HCAI
Risks, burden, process and control
Elizabeth Haworth
HPA SE
January 2008
Background
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Policy
Incidents
High rates of infection
Measurable infection rates
Interpretable infection rates
Evidence
Definition
Healthcare associated infections (HCAI)
are infections that are acquired in hospitals or as
a result of healthcare interventions.
There are a number of factors that can increase
the risk of acquiring an infection, but high standards
of infection control practice minimise the risk of
occurrence.
Policy
Documents
11 January 2008
Revised code of practice for the prevention and control of healthcare associated infections
9 January 2008
This document draws together recent initiatives to tackle healthcare associated infections and improve cleanliness and
details new areas where the NHS should consider investing to ensure that patients receive clean and safe treatment
whenever and wherever they are treated by the NHS
Clean, safe care: reducing infections and saving lives
18 December 2007
This paper presents an analysis of the contribution of organisational factors, such as bed occupancy rates, cleanliness
and use of temporary staffing, to understand the variations in MRSA rates between different hospitals. The paper also
examines how these relationships may have changed over time
Hospital organisation, specialty mix and MRSA
17 September 2007
The possibility of transmitting infections via uniforms is an important issue for employers, staff and patients. This
document outlines the existing legal requirements and current findings, to support and advise employers when
reviewing local policies in this area
Uniforms and workwear: an evidence base for developing local policy
11 April 2007
A web-based system for the surveillance of Clostridium difficile associated diarrhoea (CDAD) is being introduced in
April 2007 and Trusts will have to enter all cases in individuals aged two years and over on to this new system (subject
to Review of Central Returns (ROCR) approval).
2005 Winning Ways
DIPC, Baord accountability
Guidance
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PL CMO (2007)4: Changes to the mandatory healthcare associated infection surveillance system for Clostridium difficile associated
diarrhoea from April 2007
A plan for action
Towards cleaner hospitals and lower rates of infection and Winning ways are two key policy documents that set out a strategy to improve
hospital cleanliness and tackle hospital acquired infections.
A plan for action
Towards cleaner hospitals and lower rates of infection programme
Programme that sets out a strategy to improve hospital cleanliness and tackle healthcare associated infections. Key elements include
empowering patients and the public, the matron's charter, independent inspection and learning from the best.
Towards cleaner hospitals and lower rates of infection programme
Simple guides
Outline information on MRSA and Clostridium difficile
A simple guide to MRSA
A simple guide to Clostridium difficile
Check infection rates at your local hospital
Results of surveillance systems for MRSA, CDAD and GRE.
MRSA surveillance system: Results
Surveillance of surgical site infection in orthopaedic surgery: Mandatory surveillance of surgical site infection in orthopaedic surgery:
Report of data collected between April 2004 and March 2005
Surveillance of Clostridium difficile associated disease (CDAD)
Surveillance of glycopeptide-resistant enterococci (GRE)
Healthcare associated infection publications
Documents about healthcare associated infections, principally for health professionals.
Healthcare associated infection publications
Healthcare associated infection links
Websites and DH resources about healthcare associated infections.
Healthcare associated infection links
Root cause analysis
National Patient Safety Agency
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The Patients Association and HCAI
Infection control campaign
• Since 2000, surveys and action on patient safety eg hand-washing; use of
antibiotics; decontamination
Reports
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2000 Hospital Acquired Infection and the Reuse of Medical Devices
2001 Decontamination of Surgical Instruments - implementation of HSC
2000/032.
2002 Role of SHAs in decontamination and safe medical devices
2004 Survey of HCW non-compliance in recommended uses of devices,
endoscopes etc
2005 Tracking medical devices, implications for patient safety with ICNA etc .
The Clean Hospital Summit - reducing HCAI and 100 Day Challenge,
mandatory reporting and HCC standards
2006 Second summit Cleaner Hospitals, Safer Healthcare, to raise profile of IC.
Infection Control –Is It Only Skin Deep?
