TRUST POLICY AND PROCEDURES FOR CARBAPENEM RESISTANT ENTEROBACTERIACEAE (CRE) AND CARBAPENEM RESISTANT ORGANISMS (CRO) Reference Number POL- IC/1082/14 Version 1.2.0 Status Final Author: Helen Forrest Job Title Lead Nurse - Infection Prevention and Control Version/ Amendment History Version Date Author Reason 1 June 2014 D. Gnanarajah H. Forrest New Policy 1.1 October 2014 H. Forrest Minor amendments 1.2 November 2017 H. Forrest Review and Update Intended Recipients: All medical and clinical staff, Clinical Directors, Service Managers, Divisional Nursing Directors, Divisional Medical Directors, Clinical Governance Leads and Matrons. Training and Dissemination: Dissemination via the Trust Intranet. Two yearly infection prevention and control update training. To be read in conjunction with: Trust Policy for Standard Infection Control Precautions; Trust Policy and Procedure for Hand Hygiene; Trust Policy for Isolation. Trust policy for cleaning and disinfection. Trust policy for Inoculation incidents. Trust policy for sharps safety In consultation with and Date: Infection Control Operational Group (November 2017) Infection Control Committee (November 2017) EIRA stage one Completed Yes Stage two Completed N/A Approving Body and Date Approved Infection Control Committee Date of Issue January 2018 Review Date and Frequency Contact for Review January 2021 and every 3 years Lead Nurse Infection prevention and Control 1
Executive Lead Signature Approving Executive Signature Director of Patient Experience and Chief Nurse Director of Patient Experience and Chief Nurse 2
Contents Section 1 Introduction 4 2 Purpose and Outcomes 4 3 Definitions Used 5 4 Maintaining the Policy and Procedure for CRE/CRO 5 4.1 Early recognition of Patients who may be Colonised / Infected 5 4.2 Acting on Results of Screening / Isolation of Patients 6 4.3 Infection Prevention and Control Measures 7 4.4 Screening of Contacts 8 4.5 Environmental and Equipment Cleaning / Disinfection 9 4.6 Communication 9 5 Monitoring Compliance and Effectiveness 10 6 References 11 Appendix 1 Flowchart for the Screening of Patients for CRE and Isolation Requirements 12 3
TRUST POLICY AND PROCEDURES FOR CARBAPENEM RESISTANT ENTEROBACTERIACEAE (CRE) AND CARBAPENEM RESISTANT ORGANISMS (CRO) 1 Introduction Carbapenems are a valuable family of antibiotics normally reserved for serious infections caused by antibiotic resistant Gram negative bacteria, including Enterobacteriaceae. They include meropenem, ertopenem, imipenem and doripenem Enterobacteriaceae are a family of bacteria, (e.g. E.Coli, Klebsiella, Enterobacter, Serratia, Citrobacter that usually live harmlessly in the gut of humans and animals. These organisms can cause urinary tract infections, intra-abdominal and blood stream infections. Enterobacteriaceae can acquire resistance to Carbapenem antibiotics. If resistance is identified in this family of bacteria they are classed as Carbapenem Resistant Enterobacteriaceae or CRE. Carriage of CRE can be detected by rectal screening. Non Enterobacteriaceae bacteria, e.g. Pseudomonas, Acinetobacter, can also develop resistance to Carbapenems. These are classed as Carbapenem Resistant Organisms or CRO. CRO will be detected on clinical samples. CRO are not as easily transmitted to other bacteria like CRE. Carbapenmases, a group of clinically important β-lactamases that efficiently hydrolyse most β-lactams including the carbapenems, have emerged and spread among the Enterobacteriaceae family of bacteria worldwide. The emergence of carbapenemaseproducing Enterobactericeae (known as CPE) is currently a major public health concern, with a rapid increase in carbapenem non-susceptible Enterobacteriaceae worldwide. The number of referrals of these isolates to these organisms to Public Health England (PHE) is increasing year-on-year. These organisms are endemic in other areas of the world and there is strong evidence that when patients infected or colonised with CPE are transferred across borders this increases the risk of CPE being introduced into healthcare facilities in the country of destination. The clinical significance of infection with Carbapenem resistant organisms (CRE / CRO) is considerable. Due to their resistance to multiple antimicrobials, there are very limited therapeutic options available to treat infections caused by CRE/CRO. In addition to this, there are fewer new novel antimicrobial agents in the developmental pipeline and at present there are insufficient drug development programmes to provide therapeutic cover in 10-20 years. It is already evident that human infections with CRE/CRO are associated with poorer patient outcomes, increased morbidity, mortality, prolonged hospital stay and higher hospital costs. 2 Purpose and Outcomes This purpose of this policy is to set out the infection prevention and control standards for patients with CRE/CRO colonisation or infection and to advice staff on the detection of colonised or infected patients to prevent, therefore reducing the risk of spread within the hospital 4
