Multi resistant organisms (including Extended Spectrum
Beta Lactamases ESBL and Acinetobacter Species, Vancomycin and Glycopeptide Resistant Enterococci) Policy
Version: V3
Ratified By: Infection Prevention and Control Group
Date ratified: 16/10/2024
Job Title of Author: Head of Infection Prevention
Reviewed by Sub Group or Expert Group: Infection Prevention Group
Equality Impact Assessed by: Head of Infection Prevention
Related Procedural Documents: IPPOL21SICP
IPPOL03 Hand Hygiene policy
HSPOL14 Control of Substance Hazardous to Health (COSHH) Policy
Review Date: 16/10/2027
It is the responsibility of users to ensure that you are using the most up to date document template – i.e. obtained via the intranet.
In developing/reviewing this policy Provide Community has had regard to the principles of the NHS Constitution.
Version Control Sheet
Version Date Author Status Comment
Version1 May2018 Headof Infection Prevention
Version2 November2021 Headof Infection Prevention
Version3 October2024 Head of Infection Prevention and Control and Specialist Infection Prevention and controlNurse
RatifiedatQ&S
Ratified at IPG November2021 Updated to include the resistant organism group ESBL’s and Acinetobacter referredtoallas multi resistant organisms in title.
RatifiedAtIPCG October2024 Review and update to section7control measures to includerecordof measures in systm1.
1. Introduction
1.1 This policy details the management of patients infected/colonised with multi resistant bacteria (MRO) These organisms are often referred to as multi drug resistant organisms (MDROs), multi resistant Gram-negative bacteria (MR GNB’s), or grouped by resistance Vancomycin Resistant Enterococcus (VRE), Glycopeptide Resistant Enterococci (GRE), extended spectrum beta lactamase producers (ESBLs), Methicillin Resistant Staphylococcus Aureus (MRSA). Please note for management of MRSA please see separate MRSA policy IPOL01.
1.2 Many MRO’s are gram negative bacilli (GNB). These are a group of bacteria that includes coliforms, Pseudomonas and Acinetobacter, E.coli, Klebsiella, Proteus, Enterobacter and other similar species. Some strains of these bacteria can be classed as being multiple resistant (or multi- resistant) because they are resistant to two or more classes of broad-spectrum antibiotics.
1.3 This is especially important with regard to patients undergoing intensive care, chemotherapy or complex medical and surgical procedures, as GNB have the ability to cause opportunistic infections such as sepsis, wound infections and UTI’s.
1.4 The ability of these organisms to acquire resistance to many antibiotic agents can have significant implications when both treating and caring for patients in both the inpatient and the community setting.
1.5 It is essential that strains of MRO’s that have become resistant to multiple drugs are controlled effectively to prevent the spread of potentially untreatable infections
2. Purpose
This policy promotes the correct management of MRO’s to improve patient safety by preventing healthcare infection and reducing risk of transmission to service users and staff.
This policy has been developed in response to The Health and Social Care Act (2008) (revised 2015) – Code of Practice on the prevention of and control of infections. The guidance sets out criteria by which healthcare organisations must ensure that:
• Risks associated with Health Care Associated Infections (HCAI) are minimised
• Patients are cared for in a clean environment that is fit for purpose
• Organisations adhere to policies that will prevent and control infections
Compliance with this code is a statutory requirement for all healthcare workers and is measured by the CQC as part of their inspection process.
2.1 This policy provides the information required for all Provide staff to take prompt action for implementing general principles of infection prevention and control
when managing a patient identified (or suspected of having) a MRO including E coli and Acinetobacter species.
2.2 During normal working hours advice is available from the Infection Prevention and Control Team (IPCT) Staff are encouraged to contact the IPCT team for all routine reporting of MRO’s and the ongoing actions to be implemented, for patient management, including isolating patients.
2.3 Out of hours advice must be sought from the on call manager.
3. Roles and Responsibilities
Responsibilities
Chief Executive
Has ultimate responsibility for the implementation and monitoring of policies in use in the organisation. This responsibility may be delegated.
