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Volume 5 No 2; 14 January 2011

Healthcare-associated infections: changes to reporting requirements for MSSA bacteraemia

With effect from 1 January 2011 the Department of Health (DH) has asked NHS Acute Trusts to report diagnoses of meticillin-sensitive Staphylococcus aureus (MSSA) bacteraemia to the HPA Healthcare Associated Infection and Antimicrobial Resistance Department through the Data Capture System (DCS) currently used to collate MRSA bacteraemia and Clostridium difficile infection reports.

As this is part of the mandatory HCAI reporting programme, trusts are requested to enter data to the DCS in a timely manner. Data for January 2011 should be signed off by trust Chief Executives by 15 February, 2011. All MSSA blood culture positive diagnoses made from 1 January 2011 should be reported. Further details of the new arrangements are available on the DH website [1].

The HCAI mandatory reporting schedule for England was last extended in June 2010 to include publication of weekly, hospital-apportioned counts of MRSA bacteraemia and Clostridium difficile infections in addition to the monthly reports and quarterly commentaries reported in HPR [2].

References

1. DH, 6 January 2011. Letter from Chief Nursing Officer and Deputy NHS Chief Executive: "Extension of mandatory surveillance to Meticillin Sensitive Staphylococcus Aureus (MSSA) and updated healthcare associated infections clinical guidance (HCAI Compendium)", http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_123275.

2. HCAI surveillance data to be published weekly, HPR 4(22), http://www.hpa.org.uk/hpr/archives/2010/news2210.htm#hcai.

Confirmed measles cases in England and Wales: update to end-November 2010

Only 14 cases of measles with onset in November were confirmed in England and Wales bringing the total to 363 cases for 2010 to date, compared to 1144 cases in 2009 (see table). Six of November onset cases were in London and associated with previously reported clusters [1] and five were part of a small cluster in the East of England. Single cases were identified in the North West, South West and South East regions (table).

Cases continue to occur predominantly in unvaccinated children under 18 years of age (67%). A detailed age breakdown of cases for 2010 to the end of November by region is available at http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1223019390211.

Number of confirmed cases of measles by region and month of onset, England and Wales: January to November 2010

Month/
Year

London

East Mids

Eastern

North East

North West

South East

South West

West Mids

Wales

York & Hum

Total

Total 2009

198

47

74

122

79

276

43

95

159

51

1144

Jan-10

–

–

–

–

–

–

–

–

–

–

–

Feb-10

–

–

2

–

–

3

–

–

–

–

5

Mar-10

1

–

2

–

–

3

2

–

–

–

8

Apr-10

6

–

2

–

5

3

1

–

3

–

20

May-10

22

2

13

1

5

10

1

–

2

1

57

Jun-10

2

–

13

1

10

5

1

–

–

3

35

Jul-10

13

4

10

–

11

43

–

9

–

10

100

Aug-10

8

1

6

5

7

27

–

4

3

10

72*

Sep-10

4

–

3

3

5

6

–

–

–

8

29
Oct-10

16

–

4

–

–

2

–

–

–

1

23

Nov-10 6 – 5 – 1 1 1 – – – 14

Total 2010

78

7

60

44

43

103

6

13

8

33

363*

* Includes one case with region not known.

 

Number of confirmed measles cases by month of onset, England and Wales: January 2006 to November 2010

Reference

1. HPA. Confirmed measles cases in England and Wales in 2010: update to end-October, HPR 4(49): news.
Available at http://www.hpa.org.uk/hpr/archives/2010/news4910.htm#msls.

Increased incidence of invasive bacterial infection potentially linked to influenza activity

Analysis of surveillance data and isolate referral patterns for December 2010 has identified modest increases in numbers of invasive bacterial pathogens above those seasonally expected. Although these infections remain relatively uncommon, investigations are underway to identify whether co-infection with influenza may be contributing to these observed increases (see the HPA Weekly National Influenza Report, 13 January 2011 [1]).

As a reminder of the potential for development of severe bacterial secondary complications in influenza patients, in particular invasive meningococcal, pneumococcal, group A streptococcal, Haemophilus influenzae and Staphylococcus aureus infection, the Chief Medical Officer for England issued an alert to front-line clinicians on 10 January 2011 [2]. The cascade letter also reminded clinicians of the potentially non-specific presentations of such bacterial infections, which may be flu-like in their early stages, and requested they should:
  • continue to remain vigilant for the possibility of severe illness due to bacterial co-infection with influenza - including invasive group A streptococcal (iGAS) disease, pneumococcal and meningococcal infection - and to be aware of the possibility of such bacterial co-infection in people with flu-like illness;
  • ensure antiviral treatment is started as soon as possible in line with national guidance and that patients with a flu-like illness that fail to improve are reviewed  [3];
  • in hospital settings, obtain blood and respiratory tract samples for culture early, preferably before administration of antibiotics;
  • ensure rapid instigation of appropriate antibiotic treatment for patients known or suspected to be suffering from flu and bacterial co-infection.

Increases in invasive bacterial pathogens in December 2010 compared to the same period in previous years have been noted for invasive pneumococcal and GAS infection; latest available data are presented below.

Antimicrobial resistance rates do not indicate increased resistance with these pathogens showing normal susceptibility to first line agents. Secondary bacterial infection of influenza is suspected as contributing to these increases on the basis of high levels of circulating influenza, concurrent increases in lower respiratory tract bacterial pathogens, increases in pneumococcal infection in age-groups where high rates of influenza infection have been observed (15-44 year olds) and a series of individual case reports of bacterial co-infection of both influenza A (H1N1) and influenza B.

