Infection Prevention & Control Annual Report Public Board Meeting 30 July 2015

Infection Prevention & Control Annual Report Public Board Meeting 30 July 2015 Presented for: Presented by: Lead Author: Previous Committees: Governance Dr Yvette Oade, Chief Medical Officer and Director of Infection Prevention and Control Dr Tim Collyns, Lead Infection Control Doctor To be received at the Infection Prevention Control Committee on 17th August 2015. Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points 1. To inform the Board of the achievements in 2014-15 and challenges in 2015-16 Information 2. To comply with the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. Governance Page 1 of 21

The Leeds Teaching Hospitals NHS Trust (LTHT) Infection Prevention and Control (IPC) Annual Review Covering the period 1 st April 2014 to 31 st March 2015 PUBLICATION UNDER THE FREEDOM OF INFORMATION ACT This paper will be made available under the Freedom of Information Act 2000. 1 SUMMARY The prevention and control of infection remains a high priority for the trust. There is a strong commitment to preventing all healthcare acquired infections (HCAIs). In 2014-15 Leeds Teaching Hospitals NHS Trust (LTHT) reduced the number of cases of Clostridium difficile infection (CDI) and achieved the nationally determined objective. Disappointingly, the number of MRSA bacteraemias remained static, at seven, plus one adjudged a contaminant. However, there was the longest period so far in recent history between MRSA bacteraemic episodes - with no LTHT attributable case from early December 2014 till after 1st April 2015 (in total over 160 days). The trust also achieved the locally agreed objective for reducing the number of MSSA bacteraemias. The overall recent improvement in HCAI performance by LTHT was recognised by our commissioners. The IPC team continue to develop innovative ways of getting important messages across to our staff, patients and visitors. There is recognition that ongoing work needs to be maintained and developed in order to ensure sustained ongoing improvements in HCAI performance during 2015-16. 2 PERFORMANCE IN 2014-15 MRSA bacteraemia Mandatory MRSA bacteraemia (blood stream infection) surveillance has been undertaken since April 2001 by all NHS Trusts in England. As an organisation we have a zero tolerance approach to hospital acquired infections and, as with every NHS Acute Trust we had a contractual objective in 2014-15, agreed with our commissioners, of zero cases of MRSA bacteraemia. LTHT data for each quarter since Q1 2008-09 are shown in Figure 1. In 2014-15 LTHT recorded seven cases plus one adjudged a contaminant. This represented the same number of cases as in 2013-14. Overall, since 2008-9, there has been a reduction of nearly 90%. Figure 1 illustrates the distribution of LTHT apportioned bacteraemias per quarter since Q1 2008-9. In the last quarter of 2014-15, we achieved the longest period so far in recent history between MRSA bacteraemic episodes - with no LTHT attributed case from early December 2014 till after 1st April 2015 (in total over 160 days). This illustrates that it is entirely possible to reach zero - as also demonstrated by a handful of our peers (Figure 2). Page 2 of 21

Figure 1: Total LTHT apportioned MRSA bacteraemias by quarter, Q1 2008-9 Q4 2014-15. Comparative MRSA bacteraemia rates Figure 2 shows LTHT s MRSA bacteraemia rates per 10,000 bed days compared with those of other Teaching Hospital Trusts across England between April 2014 and March 2015. In 2012-13 LTHT had appeared 21 st of 26 Peer Trusts (4 th Quartile) on this graph. In 2013-14 the trust s relative position had improved, now ranking 14 th out of 26 Peer Trusts (3 rd Quartile), and this position was sustained in 2014-15. Figure 2: LTHT apportioned MRSA bacteraemias. Rate per 10,000 bed days compared to other Teaching Hospitals, April 2014- March 20 Page 3 of 21