Director of Infection Prevention and control (DIPC)
Has strategic responsibility for infection prevention and control within Provide and will take the lead responsibility for the development and implementation of this policy with support of the Lead for Infection Prevention and the Infection Prevention and Control Doctor.
Consultant Microbiologist/ Infection Prevention and Control Doctor
Provides advice to the medical staff on clinical management (inc. antimicrobial prescribing) of patients with MRO’s.
Head of Medicines Management
To monitor antimicrobial stewardship best practice within the organisation and the prescribing of antimicrobial therapy
Infection Prevention Team
Have responsibility for ensuring that staff are familiar with the content of this policy and of the following:
• Day to day advice and support from 9am – 5pm
• Training and education to support clinical staff in implementing the policy
• Implementing any changes to the policy in line with national guidance
• Monitoring daily laboratory list of alert organisms for inpatient ward, and ensuring appropriate management in line with policy
All Employees
Are responsible for ensuring that standards of infection prevention and control are maintained in line with the organisations policy and procedures. Infection prevention and control training will be monitored via line managers with the ESR and appraisal process.
4. Definitions
TERM
DEFINITION
Acinetobacter is a common environmental bacterium that lives in water and damp conditions but can survive in dust. It has minimal growth requirements, can survive for long periods in the environment and is relatively resistant to usual cleaning methods and drying). Acinetobacter is commonly found as a harmless coloniser of the skin of healthy people and usually poses very few risks to such individuals. However, it can cause serious infections in patients who are immunocompromised. The most common Acinetobacter infections include pneumonia, bacteraemia (blood stream infections), wound infections and urinary tract infections
Alert organisms and conditions are those identified as posing a public health risk to patients, staff or visitors as defined by the Department of Health (DOH 2007)
Carbapenamaseproducing organisms (CPO)
CPO’s are a type of bacteria which have become resistant to carbapenems, a group of powerful antibiotics. This resistance is helped by enzymes called carbapenemases, which are made by some strains of the bacteria and allows them to destroy carbapenem antibiotics. This means the bacteria can cause infections that are resistant to carbapenem antibiotics and many other antibiotics and infections then become very difficult to treat. (See IPPOL28)
Colonisation is the presence, growth and multiplication of an organism without observable clinical symptoms or immune reaction of the patient
DIPC Director of Infection Prevention and Control
Extended Spectrum Beta Lactamase (ESBL)
GNB
Glycopeptide resistant enterococci (GRE)
Enzymes (chemical) produced by some GNB bacteria which breaks down certain types of broad-spectrum antibiotics. ESBL can be produced by some strains of bacteria that normally live in the bowel, for example E.coli. This resistance can make any infection caused by the bacteria difficult to treat.
Gram negative bacteria are a group of bacteria characterised from by gram staining methodology where their cell wall structure differs to those that are gram-positive. Gram-negative bacteria can be resistant to antibiotics and in some cases will be multi-resistant rendering most available antibiotics useless. Gram-negative bacteria such as E. coli, Klebsiella spp. and Pseudomonas aeruginosa are the leading causes of healthcare associated bloodstream infections.
Enterococci are bacteria commonly found in the gut of healthy people. They can cause a range of illnesses, including urinary tract, wound and bloodstream infections, and invasive disease in immunosuppressed patients. These enterococci are resistance to glycopeptide antibiotics such as vancomycin and teicoplanin and include the group VRE.
