime, cefixime
and cefpodoxime are examples for oral use
 Clindamycin
 Quinolones (associated with the virulent 027 strain of C. difficile):
ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin, norfloxacin.
 Long courses of amoxicillin, ampicillin, co-amoxiclav or co-fluampicil.
19
17.4 Antimicrobials to choose
 All antimicrobials are associated with CDI, but those with lower risk are
trimethoprim, penicillin V, tetracyclines and aminoglycosides.
 If antimicrobials are required, prescribe a short course and follow the local
formulary.
 Where therapy has failed or there are special circumstances, obtain advice
from a local microbiologist. See contact details page 4
17.5 CDI and primary care
 CDI has commonly been associated with hospital stay but it is being
recognised that many cases originate in the community, due to indiscriminate
use of antibiotics.

Patients most at risk are the elderly, particularly if they have medical
conditions and are in close contact with others, e.g. in a care home,
residential treatment centre or hospital.
17.6 When can broad-spectrum antibiotics be recommended?
There are few indications for broad-spectrum cephalosporins or quinolones in
primary care please refer to the PCT antimicrobial formulary. (see appendix 14)
When using broad spectrum antimicrobials, counsel patients at risk to be alert for
signs of CDI and to stop their antimicrobial and seek medical help if diarrhoea
develops.
17.7 Diagnosis of Urinary Tract Infection in Adults
For advice with regards to diagnosis of urinary tract infection and information about
asymptomatic bacteriuria please refer to appendix 13: Factsheet: Diagnosis of UTI in
Adults
20
18. NOTIFICATION OF INFECTIOUS DISEASES
Health protection legislation in England has been updated to give public authorities
new powers and duties to prevent and control risks to human health from infection or
contamination, including by chemicals and radiation. The new Regulations for clinical
notifications came into force on 6 April 2010.
The new legislation adopts an all hazards approach, and, in addition to the specified
list of infectious diseases, there is a requirement to notify cases of other infections or
contamination which could present a significant risk to human health.
Under the new Notification Regulations, there are no provisions for Registered
Medical Practitioners (RMPs) to be paid fees for notifications. RMPs are expected to
provide information that is a requirement of legislation needed to protect public health
as part of their professional duties. The prime purpose of the notifications system is
speed in detecting possible outbreaks and epidemics. Accuracy of diagnosis is
secondary, and since 1968 clinical suspicion of a notifiable infection is all that is
required.
18.1 Diseases notifiable under the Health Protection Regulations 2010:































Acute encephalitis
Acute meningitis (All types)
Acute poliomyelitis
Acute infectious hepatitis (All types)
Anthrax
Botulism
Brucellosis
Cholera
Diphtheria
Enteric fever (typhoid or paratyphoid fever)
Food poisoning
Haemolytic uraemic syndrome (HUS)
Infectious bloody diarrhoea
Invasive group A streptococcal disease and scarlet fever
Legionnaires’ Disease
Leprosy
Malaria
Measles
Meningococcal septicaemia (without meningitis)
Mumps
Plague
Rabies
Rubella
SARS
Smallpox
Tetanus
Tuberculosis
Typhus
Viral haemorrhagic fever (VHF)
Whooping cough
Yellow fever
21
Examples of other infections which could present a significant risk to human
health.









Parvovirus B19 in a contact of a pregnant woman
Chickenpox in a healthcare worker
Cryptosporidiosis
Giardiasis
Campylobacter
Salmonella
Rotavirus Diarrhoea
Enteropathogenic ‘E-coli’
Haemophilus Influenza type B
Health Protection Agency (Cumbria & Lancashire Unit) contact details
01257 246450
19. TB REFERRAL AND MANAGEMENT
All cases of TB should be managed by, or in consultation with, a Chest Physician
specialising in this disease. Cumbria & Lancashire Health Protection Unit are
responsible for local surveillance, for maintaining a register/database of cases, and
for contributing to national surveillance by weekly reporting to the Office for National
Statistics and participating in enhanced surveillance and research.