Clostridium difficile infection The total number of LTHT attributable C. difficile infection (CDI) cases reported in 2014-15 was 121 compared with 144 in 2013-14. This is a reduction of over 15%. Moreover, in recognition of the national achievement in reducing C difficile rates, for 2014-2015, the DH established a process whereby Acute Trusts after internal review may declare a C difficile case to be unavoidable to its Commissioners if there was no identifiable lapse in care prior to diagnosis - for example in a patient who experienced a relapse of CDI, despite receiving appropriate treatment for the previous episode(s). If agreed, such cases wouldn t count towards the nationally set target. For 2014-15, our commissioners agreed that at least 24 LTHT-attributed cases out of the total of 121 were unavoidable on the part of LTHT. LTHT s monthly progress against 2014-15 trajectory is shown in Figure 3. This illustrates that in January 2015, we achieved our lowest monthly total, five, of attributable cases since mandatory reporting began. Figure 4 demonstrates the tremendous strides that have been made by the whole organisation over the past few years in reducing the number of patients who suffer this very debilitating infection. Figure 3: LTHT cumulative CDI performance April 2014 to March 2015. Page 4 of 21

Figure 4: LTHT-apportioned C. difficile cases by quarter (Q1 2008-09 to Q4 2014-15) Some Clinical Service Units (CSUs) achieved substantial reductions in the numbers of their patients suffering CDI, notably Children s which went from 17 in 2013/4 to 1 in 2014/15, a 95% drop, and even that one case was adjudged unavoidable by our commissioners. C difficile is a spore-forming organism; and these spores are designed to survive in hostile environments. In 2014-15, hydrogen peroxide vaporisation (HPV) continued to play a very important role in reducing the burden of C difficile on our wards. The availability of a decant ward facility in the summer allowed a significant number of wards, particularly in the Acute Medicine CSU, to undergo full ward decant, deep cleaning and HPV treatment. Furthermore, terminal side room HPV cleaning after a patient with confirmed CDI is discharged or transferred, occurs trust-wide, as well as a regular programme of pre-emptive HPV cleaning for certain areas with highly vulnerable patients such as in Adult Haematology in the Bexley Wing. HPV is also used to ensure thorough decontamination of affected areas when other antibiotic-resistant pathogens are identified. Comparative C. difficile rates Figure 5 shows LTHT s C. difficile infection rates per 10,000 bed days compared with those of other Teaching Hospital Trusts across England, April 2014 to March 2015. In 2013-14 the relative position moved up to 22 nd of 26 Peer Trusts from 24th in the year before, this progression was sustained in 2014-15, with LTHT moving up to 19th, and into the third quartile. Page 5 of 21

Figure 5: LTHT apportioned C. difficile infections. Rate per 10,000 bed days compared to other Teaching Hospitals, April 2014- March 2015. The mortality rate of patients identified with C difficile in Leeds during 2014-15 has been recently reviewed (by Microbiology StR Dr Martin and FY2 Dr Schweibert). There were 262 patients in total, including both LTHT and community, of whom 47 (18%) of these patients died within 30 days of diagnosis. This is in keeping with national (and international) mortality rates. Work to further improve mortality rates is ongoing to include determining the most effective antibiotic treatment of CDI and recording and acting upon severity scores. This will be monitored through the HCAI Action Plan 2015/16. MSSA bacteraemia As with MRSA, meticillin-susceptible S. aureus (MSSA) bacteraemias are subject to mandatory reporting. However currently there are no nationally-set trajectories. Instead there are local agreements in place with commissioners. In 2013-14 there were 62 LTHTattributable MSSA bacteraemias which was just over the locally-set trajectory of 60. For 2014-15, we agreed a trajectory of 59 cases. The total number of LTHT-attributed MSSA bacteraemias in 2014-15 fell to 58, i.e. within the target, being a further reduction of 7% on the previous year and a 35% reduction since 2011-12 (89 cases) see Figure 6. Page 6 of 21

