Alert Organisms Multi-Resistant Gram Negative Bacteria (MR-GNB) excluding MRSA

Infection Prevention and Control Assurance - Standard Operating Procedure 22 (IPC SOP 22) Alert Organisms Multi-Resistant Gram Negative Bacteria (MR-GNB) excluding MRSA Why we have a procedure? To ensure employees of the Black Country Partnership NHS Foundation Trust have a standard procedure to follow when caring for patients infected or colonised with multi-resistant gram negative bacteria (MR-GNB) to minimise and manage the risks of transmission. The Health and Social Care Act 2008: Code of Practice for the NHS for the Prevention and Control of Healthcare Associated Infections (revised January 2015) stipulates that NHS bodies must, in relation to preventing and controlling the risk of Health Care Associated Infections (HCAI), have in place appropriate core policies/procedures. Implementation of this procedure will contribute to the achievement and compliance with the Act. What overarching policy the procedure links to? This procedure is supported by the Infection Prevention and Control Assurance Policy Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Who does the procedure apply to? This document applies to all staff employed by or working on behalf of the Trust caring for patients as part of their role and job description. When should the procedure be applied? Effective prevention and control of healthcare associated infection (HCAI) must be embedded into everyday practice and applied consistently. This procedure must be applied when caring for patients colonised or infected with multi-resistant gram negative bacteria (MR-GNB). Additional Information/ Associated Documents Infection Prevention and Control Assurance Policy Hand Hygiene Policy Antibiotic Prescribing Policy Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard Infection Control Precautions Multi-resistant gram negative bacteria (MR-GNB) Page 1 of 15 Version 1.0 July 2016

Infection Prevention and Control Assurance - Standard Operating Procedure 2 (IPC SOP 2) - Transmission Based Precautions Infection Prevention and Control Assurance - Standard Operating Procedure 3 (IPC SOP 3) - Surveillance of Infection and Data Collection Infection Prevention and Control Assurance - Standard Operating Procedure 4 (IPC SOP 4) - Reporting Incidents of Infection to Public Health England and/or the Local Authority Infection Prevention and Control Assurance - Standard Operating Procedure 5 (IPC SOP 5) - Management and Recognition of Outbreaks of Communicable Infection/Disease Infection Prevention and Control Assurance - Standard Operating Procedure 6 (IPC SOP 6) - Isolation Care of Patients in Isolation due to Infection or Disease Infection Prevention and Control Assurance - Standard Operating Procedure 14 (IPC SOP 14) - Undertaking a Patient Infection Risk Assessment Infection Prevention and Control Assurance - Standard Operating Procedure 16 (IPC SOP 16) Sharing Information with other Health and Social Care Providers Infection Prevention and Control Assurance - Standard Operating Procedure 18 (IPC SOP 18) - Post Infection Review (PIR) Aims To reduce the risk of colonisation/infection by ensuring that Trust staff: Are alert to the risks of individual patients carrying or being infected by multi-resistant gram negative bacteria Are alert to the increased risk of infection or colonisation with patient transfers/ admissions from high risk oversees countries Isolate patients promptly with multi-resistant gram negative bacteria to reduce the risks of transmission To aid diagnosis by sending appropriate specimens to the laboratory in a timely manner To undertake a post infection review (PIR) on patients with multi-resistant gram negative bacterial infections to review contributory factors and lessons learned, as/ when required if deemed necessary by the Infection Prevention and Control Team Inform other healthcare providers of the patients infectious status when any transfers of care are planned either internally within the Trust or to external agencies/care providers To administer appropriate treatment as/when indicated To ensure good antibiotic stewardship to reduce the risk of multi-resistant gram negative bacteria acquisition Definitions Antibiotic stewardship ESBL Healthcare Acquired Infection (HCAI) Infection IPCT Coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration Extended spectrum beta lactamase which can destroy or inactivate broad spectrum antibiotics Healthcare associated infection (HCAI) refers to infections that occur as a result of contact with the healthcare system in its widest sense from care provided in the patient s own home, to general practice, hospital and nursing home care The presence of microorganisms on/in the body that is causing an adverse effect or host- response the person is unwell and has signs and symptoms of an infection Infection Prevention and Control Team Multi-resistant gram negative bacteria (MR-GNB) Page 2 of 15 Version 1.0 July 2016