Contact Tracing
Contact tracing is an essential part of the routine management of patients with
tuberculosis and should be carried out according to the protocol within current
National Guidelines. In Cumbria, local contact tracing is undertaken by the TB Team
See appendix 1 for TB Team contact details
22
Appendix 1
1. USEFUL CONTACTS NUMBERS
NHS Cumbria Health Protection and Infection Prevention and Control Team
Clinical Specialist: Health Protection Lead
Lyn Murphy, Tel: 01228 603753
07920 467372
Clinical Specialist: Infection Prevention
Nicola Holland, Tel: 01539 797895
07879 808305
TB Specialist Nurses for referral or patient advice
South Cumbria/ Furness: Eileen Adamson, Tel: 01229 484034
West Cumbria: Louise Sullivan, Tel: 01946 693660
North/ East Cumbria, Mairi Black, Tel: 07500121125
Consultant Microbiologists and Microbiology Medical advice
North Cumbria:
CIC: 0122881 4648/ 4640
WCH: 01946 543422
South Cumbria:
RLI: 01524 583770
FGH: 01229 491022
Health Protection Agency (Cumbria & Lancashire Unit)
Tel. 01257 246450
Occupational Health (Team Prevent)
Tel: 01768 213082
Fax: 01768 213083
23
Appendix 2
Registered medical practitioner notification form template
Health Protection (Notification) Regulations 2010: notification to the proper officer of the
local authority
Registered Medical Practitioner reporting the disease
Name
Address
Post code
Contact number
Date of notification
Notifiable disease
Disease, infection or
contamination
Date of onset of symptoms
Date of diagnosis
Date of death (if patient died)
Index case details
First name
Surname
Gender (M/F)
DOB
Ethnicity
NHS number
Home address
Post code
Current residence if not home
address
Post code
Contact number
Occupation (if relevant)
Work/education address (if
relevant)
Post code
Contact number
Overseas travel, if relevant
(Destinations & dates)
24
Appendix 3
Colour coding of waste
Colour stream
Description of waste
Example
Waste
which
requires
disposal
by
incineration Indicative treatment/disposal is
incineration in a suitably permitted or licensed
facility
Anatomical waste, Infectious
waste requiring INCINERATION
ONLY
Waste which may be “treated” Indicative
treatment/disposal required is to be “rendered
safe” in a suitably permitted or licensed
facilities, usually alternative treatment plans.
However this waste may also be disposed of by
incineration
Infectious swabs, dressings,
wipes, protective clothing and
sharps (with no medicine
contamination)
Offensive/hygiene waste
Indicative treatment/disposal required is landfill
in a suitably permitted or licensed site. This
waste should not be compacted in
unlicensed/permitted facilities.
Domestic (municipal) waste
Minimum treatment/disposal required is landfill
in a suitably permitted or licensed site.
Recyclable components should be removed
through segregation. Clear/opaque receptacles
may also be used for domestic waste.
Non-infectious
swabs,
dressings, wipes, protective
clothing,
nappies,
human
hygiene waste, sanitary waste.
Clean packaging, food paper etc
Cytotoxic and Cytostatic waste
Indicative treatment/disposal required is
incineration in a suitably permitted or licensed
facility.
Sharps contaminated with cytotoxic/static
medicines, i.e. sharps used for injections of
cytotoxic/static drugs.
Medicines used for
chemotherapy, certain antivirals,
immuno-suppressants
and
hormonal drugs
Waste which may be “treated”
Sharps not contaminated with any medicines,
i.e. sharps used for bloods, glucose, saline, etc.
Also suitable for blades and razor blades.
Sharps
used
for
bloods,
glucose, saline, etc, and blades
Waste
which
requires
disposal
by
incineration
Sharps contaminated with medicines (noncytotoxic/static),
Sharps used for injecting
medicines
25
Appendix 4
A-Z Cleaning & Disinfectant Policy For The Environment & Facilities
Equipment
Routine decontamination method
Acceptable alternative if
required
Additional information
Electrical items
including computer
equipment and
waiting room
televisions/radios
Telephones
Dust Daily.
Bowls/buckets
including those
used for patients
with leg ulcers.
Wash, dry, store inverted between
patient use (always use with plastic
liner for patient use).
If patient is infected, wash
and then disinfect using a
phenolic or chlorine-based
product.
Badly scratched buckets and
bowls used in leg ulcer
treatment should be
replaced
Carpets
Vacuum daily. Steam clean 6
monthly or if significantly stained.
For contamination spills,
clean with detergent & water
then dry (most disinfectants
will damage carpets)
Ensure vacuum filters are
changed frequently.
Carpets should be visibly
clean with no blood or body
substances, dust, dirt, debris
or spillages. Floors should
have a uniform appearance
and an even colour with no
stains or water marks.
Phones and keyboards cleaned with
detergent wipe or equivalent daily.
Do not use brooms in clinical areas.
Drains
Clean regularly.
Chemical disinfection is not
advised.
Equipment
surfaces
Damp dust contact points between
patient use with one full clean weekly.
Use freshly prepared detergent
solution, and dry.
Clean and wipe with alcohol
to disinfect.
All parts (including
underneath) should be
visibly clean, with no
blood,body substances,
dust, dirt, debris or spillages.
Floors (hard)
Disinfection of floors is not required
routinely. Wash daily with freshly
prepared detergent solution. Rinse
with water weekly to remove
detergent residues and help maintain
anti-static properties, if required. (It is
good practice to do this anyway. It
prevents slipping when floors get wet,
eg, people coming in from the rain.)
For known contaminated
surfaces, use a phenolic or
chlorine-based solution.
The complete floor
(including all edges, corners
and main floor spaces)
should have a uniform finish
or shine and be visibly clean
with no blood or body
substances, dust, dirt,
debris, spillages or scuff
marks.
Furniture and
fittings
Daily damp dust using a freshly
prepared detergent solution.
For know contaminated
surfaces, clean then use
phenolic or chlorine-based
solution.
Frequent use of
disinfectants will damage
cover.
