Healthcare Associated Infections

Management, Prevention and Surveillance of Healthcare-associated Infections and Antimicrobial Resistance

Drug-resistant bacteria and viruses are a serious healthcare problem. They make infections more difficult to treat, increasing suffering and death. Methicillin-resistant Staphylococcus aureus (MRSA) is well known as a cause of infections in hospital, but other microbes, including multi-resistant Escherichia coli , glycopeptide-resistant enterococci and carbapenem-resistant Acinetobacter have also emerged. The Health Protection Agency plays a central role in monitoring healthcare-associated infections and antimicrobial resistance and advising on prevention and control measures.

 

The Agency's routine responsibilities include:

 

 

Drug-resistant organisms will continue to evolve. The challenge is to identify novel types of resistance, understand how pathogens become resistant, measure their prevalence, and devise policies to minimise their spread. Some initiatives taken in the past year illustrate the Agency's work.

 

Antimicrobial Resistance – MRSA

photo: needleMore than 7,250 people in England suffered bloodstream infections caused by MRSA in 2004/05, surveillance work by the Agency showed. Rates of bloodstream infection have stabilised in recent years after dramatic rises in the 1990s. Work to combat this infection, however, continues apace.

In 2005, the Agency developed and introduced an enhanced surveillance system to collect more comprehensive details for each case of MRSA blood poisoning. The scheme enables NHS Trusts to input cases of MRSA blood poisoning on to a web-enabled reporting system and access results in real time. This provides a better picture of the situation and more evidence regarding risk factors for infection.

The Agency launched a study into MRSA bloodstream infections in children under 16 to determine how frequently this group is affected and who is at highest risk of infection.

We also began work with the Office for National Statistics (ONS) to link surveillance data on healthcare-associated infections held by the Agency with mortality data held by the ONS. The project will initially target MRSA.

 

Multi-Resistant Escherichia coli

The Agency published two major reports* during the year to highlight the problem of pathogens that can resist antibiotics, antivirals or antifungals.

One report made recommendations for tackling the increasing number of infections caused by new, highly-resistant, strains of E. coli that produce enzymes called extended-spectrum beta-lactamases (ESBLs). These new strains produce a particular type of ESBL called the CTX-M type. They can destroy the penicillin and cephalosporin antibiotics that are widely used in hospitals, and are resistant to several other antibiotic classes. Bacteria with CTX-M enzymes were unrecorded in the UK before 2000 but have become widespread since 2003, affecting patients in hospital and in the community.

The Agency's recommendations included: increased surveillance to identify emerging resistance, and improved guidelines on the laboratory detection of ESBL-producing bacteria and on the treatment and control of infections.

Agency scientists have worked with laboratories around the country to enable better diagnosis of infections caused by multi-resistant E. coli , provided advice on appropriate treatment and support for those investigating outbreaks of infection, and carried out surveys to establish the extent of the problem.

 

Healthcare Associated Infections

photo: pillsInfections caused by the bacterium Clostridium difficile have increased markedly in recent years. Infection usually occurs in healthcare settings after people have taken antibiotics to treat another illness. Elderly patients with other underlying diseases are most at risk. Diarrhoea, serious intestinal complications and sometimes death can occur. In 2004, the Agency introduced mandatory reporting of cases of C. difficile in people over 65. NHS Trusts reported 44,488 cases that year.

In 2005, the media reported outbreaks of C. difficile infection at a number of hospitals, including Stoke Mandeville in Buckinghamshire, where deaths had occurred and 300 people had been infected since 2003. The Agency identified that a new strain, type 027, predominated in these cases. It worked closely with the Department of Health (DH) and Thames Valley Strategic Health Authority to ensure appropriate action was taken by the hospital.

To establish what steps NHS Trusts in England were taking to control C. difficile , the Agency undertook a joint survey with the Healthcare Commission. Interim results showed that 40 per cent of Trusts did not routinely follow government guidelines on the management of C. difficile infections and reporting of outbreaks in hospitals. More than one third did not have restrictions to prevent the inappropriate use of antibiotics and, despite concerns that the infections were becoming more severe, most Trusts did not routinely collect vital data on the strains of C. difficile infecting patients.

In response to these findings, the Chief Medical Officer reminded Trusts of the need for effective procedures to control C. difficile and to comply with the Agency's mandatory surveillance scheme. DH also commissioned the Agency to lead a review of the existing guidance on control of infection with
C. difficile .

*Investigations into multi-drug resistant ESBL-producing Escherichia coli strains causing infections in England : Andrew Pearson , David Livermore, Brian McCloskey, Georgia Duckworth, September 2005.

Antimicrobial Resistance: Inevitable but not unmanageable: David Livermore, Deenan Pillay, Patricia Cane, August 2005

 

Healthcare Workers - Monitoring and Providing Advice on Preventing Infections

A programme to monitor the numbers of healthcare workers contracting blood borne viruses in healthcare settings has been in place since 1997. It focuses on cases of HIV, hepatitis B and
hepatitis C.

It was set up in response to evidence that healthcare workers were becoming infected with blood borne viruses from patients either through needle stick injuries or through splashes of fluids to the eye or mouth.

The programme, run by the Health Protection Agency, monitors not only incidents of infection, but also treatments and outcomes, including the types of drugs used, prophylaxis and vaccine where appropriate, and side effects.

It also aims to identify the risk factors surrounding the transmission of blood borne viruses to healthcare workers by understanding the factors necessary for an infection to occur. This includes collecting data on the type of exposure, the staff involved and circumstances surrounding exposure episodes.

All the data collated are used to inform the development of national prevention policies. For example, data that the Agency produced on the HIV post-exposure group was used in 2004 to change policy on the use of antiretroviral drugs in healthcare workers.

The programme has also been useful in identifying areas where there are gaps in the provision of care for healthcare workers. For example, up until now, the surveillance programme has not sought specific follow-up information on healthcare workers exposed to fluids from a patient with hepatitis B. The Agency has identified this as an issue for ensuring best care is obtained for healthcare workers and is currently reviewing whether there needs to be a change in practice.

The Agency has also highlighted, and continues to do so, the inconsistencies in the implementation of guidelines in hepatitis C post-exposure testing of healthcare workers, with the aim of ensuring better adherence to guidelines.

The programme also provides evidence of best treatment practices. It has shown the effects of early treatment when infections of hepatitis C have occurred. In the six cases where infection has occurred and treatment with *combination therapy has been prompt, all have been cleared of the virus as a result.

In addition to monitoring cases of healthcare workers being infected by patients, the Agency monitors cases of patients infected by healthcare workers. It does this as part of the UK Advisory Panel for Blood Borne Viruses Infected Healthcare Workers (UKAP).

The Agency's responsibilities as part of this panel include reviewing scientific literature and making recommendations for changes in national policy.

UKAP also provides advice on the requirement for 'look back' exercises. These are national patient notification exercises to identify whether patients have been infected by a healthcare worker who may have HIV, hepatitis B or hepatitis C. In 2005, the Agency coordinated two large look-backs involving more than 30 hospitals spanning a period of 24 years (1981-2005).

 

*text amended from 'antiretroviral therapies' as published in the original report