IC/291/10 Infection Control Precautions for Extended Spectrum Lacatamase Producers (ESBL)
BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST
Infection Control Precautions for Extended
Spectrum β− lacatamase producers (ESBL)
IC/291/10
Supersedes: IC/291/07
Owner
Final approval
committee
Authoriser
Review date
Audience
Standards
Name
Job Title
Name
Dr Nicki Hutchinson
Consultant Microbiologist
Infection Control Committee
Date of meeting
Name
Job title
Signature
05/03/2010
Anne Stebbing
Chair, ICC
Date of authorisation
(maximum 3 years from date
of authorisation)
(tick all that apply)
05/03/2010
March 2013
Trust staff
NHS
General public
Standards for Better Health &
Hygiene code
NHSLA
Reviewed in accordance with The Health and Social Care Act 2008:
Code of Practice for health and adult social care on the prevention and
control of infections and related guidance as published 16 December 2009.
Executive Summary
This is a protocol that describes the infection control precautions necessary for the
surveillance and management of patients infected with ESBL producing Gram
negative organisms. It describes the procedures necessary to prevent spread of
these infections within Basingstoke and North Hampshire Foundation Trust (BNHFT).
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IC/291/10 Infection Control Precautions for Extended Spectrum Lacatamase Producers (ESBL)
Implementation Plan
Summary of changes
This is an updated protocol written to formally describe current practice for ESBL
producers control due to rise in these infections recently. Current practice is based on
isolation precautions policy under multi drug resistant organisms.
Action needed and owner of action
•
•
•
•
•
All clinical staff need to be aware of rise in antibiotic resistance and need for
prudent use of antibiotics and infection control precautions. They are responsible
for seeking and attending infection control training sessions
The Infection control team (ICT), microbiologist are responsible for monitoring
infections as they arise as well as trends, using lab based ward liaison
surveillance, ensuring appropriate precautions are undertaken. They are
responsible for updating staff on infection trends with ESBL and isolation
precautions required to prevent spread (basic contact precautions).
Microbiologists and pharmacists are responsible for highlighting links between
ESBL infections and antibiotic prescribing, ensuring an up to date antibiotic policy
is in place and monitoring antibiotic usage
Managers should ensure that all necessary equipment for managing patients
infected with multi drug resistant organisms is in place. They are responsible for
observing trends of such infections in their areas, when reported by the ICT and
ensuring control measures are in place
The Consultants in Communicable Disease Control will be informed by
microbiologists if serious infections with ESBL-producing E. coli occur in
hospitals or the community.
Audit standard and criteria:
Standard: Patients infected with ESBL are managed according to precautions set out
in this policy and no cross infection occurred. (100%)
Audit criteria:
•
•
•
Number of ESBL infections acquired in hospital
Isolation precautions undertaken for all patients with ESBL producers regardless
to whether they are acquired in hospital or the community
Staff awareness assessment (of nature of infection and precautions required)
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IC/291/10 Infection Control Precautions for Extended Spectrum Lacatamase Producers (ESBL)
Infection Control Contacts:
Dr N Hutchinson Consultant Microbiologist/Infection Control Doctor Ext 3310
Dr F El Bakri Consultant Microbiologist Ext 3305
Hazel Gray Senior Infection Control Sister Ext 6774 or bleep 2364
Linda Swanson Infection Control Sister Ext 6774 or bleep 2364
Bruce Wake Trust Surveillance Co-ordinator Ext 3904
Table of Contents
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
10.1
10.2
10.3
10.4
Introduction
Local Epidemiology
Clinical Significance of ESBLs
Clinical Presentation and Disease Spectrum
Risk Factors
Microbiological Investigation
Treatment
Control Measures
Staff Carriage
Infection Control Measures
Hand Hygiene
Isolation of patients and environmental cleaning
Transfer of patients with ESBL
Control of antibiotic usage
References
Appendix 1: Antibiotic prophylaxis in surgery (Adults)
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IC/291/10 Infection Control Precautions for Extended Spectrum Lacatamase Producers (ESBL)
Purpose
This is a clinical and infection control protocol that sets out management standards for
patients infected with ESBL producers to ensure appropriate management of the
infection and prevent spread within the hospital. This conforms to the revised hygiene
code 16 December 2009 requirements.
