Carbapenemase-Producing Enterobacteriacea Infection Prevention and Control Team NHS GGC 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 What are CPE? Enterobacteriaceae are a family of Gram-negative bacteria which are part of the normal range of bacteria found in the gut of all humans and animals. They commonly cause opportunistic urinary tract, intra-abdominal and bloodstream infections. They include species such as E. coli, Klebsiella sp., Proteus sp. and Enterobacter sp.. 16/06/2017 eKSF dimensions Core 3 and HWB3

Antibiotic resistance Carbapenems are a valuable family of very broad-spectrum antibiotics which are normally reserved for serious infections caused by drug-resistant Gram-negative bacteria. They include meropenem, ertapenem, imipenem and doripenem. CPE bacteria carry a gene for a carbapenemase enzyme that breaks down carbapenem antibiotics. 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 CPE infection Infections caused by CPE are associated with high rates of morbidity and mortality and can have severe clinical consequences. Treatment of these infections is increasingly difficult as these organisms are often resistant to many and sometimes all available antibiotics. Over the last decade CPE have spread throughout the world and are now endemic in healthcare facilities in many countries 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Occurrence of carbapenemase-producing Enterobacteriaceae in 38 European countries based on self-assessment by the national experts, 2013. CPE outbreaks, the majority of which involve Klebsiella pneumoniae, have been reported in most parts of the world, and CPE appear to be endemic in a small number of countries, including, Greece, Italy, parts of Asia (particularly the Indian subcontinent) and some Central and South American countries.  In Greece, rates are very high, with invasive CPE increasing from 27.8% in 2005 to 68.2% in 2011. Also increase in Italy, from 1% in 2009 to 27% in 2011. 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 CPE in the UK In the UK, over the last five years, there has been a rapid increase in the incidence of infection and colonisation by multi-drug resistant carbapenemase-producing organisms. Emerging data suggests < 1% carriage rate A number of clusters and outbreaks have been reported in England Increase in number of patients who are positive for CPE, particularly in London and Manchester. Latest HPS report – 73 cases identified in Scotland. Emerging data from the UK suggest a low carriage rate of <1% in the general healthcare population however that may change as surveillance is enhanced.  16/06/2017 eKSF dimensions Core 3 and HWB3

CPE action plan Early detection, prevention and control of CPE Identification and management of suspected and confirmed cases, and contacts. This includes: - Early adoption of TBPs as well as SICPs - Environmental cleaning and decontamination - Microbiological testing - Effective communications Our plan is to adopt measures to quickly detect CPE and put measures in place to stop it spreading. 16/06/2017 eKSF dimensions Core 3 and HWB3

Management of patients Use of a clinical risk assessment (CRA) tool Management of suspected cases identified by the CRA Management of confirmed cases Management of contacts of cases The following slides cover the management of patients from screening on admission through to management of contacts 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 CPE-CRA The CRA (Clinical Risk Assessment ) defines a suspected case based on at least one the following risk factors within the 12 month period preceding admission: Previously CPE positive Been an inpatient in a hospital outside of Scotland in last 12 months Received holiday dialysis outside of Scotland in last 12 months Been a close contact of a person who has been colonised or infected with CPE 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 A close contact A close contact is defined as: - a person living in the same house - sharing the same sleeping space (room or hospital bay >8hrs) - a sexual partner 16/06/2017 eKSF dimensions Core 3 and HWB3

Management of suspected case Patient should be immediately isolated in a single room with en-suite facilities (or designated commode if en-suite is unavailable) SICPs and contact TBPs should be applied as per the National Infection Prevention and Control Manual Screening samples(s) should be taken and sent for testing Ensure that the laboratory, IPCT and relevant clinicians have been informed Advise the patient (and relatives if appropriate) of reasons for isolation and the requirement for samples (including providing patient with an information leaflet) Advise the patient (and relatives if appropriate) about the importance of hand hygiene and personal hygiene in preventing transmission. consider cohorting patients with dedicated nursing team if insufficient rooms available for isolation. A local risk assessment should be undertaken before deciding to cohort patients. 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Screening samples If a screening sample is required the following should be taken as a minimum: A rectal swab, making sure faecal material is visible on the swab OR A stool sample (if a rectal swab is not feasible/acceptable/child) AND A wound swab (if wound present at time of admission) Urine sample (if the patient is catheterised at time of admission) Stoma , ileostomy, suprapubic catheter 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Rectal swab A rectal swab is the best sample type and should always be considered preferential to a stool sample: - A rectal swab is taken by gently inserting a swab inside the rectum 3-4cms beyond the anal sphincter, rotating gently and removing. The swab should have visible faecal material. A rectal swab should not be mistaken for a perineal swab. Request CPE/CRO on Trak OR clearly mark ‘CPE screening sample’ on lab request form for microbiology. 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Ordering on Trak Select your patient as usual. Tick the “Specimen collected” box Aliases available – carba, cre, cpe, cpo or any string in the test name above. Upper or lower case may be used. e.g. – Enter cpe (upper or lower case) in the “Item” and use the magnifying glass or the F6 key to bring up possible options 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Pick list for appropriate samples. Guidance is provided in the processing notes box to the right hand side of the screen. Ensure you tick the box if you are collecting the samples straight away. If sampling a wound swab or skin swab, please choose a site from the site dictionary. Answer the questions as usual and enter password to file the order:- 16/06/2017 eKSF dimensions Core 3 and HWB3

Management of Suspected case (cont) If the screening sample result is NEGATIVE, the patient should remain in isolation until a further two consecutive samples test negative. These samples should be taken 48 hours apart, i.e. take a sample on day 0 (the initial sample), day 2 and day 4. Once three consecutive negative are achieved, the patient can be removed from isolation, no further samples required. Should any subsequent samples test positive, the patient should be managed as a confirmed case 16/06/2017 eKSF dimensions Core 3 and HWB3

