Infection Prevention and Control (IPAC) at RCHT

1. Infection Prevention and Control (IPAC) at RCHT Dr Tristan Clark Infectious Diseases physician and joint DIPC

3. General Principals • Standard precautions (including hand hygiene) • Patient isolation • Environmental decontamination • Surveillance and outbreak investigation • Antibiotic stewardship • Education and training

4. Specific organisms • MRSA • Clostridium difficile • ESBL producing gram negatives • Norovirus • Influenza (and other respiratory viruses) • Others (Chickenpox, Pertussis, PVL producing Staphylococcus aureus)

5. MRSA rates RCHT 2011/12 (per 100,000 bed days) • Acute trust apportioned MRSA bacteraemia rate = 0 • South West = 1.0 • Non-acute trust apportioned MRSA bacteraemia rate = 1.2 • South West = 1.0

6. 923 dayssince last MRSA bacteraemia

7. MRSA Bacteraemia rates 2007 / 8 (acute trust, per 100,000 bed days)

8. Clostridium difficile RCHT Numbers per annum • 2004/5 = 189 • 2005/6 = 195 • 2006/7 = 372 • 2007/8 = 228 • 2008/9 = 127 • 2009/10 = 56 • 2010/11 = 47 • 2011/12 = 41 (rate = 17 per 100,000 bd; SW rate =17; national rate = 21.8) • Numbers 2012-2013 = 24 (as of 15/02/2013) • Target (tolerance) for 2012-2013 = 41 • Target for 2013-2014 = 20 (!)

9. Standard Precautions – for all patient contact • Hand hygiene – before and after touching patients • Soap and water for all patients with diarrhoea (min 30 secs) • Alcohol gel adequate for all others (easier and faster but doesn’t eradicate C.diff) • Gloves indicated for contact with patient fluids but still need hand hygiene

10. Patient Isolation • To prevent spread of infectious agents to other patients and staff • Based on risk assessment of likely pathogen causing symptoms • Prioritisation based on high risk agents (TB, Influenza, Chickenpox, Norovirus, C.difficile) • MRSA and ESBL colonisation where possible (again based on risk assessment)

11. Environmental decontamination • Cleaning – physical removal of all foreign material (usually water and detergents) • Disinfection – elimination of all pathogenic organisms (except spores) from objects - usually chlorine based • Sterilization – complete elimination of all microbial life (e.g. Hydrogen peroxide)

12. Surveillance • Collection of accurate and relevant data on infections in real time • Clusters of infection allow targeted investigations and interventions • Detection and management of outbreaks • Comparison with other institutions • National performance targets (MRSA bacteraemia, C.difficile, MSSA, E.Coli)

13. Antibiotic stewardship • Collection of accurate data of antibiotic use in the hospital • Creation of antibiotic policy and guidelines • List of restricted ‘high risk’ antibiotics • Principal of ‘start smart then focus’ • Monitoring and policing of adherence to the above • Ongoing education and training

14. ‘Start Smart then focus’ • Use local guidelines to chose agent(s) • Cultures prior to starting abx • Antibiotics within 1 hour with severe infections • Indication, duration and review date – documented on drug chart • Review at 48 hours and make clear plan • Options include; Stop, Switch from IV to oral, Change to narrow spectrum, Continue unchanged, OPAT.

15. Consultants role in promoting Infection control • Hand hygiene • Active role in auditing of infections, antibiotic prescribing, prevalence of resistant organisms etc within dept • Influenza vaccination • Early risk assessment of suspected infections with appropriate early use of patient isolation • Early liaison with IPAC and microbiology / infectious diseases