Healthcare Associated Infections25th May 2007
Following a steady stream of reported hospital outbreaks of healthcare associated infections (HAIs or HCAIs) around the UK throughout 2006, the NHS’ ongoing battle against hospital ‘superbugs’ was back in the headlines in January with a leaked Department of Health memo telling ministers that the target to halve MRSA infection rates by 2008 was unlikely to be met. Latest figures show there is still a long way to go.
What are HCAIs?
The term ‘healthcare associated infections’ has been adopted by the NHS to refer to any infection by an agent which has been acquired by a patient as a consequence of their treatment, or by a member of staff in the course of their duties. The major HCAIs under regular surveillance by the government are summarised in the box below.
[Figure 1: Major healthcare associated infections]
MRSA (Methicillin-resistant staphylococcus aureus)MRSA is perceived as the original ‘superbug’ afflicting the NHS, though some argue it should not be referred to as one, as some antibiotics (including vancomycin) still work against it. Staphylococcus aureus is a bacterium which can cause skin and would infections, urinary tract infections, pneumonia and blood stream infections if it enters the body. Most strains of S. aureus are sensitive to antibiotics and are treated effectively, but MRSA is a strain that has developed resistance to the antibiotic methicillin. New strains of S. aureus continue to emerge with greater resistance to antibiotics, including to vancomycin.
Panton Valentine Leukocidin (PVL) is a toxin produced by some strains of S. aureus, including MRSA. PVL-positive MRSA came to public attention late in 2006 with the first reported serious outbreak at the North Staffordshire Trust in Stoke-on-Trent which affected 14 people, two of whom died. However, PVL-positive MRSA is not officially a HCAI as it is most commonly found in the community. Community associated MRSA makes up 12% of all MRSA cases.
Clostridium difficile (C. difficile)C. Difficile is now considered to be endemic in the NHS, and the new big threat due to a major rise in cases and higher mortality rates compared to MRSA. During the high profile outbreaks at Stoke Mandeville hospital in 2004 and 2005, 33 patients died out of 334 infected. C. difficile is a bacterium which is naturally present in the gut where it is kept under control by other bacteria there. When it grows out of control (for example when antibiotics are given) it can cause diarrhoea, fever, nausea and abdominal pain, and can prove life threatening in the very young and old. New research has found that it may persist despite antibiotic treatment, because of its ability to change its genetic structure and so neutralise antibiotics. Some strains, such as Type 027, have been found to produce more toxins than others and cause more severe symptoms and higher mortality rates. Type 027 was the cause of the Stoke Mandeville outbreaks, and other severe outbreaks at the Royal Devon and Exeter Trust and in Quebec, Canada.
EnterococciEnterococci are bacteria found in faeces. They can cause urinary tract, wound, and blood stream infections. Some enterococci have developed resistance to the glycopeptides group of antibiotics such as vancomycin and teicoplanin and are known as glycopeptide-resistant enterococci (GRE).
Orthopaedic surgical site infectionsUsed to describe any infection of the wound site following surgery. Symptoms can include pain, swelling, pus and fever.
The term ‘superbug’ is regularly used when referring to HCAIs, but should technically only be used to refer to those which have multiple resistance to a range of antibiotics, and are therefore much harder to treat and eradicate.
How common are HCAIs and how do we compare to other countries?
The Health Protection Agency has been responsible for the mandatory reporting of HCAIs since 2001. Last month (April 2007) it published its latest figures. The figures suggest that rates of MRSA are levelling off with the number of cases in the quarter October to December 2006 down by 7% compared to the previous quarter (1542 cases compared to 1652). There were just over 7000 cases of MRSA reported in the year 2005/06 - an 11% reduction compared to two years previously in 2003/04. There had been sizeable increases in MRSA rates up to 2003/04. When the annual figures for 2006/07 are complete it will be possible to tell if the trend is downwards overall. In general, 69% of cases of MRSA occur in the over 65s. London has the highest incidence of MRSA, despite significant decreases in recent years.
In 2004 (when mandatory surveillance began) 44,107 cases of C. difficile were reported in England. This shot up to 51,690 cases in 2005 - a 17% increase. The latest HPA figures show that there were a total of 55,681 cases of C. difficile in 2006 - a 7% increase on 2005. Although the rate of growth has therefore slowed, rates are still ‘very high’ according to the HPA. The problem is marked in small acute Trusts. There are continued concerns about under reporting which may have been addressed over recent years and explain some of the increase, but it is still thought to be a significant problem.
It is difficult to attribute deaths directly to an HCAI, but reports suggest that in 2004 there were 360 deaths from MRSA and 1300 from C. Difficile. MRSA and C Difficile were mentioned in the death certificates of 1000 and 2000 patients respectively in 2004.
The UK does not compare well with other countries’ infection rates:
- In the developed world, between 6% and 10% of hospital patients acquire HCAIs. England is at the upper end of that range at 9%.
- In the UK, the proportion of S. aureus blood stream infections which are MRSA is 44%. In Denmark and the Netherlands it is just 1%.
The Dutch operate a strict ‘search and destroy’ policy with MRSA which the UK plans to learn from. This includes screening and detection before hospital admission, routine isolation of infected patients, higher staffing ratios per patient, and thorough cleaning regimes.