Mattresses
Couch
Pillows
Use water impermeable cover. Wash
using a freshly prepared detergent
solution and dry twice daily, with
additional spot clean as required.
For know contamination,
clean and disinfect with
phenolic or chlorine-based
solution.
Refer to manufacturer.
Frequent use of disinfectant
will damage cover.
Mops (dry and dust
attracting)
Vacuum after each use.
Wash and clean every other
day.
Vacuuming between uses
prolongs the life of mops.
Mops (wet)
Wash in washing machine daily if
available. Wash and rinse after each
use, wring and store dry.
Disinfect by boiling or soak
clean mop in chlorine-based
product (solution 1000ppm
available chlorine) for 30
minutes, rinse and store dry.
Mops should not be left to
soak overnight. Fluid will
become a growing medium
for bacteria.
Rooms
Wash surfaces with freshly prepared
If infected patients have
26
(clean/dirty/clinical)
detergent solution at end of clinic
session.
been treated, wash surfaces
and then wipe down with
phenolic or chlorine-based
products.
Toilet seats
Wash with a freshly prepared
detergent solution and dry.
After use by infected patient
or if grossly contaminated,
use phenolic or chlorinebased product, rinse and
dry.
Clean toilet areas at least
once a day.
Toys
Clean with a freshly prepared
detergent and water solution.
Machine wash soft toys.
Clean toys on a regular
basis and more frequently
during ‘winter virus’ period.
All toys should be wipeable.
Soft toys are not
recommended.
Trolley tops
(clinical)
Clean with freshly prepared detergent
solution at beginning & end of
dressing clinic. Use alcohol spray
between dressings.
If contaminated, or patient
has a known infection, clean
when dressing finished and
then disinfect.
All parts (including
wheels/castors and
underneath) should be
visibly clean with no blood or
body substances, dust, dirt,
debris, spillages.
Wash basins/sinks
Clean at least once daily using a
proprietary cleaner to remove stains.
Disinfection is not normally required.
Clean and then disinfect if
contaminated.
Many products contain both
a cleaner (ie, detergent) and
a disinfectant.
Hand wash
containers/hand
rub dispensers
One full daily clean using detergent
Walls and ceilings
Clean using detergent every six
months in treatment/minor surgery
room. Clean annually elsewhere.
Curtains
Launder at least every 6 months or
when visibly dirty
Baby changing
areas
Clean daily and in between patient
use using a freshly prepared
detergent solution and dry.
Waste receptacles
Clean daily using a freshly prepared
detergent solution and dry.
Clean and disinfect if blood
or body fluids splash onto
walls or ceiling.
27
Appendix 5
28
Appendix 6
MRSA Decolonisation / Eradication Procedure
Decolonisation therapy should be prescribed as per local arrangements.
Directions for patient use supplied with the decolonisation product supplied
should be followed. If further advice is required please contact the
microbiologist or infection prevention team.
*Contact infection prevention and control nurse if patient has psoriasis or very
dry skin.
The process for the application of Mupirocin (Bactroban) nasal ointment
The nasal ointment should be applied three times a day to each nostril for five days
(for example, 08:00, 14:00 and 20:00 hours.
Use of nasal ointment:
 Put a small amount of Bactroban (matchstick head size) on a cotton bud and
apply to the inside of each nostril.
 Close the nostrils by pinching the sides of the nose together to spread the
ointment inside the nose.
 Wash your hands under running water using hand soap and warm water. Dry
with a clean towel.
During the eradication process it is advisable to change bed linen at home. The
Infection Prevention and Control Team would advise to change bed linen on:



Day 1 (commencement of the eradication process)
Day 3 (mid way through the eradication)
Day 5 (on completion of the eradication process and before re-screening)
If swab report indicates resistance to Mupirocin, Naseptin nasal
ointment will be prescribed as an alternative. The procedure for
application remains the same
Other site involvement
Contact infection prevention and control lead and/or specialist clinical nurse
for management of other site
29
Appendix 7
30
Appendix 8
31
Appendix 9
Risk Assessment – Glove Usage
ARE GLOVES REALLY NECESSARY?
Gloves are NOT required for procedures where there is minimal risk of cross
infection between patients and staff, eg:





Basic care procedures without contact with blood or body fluids
Transferring food from food trolleys to patient bedside
Making uncontaminated beds/changing or removing patients’ uncontaminated
clothing
Taking recordings (BP, Temp, Pulse)
Closed Entrotracheal Suction
Gloves ARE required for procedures where there is a risk
of cross infection between patients and staff and further
risk assessment should be carried out.
