Download G_IPC_25 Multi Resistant Gram Negative Bacteria guideline v 3

Guideline for the Management,
Prevention and Control of
Multi-resistant Gram-negative Bacteria
(including Extended Spectrum Beta
Lactamase Producing Microorganisms
(ESBLs))
Reference No:
G_IPC_25
Version:
3
Ratified by:
Infection Prevention and Control Committee
Date ratified:
25 August 2015
Name of originator/author:
Cheryl Day, Countywide Lead Infection
Prevention & Control
Name of approving
committee/responsible individual:
LCHS Infection Prevention & Control Committee
Date issued:
6 August 2015
Review date:
August 2017
Target audience:
All staff
Distributed via:
Website
Lincolnshire Community Health Services NHS Trust
Infection Prevention and Control Guideline
Version Control Sheet
Version
1 One
2 Two
3 Two
4 Two
5 Two
6 Two
7 Three
8 Three
9 Three
10 Three
Section/Para/A
ppendix
Version/Description
of Amendments
Date
Author/Amended by
All
New document
May 2010
Cheryl Day
All
Change LCHS
LCHS NHS Trust
to Jan 2013
Lynne Roberts
All
Change
“Infection Jan 2013
Control” to “Infection
Prevention
and
Control”
Lynne Roberts
9.3
Add monitoring table
Jan 2013
Lynne Roberts
Page 12
Add Equality Analysis
Jan 2013
Lynne Roberts
Page 11
Changed
Microbiologist
HPA to PHE
Jan 2013
Lynne Roberts
June 2015
Lynne Roberts
and
Document
Replaced footer
Appendix F
Updated
analysis
Equality June 2015
Lynne Roberts
Whole document
Changed Workforce June 2015
and
Development
Team to Education
and Workforce Team
Lynne Roberts
Whole document
Added
references
Lynne Roberts
guideline June 2015
Copyright © 2015 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in
whole or in part without the permission of the copyright owner.
Guidelines for the management, prevention and control of
Multi-resistant gram-negative bacteria (including Extended Spectrum Beta
Lactamase producing microorganisms (ESBLs))
Contents
1. Introduction ................................................................................................................................... 5
2. What are multi-resistant gram negative bacteria (MRGNB) ........................................................... 5
3. Scope of Guidance ....................................................................................................................... 5
4. Purpose ........................................................................................................................................ 6
5. Key Responsibilities ...................................................................................................................... 6
5.1 Chief Executive ....................................................................................................................... 6
5.2 Board lead ............................................................................................................................... 6
5.3 Managers ................................................................................................................................ 6
5.4 Employees .............................................................................................................................. 6
5.5 The Infection Prevention Team ................................................................................................ 6
5.6 Education and Workforce Team .............................................................................................. 6
6. Training......................................................................................................................................... 7
6.1 Training delivery ...................................................................................................................... 7
6.2 Process to Check Training is completed .................................................................................. 7
6.3 Follow-Up of Non Attendance .................................................................................................. 7
7. Support for patients....................................................................................................................... 7
8. Measures to prevent and control the spread of infection ............................................................... 8
8.1 Treatment ................................................................................................................................ 8
8.2 Reduce risk of transmission..................................................................................................... 8
8.2.1 Hand hygiene.................................................................................................................... 8
8.2.2 PPE .................................................................................................................................. 8
8.3 Environmental controls ............................................................................................................ 8
8.3.1 Medical equipment ............................................................................................................ 8
8.3.2 Waste ............................................................................................................................... 8
8.3.3 Linen ................................................................................................................................. 8
8.3.4 Cutlery/crockery ................................................................................................................ 9
8.3.5 Environmental contamination ............................................................................................ 9
8.4 Pathology specimens .............................................................................................................. 9
8.5 Additional Recommendations .................................................................................................. 9
8.5.1 Community Hospitals ........................................................................................................ 9
8.5.2 Residential/nursing care homes ...................................................................................... 10
8.5.3 Patients own home ......................................................................................................... 10
8.5.4 Ambulance transportation ............................................................................................... 10
9. Monitoring, Surveillance and Audit .............................................................................................. 10
9.1 Outbreaks.............................................................................................................................. 10
9.2 Surveillance ........................................................................................................................... 10
9.3 Audit ...................................................................................................................................... 10
References ..................................................................................................................................... 11
Contributors: ................................................................................................................................... 12
Putting you first is at the heart of everything we do
Page |3
Chairman:
Chief Executive:
Elaine Baylis QPM
Andrew Morgan
Lincolnshire Community Health Services NHS Trust
Guideline for the management, prevention and control of Multi-resistant gramnegative bacteria (including Extended Spectrum Beta Lactamase producing
microorganisms (ESBLs))
Guideline Statement
Background
The purpose of guideline is to implement a co-ordinated approach to
the control of multi-resistant gram negative bacteria (including
Extended Spectrum Beta Lactamase producing microorganisms
(ESBLs)) in line with current Department of Health requirements for
Infection Prevention and Control.