3 Definitions Used Carbapenem Gram negative bacteria Colonised Outbreak Decontamination Exposure Pathogen A valuable family of beta lactam antibiotics normally reserved for serious infections caused by antibiotic resistant Gram negative bacteria A class of bacteria that do not retain the crystal violet stain used in the Gram staining method of bacterial differentiation. Gram-negative bacteria cause infections including UTI, hospital acquired pneumonia, intra-abdominal infections, bloodstream infections, abdominal wound or surgical site infections, neonatal sepsis and meningitis in healthcare settings. Gram-negative bacteria are resistant to multiple drugs and are increasingly resistant to most available antibiotics. Bacteria present on the body without causing disease or infection. An outbreak may be defined as: - An incident affecting two or more people thought to have a common exposure to a potential source, in which they experience similar illness or proven infection. - A rate of infection or illness above the expected rate for that place and time, where spread is occurring through cross infection, or person-to-person. The process of cleansing an object or substance to remove contaminants such as micro-organisms or hazardous materials A state of contact or close proximity to a pathogen, by ingesting, breathing, or direct contact, e.g. on skin Micro-organism capable of causing disease 4 Managing the Policy and Procedures for CRE and CRO 4.1 Early Recognition of Patients who may be Colonised / Infected with CRE 4.1.1 Admission Screening for CRE On admission patients must be assessed to determine if in the last 12 months the patient has: Been an inpatient, with an overnight stay, in a hospital abroad 5
OR Been an inpatient in a hospital in Manchester, Liverpool or London (these areas have had a problem with spread of CRE), with an overnight stay * OR Previously been colonised or had an infection with CRE or close contact with a person who has. Infection Prevention and Control will advise if other hot spot areas have been identified and should be included in the screening criteria If one of more of the above applies the following specimens should be sent to microbiology: Rectal swab or stool specimen o Rectal swab is taken it must have faeces present o Stool sample - collect a pea sized amount of stool to send to the laboratory, in a blue stool sample container Wound swab surgical wounds, leg ulcers, pressure sores, breaks in skin, other lesions Invasive device site, PEGS, Peripheral cannula, drain sites, central lines etc Urine sample if patient catheterised Sputum sample if patient is productive Label all specimen forms as CRE screening Screening must take place within 24 hours of admission to DTHFT. Any patients screened must be isolated under contact precautions unless the patient has diarrhoea when enteric precautions must be instigated. Patients admitted as a day case do not require screening unless the decision to admit for an overnight stay is made. Carbapenem resistance in non Enterobacteriaceae bacteria will be identified from clinical samples, e.g. sputum, wound swabs. Rectal screening or stool samples are not indicated. 4.2 Acting on Results of Screening / Isolation of Patients Any patient screened for CRE, following the criteria above, must be isolated immediately, with ensuite facilities under contact precautions. If the patient has diarrhoea they should be isolated under enteric precautions. Negative on screening the patient should remain in isolation until a further two samples test negative, samples being taken 48 hours apart. Once achieved the patient can be removed from isolation, no further screening is required. Should any of the samples test positive the patients should be managed as a positive case Positive on screening (or from a routine clinical sample from this admission episode) the patient must remain in isolation. The patient should be advised to practice good hand hygiene. Whilst in hospital, weekly screening samples are advised to maintain an understanding of the patient s risk status 6
Experience from other areas of the UK has shown that, on some occasions, patients apparently cleared of CRE can re-colonise to a detectable level in the gut. A previously positive individual with subsequent negative results can revert to a positive state, especially after a course of antibiotics. Carbapenamases are enzymes that destroy carbapenem antibiotics, conferring resistance. These are made by a growing number of Enterobacteriaceae strains. There are different types of carbapenemases, with differing transmission risks. The reference laboratory will identify the specific carbapenamase mechanism. The infection prevention and control team, following consultation with a Consultant Microbiologist, will discontinue isolation on patients if it is identified that the carbapenamse mechanism is of the type with a lower transmission risk. Should a patient who is colonised or has an infection require a diagnostic test or procedure that cannot be undertaken in the patient s room, the procedure should be planned at the end of the day s list and the equipment / furniture where the patients has had contact cleaned using a chlorine releasing agent at 1000ppm av. Chlorine. Patients