HCAIS & AMR Flashcards
What is a HCAI
Infection that develops either as a direct result of healthcare interventions or from being in contact with a healthcare setting
For inpatients: not present or incubating at time of admission
May be HCAI but not become evident until after discharge
What is a community acquired infection
Present at point of hospital admission
Showing symptoms at admission
Positive test result within 48hrs of admission
5 common types of HCAI
Catheter associated UTI
Ventilator associated pneumonia (VAP)
Surgical site infections (SSI)
Central line associated bloodstream infections
Gastrointestinal infections
Common HCAI pathogens (5)
MRSA
MSSA (methicillin sensitive SA)
C diff
Gram neg bacteria e.g. E.coli & pseudomonas aeruginosa
What is ESPAUR
English Surveillance Programme for Antimicrobial Utilisation and Resistance
National data on antimicrobial prescribing and resistance, antimicrobial stewardship implementation, and awareness activities
Risk factors for HCAI
Contact with contaminated medicine, equipment, food
Contact with contaminated HCPs/patients/visitors
Procedures that enable colonisers to cause infection
invasive procedure or device
Inappropriate Abx use
Infection caused by resistant organism due to previous treatment
Poor IPC practice
Extremes of age
Immunocompromise
Broken skin/pressure sores
Length of stay
Number of procedures done
Why are hospitals high risk places for infection
Crowded wards
Pts admitted with infections
Staff make multiple patient contacts
Invasive procedures
Personal care
Shared bathroom facilities
Open wounds
Bodily fluids
Visitors
Susceptible & vulnerable patients
What do IPC teams do
carry out audits & surveillance
manage outbreaks & incidents
develop policies & procedures
educate staff
provide advice
staff immunisation
Standard principles for preventing HCAI in hospital/acute settings
- Hospital environmental hygiene (cleaning procedures)
- Hand hygiene (when & how)
- PPE (gloves, surgical facemasks, respiratory protective equipment)
- Safe use of sharps (including disposal)
- Principles of asepsis (aseptic technique training)
Public health effects of HCAIs
Morbidity & mortality risk to patients staff & visitors
Prolonged inpatient stay
High cost for patient & family
Antimicrobial resistance
Destroys trust
How is England tackling HCAIs
Outbreak & incident response
Antimicrobial stewardship
Expert knowledge, guidance, leadership
Production of guidance, education etc.
Policy & regulation
Evaluation
Advocacy
Research
Surveillance
Mandatory Surveillance conditions of national surveillance programmes
MRSA bacteraemia
MSSA bacteraemia
C diff
Gram negative bacteraemia
Other areas of national surveillance
Topic area surveillace - SSIs, ICUs, AMR prescribing, fungal)
Surveillance of outbreaks, clusters & incidents
Point prevalence survey on HCAI, antimicrobial use & antimicrobial stewardship
Resistance & usage: ESPAUR
How to investigate a HCAI outbreak
Initial Investigation: trawling questionnaires for hypothesis generation; interviews with hospital IPC, microbiology, clinical teams; extensive product sampling
Enhanced incident management: incident management team, multi-stakeholder coordination
Investigation findings:
Mitigation & control: for a product - work with NHS supply chain, issue customer notices, produce guidance for good infection prevention practice for use of whatever product was being incorrectly used
National patient safety alert (if necessary) - to get safety info to every UK hospital
UKHSA briefing notes & international alerts
Relationship between antimicrobial resistance (AMR) and health inequalities
AMR burden is higher in more deprived groups
How to tackle AMR
- Reduce the need for & unintentional exposure to antimicrobials (stop infections occurring)
- Invest in innovation (one health, anticipate impacts of climate change & mitigate)
- optimise use of existing antimicrobials (surveillance, analysis, good stewardship)
AMR approaches tried already
Media campaigns
recommendations to GPs
Issuing back up prescriptions
explain prescription decisions more fully
make sure correct Abx when given
Tackle misconceptions & education
How common is AMR in England?