1.0 Introduction
Since 2003, new highly resistant strains of the bacterium Escherichia coli have become
widespread in England and parts of Northern Ireland. These strains of E. coli are able to
destroy a large number of common antibiotics, making the infections they cause very
difficult to treat. The bacteria produce enzymes called extended-spectrum β-lactamases
(ESBLs) that destroy, and confer resistance to, antibiotics.1
ESBL-producing microbes are not new, having first been recognised in the 1980s. But
the new strains produce a particular type of ESBL, the CTX-M type, which is able to
break down a wider range of antibiotics. These strains were unrecorded in the UK prior
to 2000. They have spread rapidly since 2003, causing infections such as urinary tract
infections (UTIs) in hospital patients as well as those treated in the community. 1
Infections with ESBL-producing E. coli are occurring in both community and hospital
patients. Earlier ESBLs-not belonging to the CTX-M family-were largely identified in
another bacterium, Klebsiella, and were almost exclusively associated with hospitalised
patients, mostly in specialised care e.g. cancer care units and intensive care. 1
CTX-M β-lactamases have spread extensively in E. coli in England in a short period of
time. Most CTX-M-producing E. coli are exceptionally resistant to multiple antibiotics.
These include penicillins and cephalosporins, two of the most important and widely used
classes of antibiotics. As a result, there are very limited options for oral treatment for
mild to moderate infections. One option, fosfomycin, is not readily available in the UK.
Serious infections require the use of very powerful antibiotics, such as carbapenems
(Meropenem, Ertapenem and Imipenem). 1
Epidemiological studies revealed that a number of patients (often elderly and with
serious illness) who became infected with CTX-M-producing E. coli had subsequently
died. An independent clinical analysis of 54 patients who died in hospital, and who had a
history of infection or colonization with ESBL-producing E. coli, concluded that these
organisms had contributed directly to the death of 10 patients (19 per cent). In a further
four cases there was some evidence that infection may have contributed to death, but it
was not conclusive. Most of the patients were elderly and had one or more potentially
fatal diseases.1
A survey undertaken by the health protection agency (HPA) in 2004 found that many
diagnostic laboratories were using methods that would not detect CTX-M-producing E.
coli and would result in inappropriate advice being given to doctors. In addition, only half
of the laboratories that had investigated ESBL producers had submitted samples to the
Agency's Reference Laboratory for further characterisation. Just two of these
laboratories had reported these as 'serious untoward incidents'. Guidelines issued by the
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IC/291/10 Infection Control Precautions for Extended Spectrum Lacatamase Producers (ESBL)
Agency in 2004 have substantially rectified the testing/detection issues, as confirmed by
a follow-up survey in 2005. 2
There is evidence that ESBL-producing bacteria are carried in faecal matter, which may
imply spread via the food chain, thereby producing a reservoir of multi-resistant bacteria
in the gut that may then cause urinary infections in vulnerable patients.1 Studies have
failed to demonstrate clear links with any particular food products or environmental
source in the UK.
2.0
Local epidemiology
At BNHFT laboratory testing methods have been updated to reflect HPA guidance and
ensure that ESBL producers can be detected. A wider, standardised range of antibiotics
are tested so that emerging resistances, including that due to ESBL production, are
detected early.
Guidance to local GPs has been given in form of newsletter communications as well as
training sessions. Guidance on the submission of urinary specimens to the laboratory
has also been issued.
Locally ESBL producers are not very prevalent. However, a rise in infections mainly in
the community, in elderly patients with or without urinary catheters and recent hospital
admissions, has been documented (see table below). All the isolates fro GPs and most
of the hospital isolates were from urines.
Table 1: ESBL producers isolated from inpatients 2007 to Feb 2010 BNHFT
Spec
Abdominal wound
Blood Culture
Foot Swab
Pus Swab
Sputum
Urine
Wound swab
Grand Total
2007
1
2
1
1
1
7
2008
13
16
2009
2010
4
12
1
34
1
36
7
7
Grand Total
1
6
1
1
2
60
1
72
Junior medical staff are provided with local updates of microbial resistance patterns to
inform therapeutic decisions and improve infection control measures (e.g. with respect
to a UTI patient admitted from the community with proven or suspected ESBL-positive
E. coli).
3.0 Clinical significance of ESBLs
ESBL producers are clinically significant because:
•
•
•
•
Delayed recognition and inappropriate treatment of severe infections caused by
ESBL producers with cephalosporins has been associated with increased
mortality
ESBL-mediated resistance is not always obvious in vitro to all cephalosporins
Many ESBL producers are multi-resistant to non-β-lactam antibiotics such as
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•
•
quinolones, aminoglycosides and trimethoprim, narrowing treatment options.