Statement
This guideline is comprehensive, formally approved and ratified, and
disseminated through approved channels. It will be implemented for
Lincolnshire Community Health Services NHS Trust.
Responsibilities
Compliance with this guideline will be the responsibility of the
relevant Lincolnshire Community Health Services NHS Trust staff.
Training
The Infection Prevention Team will support/deliver any training
associated with this policy.
Dissemination
Via intranet.
Resource implication
This guideline has been developed in line with the NHS Litigation
Authority guidelines to provide a framework for staff within NHS
Organisations to ensure the appropriate production, management and
review of organisation-wide guidelines.
Putting you first is at the heart of everything we do
Page |4
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
Guideline for the management, prevention and control of
Multi-resistant gram-negative bacteria (including Extended Spectrum
Beta Lactamase producing microorganisms (ESβLs))
1. Introduction
The increasing prevalence of antibiotic resistant micro-organisms, especially those with multiple
resistances, is causing international concern. Their control is vital.
As antibiotic resistance makes infections difficult to treat, increases the length of severity of illness,
the period of infection, adverse reactions, length of hospital admission and overall costs.
2. What are multi-resistant gram negative bacteria (MRGNB)
Gram negative bacteria (GNB) are commonly found in the gastro-intestinal tract, in water and in soil.
In hospitalised patients, colonisation of the gastro-intestinal tract and oropharynx is common. GNB
can be part of the transient flora on the hands of healthcare workers.
Some species of bacteria commonly found in the bowel (e.g. Escherichia coli, E.Coli, Klebsiella,
Proteus, Pseudomonas Enterobacter and Acinetobacter) can develop multi-resistance to antibiotics
where they become collectively referred to as Multi-resistant gram negative bacteria or MRGNB.
MRGNB are seen most frequently in patients who have received broad spectrum antibiotics and
where patients have diminished immunity. MRGNB may cause urinary tract infections, pneumonia
and surgical site infections.
Some MRGNB contain beta-lactamases which can destroy/inactivate even broad spectrum
antibiotics such as cefuroxime and cefotaxime. These are referred to as extended spectrum beta
lactamases or ESβL.
ESβL-producing coliforms are resistant to intravenous cephalosporins and they are frequentlyresistant to many other antibiotics including ciprofloxacin and aminoglycosides. Multi-resistant
Acinetobacter are defined as isolates which are resistant to any aminoglycoside and to any third
generation cephalosporin. Some multi-resistant Acinetobacter strains are also resistant to
carbapenem antibiotics (these strains are designated MRAB-C). Multi-resistant Pseudomonas are
resistant to at least two of the following: ceftazidime or piperacillin/tazobactam or gentamicin (or
other aminoglycoside) or ciprofloxacin. Multi-resistant Pseudomonas strains are occasionally
resistant to carbapenem antibiotics.
3. Scope of Guidance
This guideline is intended to guide practice of staff working within Lincolnshire Community Health
Services NHS Trust.
The principles contained within the guideline reflect best practices and applies to those members of
staff who are directly employed by Lincolnshire Community Health Services NHS Trust.
However, it is recognised that the management and control of multi-resistant organisms requires
countywide action and this guideline may be used and adapted by other organisations as
appropriate.
Putting you first is at the heart of everything we do
Page |5
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
4. Purpose
This guideline applies to all relevant Lincolnshire Community Health Services NHS Trust employed
staff. It sets out the arrangements within the organisation to prevent and control the spread of multi
resistant gram-negative bacteria and to promote effective and evidence based patient care.
5. Key Responsibilities
5.1 Chief Executive
Overall responsibility for matters relating to Infection Prevention lies with the Chief Executive to
Lincolnshire Community Health Services NHS Trust.