What is being done by hospitals to tackle HCAIs in the UK?
Staff, trusts, unions and governing bodies have argued, sometimes controversially, that a number of factors have caused the rise in HCAIs in recent years. These include:
- High bed occupancy levels.
- Patients being moved from ward to ward more often during their stay because of bed shortages and the need to ‘juggle’ patients around.
- Busier staff having less time to wash their hands between patients and take other routine precautions.
- Hospital cleaning services being contracted out of the NHS to private contractors.
The main lines of attack against HCAIs are:
- Limited screening of patients before admission to hospital – widely used in other countries where infection rates are low.
- Antibiotic prescribing regimes. The BBC reported in January 2007 how Queen Elizabeth Hospital in Kings Lynn has been able to reduce its incidence of MRSA by varying antibiotic prescribing.
- Hand hygiene. The National Patient Safety Agency is running the cleanyourhands campaign (http://www.npsa.nhs.uk/cleanyourhands).
- Catheter care, and care of wound sites and other sites where tubes are inserted.
- Cleanliness of the environment.
- Availability of isolation facilities for infected patients (eg single rooms).
- Separating elective and emergency patients.
- Making sure patients do not move between wards too many times during their admission.
Experts have commented that much has been done to introduce simpler and cheaper measures such as hand hygiene, but that this is not sufficient without more expensive measures being implemented as well. When speaking on the BBC recently, Dr Mark Enright of Imperial College suggested that C. difficile has continued to spread unchecked whilst the attention has been on MRSA, because infection control measures have only partially been introduced. Alcohol hand rubs, now widely adopted to stop the spread of MRSA, do not work on C. difficile. Proper hand washing with soap and water is required, along with other measures such as isolation in single rooms which are still not available to many infected patients.
What is the government doing about HCAIs?
Since 2000, the government has produced much guidance for NHS bodies on how to prevent, control and report HCAIs, including:
[Figure 2: Government action on HCAIs since 2000]
|2000||Patient environment action teams (PEAT) have been surveying cleanliness in hospitals since 2000 and report consistent improvements year on year.|
|2001||National cleaning standards for the NHS were issued for the first time ever.|
|Hospitals have been required to report incidence of blood stream infections of MRSA since 2001, and now have to do the same for C. Difficile, GRE, and orthopaedic surgical site infections. From this month, these figures will be available on a quarterly basis.|
|2003||The Chief Medical Officer publishes Winning Ways setting out seven action areas for infection control.|
|2004||The Matrons’ Charter sets out principles for delivering cleaner hospitals.|
|2005||The Healthcare Commission’s Annual Health Check for acute trusts includes a core standard to ensure risk of HCAIs is reduced, emphasis is placed on high standards of hygiene and cleanliness, and there must be year on year reductions in incidence of MRSA.|
|2006||In May High Impact Intervention for the Reduction of C Difficile is published as part of the Saving Lives delivery programme.|
|In October the Department of Health issues the Code of Practice for the Prevention and Control of HCAIs, requiring compliance with national guidelines and good practice on infection control and prevention, including the need for a specific policy on C. Difficile. The Healthcare Commission has powers to issue statutory improvement notices if the Code is not being applied.|
|In December £50m is announced to help trusts tackle HCAIs. The money could be used for refurbishment programmes, providing more single rooms, cleaning equipment, and better decontamination of surgical instruments.|
|2007||The 2007/08 operating framework considers whether the model contract should include financial penalties for trusts not meeting targets. PCTs and Trusts will have to agree ‘stretching’ local targets for the reduction of C. difficile.|
|2008||By April 2008 incidence of MRSA in the blood must be halved compared to 2004 levels.|
The memo from Liz Woodeson, Director of Health Protection, leaked to the Health Service Journal in January, warned ministers that though MRSA levels were coming down,
- There would only be a reduction of a third by the April 2008 deadline. Latest figures from the HPA suggest this is still the case. The target of halving incidence may not be achieved even if more time were available as ‘certain’ levels of MRSA were ‘unavoidable’, though it is not clear what that level is.
- The problem was across the board (116 trusts struggling to hit the target), not just with a small number of trusts.
With the growing threat from C. difficile, the government is now considering further integrated targets on HCAIs, rather than focusing on MRSA alone. Andy Burnham, the health minister, recently said that tackling outbreaks, such as the one at Stoke Mandeville, must be given the highest priority by trusts – above all other targets.
- The Department of Health has charged the Health Protection Agency with developing national guidelines for tackling C. difficile following publication of the most recent set of results.
- The Department of Health is introducing a new wed-based system for monitoring C Difficile associated diarrhoea. It will map hot spots at local level which is not possible using national surveillance data.
- The Homerton University Hospital NHS Foundation Trust has slashed its C Difficile from 3 in 1000 to 0.75 in 1000 by changing its antibiotic prescribing policy (http://www.networks.nhs.uk/news.php).
- Imperial College London has identified an antimicrobial agent that kills bacterial cells by preventing their reproduction. AQ+ has been validated for use against infections including C Difficile and some strains of MRSA (http://www.hdmagazine.co.uk/story.asp...)
For more information on HCAIs go to:
www.hsj.co.uk News, 11 Jan 2007
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