HCAI Health Care Associated Infection
IPCG Infection Prevention and Control Group
IPCT Infection Prevention and Control Team
IPCN Infection Prevention and Control Nurse
MR-GNB Multi-resistant gram-negative bacilli
Multi-resistant
Acinetobacter baumannii (MRAB)
Multi- resistant Acinetobacter baumannii are common environmental organisms that live in water and damp conditions but can survive in dust. Capable of surviving long periods in the environment and is relatively resistant to usual cleaning methods. Frequently colonised on human skin. Intrinsically resistant to most commonly available antibiotics and often reported as a cause of outbreaks in intensive care units
Opportunistic infection
An infection by a microorganism, bacteria, virus, fungi that normally does not cause disease but becomes pathogenic when the body's immune system is impaired and unable to fight off infection
Source isolation is the physical separation of one patient from another. Source isolation is required for patients who are infected or colonised with a particular infection to prevent the transfer of a specific infection to others Vancomycin
Resistant Enterococci (VRE)
Organism that colonises the bowel and may be implicated in urinary tract infections, peritonitis, cholecystitis and endocarditis. VRE are enterococci that are resistant to the antibiotic Vancomycin and can also be referred to under GRE isolates. Spread through direct contact via hands of healthcare workers and indirectly through the environment. Acquired antimicrobial resistance has emerged in enterococci, in particular E. faecalis and E. faecium, with several resistant strains identified (VRE). High-level resistance to both vancomycin and Teicoplanin (glycopeptides) is of greatest significance. Excessive use of antimicrobials to treat minor infections is likely to be a major contributory factor to the emergence of VRE.
Spp. Species
5. Key Points
5.1. GNB’s are commonly found in the gastro-intestinal tract, in water and soil. In hospitalised patients, colonisation of the gastro-intestinal tract and
5.2. oropharynx with GNBs is common. Any moist environment is favourable to their survival
5.3. As with all Health Care Associated Infections (HCAI), Acinetobacter species and other GNBs can be part of the transient flora on the hands of health care workers, on equipment and the patient’s environment
5.4. Multi-resistant bacteria are seen more frequently in areas that have high usage of broad-spectrum antibiotics and where patients have diminished immunity e.g. critical care and oncology units
5.5. GNBs may achieve antibiotic resistance to a large range of different antibiotics even if they have been exposed to only one or two antibiotics
5.6. The genes that confer antibiotic resistance can spread to other bacteria
5.7. MRO’s have been implicated in outbreaks of infection in intensive care units (ITU), neonatal and oncology units, among other places. They can cause a range of infections including urinary tract infections, surgical site infections and chest infections
6. Infection Prevention and Control
Source Isolation
6.1. A patient may be colonised rather than infected with multi-resistant bacteria e.g., faecal carriage of multi-resistant GNBs. Colonisation of a patient with an MRO will not cause them harm but action may be necessary to prevent further spread All
patients on staff caseload must have evidence of a routine risk assessment for MRO colonisation. This may include the need for source isolation precautions
6.2. A single room with en-suite facilities is recommended for patients known to be infected with an MRO and is essential if a patient has a discharging wound, abscess, cellulitis, shedding skin condition, productive cough, or diarrhoea. Where ensuite facilities cannot be provided patients’ must be provided with designated commode for sole use or allocated individual toilet/bathroom for sole use. A patient with an MRO infection should not share a room or bay if they or the other patient(s) has a wound or invasive device. If a side room is not available, advice must be sought from the IPCT or the Consultant Microbiologist
6.3. In circumstances of an outbreak, patients may be nursed together in a cohort This decision must be made with the outbreak group and in conjunction with the IPCT
6.4. Patient placement and source isolation precautions.
Extended spectrum beta lactamases (ESBL)
Carbapenemase producing Organisms (CPO’s)
Multi- drug resistant Acinetobacter baumannii
Multi- drug resistant Pseudomonas
Glycopeptide resistant
Enterococci (GRE) and Vancomycin Resistant
Enterococci (VRE) and GRE
A decision on isolation for a patient who is found to have an ESBL requires an infection risk assessment. This must be carried out in conjunction with IPCT, taking into consideration any indwelling devices the patient may have e.g. urinary catheters, a discharging wound, abscess, cellulitis, shedding skin condition, productive cough or diarrhoea.
A patient found to have a CPO always requires a single room with ensuite facilities. On all subsequent admissions to hospital, a patient with a history of CPO must always be admitted into a side room. See IPOL 28 CPO policy
Patient should be placed in a single room. Where single room is unavailable IP team must be contacted to undertake risk assessment to establish prioritisation of isolation.