5.2 Board lead
The Director of Infection Prevention and Control (DIPC) has the board lead for Infection Prevention
and Control for Lincolnshire Community Health Services NHS Trust.
5.3 Managers
Managers have the responsibility to ensure that all staff are aware of this guideline and have
received relevant induction/training. They will be responsible for ensuring staff have access to IPC
guidance, highlighting staff training, areas for audit and areas for risk assessment and ensuring that
infection prevention and control is embedded in their service delivery.
5.4 Employees
All employees have a responsibility to abide by this guideline and any decisions arising from the
implementation of it. Any decision to vary from this guideline must be fully documented with the
associated rationale stated.
It is important that staff report any concerns/difficulties in relation to implementing this guideline to
their line manager. All accidents/Incidents deemed to be in breach of this guideline must be
reported by the usual reporting mechanisms outlined by Lincolnshire Community Health Services
NHS Trust.
Employees have a responsibility to attend mandatory training/update training as identified within the
Organisation’s Mandatory Training Matrix.
5.5 The Infection Prevention Team
The Infection Prevention Team will review the guidance annually.
In addition they will review the document in response to the publication of any urgent
communications from the Department of Health.
Assist managers with the audit of compliance with the guidance as required.
Deliver associated Infection prevention and control training as required.
5.6 Education and Workforce Team
The LCHS NHS Trust Education and Workforce Team has a responsibility to ensure the
coordination of the learning and development of staff, as identified within the Workforce
Development Policy and training matrix.
Putting you first is at the heart of everything we do
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Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
6. Training
6.1 Training delivery
Training requirements will be highlighted through the local training needs analysis.
The Infection Prevention Team, will as appropriate in conjunction with Education and Workforce
Team, provide education, as appropriate to all staff on corporate mandatory induction, clinical and
non clinical mandatory update sessions.
Further training needs may be identified through other management routes, including root cause
analysis following an incident/infection control outbreak (see incident reporting and serious incident
reporting policy). By agreement additional targeted training sessions will be provided by the
Infection Prevention & Control team.
6.2 Process to Check Training is completed
The statement of main NHS terms and conditions for employment for LCHS under Agenda for
Change identifies that all staff will be expected to undertake appropriate and relevant training and
development to enhance their performance in their post.
Confirmation of staff completion of relevant training; commensurate with their job role (inclusive of
mandatory training) will be achieved through:
Corporate Induction Arrangements: Appointing managers will ensure that all employees are aware
of the induction policy upon joining LCHS and ensure that the staff member is booked on the
corporate mandatory induction. Non attendance is followed-up as identified below.
Local Induction Arrangements:
Line managers will ensure that all new staff receive a
comprehensive local induction, within two weeks of the staff member commencing in their post,
guided by the local induction checklist. The local induction checklist records the date corporate
mandatory induction is undertaken.
Line Managers are required to keep accurate records of staff training. Utilising this information, Line
Managers review and discuss on an ongoing basis, training needs of staff and training attended. In
addition, the Line Manager will review staff training attended as part of the annual development
review, knowledge and skills framework and Agenda for Change progression.
6.3 Follow-Up of Non Attendance
Mandatory Training (Corporate Mandatory Induction and Updates).
The Education and Workforce Team will maintain attendance records for all induction and
mandatory training session delivered. Non attendees will be notified to the appropriate line manager
for action.
7. Support for patients
This guideline will be publically available on the Lincolnshire NHS website. Patients will receive
verbal and or written information appropriate to their episode of care. Lincolnshire Community
Health Services NHS Trust can provide additional support to clients via the Patient Advice and
Liaison Service (PALS)
Putting you first is at the heart of everything we do
Page |7
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
8. Measures to prevent and control the spread of infection
8.1 Treatment
Avoidance of inappropriate prescribing is vital in the control of MRGNB. Treatment is a dvocated for
those service users who have clinical signs of infection. Advice on antibiotic treatment is outside of
the scope of this guideline.
Advice can be obtained from the Consultant Microbiologist and the Medicines Management Team.
8.2 Reduce risk of transmission
Use of Standard Precautions at all times for all patients is essential to prevent the spread of
MRGNBs and ESβLs.
Common routes of transmission are:

Direct spread e.g. via healthcare workers hands

Indirect spread e.g. via used healthcare equipment/environmental contamination
8.2.1 Hand hygiene.
The main source of infection is via colonised or infected sites. Effective hand hygiene is essential
before and after patient contact (See G_IPC_17 Hand Hygiene guidelines).
