QUICK REFERENCE GUIDE



36379157620000-1104907366000.17526022225Working together to drive excellence in care for our patients and communitiesour patients and communities00Working together to drive excellence in care for our patients and communitiesour patients and communitiesMULTI-DRUG RESISTANT GRAM NEGATIVE ORGANISMS (MDRGNO) POLICY INCLUDING ESBL AND AMP C PRODUCING BACTERIAVersion1.1Name of responsible (ratifying) committeeInfection Prevention Management CommitteeDate ratified05 April 2019Document Manager (job title)Infection control doctorDate issued12 June 2019Review date11 December 2021Electronic locationInfection Prevention and Control PoliciesRelated Procedural DocumentsTrust policies: Hand Hygiene policyIsolation PolicyStandard Precautions policyDecontamination policyCPE and S aureus policiesKey Words (to aid with searching)Gram negative, ESBL, ampC, antibiotic resistantVersion TrackingVersionDate RatifiedBrief Summary of ChangesAuthor1.101/02/21Due to the second wave of the Coronavirus pandemic and continuing exceptional circumstances, the Trust Board have agreed that all policies which are currently within review date will have their review date further extended by six months-105/04/2019New documentSWCONTENTS TOC \o "1-2" \h \z \t "Appendix,1,Heading,2" QUICK REFERENCE GUIDE PAGEREF _Toc411502469 \h 31.INTRODUCTION PAGEREF _Toc411502470 \h 42.PURPOSE PAGEREF _Toc411502471 \h 43.SCOPE PAGEREF _Toc411502472 \h 44.DEFINITIONS PAGEREF _Toc411502473 \h 45.DUTIES AND RESPONSIBILITIES PAGEREF _Toc411502474 \h 46.PROCESS PAGEREF _Toc411502475 \h 47.TRAINING REQUIREMENTS PAGEREF _Toc411502476 \h 48.REFERENCES AND ASSOCIATED DOCUMENTATION PAGEREF _Toc411502477 \h 59.EQUALITY IMPACT STATEMENT PAGEREF _Toc411502478 \h 510.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS PAGEREF _Toc411502479 \h 6QUICK REFERENCE GUIDEThis policy must be followed in full when developing or reviewing and amending Trust procedural documents.For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily explain the key issues within the body of the document Multi-drug resistant Gram negative organisms (MDRGNO) are bacteria that are resistant to at least three different antibiotics, are commonly found in the gut where they do no harm, however they can cause infection especially urinary tract infection in both community and hospitalized patients. They can also cause septicaemia or bloodstream infection which has an associated mortality. Appropriate infection prevention and control precautions including hand hygiene, use of personal protective equipment (PPE), equipment and environmental cleaning and patient isolation alongside good antimicrobial stewardship are required to control and prevent the spread of MDRGNO. This policy aims to give clear guidance about patients infected or colonized with multi-drug resistant Gram negative organisms (MDRGNO) to ensure appropriate management of the patient and prevent spread within the hospital. There is a separate CPE and S aureus policy which should also be referred to. The prioritisation of side rooms for patients depends on the infecting organism, the nature of transmission of the infecting organism, the burden of colonization or transmissibility of infection and the vulnerability or susceptibility of nearby patients. It is the duty of the Infection prevention and control team to advise on prioritization of side room facilities or cohorting of patients. It is the duty of the microbiology team to review laboratory policies and SOPs on screening, detection and reporting of MDRGNO, alert the Infection Prevention and Control Team and clinical teams of patients with presumptive or confirmed MDRGNO isolated from clinical samples or screens and advise on the antimicrobial management of patients infected with MDRGNOINTRODUCTIONMulti-drug resistant Gram negative organisms (MDRGNO) are bacteria that are resistant to at least three different antibiotics. These bacteria are commonly found in the gut where they do no harm and are part of the normal colonizing faecal flora, however they can cause infection in both community and hospitalized patients. The most common infection caused is urosepsis which may be a simple urinary tract infection (UTI) when the bacteria are found in the urine or ascending urosepsis with pyelonephritis and bacteraemia when the bacteria are found in the bloodstream. Other infections such as pneumonia and surgical wound infections may be caused by MDRGNO which have resulted from the patient’s own flora or from acquisition from the hospital environment. Infections caused by MDRGNO are more difficult to treat and generally require intravenous antibiotics. These infections can