Figure 6: Progress in 2013-14 against locally agreed trajectory for MSSA bacteraemia Pseudomonas aeruginosa Following on from the well-published outbreaks of Pseudomonas aeruginosa (PA) infections in neonatal units in Northern Ireland in late 2011 comprehensive advice was published by the Department of Health in 2012 that required all trusts to develop a Water Safety Plan (WSP) and introduce routine water sampling for P. aeruginosa in Augmented Care units (i.e. those wards caring for the most vulnerable patients, such as neonates and transplantation patients). This process is now well embedded for the wards that have been assessed as being Augmented Care units in LTHT, with a range of actions that are initiated if P aeruginosa is detected in a sample, including the fitting of water filters, chlorination, and removal and/or replacement of taps. To date there has been no evidence that P. aeruginosa originating from the hospital s water system has caused harm to any of our patients. The results are overseen by the LTHT Water Safety Group. The set-up in LTHT and the associated Water Safety Plan has been recognised externally as an example of good practice for other Trusts to consider adopting. Regular use of outlets is crucial in preventing build-up of potential pathogens, such as P aeruginosa, at the distal point - this can be assured by regular flushing. The flushing of defined water outlets in LTHT is monitored by an independent company, L8Guard. For 2014, we averaged 99% flushing compliance in Augmented Care units across the Trust and L8Guard have reported that LTHT is the best performing of the Trusts that they monitor. Moreover, outlets that are not in regular use and are judged redundant can be removed. Page 7 of 21

3 OUTBREAKS AND OTHER COMMUNICABLE DISEASE INCIDENTS One of the main roles of the IPC Team is the prevention and management of outbreaks of infection. Ebola. An emerging potential threat to LTHT patients and staff in 2014-15 was the outbreak of haemorrhagic fever, caused by the Ebola virus, in West Africa. An extensive education and training programme was introduced to protect staff and prevent transmission within LTHT, primarily based in the Emergency Departments (Adult and Paediatric), and Infectious Diseases. A robust system was also established to ensure safe transport and timely testing of samples. The pathways developed were used in managing a handful of possible cases so far (none of whom tested positive). The LTHT experience that was gained in such incidents was shared nationally. Some healthcare workers from LTHT volunteered to provide assistance in West Africa, using the LTHT IPC guidelines as a resource. M chimaera In March 2015, Public Health England (PHE) issued a Briefing Note regarding Mycobacterium chimaera systemic infections post cardiac surgery. This arose due to the report of six clinical cases in Switzerland and one in the Netherlands. Extensive environmental investigation to identify potential source(s) for this organism had been undertaken in those countries; and it is believed that the likely source was from certain contaminated heater-cooler machines used during cardiac bypass surgery. A national look-back exercise was initiated. At least 14 cases of M chimaera have now been identified nationally, involving multiple Trusts. Four cases potentially associated with cardiac surgery over the past ten years in Leeds have been identified. Water samples from the heater-cooler machines in use at the time have been tested and shown to be positive for this organism. The machines were being maintained in accordance with the manufacturer s instructions in place at the time; however a number of additional measures have now been introduced to prevent any potential transmission and there is ongoing surveillance of the machines. C difficile Continued improvements in Infection Prevention and Control (IPC) practices have resulted in a further reduction in the number of recorded C. difficile outbreaks, such that no C difficile outbreak was declared in 2014-15 on the basis of identified transmission from one patient to another. This is consistent with the downward trend in recent years, in which there were three such outbreaks in 2013-14, compared to six recorded in 2012-13 and the 12 recorded in 2011-12. LTHT is fortunate in having the national C difficile typing service based in the laboratory here, and hence is able to identify rapidly whether cases linked in time and/or space appear to represent apparent transmission of one strain. Increasingly, there is earlier recognition of cases with attendant reduction in the risk of ongoing spread. This is coupled with the HPV program to remove any environmental contamination. The vast majority (>90%) of our CDI cases have recently not been linked by typing to other cases of in-hospital CDI but the exact routes of acquisition remain unclear. LTHT is involved in ongoing research to understand such routes better. Page 8 of 21