IS THERE A HIGH RISK OF EXPSOURE TO
BLOOD AND BODY FLUIDS
NO
NON-STERILE VINYL
DON’T WEAR GLOVES
YES
IS A STERILE FIELD
REQUIRED
YES
NON-THEATRE ENVIRONMENT:
 STERILE LATEX OR
NITRILE
THEATRE ENVIRONMENT:
 ELASTRYN
 NEOPRENE
 NITRILE
 NON-POWDERED LOW PROTEIN
LATEX
 SYNTHETIC POLYISOPRENE
 TACTYLON
No
NON-STERILE
LATEX OR
SYNTHETIC
NITRILE GLOVE
WITH EQUIVALENT
BARRIER
PROPERTIES
32
Appendix 10
Glove selection guidance
ALL GLOVE SELECTION MUST BE PRECEDED BY RISK ASSESSMENT
Cleaning
General
cleaning
‘Colour
coded’
marigolds
Blood borne
virus
exposure/
spillage
Food
Handling,
Preparation,
Serving
Polythene
Tasks where there is a low risk of
contamination, non-invasive clinical
care, or environmental cleaning, eg:
Procedures involving high risk of
exposure to BBVs and where high
barrier protection is needed, eg:











Oral care
Emptying catheter drainage bags
Emptying urinals/bedpans and
suction jars
Handling low risk specimens
Clinical cleaning
Dressing wounds when contact
with
blood/body fluids is unlikely, eg,
gastrostomy dressings
Endotracheal suction
Applying creams
Touching patients with unknown
skin rash/scabies/shingles
Making beds/changing clothing of
patients in isolation
Non-Sterile Vinyl
Non-Sterile
latex/Nitrile
TYPE OF ACTIVITY








Potential exposure to blood/body
fluids, eg, blood spillages, faecal
incontinence, blood glucose
monitoring, administering
enemas/suppositories and rectal
examinations
Handing cytotoxic material
Handling disinfectants
Venepuncture/cannulation
Vaginal examination
Basic care and specimen collection
procedures on patients known or
suspected to be high risk of BBV
Procedures which require
a sterile field and high
barrier protection for
example:
 Lumbar punctures
 Liver biopsies
 Clinical care to
surgical wounds/drain
sites
 Procedures for
neutropenic patients
 Insertion of urinary
catheters
 Vaginal examination in
obstetrics
Non Surgical dentistry/podiatry
Handling dirty/used instruments
Processing specimens in a laboratory
All Surgery
and Invasive
Radiological
procedures
STERILE
SURGICAL
GLOVES:
 Elastryn
 Neoprene
 Nitrile
 Non-powdered
low protein
Latex
 Synthetic
polyisoprene
 Tactylon
Sterile Latex or
Synthetic alternative
Nitrile Examination
Gloves
Non-Sterile latex or
Synthetic alternative
Nitrile
33
Appendix 11
Handwashing
1
2
3
Palm to palm.
4
Backs of fingers to opposing palms
with fingers interlocked.
Right palm over left dorsum
and left palm over right dorsum.
5
Palm to palm
fingers interlaced.
6
Rotational rubbing of right thumb
clasped in left palm and vice versa.
Rotational rubbing, backwards and forwards
with clasped fingers of right hand in left palm
and vice versa.
5.3
34
Appendix 12
GP Surgery Infection Prevention & Control Audit Tool
This audit tool has been adapted for use by NHS Cumbria General Practitioners (from the ICNA ‘audit tools for
monitoring infection control guidelines within the community setting, 2005’) It is intended for use by Infection
Prevention and Control Link Practitioners and/ or GPs/ Practice Managers.
Scoring
All criteria should be marked ‘Yes’, ‘No’ or ‘N/A’ (not applicable). To work out a ‘percentage’ the number of N/A
answers must first be deducted from the overall number of criteria in the section to give a ‘potential’ score. That
number is divided in to the overall number of ‘yes’ scores and the answer multiplied by 100.
Following the audit an action plan should be formulated to address any areas which do not meet the required
criteria. This should be shared with the Infection Prevention and Control Team and updated at least quarterly.
Part 1: Hand Hygiene
Standard statement: Hands will be decontaminated correctly and in a timely manner using a cleansing agent to
reduce risk of cross infection.
Ref
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
.
Yes
Staff have received training in hand hygiene
procedures (ask member of staff)
Clinical staff nails are short, clean & free from nail
extensions & varnish
No wrist watches, stoned rings or other wrist jewellery
are worn during clinical procedures
Hand hygiene is encouraged and alcohol hand rubs
are made available for visitors
Posters promoting hand hygiene are on display
(including ‘how to’ posters by sinks)
There is a hand wash basin in each treatment/ clinical
area
Hand washing facilities are clean and intact (check
sinks, taps, splash backs, soap & towel dispensers)
Hand wash basins are dedicated for that use only and
are free from equipment & inappropriate items
There is easy access to the hand wash basin
The hand wash basin complies with HTM64 (ie; no
plugs, no overflow, water from taps not directly over
plughole)
Elbow or non-touch taps are available at all hand wash
basins in clinical areas
Liquid soap (in the form of single use cartridge
dispensers is available at each hand wash basin
There is no bar soap at hand washing basins in
treatment/ clinical areas
Alcohol hand rub is available at entrances/ exits
as appropriate
Alcohol hand rub is available at the point of care as per
local & national standards
Clinical staff are encourage to use moisturisers that
are pump operated or personal use only
No
N/A
1.17
1.18
1.19
1.20
Soft absorbent paper towels are available at all hand
wash sinks
There are no reusable cotton towels used to dry hands
There are no reusable nail brushes used or present at
hand wash sinks
There is a foot operated bin for waste towels in close
proximity to hand wash sinks which are fully
operational
Overall Scoring:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
Part 2: Environment
Standard statement: The environment will be maintained appropriately to reduce the risk of cross infection
Ref
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
.