with a known or recently confirmed CRE infection / colonisation who are visiting an outpatient area must go directly into an examination room, under standard precautions and not stay in the waiting area. The patient must remain in the room until the consultation is over, then directly leave the department. Patients with a known or recently confirmed CRE infection / colonisation who are admitted to a high risk day case area e.g. chemotherapy day case, renal dialysis unit must be isolated for the duration of their stay under contact precautions. Terminal cleaning of the isolation room, furniture and re-useable equipment should be undertaken using a chlorine releasing agent at 1000 ppm av. Chlorine. Curtains must be changed if the patient has had diarrhoea whilst in the department. This should be arranged via the facilities helpdesk. It is not necessary to isolate contacts whilst awaiting screening results cohort such contacts if possible. Patients identified as CRO positive from a clinical sample should be isolated, under contact precautions for the duration of their hospital stay. Re-screening is not routinely advised. Patients previously identified as CRE or CRO positive should be isolated on readmission to Derby Hospitals. Rectal swabs / stool sample and a swab of site identified as positive should be taken for patients that were CRE positive previously. Swabs / samples of previously positive sites should be taken for patients previously identified as CRO positive. Rectal swabs / stool samples are not required. Screening is not required for contacts of CRO positive patients 4.3 Infection Prevention and Control Measures All relevant staff must be made aware that the patient is a suspected or confirmed CRE/CRO colonisation or infection Decolonisation is not advised for the following reasons: 7
Skin decolonisation these bacteria generally colonise the gut rather than the skin; therefore skin decolonisation would not be effective. Gut decolonisation (by prescribing antibiotics) is not routinely recommended as there is concern that their use would contribute to increasing resistance in the long term 4.3.1 Hand Hygiene Hand decontamination must be carried out after each contact with the patient and their environment; this must be with soap and water if a patient has diarrhoea / is cared for under enteric precautions It is vital that all patients are assisted to wash and dry their hands with soap and water after using the toilet and before eating. Visitors must be encouraged to wash and dry their hands with soap and water when entering and leaving the isolation room 4.3.2 Personal Protective Equipment All healthcare staff are required to wear disposable long-sleeve gowns and gloves when caring for patients if any part of a staff uniform, not protected by an ordinary disposable apron, is expected to come into contact with the patient, e.g. when assisting movement for a dependant patient. Masks are NOT routinely required Visitors should wear disposable aprons and gloves whilst visiting the patient if assisting with personal care. Gloves and aprons should be removed and hands washed with soap and water after the care episode has ended. 4.4 Screening of Contacts Screening of contacts is only required if the index patient is CRE positive and the patient has not been isolated on admission, or during an outbreak situation. Screening of patients in the same setting is not normally required if the case was identified on admission and the patient isolated immediately Screening of patient contacts must be undertaken if the case has remained in a bay with other patients before, or despite, having a positive CRE result, the IPCT will advise. Screening should be undertaken on a weekly basis for a period of 4 weeks after the last case was identified. Screening should be restricted to patients who remain in hospital. Any patients screened as a contact found to be positive must be isolated immediately. If patients are found to be positive following contact screening, consideration, following discussion with PHE, will be given to screening the whole ward and discharged patients. Screening of household contacts and healthcare staff is not required. There is no compelling evidence to suggest that screening the household contacts or healthcare workers to check for colonisation will provide additional benefit in controlling spread in the healthcare setting 8
