HCAIS & AMR

Question 1

What is a HCAI

Answer 1

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

Question 2

What is a community acquired infection

Answer 2

Present at point of hospital admission
Showing symptoms at admission
Positive test result within 48hrs of admission

Question 3

5 common types of HCAI

Answer 3

Catheter associated UTI
Ventilator associated pneumonia (VAP)
Surgical site infections (SSI)
Central line associated bloodstream infections
Gastrointestinal infections

Question 4

Common HCAI pathogens (5)

Answer 4

MRSA
MSSA (methicillin sensitive SA)
C diff
Gram neg bacteria e.g. E.coli & pseudomonas aeruginosa

Question 5

What is ESPAUR

Answer 5

English Surveillance Programme for Antimicrobial Utilisation and Resistance

National data on antimicrobial prescribing and resistance, antimicrobial stewardship implementation, and awareness activities

Question 6

Risk factors for HCAI

Answer 6

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

Question 7

Why are hospitals high risk places for infection

Answer 7

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

Question 8

What do IPC teams do

Answer 8

carry out audits & surveillance
manage outbreaks & incidents
develop policies & procedures
educate staff
provide advice
staff immunisation

Question 9

Standard principles for preventing HCAI in hospital/acute settings

Answer 9

1. Hospital environmental hygiene (cleaning procedures)
2. Hand hygiene (when & how)
3. PPE (gloves, surgical facemasks, respiratory protective equipment)
4. Safe use of sharps (including disposal)
5. Principles of asepsis (aseptic technique training)

Question 10

Public health effects of HCAIs

Answer 10

Morbidity & mortality risk to patients staff & visitors
Prolonged inpatient stay
High cost for patient & family
Antimicrobial resistance
Destroys trust

Question 11

How is England tackling HCAIs

Answer 11

Outbreak & incident response
Antimicrobial stewardship
Expert knowledge, guidance, leadership
Production of guidance, education etc.
Policy & regulation
Evaluation
Advocacy
Research
Surveillance

Question 12

Mandatory Surveillance conditions of national surveillance programmes

Answer 12

MRSA bacteraemia
MSSA bacteraemia
C diff
Gram negative bacteraemia

Question 13

Other areas of national surveillance

Answer 13

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

Question 14

How to investigate a HCAI outbreak

Answer 14

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

Question 15

Relationship between antimicrobial resistance (AMR) and health inequalities

Answer 15

AMR burden is higher in more deprived groups

Question 16

How to tackle AMR

Answer 16

• 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)

Question 17

AMR approaches tried already

Answer 17

Media campaigns
recommendations to GPs
Issuing back up prescriptions
explain prescription decisions more fully
make sure correct Abx when given
Tackle misconceptions & education

Question 18

How common is AMR in England?

Answer 18

> 58000 infections in England 2022
Up 4% from 2021
2200 died of resistant infections

Question 19

Initiatives against AMR

Answer 19

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

Question 20

Where is MRSA and prevalence

Answer 20

Skin & nasal carriage
30% carriage in UK nursing home population

Question 21

Transmission of MRSA

Answer 21

Mainly direct contact
But also indirect contact (fomites, equipment, environment)

Rarely invades intact skin - broken skin = common route of entry

Question 22

How can hospital practice facilitate MRSA spread

Answer 22

Overuse of Abx
rapid turnover of beds
frequent ward transfers
overcrowding
poor hygiene and cleaning

Question 23

Who is most at risk of MRSA infection

Answer 23

Newborns
Elderly
IVDU
Pts undergoing surgery

Question 24

What sort of infections can MRSA cause

Answer 24

Skin infections
Cellulitis
Bactaraemia & septicaemia
Septic arthritis, acute osteomyelitis
pneumonia

Question 25

How to prevent MRSA

Answer 25

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

Question 26

MRSA outbreak control measures

Answer 26

• 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

Question 27

C. difficile about
where to find
asymptomatic carriage numbers

Answer 27

• 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

Question 28

C diff transmission

Answer 28

Faeco-oral route directly or through spores
Asymptomatic carriers without diarrhoea are unlikely to spread it

Question 29

What is C diff associated with

Answer 29

Abx use - especially broad spectrum

Question 30

C diff in hospitalised pts causes

Answer 30

Antibiotic associated diarrhoea
Antibiotic associated colitis
Pseudomembranous colitis

Question 31

C diff mortality

Answer 31

High
especially in elderly and ill pts (who are more likely to get c diff)

Question 32

C diff & hygiene

Answer 32

spores = resistant to chemicals
alcohol rub doesnt work - need to hand wash with soap & water

Question 33

C diff prevention

Answer 33

Hygiene
Control Abx (especially ampicillin, amox & cephalosporins
Standard infection control
Surveillance & case finding

Question 34

C diff case management

Answer 34

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

Question 35

CPE names

Answer 35

Carbapenemase Producing Enterobacteria (CPE)
Carbapenem Resistant Enterobacteria (CRE)
Carbapenemase producing organisms (CPO)

Question 36

What & where is CPE

Answer 36

enterobacterales typically harmlessly colonise the gut
if get into wrong place (bladder, blood) –> infection
resistant to carbapenems

Question 37

What is carbapenemase & carbapenems

Answer 37

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.

Question 38

Who gets CPE infections

Answer 38

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

Question 39

How serious is CPE

Answer 39

Extremely
CPE are usually resistant to lots of other abx too - associated with significant pathogens
plasmid mediated - cpe gene can hop

Question 40

How to manage CPE

Answer 40

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