2007 Supported epic2 guidelines for preventing HCAI
The Patients Association's Ten Top Tips to using
your Patient Power!
Check Trust’s Annual Health check ratings October 2006 www.healthcarecommission.org.uk
2 Before planned admission take a long hot soapy bath or shower…to help
prevent
unwanted bacteria coming into hospital with you and complicating your
care.
3 Pack antiseptic hand-wipes, bulldog clips & plastic bags for waste
4 Note & point out to staff messy/dirty areas
5 Arrange a “phone tree” with family and friends to save staff time
6 Ask visitors to co-ordinate visits and restrict to two at bedside (after bath or
shower)
7 Ask visitors to use hand cleansers on arrival and departure
8 Discourage child visitors
9 Tell visitors not to sit on your bed and not to come if have URTI
10 Don’t be afraid to ask a nurse or a doctor whether they have washed their
hands or used the disinfecting hand gel
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Don’t be afraid to ask questions, especially about your own condition or to make valid complaints
Select Committee on Science and Technology Seventh Report
1998
Comprehensive report on antibiotic resistance and its public health consequences, commissioned by the
United Kingdom Parliament, Select Committee on Science
CHAPTER 4 INFECTION CONTROL
4.1 As resistance to antimicrobials increases, so does the importance of infection control. Preventing the
spread of organisms which are resistant and therefore hard to treat is obviously desirable. Less obvious, but
equally desirable, is control of infection by organisms which are still susceptible; every infection not prevented
requires treatment, and every treatment adds to the selective pressure towards resistance.
Infection control in hospitals
4.2 In some respects, hospitals achieve the level of infection control for which they are willing or able to pay.
Money can buy infection control in various ways, some of which are considered in the next few paragraphs.
Standards of hospital infection control management in England and Wales were recently defined by the "Cooke
Report"[45]; looking ahead, that Report said, "Antibiotic-resistant bacteria will almost certainly be an increasing
problem [for hospital infection control] in the future".
Infection control teams
4.3 According to the Cooke Report (ch. 2), every acute hospital should have an infection control team.[46] The
team should consist of an infection control doctor (normally a consultant medical microbiologist) and one or more
infection control nurses. Non-acute hospitals should be covered, under contract, by a team from a neighbouring
acute hospital. Every hospital should also be covered by a multidisciplinary Hospital Infection Control Committee.
4.4 A recognised qualification for infection control doctors has been established (DipHIC). As for nurses, the
Infection Control Nurses Association (ICNA)[47] told us, "The minimum recommended training requirement for
infection control nurses is a post-basic diploma-level course in infection control and previous management
experience...Most NHS trusts comply with this; however some private hospitals do not" (Q 201).
Infection rates
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DH monitoring rates
Rates from incidents/outbreaks
Measurable infection rates
Interpretable infection rates
Evidence
Roles and responsibilities for action
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Infection Control - providers
Surveillance – providers, HPA
Advice/support - HPA
Performance management – SHA, DH (PCT)
Investigation – Provider, HPA
Management - Provider
Working together - All
Litigation
£5m hospital bug payout for Ash
Actress Leslie Ash has won a record £5m
compensation payout after contracting a hospitalacquired infection. The Men Behaving Badly star
developed MSSA (Methicillin-Sensitive Staphylococcus
Aureus) at Chelsea and Westminster Hospital in London in
2004.
The payment to Ms Ash, 47, who now walks with a stick,
includes compensation for money she would have earned if
she had carried on working.
The hospital said it had "learnt from its mistakes".
“It's the highest we have ever paid
out”
Ms Ash had been admitted to hospital in April 2004 after
suffering two cracked ribs after falling off her bed on to a
Steve Walker
table during a love-making session with her husband,
NHS Litigation Authority CEO
retired footballer Lee Chapman
US Patient Safety
The Association for Professionals in Infection Control & Epidemiology
Hospital-Acquired Infections
Hospital-acquired infections are one of the top ten leading causes of death in
the U.S. and significantly increase the cost of health care.
reports that 1.2 million hospital patients are infected with dangerous, drugresistant staph infections each year.
