Infection control in practice

1. Infection control in practice Miriam Chibamu, Infection Control Nurse, CNWL Brid Fitzgerald, Infection Control Nurse, C&I

2. Question 1: What percentage of healthcare infections are avoidable? • 10% • 20% • 30% • 40%

3. Question 2: what is the most important part of standard precautions? (a) Hand Hygiene (b) Personal Protective Equipment (C) Needlestickand Sharps Injury Prevention (d) Cleaning and Disinfection (e) Respiratory Hygiene

4. Question 3: The correct order to remove PPE is: a) Apron first, gloves second, mask and finally eye protection if worn b) Eye protection, then mask if worn, then apron and finally gloves c) Gloves first, apron second, mask and finally eye protection if worn d) It doesn’t matter

5. Question 4: If you have a needlestick injury or bite to the skin you must: • Suck it and cover it with a waterproof plaster • Report it to your manager • Make the wound bleed, wash with running water and apply waterproof plaster • Put on gloves

6. Question 5: Routine cleaning should carried out using: • Acticlor • Pine disinfectant • Warm water and detergent • Warm water and antibacterial detergent • Detergent wipes

7. Question 6: How can you minimise adverse effects of frequent handwashing • Dry hands thoroughly • Use moisturising creams • Wear gloves • Avoid contact with patients • Use cold instead of hot water • A and B • C and D

8. Question 7: You have two or more patients in your unit with inexplained diarrhoea and vomiting. Who will you inform and where will you access advice? Choose three answers a) The Trust Chief Executive b) The Infection Prevention & Control Team c) The Outbreak Folder on Trustnet or local Outbreak management procedure d) Google Search e) The Locality Housekeeping Supervisor

9. Question 8:How long do you stay off work if you have diarrhoea and vomiting? a) While you are still ill b) When your diarrhoea has stopped and you no longer have symptoms c) 48hours after symptoms have stopped

10. Question 9: Most clinical procedures involving patients are likely to require sterile gloves True or False

11. Question 10: In an inpatient environment, if you are wearing apron and gloves while looking after a patient, you can leave his/her room without removing them to fetch a piece of equipment, for example True of False

12. Resources • TARGET leaflets, education for primary care http://www.rcgp.org.uk/targetantibiotics/ • Start Smart the Focus https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus • European Antibiotic Awareness Day • ESPAUR Report https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report

13. Antimicrobial Stewardship Prof Peter Wilson University College London Hospitals

14. Antimicrobial Stewardship Prof Peter Wilson University College London Hospitals

15. Antimicrobial Resistance • Spreading multiresistant Gram negatives • Few antimicrobial agents in pipeline – expensive and return poor • Veterinary use • Loss of therapeutic options in Southern Europe

16. Transmission • Complex network of transmission between humans, sewage, environment, food • Pressure of human/animal antibiotic use • CTX-M E coli oftenciprofloxacin resistant • Urinary infection most common • Old age, long stay

17. MDR Gram negatives • Significant threat to patient treatment • Hospital – community transfer by patients, staff and equipment • Colonization of travellers • Antibiotics, urinary catheters, hand wash sinks • Pan-resistance yet few new agents • No suppression regimens • Infection control is best defence

18. 2008 MDR K pneumoniae

19. 2016 MDR K pneumoniae

20. HIS/BSAC/BIA Working Party • NICE accredited systematic review • Expert panel • Evidence and recommendations • Infection control JHI 2016 92: Supplement 1 S1-S44 • Antimicrobial stewardship and treatment: J AntimicrobChemother. 2018 Mar 1;73(suppl_3):iii2-iii78.

21. Antimicrobial Stewardship J AntimicrobChemother. 2018 Mar 1;73(suppl_3):iii2-iii78. • Reduction inappropriate use effective • Rapid susceptibility testing / surveillance • Interventions 25% reduction MDR GNR • Program in all hospitals – audit feedback • Bacteremia outcomes publicly available • Restrictive policies better in short term • Carbapenem restriction increases diversity

22. Antibiotic Stewardship • Staff training • Monitor and feedback use of antibiotics • Limit 3rd generation cephalosporins, quinolones and aminoglycosides • Do not treat colonisations

23. Basic rules • Courses as short as possible • Narrow spectrum antibiotics when pathogen known • High dose short duration better than low dose long duration • Rotate first choice antibiotics yearly

24. Antibiotic Policy • Limits choice • Based on local and published data • Limits toxicity • Allows familiarity with dose and monitoring • Avoids duplication, reduces cost • Public Health England

25. Emergence of resistance • Antibiotic restraint delays emergence e.g. MRSA and cephalosporins • Plasmid transfers occur when high antibiotic use • Avoid specific agents if resistance high e.g. trimethoprim • Maintain clinical efficacy of other agents • Reduce length of course and topical use

26. National Antimicrobial Stewardship • CQUIN Reduction in meropenem, piptazobactam and total antibiotic use • Quality Premium to reduce broad spectrum antibiotic in primary care • Antimicrobial stewardship - AWARE index

27. q q

28. Fingertips https://fingertips.phe.org.uk/ • 116 indicators • NHS England initiatives • Antibiotic Prescribing • Healthcare associated infections • Infection Prevention • Stewardship

29. Infections in Critical Care Quality Improvement Programme • National surveillance of bloodstream infection in critical care • Analogous to Matching Michigan • 127 of 151 Trusts registered, 84 ICU entered data in first year • One third BSI ICU associated : E coli 12.1%, E faecium 10.8%, coagulase neg staph 9.1%

30. Recommendations • Local guideline antibiotic use • Local IT bacteremia resistance and outcome • Open available national data CCG/hospital • Public national incidence and outcome data • Collate national/regional resistance rates • Interventions reduce broad spectrum antibiotic in care homes: audit & feedback