Patient should be placed in a single room. Due to limited availability of side rooms a risk assessment may be required to establish if cohort nursing is practical
Patient should be placed in single room if considered to have risk factors e.g., diarrhoea, urinary infection, urinary catheter or incontinent. Where single room is unavailable IP team must be contacted to undertake risk assessment. GRE/VRE do not cause gastroenteritis, but diarrhoea makes spread of infection a greater risk.
6.5 Standard infection Prevention Precautions for care of inpatients with MRO’s
Personal Protective Equipment (PPE)
Appropriate personal protective equipment (PPE) must be worn when delivering clinical care and when in contact with the patients’ environment. The appropriate use of PPE includes aprons and gloves, face masks for where risk of respiratory infection and aerosol generating procedures are being performed. Eye protection must be worn in circumstances where there is a risk of splash of blood and body fluid. Rarely MROs will require droplet or airborne infection control precautions -
for further information on droplet and airborne precautions (See IPPOL21) For management of CPO full sleeve gowns maybe indicated as part of PPE (See IPPOL28)
Hand hygiene
• Hand hygiene is the most important measure for preventing transmission of infection. Hands should be decontaminated with liquid soap and water or alcohol hand gel on entry to and when leaving healthcare premises/isolation room, or patient’s home, before patient contact, before an aseptic procedure, after body fluid exposure risk, after contact with patient and after contact with patient surroundings Handwashing (not alcohol hand gel) must always be undertaken when hands are visibly soiled and when patient has diarrhoea.
• Patients must be offered hand hygiene facilities prior to eating and after using the toilet or commode (This must occur for all patients regardless of their infection status)
• Visitors / carers must also be asked to wash their hands on entering and leaving the side room and if they are giving any patient contact
Clinical waste
All clinical waste must be disposed of in the appropriate waste stream. Orange bags must be used for the disposal of waste from a patient with a suspected or confirmed MRO.
Linen
Contaminated linen from a patient with a suspected or confirmed MRO must be disposed of appropriately – in a red alginate bag and then into a white bag.
Decontamination of equipment
All reusable equipment must be decontaminated appropriately before and after use in line with decontamination of medical equipment policy IPOL9 Any reusable equipment used on the wards must be cleaned using an approved chlorine solution product such as Tristel before use on another patient.
• Patients in isolation must have dedicated equipment allocated to them, including BP machine, commodes,
• Equipment must be kept to a minimum in the bay/side room, e.g., incontinence pads, tape. All consumables must be destroyed on the patient’s discharge
• Patient’s notes must be kept outside the side room
Antibiotic treatment
• Antibiotic treatment of infection due to MRO’s should be based on the sensitivity and susceptibility testing of specimens and the clinical assessment. Advice can be sought from the consultant microbiologist.
• As part of best practice in antimicrobial prescribing specimens should be sent prior to commencing treatment e.g., wound swab, catheter specimen of urine
• All antimicrobials prescribed are reviewed within 72 hours and have a documented duration of treatment or date of review.
Patient transfers
• If the patient needs to transfer to another hospital or department, for clinical investigations e.g. X-ray, the department must be notified of the infection control restrictions that are in place. Where possible and practical, the patient must be seen last on a list, unless clinically not appropriate. Appropriate cleaning must occur once a patient leaves the department visited. Transfer of patients to other hospital wards should be avoided, unless there is a clinical need for the patient, and this is clearly documented
• If a patient requires a transfer to another hospital, the infection risk must be appropriately communicated to the receiving Trust and to the transport system that will be used to transfer the patient. Failure to do so will result in a greater risk of transmission of infection.
• Patients who have active symptoms of diarrhoea should not visit other departments unless the treatment is critical to their current care (this applies to all patients who have suspected infective diarrhoea)
Screening
Screening for MRO’s should be undertaken when any type of infection is suspected. e.g., urine, wound swab, blood culture, line tip etc. Generally screening for carriage/colonisation of MRO’s in the community (excluding MRSA) is not undertaken and would only be advised in the event of an incident, or outbreak, under guidance from local UK Security Health Authority (UKSHA).
