HCAI includes any infection that results from a person’s treatment by the NHS or which is acquired by a health care worker in the course of their NHS duties, as defined in the Health Act, 2006. In general terms these are infections that are acquired in healthcare settings such as hospitals or as a result of healthcare interventions. There are a number of factors that can increase the risk of acquiring an infection, but high standards of infection control practice minimise the risk of occurrence.
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Antibiotic resistant organisms including MRSA and Clostridium difficile are commonly associated with HCAI.
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MRSA stands for Methicillin resistant Staphylococcus aureus. Staphylococcus aureus (Staph. aureus) is a common bacteria that is carried in lots of people’s noses and skin.
MRSA is a type of Staph. aureus that has become resistant to many types of antibiotics such as methicillin.
Around 25% of the UK population harmlessly and unknowingly carry Staph. aureus on their skin. This is called colonisation, and is very different from being infected with MRSA.
It is very important that you understand the difference between colonisation and infection:
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Colonisation means that the MRSA is carried in the nose, on the skin and possibly in wounds but is not causing harm or producing symptoms. Staph. aureus and MRSA are not normally a risk to healthy people.
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Infection with MRSA can occur when the MRSA gets into the body through a break in the skin.
There is no evidence that MRSA is more likely to cause an infection than common bacteria, Staphylococcus aureus.
The main difference is that when a patient is infected with MRSA different antibiotics, such as vancomycin or teicoplanin, have to be used, which may not be as effective and have more side effects.
If a patient is found to have an infection following surgery, this is usually caused by the patient’s own bacteria (that is, bacteria they were already carrying at the time of the operation) rather than those present in the hospital environment or on the hands of healthcare workers.
Keeping the amount of time a patient stays in hospital before their operation to a minimum reduces the risk of them acquiring and carrying antibiotic resistant organisms, such as MRSA, with them to the operating theatre.
We have found that organisms with resistance to one or more antibiotics are particularly associated with people treated as in-patients in hospitals.
Antibiotic resistant organisms are usually the result of the use of antibiotics, which are needed to treat/prevent other infections. Sometimes the resistant organisms are transferred from patient to patient, probably via hands, gloves or equipment; and occasionally directly from the environment.
Measures designed to reduce this spread are therefore at the heart of infection control.
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Clostridium difficile is a bacteria that produces toxins (poisons). It is usually found in the gut where it is present in small numbers in 3% of healthy adults and 66% of infants. However, Clostridium difficile rarely causes problems in children or healthy adults, as it is kept in check by the normal (good) bacterial population of the gut. When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness such as diarrhoea.
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The majority of MRSA appears to occur in patients with what we call risk factors. These include patients who:
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live in nursing or residential homes
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have been admitted to any hospital in the recent past
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have been in the hospital for a long time
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have household contacts who are known to be MRSA positive
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have been receiving antibiotics
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work in health care settings
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have broken skin, for example leg ulcers or skin conditions such as eczema
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have long-term urinary catheters or feeding ports
For Clostridium difficile infections, people who have been treated with broad spectrum antibiotics (those that affect a wide range of bacteria), people with serious underlying illnesses and the elderly are at greatest risk. Evidence shows that over 80% of Clostridium difficile infections reported are in people aged over 65 years.
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West Middlesex University Hospital has an active Infection Control Team and an Infection Control Committee that work together to advise the Trust Board, managers and healthcare workers how best to minimise the infection risk to patients, staff and visitors.
We have strict policies for controlling the spread of all antibiotic resistant organisms including MRSA and Clostridium difficile. These include:
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Routinely screening patients in ‘high risk’ areas for MRSA.
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Eradication of MRSA with antibacterial soap and shampoo.
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Isolating affected patients in a side room (where possible). When patients cannot be isolated they are nursed together as ‘cohorts’.
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Use of hygienic hand rub for staff and visitors
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Enhanced environmental cleaning in affected areas.
All staff joining the hospital attend a session on infection control during their induction as well as attending mandatory infection control training annually, where local infection rates and audit results are fed back with refresher information and questions on infection control practices.
We carry out quarterly audits to check that staff are complying with the Trust Hand Hygiene and Dress Code Policy.
Local rates of antibiotic resistant organisms and Clostridium difficile are passed back to wards and hospital management on a regular basis, ensuring all departments are up to date with the progress.
The Infection Control Team and ward-based staff can track patients who have previously had MRSA and other antibiotic resistant organisms when they are re-admitted to the hospital using an electronic alert flag on the patient administration system.
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The absolute rate of MRSA inpatients at West Middlesex is not known as the cost of screening and re-screening all patients would be prohibitively expensive. However local surveillance suggests the rate of MRSA was relatively constant between mid-year of 2002 to the beginning of 2004 and there have been two significant decreases since then.
Local surveillance shows that approximately 250 patients from approximately 35,000 hospital admissions are colonised (these are patients who harmlessly and unknowingly carry the bacteria on their skin but are not infected) with MRSA each year. This corresponds to about 0.7% of all patients and only one third of these (0.2% of all in-patients) will actually result in an MRSA infection.
The above rates may be underestimated as not all patients are screened for MRSA, a proportion of admissions will actually be the same patients being readmitted (meaning that less than 35,000 different people are admitted) and infections may only be detected when the patient is in the community, but the data is nevertheless useful in monitoring trends.
To reduce the risk to themselves and other patients, all those being admitted to ‘high-risk’ specialities such as orthopaedic (hip and knee) replacement and vascular surgery are being pre-screened before surgery (during pre-assessment).
These patients are then given a special skin wash and ointment to the nose to help eradicate these bacteria.
Many of the MRSA bloodstream infections arise as a direct consequence of new types of medical procedures introduced in recent years. It is likely that without these interventions many of these patients would have deteriorated and died. A large number of patients who are more at risk of having this type of infection are those:
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requiring intravenous lines
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in the Intensive Care Unit
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have diabetic foot ulcers
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elderly patients with chronic leg ulcers.
However, West Middlesex is currently working to reduce infectious complications of such procedures to a minimum, including: the introduction of an intravenous line care team to oversee and help prevent the spread of bacteria, and the feedback of infection rates to wards and doctors.
Local surveillance suggests the rate of Clostridium difficile rose steadily up to early 2004, after which the level remained relatively constant and indeed has decreased since the middle of 2006.
This is due to the concerted effort of all clinical staff working with the infection control team, including the contractors for cleaning. In compliance with the guidelines “Operational Management of Clostridium difficile Associated Disease”, published by the Department of Health, the Trust has reviewed the antibiotic prescribing policy with regular audits in place. The Trust has also introduced testing samples for Clostridium difficile seven days a week in order to make an early diagnosis.
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