prolong a patient’s hospital stay and can cause much morbidity and even mortality.The most common MDRGNO currently identified are bacteria which can produce extended spectrum beta lactamase (ESBL) enzymes. These enzymes confer resistance to third generation or “extended spectrum” cephalosporins e.g. ceftazidime and cefotaxime. They also confer resistance to penicillins and are often linked with resistance mechanisms to other classes of antimicrobials thus limiting the range of available treatment options. ESBL enzymes can be encoded on plasmids (independent pieces of DNA within bacterial cytoplasm) or on the chromosomal DNA of the bacteria, the latter are called ampC ESBLs. Some of the most resistant MDRGNO are the Carbapenemase-producing Enterobacteriaceae (CPE). These bacteria may be resistant to almost all antibiotics.Other MRGNO which can cause healthcare associated infection are called “non-fermenters” and include Acinetobacter species particularly Acinetobacter baumanii, Pseudomonas species including Pseudomonas aeruginosa and other environmental bacteria such as Stenotrophomonas maltophilia. These bacteria can be transmitted from contaminated water or environment and cause invasive infection in patients. Appropriate infection prevention and control precautions including hand hygiene, use of personal protective equipment (PPE), equipment and environmental cleaning and patient isolation alongside good antimicrobial stewardship are required to control and prevent the spread of MDRGNO. PURPOSETo set out clear guidance about patients infected or colonized with multi-drug resistant Gram negative organisms (MDRGNO) to ensure appropriate management of the patient and prevent spread within the hospital. There is a separate CPE and S aureus policy which should also be referred to. SCOPETo whom the document applies.‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’DEFINITIONSAmp C and ESBLExtended spectrum beta-lactamases (ESBLs) are enzymes which are produced by some Gram negative bacteria, mostly the Enterobacteriaceae, typically Escherichia coli and Klebsiella pneumoniae. These ESBL enzymes are encoded on plasmids which are mobile pieces of DNA which can be readily transferred between bacteria hence are of Infection control concern. Some ESBL enzymes are encoded on the chromosome of the bacteria in which case they are called Amp C ESBLs. Amp C ESBLs are commonly found in Citrobacter freundii, Enterobacter cloacae, Enterobacter aerogenes, Morganella morganii, Serratia marcesens, Providentia sp., Hafnia alvei, Aeromonas sp. and Pseudomonas aeruginosa. The resistance genes in ampC organisms are not readily transmissible to other bacteria.Beta-lactam antibioticsAntibiotics which include a beta-lactam ring in their molecular structure include penicillins, cephalosporins, monobactams and carbapenems. Bacteria usually become resistant to these antibiotics by producing enzymes which break down the beta-lactam ring. These enzymes are called beta-lactamsesColonisationColonisation refers to the presence of bacteria on the surface of the host either on the skin, in the respiratory tract or the gastrointestinal tract. These bacteria are causing no harm to the patient but they may be transmitted to other vulnerable patients and may cause invasive infectionGram negative bacteriaA class of bacteria that do not retain the crystal violet stain used in the Gram staining method of bacterial identification. Gram-negative bacteria cause infections including UTI, hospital acquired pneumonia, intra-abdominal infections, blood stream infections, abdominal wound or surgical site infections, neonatal sepsis and meningitis in healthcare settings. Some Gram-negative bacteria are resistant to multiple antibiotic drugs and hence are difficult to treatHealth-care associated infection (HCAI)Healthcare associated infection is any infection acquired as the result of a course of treatment, intervention or care within the healthcare setting ImmunosuppressionSuppression of the immune system as a result of disease or drugsInfectionInfection is the inflammatory response to invasion of harmful bacteria manifesting as sepsisPersonal protective equipment (PPE)Specialised clothing or equipment worn by employees for protection against health and safety hazards and includes: gloves, aprons, gowns, masks and eye protectionSource isolationIsolation or the patient usually in a side room to prevent transmission of colonising or infecting organisms to other patientsStandard precautionsPrecautions that are used such as Personal Protective Equipment (PPE) and hand washing to prevent the spread of infectionPrioritisation of isolation facilitiesThe prioritisation