MRSA. Three outbreaks of MRSA colonisation/infection were identified in 2014-15; one of which was declared a major outbreak, involving 19 cases. This outbreak was closed in June 2014, after a series of control group meetings, with a range of improved infection prevention and control practices put in place. Other Organisms: One ward had an outbreak involving two patients, who were identified with the multiresistant bacterium, vancomycin-resistant enterococcus (VRE); whilst one ward had two patients identified with an uncommonly found yeast, Rhodotorula mucaliginosa. Last year, there had been an outbreak of an emerging multi-resistant bacterium, named KPC-Klebsiella which affected the Liver Transplant Unit at SJUH. This is a form of Super Bug that is resistant to almost all antibiotics and has been referred to by the Chief Medical Officer of England in her five year strategy to reduce antimicrobial resistance [1].The Liver Unit and certain other high-risk areas utilise a pro-active screening process to look for KPC-Klebsiella and similar organisms to help reduce the risk of further outbreaks in future. A multi-resistant Citrobacter, similar to the KPC-Klebsiella, was identified in two patients; whose only known contact in LTHT had been in an Outpatient clinic - additional measures were instituted to prevent such transmissions in these settings. Other CSUs have also now adopted similar pro-active surveillance for these super-bugs, which is consistent with the best practice advice from Public Health England published in December 2013 [2]. There was a temporal cluster of three cases where P aeruginosa was isolated in respiratory samples from babies on the neonatal unit at LGI. In view of outbreaks reported elsewhere, the water outlets were all tested at the time, in addition to the routine surveillance tests. No P aeruginosa was isolated from any water outlet in a clinical area. P aeruginosa was isolated in two sources in non-clinical areas, these isolates were not the same as those identified in the cluster cases and remedial actions were taken. Viral gastroenteritis (VG) The number of VG incidents reported across LTHT in 2014-15 was 172, which reflects the recent trend - having been 209 in 2013-14, 223 in 2011-12, and the recent peak of 343 in 2012-13. This was mirrored regionally where the weekly laboratory reports of norovirus in 2015 so far have been consistently below the mean for the weekly reports 2010 2014, except for a single week (source: PHE Laboratory Surveillance). The IPC team continued to use a flexible and pragmatic approach to the management of suspected outbreaks of VG, as advocated in Public Health England s guidance issued in 2012. The closure of bays rather than whole wards in most incidents has less impact on the overall delivery of a high-quality clinical service by the Trust. There were considerably fewer delayed discharges identified in 2014-15 (38), than in previous years, 2013-14 (128), 2012-13 (178), and 2011-12 (251). In addition to this more flexible approach, the Infection Prevention and Control Nurses (IPCNs) continued to provide seven day working with an on-call rota from September to April to coincide with the peak season for norovirus. Between 9am and 5pm on these days IPCNs visited affected wards to assess the on-going situation and, with Consultant Microbiologist support, were able to give further advice to ward staff and Clinical Site Managers about outbreak management and the status of affected wards. Further Page 9 of 21

reductions in incident duration and delayed discharges supports the utility of this approach and the success of clinical teams in limiting the transmission of VG in wards Inability to isolate The Source Isolation policy requires that any inability to isolate patients within two hours of identifying that it is necessary should be recorded and reported to the General Manager. In order to better manage our side room capacity, particularly along acute admissions pathways, the Trust s MRSA guidance was amended in September 2013 to recommend that nursing home residents were instead treated with daily chlorhexidine body washes rather than simply source isolated pending the results of MRSA screening. This change has been associated with a substantial reduction in recorded failure to isolate events. The numbers for different wards in the Acute Medical admissions pathway are displayed in Table 1. For the same wards in 2013-14, more than 400 such events were recorded, a reduction of over 70%. This change has not been associated with any identified increase in MRSA transmission - however, we continue to be vigilant. To assist further in prioritising which patients / organisms / conditions in LTHT need to be source isolated, a Red-Amber-Green (RAG) rated risk assessment tool has also now been developed. Table 1: Number of Failure to Source Isolate within two hours events occurring in the Acute Medical Admissions pathway in 2014-15 Page 10 of 21