31. Resources • TARGET leaflets, education for primary care http://www.rcgp.org.uk/targetantibiotics/ • Start Smart the Focus https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus • European Antibiotic Awareness Day • ESPAUR Report https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report

32. To dip or not to dip - diagnosing UTI’s. Jane Young Nurse Consultant Bladder & Bowel 12/9/19

33. UTI definition • “Inflammatory response of the urinary epithelium to microbial infection of any anatomical constituent of the upper or lower urinary tract” • Bacteriuria : bacteria in urine

34. Lower UTI • Cystitis: infection& inflammation of the bladder • Frequency, small volumes, dysuria, urgency, offensive urine, SP pain, haematuria, fever & incontinence

35. Route of infection • Ascending • Short urethra • Reflux • Impaired ureteric peristalsis • Pregnancy • Obstruction

36. Risk factors to bacteriuria • Stones • GU Malignancy • Age / Gender • Low estrogen ( menopause) • Pregnancy. • D.M • Previous UTI • Obstruction • Voiding dysfunction • Institutionalized elderly • Indwelling catheters

37. Complicated VS uncomplicated Uncomplicated UTI: • UTI structurally & functionally normal urinary tract. • Female • Respond to short course of antibiotic Complicated UTI: • Anatomical or functional abnormality. • Male • Longer time to respond to treatment

38. Diagnosis of urinary tract infectionsQuick reference tool for primary care for consultation and local adaptationApril 2019

39. Urinalysis

40. Sampling in all men and women Women: mid-stream urine and holding the labia apart may help reduce contamination but if not possible can still be sent for culture, no antiseptic wipes Elderly frail: only take urine sample if symptomatic and able to collect good sample. If incontinent, intermittent catheters and condom catheters for men may be viable options but little evidence to support Men: retract foreskin and mid stream sample People with urinary catheters: Collect a sample from the sampling port using a 70% alcohol wipe and sterile 10ml syringe. Boric acid can cause false negative culture if urine not filled to correct mark on specimen bottle and can affect urine dipstick tests

41. Catheter specimen of urine ( CSU )

42. Reading the parameters • Blood (b): Serious infections of the kidneys or urinary tract, suspected renal or bladder neoplasms • Leucocytes (l): Symptomatic of inflammatory renal and urinary tract diseases • Urobilinogen (u): Acute and chronic liver damage, haemolytic jaundice • Bilirubin (br): Liver parenchyma damage, obstructive jaundice (also indicating biliary obstructions) • Nitrite (n): Bacterial infection of the kidneys or urinary tract

43. Continued • Specific Gravity (sg): Concentration ability of kidneys, supplement for other parameters • Glucose (g): Early detection and supervision of diabetes mellitus • Protein (p): Symptomatic of renal and urinary tract diseases • Ketones (k): Metabolic abnormalities, indication of ketoacidosis • pH (ph): Useful in relation to other parameters, pH of >9.0 tend to get lower protein reaction

44. Biochemical dipstick Normal urine contains chemicals called nitrates. Some bacteria convert nitrates to nitrites • E. Coli • Some proteus Always make sure you wait long enough! Rule of thumb – if the dipstick is positive for nitrites or leucocyte esterase AND the patient is symptomatic – then UTI is very likely. However if symptomatic and the dipstick is negative this does not mean they do not have a UTI!

45. Diagnostic points for women < 65 Using symptoms and dipsticks to help diagnose UTI: no individual or combination are completely reliable in diagnosing UTI, thus severity of symptoms and safety-netting are important in all First exclude other genitourinary causes of urinary symptoms • 75-80% with vaginal discharge will not have UTI • In sexually active check sexual history for STIs for example chlamydia and gonorrhea • Urethritis - urinary symptoms may be due to urethral inflammation post sexual intercourse, irritants, or STI’s • Genitourinary symptoms of menopause/atrophic vaginitis/vaginal atrophy

46. Diagnostic points for men < 65 Consider other genitourinary causes of urinary symptoms • If sexually active, check sexual history for STIs for example chlamydia and gonorrhea • Urethritis due to urethral inflammation post sexual intercourse, irritants, or STIs Check for pyelonephritis, prostatitis, systemic infection, or suspected sepsis using local policy • Urinary symptoms with fever or systemic symptoms in men are strongly suggestive of prostatic involvement or pyelonephritis

47. Recurrent or relapsing UTI in men should prompt referral to urology for investigation • Always send a mid-stream urine sample for culture, collected before antibiotics are given • Dipsticks are poor at ruling out infection. Positive nitrite makes UTI more likely. Negative for both nitrite and leucocyte makes UTI less likely, especially if symptoms are mild • If suspected UTI, offer immediate treatment according to NICE/PHE guideline on lower UTI: antimicrobial prescribing and review choice of antibiotic with pre-treatment culture results

48. Sending urine for culture and interpreting results in ALL adults Send a urine for culture in: • Over 65 year olds if symptomatic and antibiotic given • Suspected pyelonephritis or sepsis • Suspected UTI in men • Failed antibiotic treatment or persistent symptoms • Recurrent UTI (2 episodes in 6m or 3 in 12m) • If prescribing antibiotic in someone with a urinary catheter • As advised by local microbiologist

49. Over 65 and suspected UTI • Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm.

50. UTI LIKELY: • Always send urine culture if feasible before starting antibiotics, as greater resistance in older adults • If mild symptoms consider back-up antibiotics in women without catheters and low risk of complications • Offer immediate antibiotics using NICE/PHE guideline on lower OR catheter associated UTI: antimicrobial prescribing • If indwelling urinary catheter for over 7days consider changing (if possible remove) catheter as soon as possible, but do not delay antibiotics and review Abx after culture