Some ESBL producers achieve outbreak status, spreading among patients and
locales
4.0 Clinical presentation and disease spectrum
E. coli are one of the most common bacteria causing infections in humans, particularly
urinary tract infections (UTIs) and intra abdominal infections. These infections can
sometimes progress to cause more serious infections such as septicaemia which can be
life threatening. ESBL-producing strains of E. coli and Klebsiella species are more
difficult to treat because of their antibiotic resistance. It is very rare for E coli to cause
infections elsewhere e.g. skin and soft tissue or chest infection unless the patient is
diabetic, immunocompromised or in a high dependency unit.
Klebsiella sp. can cause severe lower respiratory tract infections in debilitated, alcoholic
or immunocompromised patients. Both Klebsiella and E. coli can rarely cause infections
related to venous access devices.
There is a very specific strain of E. coli called E. coli O157, which causes food poisoning
and sometimes haemolytic uraemic syndrome. It is a completely different strain. The
ESBL-producing E. coli are associated with UTIs rather than food poisoning.
5.0
Risk factors
Most of the infections have occurred in people with other underlying medical conditions
who are already very sick, and in elderly people. Patients who have been taking
antibiotics or who have been previously hospitalised are mainly affected.
The actual source or origin of this mechanism of resistance is not known.
6.0 Microbiological investigation
A urine sample should be sent to the laboratory as per the standard protocol for
investigation of UTIs in the community and in hospital. The standard operating
procedures in the lab will allow for detection and further investigation of any ESBL
producer. Patients suspected of having sepsis should have blood cultures taken with
appropriate clinical details documented on request form. Relevant samples e.g. pus,
sputum, blood cultures or skin swabs should be sent from patients suspected of having
or found to have abscesses (regardless of site), respiratory tract infections (ventilator
associated or otherwise), line related infections and skin and soft tissue infections
respectively.
If a patient is known to be colonised with or had an infection in the past with an ESBL
producer, the lab should be informed by documenting the information on the request
form.
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7.0 Treatment
The important factor in successfully treating an ESBL producer is quick diagnosis and
recognition that the bacteria causing infection are resistant to antibiotics, so that the
most appropriate treatment can be prescribed quickly.
There are only two oral antibiotics (Nitrofurantoin and Fosfomycin) and few intravenous
antibiotics (cabapenem group e.g. Ertapenem and meropenem and Tigecycline) that are
effective against such infections. Some strains are resistant to Nitrofurantoin. Others
appear sensitive in vitro to beta lactamase inhibitor antibiotics e.g. Tazocin and
Coamoxyclav but the in vitro activity of these antibiotics might not be reliable. Some
strains are sensitive to aminoglycosides e.g. gentamicin which has been successfully
used to treat these infections using a single daily dose of 5 mg/kg/day.
Which antibiotics are these infections resistant to?
Most ESBL-producing E. coli are resistant to cephalosporins, penicillins,
fluoroquinolones, trimethoprim, tetracycline and some other antibiotics, leaving very
limited options for oral treatment in the community, usually only nitrofurantoin and
fosfomycin. As a result of that some patients are having to be referred to hospital for
intravenous antibiotics.
Key points to remember when treating an ESBL producer infection:
•
•
•
•
•
•
•
•
Same rules apply: if simple UTI treat for 3 days, unless a male patient, suspected
prostatitis or patient with a heart valve lesion or prosthetic heart valve.
Nitrofurantoin works for sensitive strains and for lower UTI only, not
pyelonephritis.
Fosfomycin: not readily available in the UK, also for lower UTI only
Coamoxyclav/Cefixime combinations Or Pivmecillinam/ coamoxyclav
combination : no evidence, potentially antagonistic
Tigecycline is active against ESBL producers but is not excreted in urine and
therefore not suitable for treating UTIs.
Intravenous Carbapenem antibiotics form the first line treatment for hospitalised
patients with ESBL producer infections. Ertapenem should be used when
infection is confirmed to be due to an ESBL after discussion with a microbiologist
and as per the antibiotic policy.
Antibiotic treatment should be stopped as soon as infection is cleared to avoid
selection of more resistant organisms.
All other supportive clinical measures should be observed to prevent and/or treat
complicating sepsis
8.0 Control measures
Robust infection control measures are always important to prevent the spread of
infection. These include interventions, such as, hand washing and patient isolation. It is
also important to ensure that antibiotics are prescribed only when needed, in the right
dose, for the right duration, so as to reduce resistance developing in bacteria.
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9.0 Staff carriage
There have been no published reports implicating staff carriage as a source of patient
colonisation or infection. Screening of staff for carriage during an outbreak or as part of
an investigation is unhelpful and may cause considerable stress.
10.0 Infection control measures
It is important to control the emergence and spread of ESBL for the reasons stated
previously: the limited therapeutic alternatives, the increasingly compromised in-patient
population, and the potential for transfer of resistance to other pathogenic bacteria and
development of further resistance e.g. to carbapenem.