4 SURVEILLANCE Surveillance is an important activity for IPC teams. Results can serve as an early warning system. They can also be used to compare practice between individuals, hospitals, and different trusts. Results are therefore an important means of challenging practice and promoting improvement. LTHT has been conducting voluntary surgical site infection (SSI) surveillance since January 2011 using a scheme managed by the Health Protection Agency (now Public Health England). SSIs are a potential complication of any patient s surgery and it is important to minimise the risk of these to prevent patient harm. In 2014-15 SSI surveillance was conducted in cardiac surgery both in adults (post coronary artery bypass graft (CABG) and non CABG) and paediatrics; and post Caesarian sections. Adult cardiac surgery was the only one of these in the national surveillance programme (PHE SSISS) - the others were internal surveillance. Adult cardiac surgery in LTHT had an SSI rate below the national benchmark. In November, regular surveillance for MSSA (in addition to MRSA) was initiated on the Neonatal Unit for babies born under 28 weeks; in order to try prevent infections by this organism in these very vulnerable patients. 5 IPC ORGANISATION AND MANAGEMENT There was stability with the Executive leadership remaining the same during 2014-15. Dr Yvette Oade (Chief Medical Officer) is DIPC; whilst Dame Suzanne Hinchliffe CBE, Chief Nurse, is the Deputy DIPC, although is now also Deputy Chief Executive for the Trust. Staffing Two major managerial changes within the IPC team occurred in 2014-15. Dr Miles Denton resigned from being Lead Infection Control Doctor (LICD) on 31st December 2014, after three years in the post, in which significant improvements have been seen in a wide range of infection prevention and control activities within LTHT. The team is most grateful for all his endeavours. Dr Tim Collyns took over as LICD from 1st January 2015. The IPC Matron left to take up a post in Corporate Nursing within LTHT in the autumn; and we were delighted to welcome Louise Lowry as the new IPC Matron, from March 2015, coming with extensive IPC experience in Doncaster. Sue Whiteley, Senior IPN, was the acting Matron in the intervening period, and we are most grateful for all her hard work during this transition phase. Gillian Hodgson continues as IPC Head of Nursing / Nurse Consultant, and remains a metaphorical rock regarding HCAI prevention within LTHT. The IPC team has undergone further re-alignment in 2014-5, in order to provide a more strategic / pro-active framework for IPC activities across the Trust; in addition to providing a named Infection Prevention Nurse, alongside a named Consultant Microbiologist, for each Clinical Service Unit as previously. This change in emphasis was partly in response to the recommendation from the Trust Development Authority (TDA) IPC expert in January 2014, that there should be a shift in culture to focus on proactive IPC duties and service improvement. Page 11 of 21