According to the Centers for Disease Control and Prevention, one in 20
patients – about two million a year – contract an infection while in the
hospital.
Hospital-acquired infections kill over 90,000 people annually – more than
motor vehicle accidents, breast cancer, or AIDS.
Hospital-acquired infections increase the length of hospital stays up to 30
days.
The cost to the U.S. health system of treating hospitalized patients with
staph infections is astronomical – between $3.2 billion to $4.2 billion a year.
Learning from incidents/outbreaks
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SE – HCC
MRSA
C.diff
Acinetobacter baumanii
ESBL producing E .coli
GRE
TB
Flu
Lessons from incidents/outbreaks
MRSA - Kettering
Lessons from outbreaks
Original article
A major outbreak of methicillin-resistant Staphylococcus aureus caused by a new phage-type
(EMRSA-16)
R. A. Cox , C. Conquest, C. Mallaghan and R. R. Marples
Abstract
An outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection caused by a
novel phage-type (now designated EMRSA-16) occurred in three hospitals in East
Northamptonshire over a 21-month period (April 1991—December 1992). Four hundred patients
were colonized or infected. Seven patients died as a direct result of infection. Chest infections
were significantly associated with the outbreak strain when compared with methicillin-sensitive
S. aureus. Twenty-seven staff and two relatives who cared for patients were also colonized. A
‘search and destroy’ strategy, as advocated in the current UK guidelines for control of
epidemic MRSA was implemented after detection of the first case. Despite extensive screening
of staff and patients and isolation of colonized and infected patients, the outbreak strain spread
to all wards of the three hospitals except paediatrics and maternity. A high incidence of throat
colonization (51%) was observed. Failure to recognize the importance of this until late in the
outbreak contributed to the delay in containing its spread.
Key parts of the strategy which eventually contained the local outbreak were the establishment
of isolation wards in two hospitals, treatment of all colonized patients and staff to eradicate
carriage and screening of all patients upon discharge from wards where MRSA had ever been
detected.
EMRSA-16 spread to neighbouring hospitals by early 1992 and to London and the South of
England by 1993. It is distinguished from other epidemic strains by its characteristic phagetype, antibiogram (susceptibility to tetracycline and resistance to ciprofloxacin), and in the
pattern given on pulse field electrophoresis.
MRSA – past present and future
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S .aureus treatable with Methicillin when introduced in 1960
Early methicillin resistance but not considered serious
Isolation beds for management of infection used for other purposes
Cohorting rather than isolation in major outbreaks
EMRSA - (first major outbreak 1 in Australia) varying strains since
have affected most UK hospitals
National guidelines for control of MRSA 1998, 2005
High risk areas – IT, renal ~ los
Colonisation/carriers
Control of epidemics vs ‘search and destroy’
Antibiotic choice
Research – need for well designed trials
Newsom SWB. JRSM 2004; 97(11) 509-10.
MRSA – past present and future
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Antiseptic use eg tea tree oil
Environmental decontamination – steam, hydrogen peroxide,
Rapid diagnostics – Elisa, PCR
• Govt manadates – deep cleaning, screening
• Research – need for well designed trials
• ??? Too little too late
Lessons from outbreaks
CDAD - SMH
Clostridium difficile
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Clostridium difficile is an anaerobic bacterium, widely distributed in soil and intestinal tracts of
animals. The clinical spectrum of CDAD ranges from mild diarrhoea to severe life threatening
pseudomembranous colitis. The disease is not always associated with previous antibiotic use.
There is an increase of reports of community-acquired CDAD in individuals previously not
recognized as predisposed. CDAD is also recognised increasingly in a variety of animal species.
The transmission of C. difficile can be patient-to-patient, via contaminated hands of healthcare
workers or by environmental contamination.