Yes
Overall appearance of the environment is tidy &
uncluttered with only appropriate, clean and well
maintained furniture used
Fabric of the environment and equipment smells clean,
fresh & pleasant
The allocation of rooms for clinical practice is fit for
purpose
Rooms where clinical practice takes place are not
carpeted
Floor coverings are washable, impervious to moisture
and sealed regularly
The complete floor, including edges and corners are
visibly clean with no dust, body substances, dirt or
debris
Furniture, fixtures &fittings are visibly clean with no body
substances, dirt, dust, debris or adhesive tape
All dispensers, holders (couch roll, toilet paper, soap &
alcohol gel) are visibly clean with no dirt, dust, debris,
body substances or adhesive tape
Toilets are visibly clean with no body substances, dust,
lime scale stains, deposits or smears- including beneath
toilet seat and raised toilet seats
Waste receptacles are clean, including lid & pedal
Foot pedals of clinical waste bins are in good working
order
There is a procedure in place for regular
decontamination of curtains and blinds
Furniture in patient areas (eg. chairs & couches) are
made of impermeable and washable materials
Chairs are free from rips and tears
No
N/A
2.15
Couches are free from rips and tears
2.16
Pillows are enclosed in a washable and impervious
cover
Furniture that cannot be cleaned is condemned
2.17
2.18
2.19
Tables are tidy and free from clutter to enable cleaning
Medical equipment is cleaned, maintained and stored
appropriately
2.20
Water coolers are mains supplied (not bottled water),
visibly clean and on a planned maintenance programme
Animals used for pet therapy have evidence that all
appropriate worming & vaccinations are up to date and
have a flea management programme
Hand hygiene is actively encouraged after handling
animals in healthcare environment- must apply to staff,
patients & visitors
2.21
2.22
Overall score:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
Part 3: Ward (beverage) Kitchen
Standard statement: Kitchens will be maintained in accordance with current legislation to reduce the risk of cross
infection
Ref
3.1
The floor is clean and dry
3.2
There is no evidence of infestation in the kitchen
3.3
3.5
Cleaning materials used in the kitchen are clearly
identifiable and stored away from food
There is a separate hand wash sink and liquid soap and
paper towels are available
Fixtures and fittings are in a good state of repair
3.6
Fixtures, surfaces & appliances are clean & dry
3.7
Shelves, cupboards & drawers are clean & dry, free from
dust and in a good state of repair
All cooking appliances are visibly clean (look inside the
microwave)
Refrigerators are clean and free from ice build up
3.4
3.8
3.9
Yes
3.10 There is a thermometer in the fridge and there is
evidence that daily temperatures are recorded and
.
No
N/A
appropriate action taken if standards are not met (ie; if
fridge temp rises above 80C)
3.11 Patient & staff food is labelled & there is a system in
place to determine when it was opened &/ or when it
should be used by
3.12 There are no inappropriate items(eg. Specimens/
medication) in the refrigerator
3.13 All milk is stored in the refrigerator
3.14 Bread is stored in a clean, dry container
3.15 All food products are within their expiry dates
3.16 All opened food is stored in containers (eg. Tea, sugar)
3.17 There is a satisfactory system for cleaning crockery and
cutlery (eg. Dishwasher) which is clean & well
maintained
3.18 Disposable paper roll is available for dying equipment &
surfaces
3.19 There are no fabric tea towels or dishcloths in use
3.20 There are no inappropriate items or equipment stored in
the kitchen
Overall score:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
Part 4: Waste Management
Standard statement: Waste is disposed of safely without the risk of contamination or injury
Ref
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
.
Yes
Staff have attended a training session which includes
information about the correct & safe disposal of waste
There is evidence that staff are segregating waste
correctly (look in some bins)
Staff are aware of the waste segregation procedures
(randomly question a member of staff)
There are clinical waste signage posters identifying
waste segregation available
The waste storage area is clean & dry
Clinical waste sacks are secured and labelled prior to
disposal
There is no storage of waste in corridors or other
inappropriate areas whilst awaiting collection
All plastic waste sacks are fully enclosed within bins to
minimise the risk of injury
All waste bins used are lidded, foot operated and in good
working order
No
N/A
4.10
Waste bags are removed from clinical areas daily
4.11
There is no emptying of clinical waste from one bag to
another
There are no overfilled bags- bags are no more than 2/3
full
4.12
Overall score:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
Part 5: Spillage/ contamination with blood/ body fluids
Standard statement: Body fluid spillage/ contamination is dealt with appropriately to reduce the risk of cross
infection.