The epidemiology is complex: hospitals may be affected by sporadic cases of ESBL,
epidemics or endemic colonization and infection. Each of these situations will need to be
managed in different ways, depending on the risk to the patients involved.
As with all other infection control interventions, the quality of clinical care must not suffer
as a result of the precautions implemented. Because of the uncertainty surrounding the
management of ESBL, discussion between the infection control team and the clinical
staff is essential.
Control measures must be informed by a risk assessment. This will include the extent
and site of patient infection, the presence of intravenous and urinary catheters, whether
the patient is incontinent of urine or not and the susceptibility to infection of patients on
the affected wards.
Table two below summarises the infection control precautions indicated for control of
ESBL infections.
10.1 Hand hygiene
Effective hand hygiene is the most important measure to prevent and control the spread
of antimicrobial resistant organisms. Hands should be decontaminated between each
patient contact, whether or not the patient is known to be infected with ESBL.
Alcohol-based solutions or gels are effective and can be used as long as hands are
socially clean.
10.2 Isolation of patients and environmental cleaning
The decision to isolate individual patients affected by ESBL should be based on the
clinical needs and risk assessment described above, by the clinical team caring for the
patient in conjunction with the ICT. Ideally, patients infected with ESBL should be source
isolated in single rooms. However, where there are larger patient numbers and
insufficient isolation rooms, patients should be cohorted in bays on the open ward.
Patients with ESBL and incontinence or venous or urinary catheters or intra abdominal
drains are at a higher risk of spreading ESBL and must be given priority for single
rooms.
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Where there is more than one patient with the same ESBL organism isolated from the
same unit/ward, an outbreak team as per the Diarrhoea and Vomiting Outbreak
Management Protocol IC/274/09 should be convened and an investigation undertaken.
Case definitions should be agreed and dates of admission and discharge, ward and bed
locations of all infected and colonised patients documented, along with time line analysis
of patient activity such as movement to, and from, theatre. When several patients are
infected at the same time, cohort-nursing as advised by the ICT is acceptable
During ESBL outbreaks, the ward environment may become heavily contaminated and
will need further thorough cleaning following the discharge of the patients. There is no
evidence that one cleaning regimen is better than another for eliminating ESBL
producers.
The side-room in which a patient with ESBL has been cared for should be cleaned after
the patient’s discharge with a chlorine-releasing agent (500 ppm available chlorine) such
as hypochlorite or 1-2% phenolic disinfectants with special attention to horizontal
surfaces and dust-collecting areas.
Bedding and curtains should be changed as part of terminal cleaning.
10.3 Transfer of patients with ESBL
In general, ESBL neither present a risk to normal people in the community, nor to
patients in residential or nursing homes who do not have catheters, wounds or other
lesions. However Where patients infected or colonised with multiresistant bacteria, or
exposed to it but screened and thought to be clear, are being transferred to another
hospital or care provider, clinical staff should ensure that the receiving area is aware of
the patient's status and the context of the exposure to multi-resistant bacteria, and the
Infection Control Team at that hospital should be informed. This needs to happen before
the transfer takes place. Colonisation with multiple-resistant organisms, must never be a
reason for refusing admission if there are clear clinical reasons for the transfer.
Standard precautions during and after discharge are sufficient to prevent spread
10.4 Control of antibiotic usage
The emergence and spread of ESBL is encouraged by the use of certain antimicrobials.
The use of the cephalosporin has been implicated in the emergence of ESBL.
It is good clinical practice not to use any antimicrobial unnecessarily and clinical units
should adhere to the trust wide antibiotic policy. Antibiotic prophylaxis for surgery should
be as per trust policy (single dose at induction) to reduce antibiotic selection pressure.
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Table 2: summary of infection control precautions for ESBL producers (contact
precautions)
Hand washing
Gloves
Masks
Eye/face
protection
Apron/gown
Equipment
Cleaning
Linen
Isolation room
Contact
Before an after patient contact
On entering room, during care e.g. When likely to touch, blood,
body fluids and contaminated items
During procedures likely to generate contamination with blood and
body fluids
During procedures likely to generate contamination with blood and
body fluids
On entering if contact with patient or environment anticipated
As per decontamination policy
As per cleaning standards and description above
As per policy. Regard as infected
Single room and minimise time outside, unless advised by ICT
References
1. Investigations into multi-drug resistant ESBL-producing Escherichia coli strains
causing Infections in England. Health Protection Agency. September 2005
2. Laboratory detection and reporting of bacteria with extended spectrum ßlactamases. Health Protection Agency. 2004.
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APPENDIX 1
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