of side rooms depends on the infecting organism, the nature of transmission of the infecting organism, the burden of colonization or transmissibility of infection and the vulnerability or susceptibility of the patient(s). It is the duty of the Infection prevention and control team to advise on prioritization of side room facilities or cohorting of patients. High priority for isolation facilities include patients colonized or infected with Carbapenemase-producing Enterobacteriaceae, Mycobacterium tuberculosis, MDRGNOInfluenza (new diagnosis and not had 5 days of treatment), active Herpes zoster infection, toxigenic Clostridium difficileviral gastroenteritissuspected meningococcal infection for first 48 hours of antibiotic treatmentInvasive group A streptococcus (iGAS) for first 48 hours of antibiotic treatmentCases of suspected multi-drug resistant TB and any confirmed cases of viral haemorrhagic fever or Middle-East respiratory syndrome coronavirus (MERS) should be referred to specialist isolation facilities either at Southampton or the Royal Free or Guy’s and St Thomas’. Please refer to the Trust Isolation policy for further details.Patients colonized or infected with ampC producing organisms may be managed in the open ward after discussion with the IPCTDUTIES AND RESPONSIBILITIESInfection Prevention and Control Team (IPCT):?Ensure effective communication of patients risk and carriage status providing patients and staff with appropriate information leaflets (see appendices)?Give specialist advice with regards to the isolation, screening and contact tracing of patients with suspected or confirmed infection or colonisation with MDRGNO?As part of an outbreak control team, advise on the screening and isolation in the event of an outbreak?Review and update the MDRGNO policy?Include antibiotic resistance in all induction and update training for clinical staff ?Conduct regular audits and provide feedback with regards to the adherence to Infection prevention and control policies Microbiologists:?Review laboratory policies and SOPs on screening, detection and reporting of MDRGNO?Alert the Infection Prevention and Control Team and clinical teams of patients with presumptive or confirmed MDRGNO isolated from clinical samples or screens?Advise on the antimicrobial management of patients infected with MDRGNOPatient Flow / Duty Hospital Managers:?Liaise with Infection Prevention and Control with regards prioritization of isolation facilities Matrons / Ward Managers: ?Ensure effective communication of patients risk and carriage status Medical Staff:?Follow advice of the Infection Prevention and Control Team and microbiologists relating to patients infected or colonised with MDRGNO?Ensure compliance with infection prevention and antimicrobial prescribing policies with emphasis on limiting use of broad spectrum antibiotics?Ensure prudent antimicrobial prescribingAll Healthcare Staff:?Must be familiar with and adhere to the relevant infection prevention policies to reduce the risk transmission of MDRGNO which include the hand hygiene policy, standard precautions policy, isolation policy and management of invasive devices policyPROCESS6.1 General PrinciplesStandard precautions, including strict hand hygiene and appropriate use of personal protective equipment should be applied to all patients without exception, regardless of known colonisation or infection with MDRGNO (refer to standard precautions and hand hygiene policy).6.2 Infection control measuresIn the acute hospital setting and other care areas where high risk inpatient groups are found, patients should ideally be isolated in a single room. If this is not possible then advice must be sought from the Infection Prevention and Control team. Spatial isolation within a bay may be advised however it is important to avoid nursing other patients in high risk groups in the same area. This also includes patients who have indwelling urinary catheters as this increases the risk of urinary tract infection. The use of gloves and disposable aprons is recommended for direct contact and when dealing with urine and faeces6.3 Maintaining standards of careInfection Control measures should not compromise the patient’s care and should not affect the patient’s freedom to be mobilised or attend other departments for healthcare-related visits. Good hand hygiene and environmental decontamination is essential to prevent transmission6.4 Transferring of patientsIt is important to make the receiving clinical area aware that the patient has an ESBL or AmpC producing organism, with emphasis on the importance of good hand hygiene, catheter or urinary tract management6.5 Screening of patientsSamples