8.2.2 PPE
Disposable single use plastic aprons and gloves must be worn for all direct patient contact or
contact with the immediate environment, including bed making or when handling items
contaminated with blood/body fluids. (See G_IPC_26 Standard Precautions guidelines).
8.3 Environmental controls
8.3.1 Medical equipment
Medical equipment must where possible be dedicated for sole use with the patient. All equipment
must then be appropriately decontaminated before it can be used on another patient/sending for
repair. (See G_IPC_38 Decontamination of patient’s equipment)
8.3.2 Waste
Follow the Trust guidelines for disposal of all waste across all settings
8.3.3 Linen
Inpatient areas
Daily change bed linen and personal clothing is recommended. Treat all linen as infected linen.
Patients’ own clothes should be sealed securely in a water soluble bag and relatives requested to
wash clothes at home at the highest temperature that will not damage the fibre (See G_IPC_06
Linen guidelines)
Staff Uniforms; If laundered at home, uniforms should be washed separately at the highest temp for
the item ideally on a 60ºc cycle (or higher temperature) followed by a tumble dry or iron. Uniforms
should not be worn to and from work. (See P_HS_15 Uniform and Dress code policy).
Putting you first is at the heart of everything we do
Page |8
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
Patient’s own home
Advise regular changes of bed linen and clothing. Wash clothes at home at the highest temperature
that will not damage the fabric.
8.3.4 Cutlery/crockery
Inpatient areas: reprocess in industrial style dishwasher
In patient’s own home: no special precautions required.
8.3.5 Environmental contamination
Inpatient areas: Isolation rooms must be cleaned at least daily, paying special attention to dust collecting areas and horizontal surfaces using dedicated/single use equipment.
Rooms should be cleaned in accordance with the infection prevention and control policy isolation
policy. The standard terminal cleaning procedure using a solution of proprietary combined 1000ppm
available chlorine in detergent should be undertaken for vacated isolation rooms, paying spe cial
attention to dust collecting areas, horizontal surfaces and floors, and curtain laundering. NB. Visible
splashes to walls should be removed – full wall washing is not necessary.
Patient own home: Normal household cleaning will be sufficient
8.4 Pathology specimens
‘Danger of Infection’ labels are not required (unless the patient has another condition requiring
them). (See G_IPC_19 Specimen guideline)
8.5 Additional Recommendations
8.5.1 Community Hospitals
Inpatients in Community Hospitals must be nursed in a single room. Isolation should continue until
the patient has completed treatment and culture of a repeat specimen is negative. (See G_IPC_28
Management of patient in Isolation).
If a single room is not available or the patient’s condition prevents isolation, a risk assessment must
be carried out in association with the infection prevention and control team. See Management of
Notifiable of infectious disease and food poisoning.
If patient is to be isolated a clear explanation should be provided to both the patient and their
visitors. Ensure that visitors are aware of the additional precautions they need to take. Visitors for
patients will not be expected to wear aprons or gloves unless they are attending to the patient e.g.
assisting in the delivery of personal care
Patients should be allocated their own specific equipment e.g. commode, moving and handling
equipment, wash bowls and blood pressure cuffs.
Where possible single patient use equipment should be used and disposed off as clinical waste on
patient discharge or discontinuation of isolation precautions.
Patients may be discharged to their own homes. Ward staff must liaise with nursing/residential care
homes or other hospitals and ambulance transport as appropriate. It is vital that an inter-hospital
transfer form is completed and accompanies the patient.
Putting you first is at the heart of everything we do
Page |9
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
8.5.2 Residential/nursing care homes
The majority of service users identified with a MRGNB will be colonised. Normal social contact with
someone who is colonised with MRGNB does not pose a risk to healthy people There is no
justification for refusing to admit a person with MRGNB into this type of environment.
Patients/residents in the community setting with MRGNB/ESβL do not usually require isolation.
They may share a room so long as neither they nor the person with whom they are sharing has
open wounds, drips or catheters.
Patients/residents can visit communal areas, e.g. dining room, television room and can mix with
other residents/patients
Normal laundry procedures are adequate, however if laundry is soiled and is heat labile it should be
washed at the highest temperature the garment will withstand.