Where screening for carriage/colonisation of MRO (not including MRSA) is required this will be advised by IPCT. This may involve a faecal specimen, either a stool culture or rectal swab in addition to wounds, urine, line tips etc. In cases of CPO stool specimen or rectal swab are advised as part of an admission screening protocol. (See IPPOL28)
Contact screening
Contact screening is rarely required. The Consultant Microbiologist and the IPCT will undertake a risk assessment where any patients are considered to have had a significant risk exposed with a confirmed MRO. If more than one patient is then identified as having a positive MRO, the IPCT and consultant microbiologist will determine whether this constitutes an outbreak and take appropriate action as per Outbreak Policy IPPOL16.
Death of patient
No special precautions are required. The usual standard infection prevention precautions should be applied for care of deceased when performing last offices. (See CPOL64 Care of the Dying and the Aftercare of the Deceased Policy).
Visitors
• Should be asked to decontaminate their hands on entering and leaving the patients environment, and it must be requested that they do not visit other areas or patients within the ward or hospital setting.
• Visitors who are undertaking clinical care with a patient with a confirmed or suspected MRO must be advised and educated on the use of PPE and handwashing to protect themselves. It is not required for visitors to wear PPE if they are just visiting and not providing any clinical care. Visitors should be asked to limit the numbers visiting and avoid bringing in small children
Care of patient with MRO in Health Centre or clinic
The same principles of care should be applied when a patient with MRO attends a health centre or clinic treatment room setting. The patient should not be treated in a room that is used for invasive procedures e.g. nail surgery, IUCD fitting, catheterisation, venepuncture. Ideally the patient should be seen last on the morning, afternoon, or evening list to enable cleaning to be carried out before any other patients are seen in the same room.
Care of patient with MRO at home.
Isolation of patients at home are not usually necessary for patients with MRO. Community staff visiting symptomatic patients should follow the same principles of standard infection control principles. If possible, community staff should visit patients last visit in the morning or afternoon. Staff should avoid taking non-essential equipment into the patient’s home. Any equipment used which is not single use for disposal should be cleaned after use.
7. Control Measures
Environmental Cleaning to Manage the Risk of Transmission
MRO’s have been shown to have a higher capacity than some microorganisms to survive in the environment It is therefore essential that robust standards of cleaning are implemented:
• Once a patient is moved into isolation, ward staff should contact the cleaning team and request enhanced cleaning to be undertaken for the duration of the inpatient stay This should be recorded in patient notes on systm 1.
• All horizontal, vertical surfaces including frequent touch point areas for example bedside tables, door handles must be cleaned in accordance with the required enhanced cleaning using an approved chlorine solution product e.g Tristel fuse
Discharge cleaning for ward
• Once a patient is identified as being medically fit for discharge or no longer infectious and does not require source isolation, the Nurse in charge of the ward must request a terminal clean from the cleaning team leader on the ward.
• In addition to the terminal clean the IPCT may bring in additional measures such as use of steam clean or hydrogen peroxide fogging dependent on the infection and risk assessment. The IPCT will instruct the cleaning team when to use these methods in accordance with the cleaning policy.
• When the terminal clean has been completed the checklist from cleaning policy must be completed and signed off by cleaning team leader and ward manager/nurse in charge.
• All equipment including curtains must be stripped from the room and cleaned or disposed of appropriately. Disposable curtains should always be used for MRO.
• Pillows must be disposed once the patient is discharged
• Mattresses must be checked once the patient has been discharged. Inspect the cover and inner mattress for signs of soiling. Unzip the mattress, if there are any stains / soiling to the underside of the cover or mattress, remove the mattress from circulation and inform nurse in charge so that a replacement mattress can be sought and the damaged mattress disposed of
• Specialist hired mattress must be returned to the company for cleaning and decontamination
8. Additional considerations
• The IPC team must be informed or alerted to any referral of patient with MRO prior to accepting patient admission
• Patients can be discharged to their own homes without any additional requirements; however, they should be advised to continue with good hand hygiene, general cleaning (no specific products are required) and be given patient information leaflet.