Additional Band 5 staff nurses have been recruited to strengthen the IPC staff resources for SSI; as well as ongoing review of alert organisms, such as C difficile, IPC training and undertake assurance audits One Consultant Microbiologist, and former Lead Infection Control Doctor for LTHT, Richard Hobson, left in January 2015. Currently there is at least one whole-time equivalent vacant Consultant Microbiologist post in LTHT - which, inevitably, is associated with reduced staff resource regarding HCAI prevention and antimicrobial stewardship. Policies and guidelines The IPC team continued to review and revise the Trust s IPC policies / clinical guidelines during 2014-15 in line with their review dates. The guideline regarding MRSA, notably regarding pre-admission screening, is being revised in response to revised guidance issued by the Department of Health in 2014. This guidance, on the basis of lack of costeffectiveness, is now recommending a much more targetted approach to MRSA screening against the previous national policy of near universal screening pre or on admission. However, it is important to note that the zero tolerance to MRSA bacteraemias remains in force. Root cause analyses (RCA) and Post-Infection Review. Any LTHT-attributable case of S aureus bacteraemia (MRSA and MSSA) or C difficile infection has a subsequent RCA to uncover what happened and why; and then to devise an action plan to prevent such infections in the future. Depending on the organism and investigation findings, some of these RCAs are then reviewed with the clinical director and head of nursing of the relevant CSU in meetings chaired by the DIPC or deputy DIPC. Where appropriate, the RCA findings will then also be discussed with representative(s) of our commissioners. New structures Various organisational developments have been made within the LTHT IPC regarding oversight / initiating improvement in 2014-5. Such changes include (re-)establishing: Inoculation injury and needle safety group: This group which is chaired by the LICD, and includes representatives from LTHT Health and Safety, Occupational Health, Procurement and Infection Prevention and Control; promotes and facilitates appropriate strategies to reduce the risk of sharps injuries within LTHT; as well as ensuring safe working practices are reinforced if such injuries do occur. This group was re-established in response to the recent recorded rise of such incidents within LTHT as has been seen nationally. Trust Decontamination Group. In response to various recent personnel changes within LTHT and recognition of a subsequent lack of overt oversight of the procedures for the appropriate decontamination of various pieces of equipment post use within LTHT; this Group, chaired by Head of Estates, has now been formed. Page 12 of 21

6 TRAINING AND EDUCATION Agenda Item 13.4 The IPC team continue to support CSU s delivery of mandatory training in IPC. An application has recently been submitted to commissioners for funding to use technology on multiplatform media in support of this. We continue to see improvements in the number of our staff completing IPC mandatory training (See Table 2), now > 90% for all staff. Table 2: Mandatory Training Compliance Rates 2012-2015. Mar-12 Mar-13 Mar-14 Mar-15 IPC Clin 22.79% 61.56% 79.69% 89.9% IPC Non-Clin 44.20% 68.84% 85.17% 93.4% 7 CAMPAIGNS The IPC team were involved in a number of innovative Infection Prevention campaigns during 2014-15: these included a range promoting Get Stool Smart, such as The Golden Commode This was a campaign / competition run from January 2015 - March 2015, to promote ward cleanliness, in particular to ensure appropriate cleaning / disinfection of ward commodes. Page 13 of 21

Members of the IPC team also appeared in a Start the Week in January 2015 to promote the campaign, competition and C difficile information cards. Coupled with a Screen Saver campaign in December 2014, including: Page 14 of 21

Hand Hygiene Agenda Item 13.4 Various initiatives were run. One was in Paediatrics, when the type of soap used in dispensers was changed, we were able to have bespoke fronts to the new dispensers. We therefore held a competition, asking the children to design images for the front of the dispensers. The photo below is when we had a hand hygiene campaign across the Trust in November, and the two winners of the competition came in and were presented with their own dispenser and a 50 voucher. The winning designs are also detailed below. These dispensers are now throughout the Children s Hospital at the LGI. Page 15 of 21

Hand wash basins have continued to be installed at all ward / unit entrances, to promote the washing of hands with soap and water by all individuals; whether staff, visitors or ambulant patients; on their entry and exit of such areas. Following extensive consultation with service users and staff, the team also developed a range of hand hygiene animations which focussed on how dirty hands can transmit infections. These were aimed specifically at patients, doctors and members of the public. Influenza vaccination of staff. This campaign is run primarily by LTHT Occupational Health. For the 2014/5 winter, 76.4% of front-line staff were vaccinated, thereby achieving the nationally set target of > 75%. We were only one of 35 trusts nationally that achieved this target. For LTHT, this equated to 8994 doses of the vaccine being given - which is the greatest number for any Trust in England..Antimicrobial stewardship Antimicrobial stewardship (AMS) is an overarching system of strategies to improve the use of antibiotics to benefit patient outcomes from infection, simultaneously minimising collateral damage (eg antimicrobial resistance, adverse events such as C.difficile infection, etc). The approach in LTHT is both pro-active (antimicrobial policy rule book, formulary and restriction, guidelines or pathways for treatment and prophylaxis), and reactive (antimicrobial prescription review, audit and feedback). New adult medication prescription chart A separate antimicrobial prescription section was introduced. This was designed to improve the quality of antimicrobial prescribing by including sections for indications and duration. Page 16 of 21

