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ESBL-producing bacteria
Extended Spectrum Beta-Lactamase (ESBL) producing bacteria
Frequently Asked Questions
Key points
ESBL-producing bacteria can be present in the gut of patients
without signs or symptoms, therefore the application of Standard
Infection Control Precautions at all times is essential to prevent
cross-infection with these multi-resistant organisms
Hand decontamination before and after every patient contact is the
most important step in preventing transmission
The risk of transmission is increased if a patient has diarrhoea
or a urinary catheter in situ
What is ESBL?
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ESBL stands for Extended Spectrum Beta-Lactamase.
ESBLs are enzymes that are produced by some bacteria and confer resistance to
almost all beta-lactam antibiotics (penicillins and cefalosporins), and in addition
may be associated with resistance to a range of other frequently used antibiotics
(e.g. ciprofloxacin, gentamicin, trimethoprim).
ESBL-producing bacteria are becoming more prevalent in both community and
healthcare settings in the UK. Imported infections in travellers returning from
abroad are being increasingly reported. Infections caused by these organisms are
challenging to treat as there are fewer effective antibiotics to use.
What infections do ESBL-producing bacteria cause?
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The most common ESBL producers are members of the Enterobacteriaceae
group of bacteria e.g. Escherichia coli (E.coli) and Klebsiella species. These are
found in the human bowel as normal colonising (commensal) bacteria.
Active clinical infection occurs when these bacteria are introduced into areas of
the body where they are not normally found. The most common clinical
presentation is urinary tract infection, but intra-abdominal infections (e.g.
cholangitis, visceral abscesses) and pneumonia also occur, and blood-stream
infection (BSI) may result.
How are these bacteria spread?
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Cross infection and outbreaks of infection both within acute and community
healthcare settings are well described. As with other bacteria, cross-infection can
occur either directly on unwashed or improperly decontaminated hands or
indirectly via contaminated equipment.
Environmental reservoirs e.g. sink drains or damaged fabric around hand wash
basins or other water sources/disposal areas can be problematic and can
contribute to prolonged outbreaks, particularly in high level care settings.
Who is at most at risk?
There are a number of factors that make an individual more likely to become
colonised or infected with ESBL-producing bacteria. These include:
 underlying illnesses and co-morbidities that increase susceptibility to infection
 exposure to repeated courses of antibiotics
 prolonged stay in hospital
 residential or nursing home stay
 presence of a urinary catheter
 history of previous ESBL infection – in particular patients who have recurrent UTI,
with or without the presence of an indwelling urinary catheter.
What are the antibiotic treatment options?
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Antibiotic treatment options are limited. Treatment regimens will be guided by
laboratory reported antibiotic sensitivities and where shown to be sensitive to
recommended antibiotics, Trust antibiotic policy guidelines can be followed.
Discussion with the Duty Consultant Medical Microbiologist may be required.
Other than antibiotic prophylaxis where indicated for specific situations, antibiotic
treatment is not generally recommended for people who are colonised and who
do not have signs or symptoms of infection.
What are the appropriate infection control measures?
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Standard infection control precautions must be adhered to. Strict attention to
hand hygiene is the key element for prevention of cross-infection.
Contact precautions (disposable gloves and aprons) must be used when
dealing with blood and body fluids or at all times for patients who are at highest
risk for cross-infection (see next point below), and aseptic non-touch technique
employed when manipulating indwelling devices such as urinary catheters
Source isolation must be considered for all hospitalised patients with ESBL
colonisation or infection (this includes patients with ESBL positive blood cultures
as they are likely to be harbouring these organisms in their bowel). Patients that
pose the highest risk for cross infection and must be isolated are those with
(1) indwelling urinary catheters, (2) diarrhoea or faecal incontinence, (3) urinary
incontinence, (4) large unhealed abdominal wounds that require regular
manipulation/dressings and (5) productive cough or open tracheostomy where
ESBLs have been isolated from respiratory secretions/sputum samples
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Aseptic non-touch technique must be employed when manipulating indwelling
devices such as urinary catheters
Patients should undertake hand hygiene after using the toilet and before eating.
They should be encouraged not to touch wounds, catheters and other indwelling
prosthetic devices.
High standards of environmental cleanliness must be maintained. Appropriate
disposal of waste in accordance with Trust guidelines is essential. Used linen
must be managed as per Trust policy for infected linen
Commodes and bed pan holders must be decontaminated using a chlorine
containing agent, such as Actichlor Plus.
It is not known how long colonisation with ESBL-producing bacteria persists. In
most circumstances it is not necessary to re-test or swab patients to check
whether these bacteria are still present Within the Trust at present, the Neonatal
unit is the only clinical area where routine admission and weekly screening is
performed.
When can patients be taken out of isolation?
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Patients who pose the highest risk of cross infection as listed above must remain
in single room for the duration of hospital stay. Transfer of a patient out of single
room isolation must only be considered if the patient has none of these risk
factors and the room is required for a higher priority infection control purpose
where there is no other appropriate single room available.
A full Actichlor Plus clean of the room, including curtain change, must be
undertaken before the room is re-used.
What is the risk to relatives, carers and visitors?
The risk to visitors and relatives is low if they are fit and well. Prevention of infection
rests mainly on good hand hygiene. This includes hand decontamination before
entering and leaving the ward and before helping a colonised/infected patient to eat
and drink.
What are the implications for duration of hospital stay
and transfer / discharge arrangements?
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Patients do not have to stay in hospital until ESBL infection has cleared.
Discharge will be dependent upon clinical condition.
There is no increased risk to immediate family or friends. Normal personal
hygiene (baths/showers) is sufficient, as is normal household cleaning. Clothes
can be laundered as normal.
Where a patient is known to be infected or colonised, this information must be
included in the discharge/transfer documentation.
Further information on ESBLs can also be obtained via the Health Protection Agency
website at http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ESBLs