Download C. difficile

Doctors induction 2011
Infection Control and Antibiotic
Prescribing
Dr A. Keith Morris
Overview
Transmission Based Precautions
Peripheral Vascular Catheter (PVC)
C. Difficile
Hand decontamination
Death certification
Communication
OHSAS & needle stick injuries
MRSA screening
Antibiotic prescribing
What is NHS Fife doing to prevent
HAI?
NHS Fife is doing alot and you are expected
to do your part
 Process will be different in Fife
 Infection Control Manual on intranet
 Ward Boards
 Antibiotic management
 Protecting YOU from the patient and the
patient from YOU
Infection control terminology
Standard infection control
precautions
Transmission
based
precautions
Standard precautions
Older terms that now should not be used
- “Universal precautions”
- “Enteric precautions”
Transmission based precautions

Supplement standard precautions.


specify precautions to individual patients documented/suspected
of being infected or colonised with highly transmissible and/or
epidemiologically important pathogens or clinical syndromes
Three types
 Contact
 Droplet
 Airborne
Transmission Based Precautions


Infection Control Manual found on the right
hand side of the NHS Fife Intranet home page
Has all you need to know for every infectious
organism you will come across but…….
If in doubt call the Infection Prevention &
Control Team x28833
C. difficile
How good are we?
C. difficile rate( per 1000 OCBDs) in >65s in Fife compared to
Scotland
Rate per 1000
OCBD
Rate per 1000 OCBD in ≥ 65 in NHS Fife
Rate per 1000 OCBD (≥ 65) Scotland
1.6
1.2
0.8
0.4
0
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010 2011 2011
Quarter
NHS Fife has one of the lowest rates of CDI in Scotland
C. difficile



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Microbiologist will contact the ward to speak to
the FY1/FY2 about the case
You need to be able to assess the severity
Know which antibiotic to give depending on the
severity
In Fife there is a CDI care pack. Consists of
-C. difficile Notification Form
-CDI Medical Management Form
-Stool chart – monitored daily
-Algorithm for the Management of CDI
Clostridium difficile associated disease (CDAD) – MEDICAL MANAGEMENT
This form should be used for all adults (>16yrs old) diagnosed with C. difficile infection. The form should be entered in
the patient’s medical notes as part of the record of their care.
Name:
Address:
Date of birth:
Hospital Number:
CHI Number:
DAY
DATE
SEVERITY OF
CDAD (severe, nonsevere or asymptomatic
– see below)
SIGNATURE
PRINT NAME
GRADE
(these columns need only be filled in the first time an individual
signs the form)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
IN ALL CASES

Patients must be fully assessed by medical staff when they are identified as being C. difficile positive.

The need for any currently prescribed antibiotics should be reviewed and if possible stopped or a narrower
spectrum agent chosen. Discuss with duty microbiologist if in doubt.

Antimotility agents and gastric acid suppressive therapy should be stopped.

Fluid, electrolyte and nutritional status must be assessed and replaced/supplemented if indicated.

Severity of CDAD must be assessed and managed accordingly (see below). Assessment must be carried out
at least daily until the patient has been asymptomatic for 48hours, though beware, relapses can occur. The
outcome of the assessment must be recorded on this sheet each day. This includes weekends and patients
must be handed over to the hospital at night team to ensure this happens.

If active management of CDAD is not being pursued this should be clearly documented, with the reason, in the
patient’s medical notes. Further completion of this form is then not required.
SEVERE DISEASE
If the patient meets any of the following criteria they should be managed as having severe CDAD:

Admitted to ITU for treatment of CDAD or its complications

Suspicion of/confirmed pseudomembranous colitis, toxic megacolon, ileus
o

Temperature >38.5 C
9

White cell count <1.5 or >15 X10 /L

Serum albumin <25mg/l

Acutely rising serum creatinine or creatinine >1.5 times baseline

Colonic dilatation on CT scan >6cm

Patient immunocompromised (eg neutropenic, on immunosuppressive therapy)
rd
Severe cases (or if >/= 3 episode of CDAD) must be:

Started on oral vancomycin 125mg qid for 10 days if able.

Discussed with the duty microbiologist to discuss whether there is a need for alternative/additional antibiotic
management and to arrange stool culture for C. difficile.
st
nd
NON-SEVERE DISEASE (symptomatic but do not meet any of criteria for severe CDAD) and 1 or 2 episode of CDAD
Treat with oral metronidazole 400mg tid for 10 days
If no improvement after 5 days of metronidazole, change to oral vancomycin 125mg qid for 10 days
ASYMPTOMATIC C. DIFFICILE POSITIVE PATIENTS
Antibiotics active against C. difficile are not required.
IF ANY UNCERTAINTY REMAINS PLEASE CONTACT CONSULTANT MICROBIOLOGIST TO DISCUSS
What else you should be doing
Monitor – fluid balance and nutritional
status with U&Es, albumin
 Stop gastric acid suppressants
 Contact precautions
 Wash hands with soap and water

Hand Decontamination

Hand hygiene is the most important action to prevent the
spread of infection

Use alcohol rubs if hands socially clean

Hands MUST be washed after removing gloves

Use alcohol gel before EVERY patient contact
If patient has diarrhoea or vomiting must
wash hands with soap and water
Hand decontamination –SPSP
expect

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Bear below the elbows plus removal of watches
and rings with stones
Wet hands AND THEN apply soap to all
surfaces
Rinse hands
Dry hands with paper towels
Dispose of paper towels with out contaminating
hands
CMO letter (2011)13
This makes it mandatory in Scotland to inform the
Infection Prevention Control Team if any of the
following terms are written on either part of a
death certificate
 MRSA – inform Procurator fiscal
 C. difficile – inform Procurator fiscal
 Hospital acquired infection
 S, aureus bacteraemia – all SAB related deaths to
be investigated
Communication