Group A streptococcal disease

  • 164 iGAS cases in England for December 2010 have been identified through sterile site isolates submitted to the national reference laboratory compared with 103 in December 2009, an overall increase of 37%. Routine laboratory surveillance data and scarlet fever notifications also suggest increase GAS activity this season compared to recent years.
  • Increases in isolate referrals are noted in several regions in particular, the South East, North West, South West, West Midlands and the North East. Analysis of routine surveillance data has also identified increases in the East of England, East Midlands, London and Wales.
  • Characterization of submitted isolates does not suggest the emergence of an unusual strain although one emm type is currently predominating, emm 1 (48% of December isolates).
  • The age distribution of cases has not changed with most of the cases in December occurring within the 15-64y (42%) and >64y age groups (34%).
  • Invasive isolates remain fully sensitive to penicillin with erythromycin resistance reported in 4%, similar to previous years  [4].

Meningococcal disease

  • 150 cases of meningococcal disease were confirmed by the HPA Meningococcal Reference Unit in December 2010. This number of cases is higher than in 2009 (88) but is similar to the number of cases seen in 2008 (192) and 2007 (141).

Pneumococcal invasive disease

  • 697 cases of invasive Streptococcus pneumoniae infection were identified through sterile site isolates submitted to the national reference laboratory in December 2010, a 13% increase compared to December 2009 (619).
  • Regional variations are noted with London, North East and South East reporting slightly fewer cases in December 2010 compared with December 2009 whereas increases are noted in the South West, North West and Yorkshire and Humber.
  • The increase in cases is predominately seen in adults up to 65 years of age, particularly in the 15-44 age group (99 reports in December 2009 vs 194 reports in December 2010).
  • It is important to note the introduction of the 13-valent pneumococcal conjugate vaccine in April 2010 (replacing the 7-valent vaccine) as this will have reduced the number of cases of disease with a vaccine serotype in the targeted age group. A reduction in cases between 2009 and 2010 was seen in children aged less than two years (age group targeted for vaccination with PCV) and in those aged over 65 years (as a result of herd immunity) [5].

Invasive Haemophilus influenzae infections

  • At present there is no discernible upward trend in invasive infection due to Haemophilus influenzae in December 2010 compared to December 2009.

 

Staphylococcus aureus bacteraemia

  • As for Haemophilus influenzae, at present there is no evidence of any increase in S. aureus bacteraemia overall or in particular age group or region in December 2010 compared to December 2009 as detected through analysis of routine or mandatory surveillance data.

 

Surveillance of antibiotic susceptibility of lower respiratory tract infection

  • Analysis of data collected by 83 laboratories across England and Wales participating in this scheme has identified increases in December 2010 compared to December 2009 for pneumococci (14%, 1,064 to 1,212), H. influenzae (8%, 3,275 to 3,521) and S. aureus (7%; 1,472 to 1,578). Increases were also noted for S. pyogenes (26 to 44) although should be interpreted with caution given the small numbers.
  • Susceptibility results for a total of 14,952 respiratory isolates are shown below. These data were collected by 90 laboratories for the 12 week period ending 2 January 2011.
S. pneumoniae:
Penicillin 94% Sensitive
  Erythromycin 87% Sensitive
Tetracycline 90% Sensitive
H. influenzae:
Amoxicillin 75% Sensitive
Co-amoxiclav 92% Sensitive
Tetracycline 98% Sensitive
S. aureus:
 Methicillin 83% Sensitive
Erythromycin 70% Sensitive
Tetracycline 94% Sensitive
Group A streptococci:
 Penicillin 100% Sensitive
Tetracycline 98% Sensitive
Erythromycin 98% Sensitive

Further investigations are underway to identify rates of bacterial co-infection in cases of laboratory confirmed influenza diagnosed during this season and to assess the impact of co-infection on patient outcome. Results will be compared to similar analyses undertaken during the 2009 H1N1 pandemic where low rates of secondary bacterial infection were noted [6].

Microbiology laboratories are reminded of the importance of prompt reporting of surveillance data and submission of isolates to the respective national reference laboratory. Isolates submitted as part of outbreak investigations should have this clearly labelled to prioritise testing.

 

References

1. HPA Weekly National Influenza Report, 13 January 2011. Available from the HPA website at: Home > Topics > Infectious Diseases > Infections A-Z > Seasonal Influenza > Epidemiological Data > HPA National Influenza Report.

2. Chief Medical Officer. Central Alerting System: Influenza Meningococcal Infection and Other bacterial co-infections including pneumococcal and iGAS. Department of Health. 2011 (available at https://www.cas.dh.gov.uk/ViewAndAcknowledgment/viewAlert.aspx?AlertID=101528)

3. Salisbury DM. Influenza season 2010/11 - use of antivirals. Department of Health. 2010 (available at: www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_122572)

4. HPA. Pyogenic and non-pyogenic streptococcal bacteraemia, England, Wales and Northern Ireland: 2009. HPR 4(46): bacteraemia.

5. Pneumococcal Disease. HPA website: Home > Topics > Infectious Diseases > Infections A-Z > Pneumococcal Disease.

6. Degail MA, Grant A, Lamagni T, Campbell C, Keppie N, Kaye P et al. Concurrent invasive bacterial infections in confirmed Pandemic (H1N1) 2009 influenza cases in England, 2009- 2010. Health Protection 2010 conference; September 2010; Warwick.