To overcome the historical problem of inadvertent administration in patients with penicillin allergy, these are now listed with trade names and generic names. All antimicrobials now need a daily review code completing. To improve the recording of MRSA colonisation status, a section has been included to improve rescreening. e-whiteboards identifying patients on antimicrobials A column has been developed on PPM+ to record those patients on IV or oral antibiotics to help staff doing board rounds to identify and review those on antibiotics. Revision of antimicrobial stewardship group The AMS group reviewed its terms of reference and membership in line with the updated PHE AMS guidelines (Start Smart then Focus). There is a new Chair from a bed-holding CSU. The format has changed to invite each CSU to present their AMS activity at least annually. Antimicrobial guidelines In 2014-5, 23 new guidelines were developed, and 70 updated. In total there are now 128 (88 adult; 40 paediatric) guidelines on Leeds Health Pathways (LHP). This represents one of the most comprehensive set of antibiotic guidelines in any acute trust. The number of hits on LHP Antimicrobial Guidelines grew by 18% and reached almost 37,000 per quarter (see Figure 1). Figure 1 - LTHT AB guideline hits 2008-15 Antimicrobial Audit and feedback Ward pharmacists continue to perform monthly point prevalence audits of antimicrobial prescribing standards and usage (See Table 3). Quality has increased by 4% and 3% to 95% indication and 93% duration. This represents year on year improvement. The number of patients receiving antimicrobials in 2014-5 increased by 2% to 30% compared to the previous year. However this figure remains significantly less than the 32% of LTHT s Page 17 of 21

patients receiving antimicrobials in 2008-9 and is also lower than the current mean in English hospitals of 34%. The proportion on IV antibiotics increased by 1% to 56%, and for those remaining on them for longer than 48 hours it increased by 2% to 57%, though the proportion judged to be able to be switched to oral treatment remains stable and low at 3%. Year No on Abs % % with indication % Abs with duration or review % of Abs orally % of Abs IV % of IV Abs given for >48hr % possible for oral switch 2008 35% 80% 62% 54% 46% 50% 10% 2009 28% 91% 72% 49% 52% 59% 6% 2010 27% 87% 87% 47% 53% 54% 3% 2011 27% 92% 92% 49% 51% 56% 3% 2012 28% 91% 91% 46% 54% 51% 3% 2013 28% 91% 90% 45% 55% 55% 3% 2014 30% 95% 93% 44% 56% 57% 3% At Trust level, 2014-15 has the best antimicrobial prescribing standards performance since records began Nov 2008. Only Women s CSU consistently scored less than 90%. Most other CSUs scored over 95%. Consultant microbiologists continue to expand the number of antimicrobial stewardship rounds undertaken across the Trust in order to re-enforce appropriate use of antimicrobials The 2014-5 mandatory antimicrobial audit was a repeat of the surgical or procedural prophylaxis audit. There was improvement across the board except guideline compliance which dropped slightly. This was due to re-dosing antibiotics in long operations. The surgical prophylaxis guidelines are to be amended to make this clearer. Specialties required to undertake the audit 2013-4 N=43 2014-15 N = 35 Allergy box fully completed 88% 95% Antibiotic given within 60 minutes of incision or tourniquet 57% 64% (documentation of time given) Antibiotic prescribed on drug chart 49% 64% Antibiotic only prescribed on anaesthetic chart 50% 38% Indication written on drug chart 26% 41% Guideline compliance 88% 85% Antimicrobial usage Total antimicrobial consumption as defined daily doses (DDD) had a non-significant increase (<2 SD) of 3% during 2014-5 compared to the previous year. This is not adjusted for activity. There was also a 2% increase in broad spectrum antibiotics, and a 4% increase in narrow-spectrum or targeted antibiotics. Page 18 of 21