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The impact of CDAD on modern healthcare is significant. In terms of costs, this translates into
€5.000-15.000 per case in England and $1.1 billion per year in the USA. Assuming the population
of European Union to be 457 million, CDAD can be estimated to potentially cost the Union €3.000
million per annum. It is expected to almost double over the next four decades.
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Since March 2003, increasing rates of CDAD have been reported in Canada and USA with a more
severe course, higher mortality, and more complications. This increased virulence is assumed to
be associated with higher amounts of toxin production by fluoroquinolone-resistant strains
belonging to PCR ribotype 027, toxinotype III and PFGE NAP1. Epidemics of CDAD due to the
new, highly virulent strain of C. difficile PCR ribotype 027 have been recognized in 44 hospitals in
England, 8 hospitals in the Netherlands and 6 hospitals in Belgium. Retrospectively, PCR ribotype
027 was shown to have already caused outbreaks in 2002 in all three countries. The outbreaks
are very difficult to control. Preliminary results from case-control studies indicate a correlation with
the use of fluoroquinolones and cephalosporins. No information is available on communityacquired cases of type 027. Data on the incidence of type 027 in nursing homes are limited, but at
least one outbreak has been detected.
ECDC
CDAD definitions
Severity
Kuipjer et al 2006
Media coverage
Healthcare
Commission enquiry
Recommendations (19)
Recommendations
Recommendations
Grave failure of patient protection - change in leadership
Actions by managers to control risk of infection
1-3 Infection control and training
Standards of care
4-7 Clinical care, patient dignity, transfer, clinical decision
dissemination
Staffing
8 Levels and training for safe care
Clinical governance and risk management
9-13 Clinical risk management including infection control
Handling and learning from complaints
14 Serious complaint investigation and management responsibility of
board
National responsibilities
15-19 NHS, HPA, DH
Epidemic curve and control
SMH Acquired C.difficile
Dec 03 - Feb 06
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March 04:
Removal of co-amoxiclav, amoxicillin,
clindamycin, cephalosporins
Use of hypochlorite disinfectant
Creation of cohort area
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March 05:
Removal of ciprofloxacin
Use of hydrogen peroxide vapour
on a few wards
Creation of a C.diff ward.
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• Routine
surveillance (lab)
• Enhanced
surveillance
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• OCT
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• Control measures
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• Investigation
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• Action plan
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• Continuing
vigilance
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Kindly provided by Dr J O’Driscoll, Consultant Medical Microbiologist, Buckinghamshire NHS Trust
C. difficile in Bucks NHS Trust
Outbreak one of several in UK
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About 500 cases of CDAD since Dec 2003 at Bucks Hospital NHS Trust
Oct 03 - June 04: 174 new cases, 19 deaths due to C.difficile infection, 16 SMH
acquired
Oct 04 – June 05: 160 new cases, 19 deaths due to C.difficile infection, 17 SMH
acquired
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Mortality higher than expected in infected patients
>100 patients infected with C difficile died, 78 with C.difficile infection
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Control measures contained problem summer 2004 and summer 2005
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Most recent cases biotype 027 (Canadian/American strain PulsoverA/BI)
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027 hypertoxin producing strain causing severe disease of prolonged duration
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Resistant to antibiotic therapy
C.difficile biotypes in SMH
since Dec 2004
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027
No of isolates tested = 60
Lessons from outbreaks
The epidemiology of the second phase of an outbreak of Clostridium difficile associated
diarrhoea (CDAD) at Stoke Mandeville Hospital
Objectives
To establish epidemiology of second phase of Stoke Mandeville Hospital (SMH) CDAD outbreak 1 Dec 04 - 31 May 05,
and to document control measures.
Methods
229 incident cases of CDAD and readmissions with positive isolates for both admissions to Bucks Hospitals
NHS Trust included. Hospital acquired if symptoms > 3 days from admission. Relapse - 2 confirmed diagnoses > 3
months apart. Demographic and clinical information extracted from case notes. Autopsy findings extracted from
pathology systems and infection control measures obtained from infection control records and clinical notes. LREC
approval. Data analysis used STATA 8.2.