• If a patient is discharged home and requires additional support from District nurses, or other support service they MUST be informed of the patient’s status on the intertransfer form and discharge summary. This also applies to discharge of any individual to a care home or residential facility.
• All wounds and/or invasive devices must be managed in accordance with the principles of ANTT
• Advice on clinical signs of infection in the community should be obtained from the patients GP, additional advice re antimicrobial management can be obtained from the Consultant Microbiologist
• As far as practicable keep items to a minimum in the patient’s room, this includes patient’s personal items. It may be appropriateto request extra items are sent home
9. Outbreak Management
An outbreak is identified based on national guidance of two or more linked cases, this will be managed in line with Outbreak policy, notification will also be made to Public Health England. In the event of an Outbreak the Infection Prevention team will advise and lead on actions to be taken and any screening required.
10.Training
All clinical staff must undertake infection prevention and control mandatory training every 2 years. Additional training on management of MRO’s will be provided by the IPCTwhere it is identified there is an additional requirement
11.Monitoring Compliance
The policy and its implementation will be monitored and ratified through the Infection Prevention Group and will be included in the procedural documents report that goes to Quality Provide Leadership Team.
The infection prevention team will review and investigate incidents reported relating to this policy and audit departments compliance as part of the annual audit programme.
Failure to follow the guidance in this policy will be reviewed as part of the post infection review process and consideration given if this constitutes a lapse in care contributing to the development of an infection. This will be monitored through the Infection Prevention Group.
Non-compliance with the policy will be managed via the staff disciplinary route.
12.Legislation, Guidance and Reference
Chief Medical Officer (2011) Annual Report of the Chief Medical Officer Volume Two, 2011 Infections and the rise of antimicrobial resistance [pdf] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138331/C MO_Annual_Report_Volume_2_2011.pdf
Department of Health. (2007). Isolating patients with HCAI. Summary of best practice. http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011/03/ Document_Isolation_Best_Practice_FINAL_100917.pdf
Department of Health (2015) The Health and Social Care Act 2008, Code of Practice on the prevention and control of infection and related guidance Available at: https://www.gov.uk/dh
Loveday, H.P. Wilson J,A. Pratt, M. Golsokhi, A. Tingle, A. Bak, J. Browne, J. PrietoJ. Wilcoc M. (2014). Epic 3: National Evidence- Based Guidelines for
Preventing Healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. 86S1 (2014) S1-S70.
NICE quality standard (2014) Guidelines for Infection Prevention and Control
National Institute for Health and Care Excellence (2015) Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use https://www.nice.org.uk/guidance/ng15
National Institute for Health and Clinical Excellence (April 2016) Antimicrobial Quality Standard [QS121]
https://www.nice.org.uk/guidance/qs121
Public Health England (2008) Acinetobacter species.
https://www.gov.uk/guidance/acinetobacter-species#diagnosis
Public Health England (2020) Framework of actions to contain carbapenemase-producing Enterobacterales
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment _data/file/923385/Framework_of_actions_to_contain_CPE.pdf
Public Health England (2008) Enterococcus species and glycopeptide-resistant enterococci (GRE).
https://www.gov.uk/guidance/enterococcus-species-and-glycopeptide-resistantenterococci-gre
Public Health England (2017) Gram-negative bacteria: prevention, surveillance and epidemiology.
https://www.gov.uk/guidance/gram-negative-bacteria-prevention-surveillance-andepidemiology
Public Health England (March 2015) Start Smart - Then Focus: Antimicrobial Stewardship Toolkit for English Hospitals.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment _data/file/417032/Start_Smart_Then_Focus_FINAL.PDF
WHO (2006) Your 5 moments of hand hygiene [pdf] Available at: http://www.who.int/gpsc/tools/Five_moments/en/