Table 1 - Antimicrobial usage Agenda Item 13.4 AB group AB Class % of total Last 12 months Prev 12 months Diff qty Growth % AB Narrow / targetted 55% 514265 496176 18088 4% Broad "C drugs" 1G Ceph's 1% 9081 12985-3903 -30% 2G Ceph's 1% 11804 10724 1080 10% 3G Ceph's 1% 9968 8775 1193 14% Quinolones 8% 76950 78343-1394 -2% Clindamycin 2% 19997 18008 1989 11% Co-amoxiclav 24% 228829 222992 5836 3% Ultra broad Carbapenem 4% 35902 34730 1172 3% Pipercillin-Tazo 4% 35192 33551 1641 5% Grand Total 100% 941988 916285 25702 3% Total broad spectrum 45% 427723 420109 7614 2% Ultra broad (Penems / pip-tazo) 8% 71094 68282 2812 4% Broad "C drugs" 38% 356629 351827 4802 1% The main reason for this was the busiest winter on record for antimicrobial consumption (locally and nationally in primary care and hospitals) because of the poor coverage by the influenza vaccine this year (see figure 1). Figure 2 - antimicrobial consumption National medicines benchmarking software (Rx-Info Define) allows LTHT comparison against our peers normalised to bed-base (per 1000 beds). Despite LTHT appearing to have one of the highest CDI rates in England, our overall antibiotic use was slightly less than the mean, our use of antibiotics associated with higher risk of CDI is much lower than the mean. Page 19 of 21

Co-amoxiclav accounted for 24% of our broad spectrum antibiotic use, but LTHT is the 3rd lowest user in our peer group, but LTHT (097) is slightly higher than the peer group mean for ultra-broad spectrum antibiotics (carbapenem and piperacillin-tazobactam). Antimicrobial resistance The Leeds Pathology service started uploading data to the PHE 2nd generation surveillance scheme in March 2015, so no useful information was available to report. Page 20 of 21

CHALLENGES FOR 2015-16 Agenda Item 13.4 The IPC team will continue to work with CSUs to support their own IPC groups. CSUs will be encouraged to take greater ownership of their own HCAI agendas and for the IPC team to act in a supportive capacity. The aim is to reduce ALL patient harm caused by HCAIs, not just that caused by MRSA, MSSA and CDI. The Zero Tolerance approach to MRSA bacteraemias remains and LTHT is firmly committed to achieving this. The Trust s national CDI objective has been set at 119 for 2015-16. There is a postinfection review process whereby commissioners can agree that at least in some instances there were no significant lapses in care during a patient s pathway in LTHT. Such cases will not then count towards the Trust threshold, thus reducing the possible sanctions that could be imposed. However, LTHT is committed to preventing any patient in its care developing C difficile infection where possible. There will continue to be emphasis on the successful interventions that have been introduced recently, particularly the use of HPV cleaning technology. There will also be a greater focus on antimicrobial prescribing to ensure that patients are receiving the most appropriate antibiotics for their clinical condition. There is recognition that the evolving threat of antibiotic-resistant bacteria affects the whole population and that LTHT can and will play a significant part in reducing that threat. We will also remain watchful for any unanticipated or novel infections emerging in our global village in 2015-6, such as Ebola in 2014; such that we can meet any challenge to our patients and staff. References [1] Annual Report of the Chief Medical Officer 2011: Volume Two. Department of Health, 11 th March 2013. [2] Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae. Public Health England, December 2013. Report compiled by Tim Collyns, Lead Doctor for Infection Prevention and Control, with contributions gratefully received from all members of the IPC Team, including Philip Howard, Consultant Antimicrobial Pharmacist. July 2015 Page 21 of 21