Patients with an infectious disease or syndromes
e.g. D&V, MUST NOT be transferred or sent for
investigation without warning the receiving unit

This requires documentation on transfer letters,
and investigation requests

Follow up results as soon as available if patient has
moved elsewhere
Peripheral Vascular Catheters (PVCs)
 All PVCs to have the time & date of




insertion
clearly labelled on the dressing
Insertion sticker in the Medical notes (A&Eprinted on front sheet of A&E record)
Maintenance sticker in the nursing notes (nurses
perform this task)
PVC change after 72 hours
DO NOT take blood cultures through PVCs
Make your life easy switch to oral agents!
Ensure an Insertion Label is completed
for every venflon inserted
I feel assured!
Are you?
Date &
time visible
Insertion site
clearly visible
Every patient…
Further details from ward
staff
Every time!
What else have I to do once I have inserted a
venflon?
Venflon to be checked
Date & time of insertion
to be written on venflon
dressing
daily. Complete a daily
check label
example
Complete an
Insertion Label
example
Place label in medical
notes / episode of care
sheet
Peripheral Vascular Catheter Care Bundle
HPS
Cannula site:
Cannula gauge / colour:
Still in use / required
Y N
Absence of inflammation / extravasation
Y N
Dressing intact and dated & timed
Y N
Inserted for less than 72 hours
Y N
Hand hygiene before & after all PVC bundle
checks
Y N
Please circle
PVC removed
PVC left
in situ
Reason for removal:
Date:
/
/
Time:
Insertion stickers



Collect them when you collect other items for
the PVC insertion
Where do you find them on blood trolleys and
nursing stations
Insert them into the medical notes after you
have inserted the venflon and complete
Does strict PVC management have
an effect?
Quarterly SAB rate per 1000 OCBDs
Scotland
Intervention
0.800
0.600
0.400
0.200
20
Q 08
2
20
Q 08
3
20
Q 08
4
20
Q 08
1
20
Q 09
2
20
Q 09
3
20
Q 09
4
20
Q 09
1
20
Q 10
2
20
Q 10
3
20
Q 10
4
20
Q 10
1
20
Q 11
2
20
11
0.000
Q
1
Rate per 1000 OCBDs
NHS Fife
Quarter
SABs and you

All hospital acquired SAB will be investigated.

All SAB related deaths to be reported to the Infection
Prevention & Control office

If a SAB occurred on your patient you will have to
explain any failings in the management of the PVC,
pressure sores, etc.

Make your life easy remove PVCs, catheters and ask the
nursing staff about pressure sores and broken skin.
OHSAS
Know you immune status too:
 HBV
 Chicken pox
 Mumps
 Measles
 Rubella
Needle Stick Injuries

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What to do
Who to inform (line manager, OHSAS)
Who performs risk assessment
Who takes blood (patient and HCW)
Where to get PEP
Mandatory MRSA screening in
Scotland

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All elective admissions (except obstetrics &
paediatrics)
All emergency and elective admissions to ICU,
vascular, orthopaedics and renal unit
Clinical Risk Assessment on all other patients
If answer positive to ≥1 of three questions then
patient screened
Antibiotic Stewardship
NHS Fife is different.....!
Why has antibiotic control
become so important?


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Increasing antibiotic resistance in Fife
Lack of new antibiotics in the pipe line
C. difficile
“The age of
liberal antibiotic policies is over. The time for antibiotic
restriction has arrived”
Dr Keith Morris
2008
What are we trying to do in Fife?


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Restrict the use of certain antibiotics/antifungals with
out Microbiology or ID approval
Abbreviated antibiotic guidance for common infections
applicable to all in-patient areas
Making antibiotic guidance accessible
-Pocket guidance
-Ward posters

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Full guidance available in the intranet
Collect data on antibiotic consumption
Provide surveillance information to wards
AMT controls antibiotic use in Fife
Examples of restriction
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The only use of ceftriaxone is meningitis
Ceftriaxone to be removed form drug cupboards on
adult general medical & surgical wards
Meropenem and tigecycline
Temocillin
Linezolid
Voriconazole
Is it having any effect?
Always think..
Does this patient really need an antibiotic?
If the patient is clinically stable with a raised WCC or
temperature they do not need antibiotics?
Have a plan for what antibiotics to prescribe if patient
deteriorates
If a patient has had 5 days of an empirical antibiotic and not
improved they are on the incorrect antibiotic or source
control has not been established
Know the NHS Fife….
Dress code
-For everyone in NHS Fife

Boards for wards
-Operational division only

Healthcare Environment
Inspectorate Scotland (HEIS)

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A branch of SGHD
Inspect ALL acute hospitals in Scotland
Expect FY and STS doctors to know about and follow
-Dress code
-Where to find the Infection Control Manual
- National surveillance for infection prevention
-SSI surveillance for hip arthroplasty & C sections
-SABs & C. difficile
-Hand hygiene audits
-Cleaning audits
-Where to find ward results for the above
Summary

NHS Fife will have different practice to where you have come from and
where you trained e.g. C. difficile & PVCs

Follow NHS Fife practice not what you think is best practice

ALL medical devices and areas of broken skin will give rise to infection
if you do not manage them. THINK ABOUT THEM

If in doubt ask
-I/C ext 28833
-The switchboard for “duty microbiologist”
And one final request…