Ref
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
Yes
Staff have received training in dealing with body fluids
9ask member of staff)
Staff are aware of how to contact the occupational
health dept in the event of an inoculation injury
Dedicated spillage kits are available for
decontaminating and cleaning body fluid spillages
Personal Protective equipment is available (aprons,
gloves, masks, eye protection)
Equipment used to clear up body fluid spillages is
disposable or able to be decontaminated
Sodium hypochlorite solution in the strength 1:10,000
ppm (1%) or NaDCC (sodium dichloroisocyanurate) is
available
Medical equipment which has been contaminated with
body fluids is cleaned appropriately and a permit to
work document completed (eg. Decontamination
certificate/ label)
Furniture which has been contaminated with body
substances and cannot be cleaned is condemned
Overall score:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
.
No
N/A
Part 6: Personal Protective Equipment
Standard statement: Personal protective equipment is available and used appropriately to reduce the risk of
cross infection
Ref
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
Yes
Staff are trained in the use of personal protective
equipment as part of local departmental induction
GLOVES
Sterile & non sterile gloves (powder free, not polythene
and conforming to EC standards) are available in all
clinical areas
There is an appropriate range of sizes available
An alternative (eg. Nitrile) to natural latex rubber is
available for practitioners/ patients with NRL sensitivity
Gloves are worn as single use items for each clinical
procedure or episode of patient care
Hand are decontaminated following removal of gloves
Gloves are stored appropriately
APRONS
Disposable plastic aprons are worn when teher is a risk
that clothing or uniform may become exposed to body
fluids or become wet
Disposable plastic aprons are worn as part of food
hygiene practices (ie; food prep/ serving of meals)
Aprons are stored appropriately
FACE/ EYE PROTECTION
Clean face masks & eye protection is worn when there
is a risk of body fluids splashing in to the face/ eyes
(COSHH)
Overall score:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
.
No
N/A
Part 7: Prevention of sharp injuries
Standard statement: inoculation injuries & splashes involving blood/ other body fluids are managed in a way
which reduces the risk of injury or infection
Ref
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
Yes
There are arrangements in place which ensure staff are
dealt with appropriately in the event of an inoculation
injury
All staff receive training in sharps/ splash/ bite injury
management and are aware of the actions to take
following an injury
All inoculation/ sharp injuries are recorded
There are appropriate devices used for exposure prone
procedures
There is signage (eg;poster) displayed for management
of inoculation/ splash injuries
Sharps bins comply with BS 7320 (1990)/ UN 3291
Sharps containers are correctly assembled, labelled with
date, locality & signed
Sharps containers are available at the point of use
When full & ready for disposal all sharps containers are
dated & signed
Sharps containers are store safely away from the public
and out of reach of children
Sharps containers are not filled beyond the indicator
mark (ie; not more than 2/3 full
The are no inappropriate items (eg; swabs/ packaging/
gloves) in the sharps container
Needles & syringes are disposed of as a single unit
7.14 Syringes with a residue of prescription medication are
disposed of according to current legislation
7.15 The temporary closure mechanism is used when the bin
is not in use
7.16 Full sharps containers are sealed with the bin’s integral
lock (tape or stickers are not used)
7.17 Sharps containers are not put in waste bags prior to
disposal
7.18 Sharps containers are available for use & located within
easy reach
7.19 Sharps containers are visibly clean with no bodt
substances, dust, dirt or debris
7.20 Inappropriate re-sheathing does not occur (ask member
of staff)
Overall score:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
.
No
N/A
Part 8: Specimen Handling
Standard statement: Specimens are handled in an appropriate manner which reduces the potential risk of cross
infection to all staff.
Ref
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11
8.12
Yes
Specimens are sent to the microbiology laboratory in
appropriate containers
Patients are provided with an appropriate specimen
container if required to produce specimens at home
Specimens are sealed in appropriate plastic transit bags
Request forms are not in the same part of the transit bag
as the specimen
Transit bags are not sealed with staples or paper clips
Specimens awaiting transit are stored away from the
public/ staff rest areas
Refrigeration) for specimens away from food) is available
if required
Specimens are transported in leak resistant boxes with
lids which can be fastened
Specimen transport boxes are visibly clean with no body
substances, dust, dirt or debris visible
Specimen testing on the ward is undertaken in an
appropriate designated area
The test area is cleaned after use
Samples tested on site are disposed of down a toilet or
sluice
Overall score:
Potential score:
(Overall number of questions less any N/A)
Percentage:
(‘overall’ divided by ‘potential’ score X 100)
Date of next audit:
.
No
N/A
Appendix 13: UTI factsheet
.
.
.
.
.
Appendix 14: Abbreviated Antibiotic Guidelines
Condition
UPPER RESPIRATORY TRACT/ENT
Tonsillitis/ pharyngitis/ sore throat
Acute sinusitis
Otitis media (acute) – child doses
Comments
Drug and dose
(listed in order of preference)
Avoid antibiotics as 90% resolve in 7 days without and pain only reduced by 16
hours.
Antibiotics to prevent quinsy, NNT >4000
Antibiotics to prevent otitis media, NNT 200
Most episodes are viral. Symptomatic benefit from antibiotics small – 69% resolve in
7-10 days without antibiotics; and 84% resolve with antibiotics; reserve antibiotics
for:
 persistent symptoms (e.g. lasting more than 10 days),
 severe symptoms (e.g., profuse purulent nasal discharge, facial pain, systemic
symptoms),
 symptoms that are deteriorating significantly
Intranasal decongestants may be useful for short-term use. Steam inhalations,
antihistamines, mucolytics and intranasal corticosteroids not recommended.
Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness.
Use paracetamol or NSAID. Illness resolves in 4 days in 80% without antibiotics.
Need to treat 20 children > 2 years and seven 6-24 months old to get pain relief
in one at 2-7 days.
If antibiotic is required,
Phenoxymethylpenicillin 500mg
QDS (severe), or
Clarithromycin 250-500mg BD
Antibiotic treatment not routinely
recommended
Use antibiotics if:
 < 3 months of age (consider admission)
 > 4 days symptoms and not improving
 Systemically unwell or patient at high risk of complication due to underlying
medical condition
Immediate prescribing may be appropriate for the following groups:
 otorrhoea
 <2 years with bilateral acute otitis media
LOWER RESPIRATORY TRACT
Lower respiratory tract infection (including
acute bronchitis) in otherwise healthy
individuals
Exacerbations of COPD
Community acquired pneumonia
.
Antibiotics are not routinely indicated.
Consider prescribing an antibiotic if the person has a significantly impaired ability to
fight infection or if acute bronchitis is likely to worsen an existing condition.
Alternative antibiotics may be used on the basis of sputum results.
30% viral, 30-50% bacterial, remainder undetermined. Sending sputum samples for
culture not recommended in primary care. Use antibiotics if:
 exacerbation of COPD AND
 increased purulence of sputum
Assess the person's need for admission by determining respiratory rate, blood
pressure, age (65 years and older), and whether they are confused (the 'CRB-65'
scale).
If admission is not indicated, arrange a chest X-ray for people over the age of 50
years that smoke, and give advice on self-care such as using analgesia and keeping
hydrated.
If antibiotic is required, Amoxicillin
500mg TDS, or
Doxycycline 200mg stat, then
100mg daily, or
Clarithromycin 250mg BD
Antibiotic treatment not routinely
recommended
If antibiotic is required, Amoxicillin
40-90mg/kg/day in 3 divided doses
up to 1 gram TDS,or
Clarithromycin
<8kg - 7.5mg/kg BD
8-11kg – 62.5mg BD
12-19kg – 125mg BD
20-29kg – 187.5mg BD
30-40kg – 250mg BD
2nd line Co-amoxiclav
1-6yrs - 156mg TDS
6-12yrs - 312mg TDS
If antibiotics are required,
Amoxicillin 500mg TDS, or
Doxycycline 200mg stat, then
100mg daily
Amoxicillin 500mg TDS, or
Doxycycline 200mg stat, then
100mg daily, or
Clarithromycin 500mg BD
Amoxicillin 500mg to 1 gram TDS,
or Doxycycline 200mg stat, then
100mg daily,
or Clarithromycin 500mg BD
If no response after 48 hours or
atypical pathogen is suspected give
Amoxicillin + Clarithromycin
Duration
(days)
10
5
7
7
7
5
5
5
5
5
5
5
5
5 to 10
5 to 10
5 to 10
NICE CLINICAL GUIDELINE 69: ANTIBIOTIC PRESCRIBING FOR RESPIRATORY TRACT
INFECTIONS
No antibiotic (or delayed prescription) for:





Acute otitis media
Acute sore throat/acute pharyngitis/acute tonsillitis
Common cold
Acute rhinosinusitis
Acute cough/acute bronchitis
Consider immediate antibiotic prescribing strategy,
depending on clinical assessment of severity for:
 Bilateral acute otitis media in children under 2 years
 Acute otitis media in children with otorrhea
 Acute sore throat/acute pharyngitis/acute tonsillitis when
3 or more Centor criteria are present:
 Temperature >38°C
 Absence of cough
 Swollen anterior cervical nodes
 Tonsillar swelling or exudate
Immediate antibiotic prescription should only be offered if:
 Patient is systemically unwell
 The patient has signs/symptoms of serious illness and/or
complications (pneumonia, mastoiditis, peritonsillar
abscess, peritonsillar cellulitis, intraorbital and
intracranial complications)
 Patient is at high risk of serious complications because of
pre-existing co-morbidity (heart, lung, renal, liver,
neuromuscular disease, immunosuppression, cystic
fibrosis and young children born prematurely)
 The patient is >65 years with acute cough + 2 or more of
the following or >80 years with acute cough + 1 or more
of the following:
 Hospitalisation in last year
 Type 1 or type 2 diabetes
 History of congestive heart failure
 Current use of oral glucocorticoids
This guidance does not override the individual responsibility of health professionals to make decisions in the exercise of
their clinical judgement in the circumstances of the individual patient.
Abbreviated antibiotic choices overleaf
Date of preparation January 2011
The FULL antibiotic guidelines can be found at:
http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/antibioticguidelin
es.pdf
.
The NW SHA has
one of the
highest rates for
C difficile in England
Best practice in antimicrobial drug prescribing
CUMBRIA has
the
2nd highest rate for
C difficile infection
in the NW SHA
Clostridium difficile infection (CDI) is associated with antimicrobial use.