> 58000 infections in England 2022
Up 4% from 2021
2200 died of resistant infections
Initiatives against AMR
UK National Action Plan (NAP) for AMR
Target antibiotics toolkit for primary care
Start Smart then Focus Clinical management algorithm
Being AWaRe (Access, Watch, Reserve)
- Access = first and second choice Abx for treating most common infections
- Watch = Abx with higher resistance potential that should only be prescribed for specific indications
- Reserve = last resort options only to be used when others have failed
Where is MRSA and prevalence
Skin & nasal carriage
30% carriage in UK nursing home population
Transmission of MRSA
Mainly direct contact
But also indirect contact (fomites, equipment, environment)
Rarely invades intact skin - broken skin = common route of entry
How can hospital practice facilitate MRSA spread
Overuse of Abx
rapid turnover of beds
frequent ward transfers
overcrowding
poor hygiene and cleaning
Who is most at risk of MRSA infection
Newborns
Elderly
IVDU
Pts undergoing surgery
What sort of infections can MRSA cause
Skin infections
Cellulitis
Bactaraemia & septicaemia
Septic arthritis, acute osteomyelitis
pneumonia
How to prevent MRSA
Hygiene: handwashing, bare below the elbows, aseptic techniques, appropriate wound care, use of PPE, ward cleaning, waste disposal, cleaning/sterilisation of equipment
Training & feedback to staff
Sound abx use
Surveillance systems
Screening elective admissions
Decolonisation where necessary
Liason between hospital & community
MRSA outbreak control measures
- investigate outbreaks
- Confirm cases are linked (lab tests for strain type)
- screen staff to detect carriers
- environmental investigation
- review clinical practice
- review infection control practice (hand hygiene)
- restrict/suspend admissions
- minimise staff & patient movement
- limit use of temporary agency staff
- limit visitors
- ward closure
C. difficile about
where to find
asymptomatic carriage numbers
- widely distributed in soil & digestive tract
- spores resistant to heat, drying & chemicals
- asymptomatic carriage in 2-3% healthy adults & ~36% hospital patients
80% of symptomatic cases in >65s
Causes 20% of abx associated diarrhoea
C diff transmission
Faeco-oral route directly or through spores
Asymptomatic carriers without diarrhoea are unlikely to spread it
What is C diff associated with
Abx use - especially broad spectrum
C diff in hospitalised pts causes
Antibiotic associated diarrhoea
Antibiotic associated colitis
Pseudomembranous colitis
C diff mortality
High
especially in elderly and ill pts (who are more likely to get c diff)
C diff & hygiene
spores = resistant to chemicals
alcohol rub doesnt work - need to hand wash with soap & water
C diff prevention
Hygiene
Control Abx (especially ampicillin, amox & cephalosporins
Standard infection control
Surveillance & case finding
C diff case management
Any patient with diarrhoea:
- isolate
- enteric precautions (isolation, ppe, hand hygiene, hot wash for dishes & linen, room cleaning, clinical disposal (yellow bag)
- test stool samples
- environmental cleaning
- treat cases with metronidazole or vancomycin
CPE names
Carbapenemase Producing Enterobacteria (CPE)
Carbapenem Resistant Enterobacteria (CRE)
Carbapenemase producing organisms (CPO)
What & where is CPE
enterobacterales typically harmlessly colonise the gut
if get into wrong place (bladder, blood) –> infection
resistant to carbapenems
What is carbapenemase & carbapenems
Carbapenemase: enzyme that hydrolyses carbapenem Abx making organism resistant
Carbapenems: all IV - meropenem, imipenem, ertapenem, doripenem. Broadest spectrum & most effective abx available - last line of defence (often used for critical care, haemato-oncology, transplantation etc.
Who gets CPE infections
Not healthy people
Associated with ventillators, urinary catheters, IV catheters, long courses of certain abx
Contribute to death in 50% of patients who become infected
How serious is CPE
Extremely
CPE are usually resistant to lots of other abx too - associated with significant pathogens
plasmid mediated - cpe gene can hop
How to manage CPE
UK Framework of actions to contain CPE document
- screen (active admission screening for risk groups)
- monitoring and surveillance
- minimize transmission
- cleaning & decontamination - minimise CPE reservoirs
- lab methods
- abx stewardship
- IPC
- prompt recognition of outbreaks –> effective management