Management of Confirmed case If not already, the patient should be immediately isolated and remain in isolation for the duration of their hospital stay. Samples should be obtained using the same protocol as described SICPs and contact TBPs should be applied A CPE case should be considered as a priority for use of a single room facility and a local risk assessment to determine priorities should be undertaken with the IPCT. If the patient has an infection, they should be assessed for appropriate treatment Provide IPC advise to patient and family/carer Documentation: Update written notes / hand held records to include details of the positive CPE result. CPE inhabits the gastrointestinal tract and decolonisation therapy merely suppresses / reduces the amount of CPE; elimination of the carrier state currently seems seems unlikely to be successful 16/06/2017 eKSF dimensions Core 3 and HWB3

Management of Confirmed case (cont) The patients will be tagged on Trak with CPE Information about the positive result should be included on all transfer/admission documents if the patient is moved to another healthcare setting or referred for community care All relevant staff should be made aware when a patient is being treated as a suspected and /or confirmed CPE case Staff can use the transfer form on our web site if they do not have one already. If they have their own remind them to put CPE +ve on it. 16/06/2017 eKSF dimensions Core 3 and HWB3

Treatment of confirmed case No antibiotic treatment is required for colonisation Decolonisation is NOT advised for the following reasons: - Skin decolonisation- is not advised as these bacteria generally colonise the gut rather than the skin - Gut decolonisation (by prescribing antibiotics) – concern that their use would increase resistance in the longer term. Treatment should be guided by susceptibility results and under the advice of the microbiologist. 16/06/2017 eKSF dimensions Core 3 and HWB3

Screening of contacts in a ward Screening of patients in the same setting is NOT normally required if the case was identified on admission and isolated immediately. Contacts (in-patients) should be screened. A contact is a patient who has spent >8 hours in the same bed bay as a positive case. It is not necessary to isolate contacts whilst awaiting screening results – cohort such contacts if possible (until screening completed and is negative) and reiterate SICPs including hand hygiene for staff and patients Screen all patient contacts (who are still in hospital) once per week for 4 weeks . Screening of household contacts and healthcare staff is NOT required A contact is an in-patient who has spent >8 hours in the same bed bay as a patient who is confirmed CPE +ve. It is not necessary to arrange screening of contacts who have been discharged. 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Patient transfer Scottish Ambulance Service (SAS) will transport a patient with CPE in a separate ambulance When arranging transfer, please tell SAS that the patient is CPE +ve 16/06/2017 eKSF dimensions Core 3 and HWB3

Subsequent admissions of a case Previously positive patients may require to be screened on admission to hospital again. Isolate the patient and contact the local IPCT for advice. Treat previously positive patient as always positive - extenuating circumstances If positive patient requires a non-emergency diagnostic test or procedure out-with patient’s own room, procedure should be planned, wherever possible, at the end of the day’s list and the room cleaned. An apparently cleared carbapenemase-producer can regrow to a detectable level in the gut flora of patients. A previously positive individual with subsequent negative screening results can revert to a positive state. If +ve patient readmitted, contact local IPCT for advice on rescreening . A previously positive patient should always be treated as positive and managed as a confirmed case. (In extenuating circumstances, e.g. patient’s wellbeing particularly in patients being cared for long term in acute care e.g. neuro-rehabilitation patients , if patient has 3 negative screens, a risk assessment by IPCT to removed from isolation). 16/06/2017 eKSF dimensions Core 3 and HWB3

Out-patient CPE patients Known positive outpatients who require a diagnostic test or procedure, should be planned, wherever possible, at the end of the day’s list and equipment cleaned as per the NIPCM. 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Renal Dialysis - OP Patients attending NHS GGC for holiday dialysis from outside Scotland: If patient has a negative screen from own Board, this is acceptable. If patient doesn’t have a screen from own Board, treat as positive and place at end of list If a haemodialysis patient has only had outpatient hospital haemodialysis at a hospital out with Scotland no screening/isolation is required. If the patient subsequently requires admission, they require to be isolated and screened. 16/06/2017 eKSF dimensions Core 3 and HWB3

Renal dialysis – OP Patients NHS GGC patients attending for NHS GGC: If a haemodialysis patient has only had outpatient hospital haemodialysis at a hospital out with Scotland no screening/isolation is required. If the patient subsequently requires admission, they require to be isolated and screened. 16/06/2017 eKSF dimensions Core 3 and HWB3

Renal dialysis – in-patients If any renal patient has been an in-patient / OP for dialysis in a hospital out with Scotland and requires admission: Screening for CPE/isolation should be advised as for any other patient. If haemodialysis is required it should be undertaken in their own single room, where possible . 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 Obstetric patients CRA CRA will be undertaken at maternity triage, labour suite or in ward at induction and outcome recorded on CPE sticker. Sticker will be placed in patient hand held record If answer yes to CRA, midwife will organise first rectal screen as soon as possible: Labour / Post natal: If 3 rectal swabs (48 hours apart) can be undertaken this admission and are negative, no further action to be taken. If first screen negative and patient discharged post delivery, no requirement to chase further two screens. Baby does not need to be screened unless mum answers YES to CRA AND baby is admitted to NICU. Antenatal: If first screen negative and patient discharged, further two screens should be obtained at optimal point in obstetric journey, either antenatal or once admitted for delivery. TrakCare is used by obstetrics and therefore can be used to view tags. 16/06/2017 eKSF dimensions Core 3 and HWB3

eKSF dimensions Core 3 and HWB3 End Any questions ? 16/06/2017 eKSF dimensions Core 3 and HWB3