On discharge patient rooms should be cleaned in accordance with local policy paying special
attention to dust collecting areas, horizontal surfaces and floors, and curtain laundering.
If a patient/resident requires hospital admission/transfer to another service provider an inter healthcare transfer form must be completed. This will enable a risk assessment to be undertaken to
determine whether the patient should be isolated on admission.
8.5.3 Patients own home
In general no special precautions are needed.
8.5.4 Ambulance transportation
The ambulance service should be notified in advance by ward/clinical staff. An inter healthcare
transfer form should be completed and accompany the patient.
9. Monitoring, Surveillance and Audit
9.1 Outbreaks
The Infection Prevention monitor MRGNBs and ESBLs on behalf of Lincolnshire Community Health
Services NHS Trust and will investigate any suspected outbreaks in line with the outbreak
guidelines. Outbreaks will be reported as a serious incident and will be reported to and monitored by
Quality and Risk and Risk Committee and the Infection Prevention and Control Committee.
9.2 Surveillance
The Infection Prevention Team will monitor trends in relation to MRGNB where these are associated
with service areas under their remit and on a monthly basis report those trends to the Director of
Infection Prevention & Control, the Infection Prevention & Control Committee and the Trust Board.
The Quality and Risk Committee will receive information on any specific concerns, escalated from
the Infection Prevention and Control Forum relating to Infection prevention and control issues. The
concerns will be assessed and action taken to address the issue identified.
9.3 Audit
This guideline may be monitored to determine compliance either following an incident or by the
forward audit programme.
Putting you first is at the heart of everything we do
P a g e | 10
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
Minimum
requirement
to
be
monitored
Process for
monitoring
e.g. audit
Responsible
individuals/
group/
committee
Compliance Audit
& Manager/
surveillance IP&C
Frequency
of
monitoring/audit
Responsible
individuals/
group/ committee
(multidisciplinary)
for
review
of
results
Responsible
individuals/
group/
committee
for
development
of
action
plan
Responsible
individuals/
group/
committee
for
monitoring
of
action
plan
Monthly
surveillance
IP&C
Committee
IP&C
Committee
IP&C
Committee
References
Department of Health (2000) UK Antimicrobial Resistance Strategy and Action Plan
Department of Health (2002) Getting Ahead of the Curve: a strategy for combating infectious
diseases
Department of Health (2009) Health & Social Care Act 2008: Code of practice on the prevention and
control of healthcare associated infections and related guidance, London
Health Protection Agency. Investigations into multi-drug-resistant ESBL- producing Escherichia coli
strains causing infections in England. http://www.hpa.org.uk/hpa/publications/esbl_report_05/
Putting you first is at the heart of everything we do
P a g e | 11
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
Contributors:
Persons involved in development of this guideline / procedure:
Name:
Designation:
Gail Beckett
Public Health England
Dr Bethan Stoddart
Pathlinks
Members of the Infection Prevention
Team
LCHS
Putting you first is at the heart of everything we do
P a g e | 12
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan
Appendix F. Equality analysis
A.
Briefly give an outline of the
key objectives of the policy;
what it’s intended outcome is
and who the intended
beneficiaries are expected to
be
Does the policy have an
impact on patients, carers or
staff, or the wider community
that we have links with?
Please give details
Is there is any evidence that
the policy\service relates to an
area with known inequalities?
Please give details
Will/Does the implementation
of the policy\service result in
different impacts for protected
characteristics?
B.
C.
D.
To provide staff with guidelines on the
management, prevention and control of Multiresistant gram-negative bacteria (including
Extended Spectrum Beta Lactamase producing
microorganisms (ESBLs))
This has an impact on all staff, patients and
careers.
None
Yes
Disability
Sexual Orientation
Sex
Gender Reassignment
Race
Marriage/Civil Partnership
Maternity/Pregnancy
Age
Religion or Belief
Carers
No
√
√
√
√
√
√
√
√
√
√
If you have answered ‘Yes’ to any of the questions then you are required to
carry out a full Equality Analysis which should be approved by the Equality
and Human Rights Lead – please go to section 2
The above named policy has been considered and does not require a full equality analysis
Equality Analysis Carried out
Lynne Roberts
by:
Date:
02.04.15
Putting you first is at the heart of everything we do
P a g e | 13
Chair: Elaine Baylis QPM
Chief Executive: Andrew Morgan