Multiresistant gram negative bacteria Pathogenic Risk Assessment Gram negative bacteria are commonly found in the gastro-intestinal tract, in water and in soil. Some of these species of bacteria can develop multiresistance to antimicrobial drugs where they become collectively referred to as Multi-resistant gram negative bacteria or MR-GNB e.g. ESBLs, CROs, VRE, MDR Acinetobacter spp etc. A medical term that describes micro-organisms that can cause some kind of disease A process used to identify and potential hazards and analyse what could happen and to identify steps to be taken to reduce or minimise the risk What are Multi-Resistant Gram Negative Bacteria (MR-GNB)? Multi-resistant gram negative bacteria (MR-GNB) are defined as bacteria that are resistant to one or more classes of antimicrobial agents. They can also be referred to as multi-drug resistant organisms (MDROs). The organisms most often associated with multi-resistance are: Multi-resistant Acinetobacter baumanii Extended spectrum betalactamase producing organisms (ESBL-producers) Multi-drug resistant Pseudomonas aeruginosa A bacterium that causes infections such as pneumonia, particularly in people who have a compromised immune system. Resistant to both aminoglycoside (e.g. gentamicin) and a third generation cephalosporin (e.g. ceftazidime). When this pattern is combined with resistance to carbapenems (e.g. meropenem), such strains are labelled MRAB-C strains ESBL producers have the ability to hydrolyse and are therefore resistant to penicillins and broad-spectrum cephalosporins such as cefuroxime and cefotaxime. The major ESBL producers are Escherichia coli and Klebsiella species Pseudomonas resistant to varying combinations of antipseudomonal antibiotics e.g. ceftazidime, piperacillin, tazobactam, aminoglycoside, ciprofloxacin and carbapenems Multi-resistant gram negative bacteria (MR-GNB) Page 3 of 15 Version 1.0 July 2016

Carbapenemase-producing Enterobacteriaceae (CPEs) Carbapenem resistant organisms (CROs) Glycopeptide Resistant Enterococci (GRE) Vancomycin Resistant Enterococci (VRE) New Delhi Metallo-beta lactamase 1 (NDM-1) Any of a class of Gram-negative rod-like bacteria that occur in the gastrointestinal tract. Carbapenems are a class of beta-lactam antibiotics with a broad spectrum of activity against Gram-positive and Gram-negative bacteria e.g. meropenem and ertapenem. Whilst carbapenems are used for the treatment of Gram-positive infections, the emergence of Gram-negative bacteria with resistance to the carbapenem antibiotics is a health issue that has prompted unusually dramatic health warnings from the US CDC, Public Health England and the European CDC. Enterobacteriaceae are a large family of bacteria, including species such as E. coli, Klebsiella spp and Enterobacter spp. that live harmlessly in the gut but are common causes of UTI, intra-abdominal and bloodstream infections An enzyme that makes bacteria resistant to a broad range of beta-lactam antibiotics including the carbapenem family. The gene for NDM-1 first identified in 2009, is one member of a large gene family that encodes betalactamase enzymes called carbapenemases Multi-resistance in these organisms limits the therapeutic options available when they cause serious infections such as septicaemia and post-surgical sepsis. See Appendix 1 for key recommended control measures MR-GNB. Risk Factors for Infection with MR-GNB When MR-GNB are introduced into the healthcare setting, a number of factors aid the transmission and persistence of resistant strains in the environment. These include: The presence of vulnerable patients, such as those with compromised immunity from underlying medical conditions and those who have indwelling devices e.g. percutaneous endoscopic gastroscopy (PEG) tubes or urinary catheters The reservoir of infected or colonised patients The effectiveness of local infection prevention and control measures being applied consistently by healthcare staff. (see Appendix 1 and 2) Risk factors for infection with multi-resistant gram negative bacteria include: Antibiotic usage, particularly broad-spectrum agents Prolonged hospital stay Admission to ICU, renal or haematology/oncology units in an acute hospital Have permanent in-dwelling invasive devices e.g. percutaneous endoscopic gastroscopy (PEG) tubes or urinary catheters MR-GNB infections usually affect the most vulnerable of patients and can easily spread from patient to patient, leading to outbreaks of infection. Routes of Transmission for MR-GNB Antibiotics therefore must be prescribed judiciously to prevent multi-resistant organisms from spreading. MR-GNB may be spread in 2 main ways: Multi-resistant gram negative bacteria (MR-GNB) Page 4 of 15 Version 1.0 July 2016