Results
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Incidence of CDAD at SMH was 2.11/1000 bed days and accounted 5312 bed days. Monthly incidence highest in
winter months with January peak.
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Most cases due to the 027 ribotype.
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88% of patients > 65 years of age
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60% female and 25% were community acquired. .
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Mean LOS in hospital before symptoms 12.4 days, total mean LOS 48.8 days.
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MRSA coinfection in 16.3%.
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High ciprofloxacin use.
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CDAD attributable mortality 15%.
Conclusion
Confirmed 027 ribotype as UK outbreak strain with high mortality and morbidity. Raised the national profile of CDAD.
Applying the national additional hospital cost of £4000/ CDAD cost to NHS Trust about £900 000 over 6 months.
Lessons from outbreaks
CDAD - Maidstone
Healthcare
Commission enquiry
Recommendations
Significant failing on the part of the trust.
1. Action by the board - review leadership with performance manager of the
trust the SHA taking overall responsibility for this
2. Clinical governance and the management of risk - control of infection an
integral part of clinical governance
3. Action by board and managers to control the risk of infection - greater
priority to the control of infection including effective isolation
4. Standards of care - diagnosis of C. difficile needs to be regarded as a
diagnosis in its own right with care and treatment in line with good practice
National responsibilities
5. Staffing levels and training - ensure acceptable and safe levels and training
6. National recommendations
C. difficile- a diagnosis in its own right,
- proper management as a potentially life threatening condition.
- commissioners of care ensuring guidelines for prevention and
management
- education and supervision of trainee doctors, including death
certification, ab use
Recommendations
Recommendations
- antibiotics of the narrowest spectrum possible used for the shortest
time possible.
- NHS and HPA to agree clear and consistent arrangements for the
monitoring of rates of C. difficile infection, using all relevant local and national
information.
- Every NHS trust to understand the role and responsibilities of the
DIPC and receive regularly, information about incidence and HCAI trends
Duty 2 of the hygiene code
HCC and Leicester
In early October 2006, contact was made
between University Hospitals of Leicester
NHS Trust and the Healthcare
Commission regarding the high number of
cases of the Clostridium difficile infection
at the trust in 2005 and 2006.
HCC agreed to explore the issue further
with the trust to understand the
arrangements and challenges in the
management of Clostridium difficile
infection, using the Government’s Hygiene
Code as a framework for review. The main
purpose of the review was to assess the
trust’s arrangements for preventing and
controlling of the infection.
Lessons from outbreaks
ESBL producing E.coli
SE and London regions
Case - control study
Death analysis
Southampton
St Peters
Ashford
Infection rates – HPA publications
HPA publications
HCAI data
HCAI data
Infection rates – HPA publications
Glycopeptide-Resistant Enterococcal (GRE) Bloodstream Infections
HCAI data
HCAI data
HCAI data
HCAI data
HCAI data
HCAI data
Infection rates – HPA publications
Clostridium difficile
Infection rates – HPA publications
Clostridium difficile
Infection rates – HPA publications
Clostridium difficile
SE Data
Programmes and comparisons
• ECDC - Project on antimicrobial resistance and
healthcare-associated infections
• Nordic experience
• N Am
• Australia
• UK
Control measures
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IC + expertise
DH/political
Monitoring
Improvement plan
?? Investigation
Evidence
What works
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outcome – control of infection/colonisation
how much can IC work?
evaluation
programme (place of screening/cleaning)
plan
learning from elsewhere
evidence base
HCAI: a balancing act
Multiple players
Targets
Nat. service
frameworks
Culture,
behaviour
, practice
Staffing levels
Funding
Bed
availability
Patient-centred NHS
Thanks to Dr Barbara Bannister
What next?
Questions?
Thank you