should not be sent for clearance of a MRGNO unless advised from infection prevention and control in conjunction with microbiology. Stool samples are not required and should only be sent if the patient is experiencing diarrhoea and an infection is being considered. Samples should only be sent if there is a clinical need6.6 VisitorsThe patient may continue to receive visitors. Any visitor should ensure that they wash their hands on leaving the isolation room and be instructed to use the alcohol hand sanitiser outside the room.Visitors are not routinely expected wear gloves and aprons unless they are providing personal care, however if due to resistance patterns should by the organism visitors are expected to wear personal protective equipment; this will be communicated at the time by the infection prevention and control team6.7 Deceased patientsStandard precautions must be in place during the care of a deceased patient. There are no specific risks from the body to relatives, mortuary staff or undertakers.Plastic body (cadaver) bags are not necessary. Any lesions that leak should be covered with impermeable dressings.TRAINING REQUIREMENTS?Specific training with regards antibiotic resistant organisms including MDRGNO will be provided by the Infection Prevention team during Trust induction, mandatory training sessions as well as via Infection Prevention Link Practitioners ?Clinical and non-clinical staff will receive practical hand hygiene training on induction and every 2 years thereafter (Infection Prevention Team)?Clinical and non-clinical staff will receive face-to-face induction training on aspects of infection prevention, MSSA/MRSA, Clostridium difficile, MDRGNO and Carbapenemase-producing Enterobacteriaceae (Infection Prevention Team)?Update training to be delivered as part of Patient Safety & Quality Days, departmental and drop in days, Link Advisor days and Senior Doctors Training (Infection Prevention Team)REFERENCES AND ASSOCIATED DOCUMENTATIONPrevention and control of multi-drug-resistant Gram-negative bacteria: recommendations from a Joint Working Party. A.P.R. Wilson, *, D.M. Livermore, J.A. Otter, R.E. Warren, P. Jenks, D.A. Enoch, W. Newsholme, B. Oppenheim, A. Leanord, C. McNulty, G. Tanner, S. Bennett, M. Cann, J. Bostock, E. Collins, S. Peckitt, L. Ritchie, C. Fry, P. Hawkey. Journal of Hospital Infection 92 (2016) S1eS44EQUALITY IMPACT STATEMENTPortsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.This policy has been assessed accordinglyOur values?are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:Respect and dignityQuality of careWorking togetherNo wasteThis policy should be read and implemented with the Trust Values in mind at all times.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTSMinimum requirement to be monitoredLeadToolFrequency of Report of ComplianceReporting arrangementsLead(s) for acting on RecommendationsSurveillance of cases of MDRGNO infection or colonisationIPCTApex, VitalPACQuarterly at IPMCPolicy audit report to:IPMCInfection prevention and control teamReview of new acquisitions of CPE infection or colonisationIPCTApexVitalPACQuarterly at IPMCPolicy audit report to:IPMCInfection prevention and control teamPolicy audit report to:This document will be monitored to ensure it is effective and to assurance compliance. EQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.Stage 1 - Screening Title of Procedural Document: Date of Assessment10/06/2019Responsible DepartmentInfection PreventionName of person completing assessmentKathryn NobleJob TitleInfection Prevention Manager/AnalystDoes the policy/function affect one group less or more favourably than another on the basis of :Yes/NoCommentsAgeNoDisabilityLearning disability; physical disability; sensory impairment and/or mental health problems e.g. dementiaNoEthnic Origin (including gypsies and travellers)NoGender reassignmentNoPregnancy or MaternityNoRaceNoSexNoReligion and BeliefNoSexual OrientationNoIf the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2More Information can be found be following the link below.uk/ukpga/2010/15/contentsStage 2 – Full Impact AssessmentWhat is the impactLevel of ImpactMitigating Actions(what needs to be done to minimise / remove the impact)Responsible Officer Monitoring of ActionsThe monitoring of actions to mitigate any impact will be undertaken at the appropriate levelSpecialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document:Clinical Service Centre Governance CommitteeCorporate Procedural Document:Relevant Corporate CommitteeAll actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee ................
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