The hands MR-GNB can spread on the hands of hospital and community staff. Hand washing therefore is an extremely important means of controlling infection The environment - The environment/equipment that comes into close contact with patients may also be contaminated and serve as a source of contamination of staff hands. Thorough cleaning of the environment/equipment is therefore another essential measure as MR-GNB may contaminate the environment around a patient and survive there for several days. MR-GNB have been found on staff uniforms, bed linen, beds, commodes, floors, blood pressure cuffs, stethoscopes, locker tops, chairs and in bathrooms, etc. Opportunities for transmission of MR-GNB beyond the acute care hospital setting results from patients receiving care at multiple healthcare facilities moving between acute care, mental health/learning disability care, primary care and long-term care facilities. Surveillance for MR-GNB When any type of infection is suspected it is normal practice to obtain a relevant specimen for microscopy, culture and sensitivity (M, C and S). All positive specimen results must be notified to the IPCT immediately by the Nurse-in-Charge caring for the patient. (The Microbiology laboratory will also usually inform the Infection Prevention and Control Nurse and the Consultant Microbiologist). Surveillance is a critically important component in the control of MR-GNB, allowing the early detection of newly emerging pathogens, monitoring epidemiological trends and measuring the effectiveness of interventions [see Infection Prevention and Control Assurance - Standard Operating Procedure 3 (IPC SOP 3) - Surveillance of Infection and Data Collection]. Screening swabs should only be taken on the advice of the Infection Prevention and Control Team. Screening is usually undertaken during suspected outbreaks (two new cases of MR- GNB detected in clinical specimens related in time and place) and in response to important incidents. Sites to be screened in both known positive and contact patients may include: Stool specimen Rectal swab Perineal swab Nose swab Groin swab Throat swab Wound swabs and leg ulcer swabs Swabs/specimens from invasive devices e.g. catheters, peg tubes etc. The Consultant Microbiologist and Infection Prevention and Control Team will advise on a case-by-case basis what if any screening specimens are required. Chronic carriers and those subject to frequent hospital admissions are a potential source of cross infection. Informing the Patient of their Infectious Status A patient who is found to be newly colonised or infected with MR-GNB should be informed about his/her colonisation/infectious status. The responsibility of informing the patient lies with the clinical team (i.e. consultant or their deputy) with appropriate documentation in the patient s healthcare record Multi-resistant gram negative bacteria (MR-GNB) Page 5 of 15 Version 1.0 July 2016

Key Recommendations for Management The healthcare team (including the Infection Prevention and Control Nurse and Consultant Microbiologist) should assess each patient to distinguish between colonisation and infection and then decide whether antimicrobial therapy and/or other interventions are necessary. Treatment if required is usually based upon susceptibility testing of the organism involved, as advised by the Consultant Microbiologist. Staff when caring for patients colonised or infected with a MR-GNB must implement good infection prevention and control procedures as detailed in appendix 1 and 2 and also refer to the following Infection Prevention and Control Standard Operating Procedures (IPC SOPs): Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard Infection Control Precautions Infection Prevention and Control Assurance - Standard Operating Procedure 2 (IPC SOP 2) - Transmission Based Precautions Infection Prevention and Control Assurance - Standard Operating Procedure 3 (IPC SOP 3) - Surveillance of Infection and Data Collection Infection Prevention and Control Assurance - Standard Operating Procedure 5 (IPC SOP 5) - Management and Recognition of Outbreaks of Communicable Infection/Disease Infection Prevention and Control Assurance - Standard Operating Procedure 6 (IPC SOP 6) - Isolation Care of Patients in Isolation due to Infection or Disease Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination - Cleaning, Disinfection and Sterilisation Infection Prevention and Control Assurance - Standard Operating Procedure 14 (IPC SOP 14) - Undertaking a Patient Infection Risk Assessment Caring for Patients in an In-Patient Setting The decision to isolate individual patients affected by MR-GNB should be based on the clinical needs and risk assessment. Ideally affected patients should be source isolated in single rooms [See Infection Prevention and Control Assurance - Standard Operating Procedure 6 (IPC SOP 6) - Isolation Care of Patients in Isolation due to Infection or Disease]. The highest priority for isolation should be given to those patients who have conditions which may facilitate the transmission of MR-GNB i.e. those with diarrhoea, draining wounds, incontinence, and copious respiratory secretions. It should be noted however that patients nursed in isolation may have increased anxiety and depression scores therefore efforts must be made by the healthcare team to counteract these potential adverse effects. The decision to discontinue isolation should always be made in conjunction with the Infection Prevention and Control Team on a case-by-case basis and may need to be revisited in the event that the patient requires further antimicrobial therapy. Hand Hygiene Effective hand hygiene is the most important measure to prevent and control the spread of MR-GNB. Hands should be decontaminated: Before touching a patient Before clean/aseptic procedures After body fluid exposure After touching a patient After touching a patient s environment. (See Hand Hygiene Policy for more information) Multi-resistant gram negative bacteria (MR-GNB) Page 6 of 15 Version 1.0 July 2016