Prescribing antimicrobials wisely can reduce the incidence
Clostridium difficile infection (CDI)




C. difficile is a bacterium present in the gut flora in some people.
Antimicrobials disturb the balance of the gut flora, allowing C. difficile
to multiply and cause infection.
Symptoms of CDI can vary from mild diarrhoea to fatal bowel
inflammation.
C. difficile spores are shed in the faeces. The spores can survive for
long periods in the environment. If ingested, they can transmit
infection to others.
CDI and primary care

CDI has commonly been associated with hospital stay but it is now
recognised that many cases originate in the community, due to
indiscriminate use of antibiotics.

Patients most at risk are the elderly, particularly if they have medical
conditions and are in close contact with others, e.g. in a care home,
residential treatment centre or hospital.
Which patients are most at risk of CDI?
Prudent antimicrobial prescribing
Patients are more at risk of CDI if they are:
 Elderly
 Suffering from severe underlying diseases
 Immunocompromised
 In an environment where they are in close contact with one
another (e.g. in a care home), particularly if hygiene is
lacking.
Other factors that increase the risk of CDI are:
 Use of antimicrobials
 History of CDI (ie. risk of relapse)
 Recent gastrointestinal procedures
 Presence of a nasogastric tube








The use of proton pump inhibitors (PPIs) might increase the risk of
CDI. Only prescribe PPIs when indicated.
.
Only prescribe antimicrobials when indicated by the clinical condition of
the patient or the results of microbiological investigation.
Do not prescribe antimicrobials for sore throat, coughs and colds in
patients at low risk of complications.
Consider delayed prescriptions in case symptoms worsen or become
prolonged.
If an antimicrobial is required, follow Cumbria antibiotic guidelines.
Choose a narrow-spectrum agent where possible and prescribe a short
course.
Generally, no more than 5-7 days treatment is required.
Three-day courses are appropriate in some cases.
Broad-spectrum antimicrobials should be reserved for the treatment of
serious infections when the pathogen is not known.
How we use antimicrobials affects the whole community.
CUMBRIA has the
4th highest rate of
CIPROFLOXACIN
use in the NW SHA
Please avoid using
CIPROFLOXACIN &
other antibiotics
ass.with C.Diff unless
indicated
When can broad-spectrum antibiotics be recommended?
Please refer to Cumbria Antibiotic guidelines April 2010
http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/antibioticguidelines.pdf
The following are examples of indications for 1 st line use of broad spectrum
antibiotics
Comments from the Consultant microbiologists
Antimicrobials to avoid where possible
High Risk of CDI “The four Cs”
The antimicrobials most strongly associated with CDI are:
 Cephalosporins: cefaclor, cefuroxime, cefixime (2nd and 3rd
generation)
 Clindamycin
 Ciprofloxacin and other Quinolones, levofloxacin, moxifloxacin,
ofloxacin, norfloxacin.
 Co-amoxiclav and Co-fluampicil. Also long courses of
amoxicillin and ampicillin
Antimicrobials to choose
Low to intermediate risk
Trimethoprim, penicillin V, tetracyclines and macrolides have a
lower associated risk; however, all antimicrobials are associated
with CDI.
 Follow the Cumbria antibiotic guidelines If antimicrobials are
required, prescribe a short course.
 Obtain advice from a microbiologist. Where “best guess”
therapy has failed or there are special circumstances
microbiological advice can be obtained from the Consultant
Microbiologists at:
West Cumberland Hospital  01946 693181
Cumberland Infirmary  01228 814641
Furness
Hospital
 01229
491022
This guidance
does notGeneral
override the
individual responsibility
of health
professionals to make

.
decisions in the exercise of their clinical judgement in the circumstances of the individual
patient.
Exacerbations of
COPD
Community acquired
pneumonia
Acute pyelonephritis
Acute prostatitis
Simple gonorrhoea
Animal bite or human
bite
If indicated:
Amoxicillin or Doxycycline or
Clarithromycin
Amoxicillin
or Doxycyline or Clarithromycin
Ciprofloxacin or
Co-amoxiclav
Ciprofloxacin &/or Doxycycline
Cefixime
Co-amoxiclav
There are few indications for broad-spectrum cephalosporins or quinolones in
primary care.
Counsel patients at risk of CDI to stop their antimicrobial and seek medical advice
if diarrhoea develops.
If prescribing antimicrobials to patients with a history and/or relapse of CDI, refer
to the microbiologist
Bottom line
Ciprofloxacin, Cephalosporins, Clindamycin, Co-amoxiclav and other broad
spectrum antimicrobials are associated with CDI.
Don’t prescribe antimicrobials when they’re not needed.
If an antimicrobial is indicated, prescribe a short course of a narrow-spectrum
agent at the appropriate dose, as outlined in the PCT antimicrobial formulary.
Supporting Medicines Q&A documents are available: Date of preparation January 2011
www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/
Which antimicrobials are implicated?
Are acid-suppressant medicines a risk factor?
Are probiotics useful?
.