4.5 Environmental and Equipment Cleaning / Disinfection CRE/CRO can be eliminated from the environment and equipment by stringent cleaning and disinfection. Daily cleaning of the isolation room must take place using a chlorine releasing agent at 1000 ppm av. Chlorine and single use disposable cloths. Microfibre is not to be used in isolation rooms. Decontamination is most crucial following a patient leaving a specific area. 4.5.1 Specific Cleaning Requirements Isolation Rooms Terminal cleaning of the isolation room, furniture and re-useable equipment should be undertaken using a chlorine releasing agent at 1000 ppm av. Chlorine, enhanced by 6% hydrogen peroxide. Curtains must be changed and laundered. Unused wrapped single use items in the patient s room should be discarded as they may have become contaminated by hand contact. The burden of this may be minimised by keeping limited stock in the patient s room. Emergency Department A standard between patient clean should be undertaken if a patient is identified as requiring screening in the Emergency Department. Outpatient Department / Diagnostic tests or Procedures Should the patient visit another area for diagnostic test or procedures, e.g. X-ray, the surfaces and equipment used on/by the patients must be cleaned with a chlorine releasing agent at 1000 ppm av. Chlorine. Hydrogen Peroxide decontamination is not necessary. Endoscopy and Theatre Areas Endoscopy and theatre areas should discuss cleaning requirements with the IPCT. There are no extra decontamination requirements for endoscopes above the normal organisational procedures. Any attached cameras / equipment which cannot be thermally decontaminated should be protected using a single use covering and thoroughly chemically disinfected between patients once the covering has been removed. 4.6 Communication The patient must be informed of their diagnosis by the medical team and treatment options discussed. An information leaflet should also be given to the patient where appropriate. The Infection Prevention and Control Team will visit the patient when they have been told of their diagnosis to answer any additional questions the patient or their family may have. 4.6.1 Early Communication on Discharge or Medical Transfer of Patients Receiving organisations must be informed of patients that are colonised or infected with CRE/CRO, those screened on admission that are negative and the number of negative screens achieved and those patients screened as contacts prior to transfer. 9
The Infection Prevention and Control Team (IPCT) must be informed of all transfers as they will liaise with the IPCT of the receiving healthcare provider. Patient s are not to be transferred between base wards within the Trust unless it is clinically critical for the patients to do so. The IPCT must be informed of any internal transfer plans. Communication is required with The patient so they understand on discharge: Their current status (e.g. infection cleared but may still be a carrier) and the need for good hand hygiene That, should they or a close contact be admitted to hospital / healthcare setting for any reason, they need to inform healthcare staff of the exposure Healthcare colleagues Microbiologists, IPC teams in receiving healthcare providers, care homes, primary care services especially the GP plus any other relevant care provider along the patient pathway, including social care Any Trust where there is regular inter-trust transfer from one unit to another (where one unit is affected) The patients GP must be informed of the CRE/CRO diagnosis via e-discharge. 5. Monitoring Compliance and Effectiveness Monitoring Requirement : Monitoring Method: Report Prepared by: Monitoring Report presented to: Frequency of Report Any non-compliance with this policy will be reported using the Trust reporting mechanisms The Infection Prevention and Control Team will monitor compliance during ward visits. Report on non-compliance with this policy will be prepared by the relevant divisional IPC lead or Lead Nurse IPC Infection Control Operational Group items escalated to Infection Control Committee as necessary As required 10
6. References Public Health England Guidance. Acute Trust toolkit for the detection, management and control of carbapenemase producing Enterbacteroaceae. December 2013 Health Protection Agency. Standards for Microbiology Investigations. Laboratory Detection and Reporting of bacteria with Carbapenem Hydrolising β-lactamases (Carbapenemases) 2013 11
Appendix One Screening of Patients for CRE and Isolation Requirements (Applies to patients admitted for an overnight stay, or patients admitted to Renal Dialysis Unit or Combined Day Unit) Patient identified as having admission to hospital abroad, Manchester, Liverpool or London, with an overnight stay, in the previous 12 months* or previously been told they are CRE positive YES NO Isolate under contact precautions. If the patient has diarrhoea isolate under enteric precautions Inform Infection Prevention and Control No further action required Screening required Rectal swab or stool sample (if stool sample collect pea sized amount to send to lab in a blue stool sample container) Wound swab Invasive device site swab Urine sample if catheterised Sputum if productive If screen results negative: If screen results positive: Isolate until further 2 negative samples achieved, each 48 hours apart Once achieved the patient can be removed from isolation Should any of the samples test positive manage as a positive case Patient to remain in isolation until isolation discontinued by IPCT Undertake weekly screening Patients to be isolated on readmission to DHFT and screening performed Screening of contacts is required if the index case was not isolated on admission It is not necessary to isolate contacts whilst awaiting screening results *This includes Renal Dialysis and Combined Day Unit 12