Environmental cleaning Daily enhanced cleaning of the patient s environment including frequently-touched surfaces must take place daily as a minimum with sanitary spaces cleaned at least twice daily and immediately if visibly soiled [See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination - Cleaning, Disinfection and Sterilisation]. Environmental cleaning is vitally important in preventing the spread of infection. The cleaning regime incudes the standard daily clean followed by disinfection with 1,000ppm chlorine solution with special attention to horizontal surfaces, frequent touch points and dust collecting areas. Monitoring of adherence to cleaning practices is important for the success in controlling transmission of MR-GNB and other pathogens in the environment. Bedding must be changed daily for affected patients. When the patient is discharged/ transferred the room/bed-space must be terminally cleaned including curtain changes. Antimicrobial Stewardship Clinical teams must when prescribing antimicrobial treatment always: Refer to the Trust s Antibiotic Prescribing Policy and follow its guidance As part of patient ward reviews antibiotic prescribing should be reviewed, stopping any unnecessary prescriptions and changing those that do not comply with the Trust s policy guidelines, as should all medical teams when reviewing their patients Ward Pharmacists should check patient s prescription sheets as part of their review visits and liaise with the patient s doctor accordingly. (See Antibiotic Prescribing Policy for further information) Caring for Patients in Community Settings Patients with MR-GNB may be encountered in healthcare facilities outside of the hospital setting including long-term care facilities such as nursing homes and residential care settings, alternatively they may be cared for in their own home. Patients in their own homes do not require additional infection prevention and control precautions [see Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard Infection Control Precautions and Infection Prevention and Control Assurance - Standard Operating Procedure 2 (IPC SOP 2) - Transmission Based Precautions]. Restrictions should not be placed on normal social activity of any person living in the community because they have or previously had MR-GNB. Community staff visiting symptomatic patients should if possible visit last visit in the morning or afternoon and staff should avoid taking non-essential equipment into the patient s home. Any equipment used which is not single use disposable should be cleaned after use [See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination - Cleaning, Disinfection and Sterilisation]. Community staff must ensure strict hand washing with soap and water on completion of the visit (See Hand Hygiene Policy). Management of a Deceased Patient Measures must be taken as follows for patients known to be infected with MR-GNB prior to their death in addition to standard last offices: Infection control precautions are the same as those used when the patient was alive Multi-resistant gram negative bacteria (MR-GNB) Page 7 of 15 Version 1.0 July 2016

Ensure a terminal clean of the bed/bedspace is undertaken clean all equipment and the environment initially with detergent and water followed by chlorine solution 1,000ppm available chlorine. Bed screens/curtains should be changed/laundered Cadaver bags are NOT required Patient/Carer Information Information for the patient/carer can be found in the patient information leaflet see appendix 4. Discharge/Transfer of Patients with MR-GNB Transfers out - If a MR-GNB positive patient is to be transferred to another hospital or other care provider, the receiving ward/department/care home should be notified prior to the transfer taking place this is the responsibility of the Nurse-in-Charge and the IPCT will inform the IPCT at the receiving hospital. This allows the receiving institution to take the necessary measures to protect vulnerable patients [See Appendix 3 and Infection Prevention and Control Assurance - Standard Operating Procedure 16 (IPC SOP 16) - Sharing information with other health and social care providers]. Transfers between wards If a MR-GNB positive patient is to be transferred to another ward the receiving ward/department should be notified prior to transfer this is the responsibility of the Nurse-in-Charge, in addition the IPCT must also be informed of the planned transfer PRIOR to the transfer taking place so that appropriate information and advice can be given. Discontinuation of Infection Control Precautions Carriage of MR-GNB can be prolonged and clearance of MR-GNB is difficult to establish. Infection control special precautions must not be discontinued without the approval of the IPCT. N.B When a patient with MR-GNB is transferred/discharged the room/bedspace must have a terminal deep clean undertaken before its re-use this includes replacing curtains. Contact the Estates and Facilities Helpdesk to arrange on 0121 612 8010 or ext.: 8010 Reporting All cases of MR-GNB reported to the Infection Prevention and Control Nurse will be immediately escalated to the Director for Infection Prevention and Control. Formal reports following the completion a Post Infection Review will be submitted to the Infection Prevention and Control Committee and the Quality and Safety Steering Group if deemed necessary by the Director of Infection Prevention and Control to ensure lessons learned can be shared across the organisation. Post Infection Review (PIR) for Patients with MR-GNB Infection MR-GNB can increase a patient s length of stay in hospital, the likelihood of complications and reduce the chances of a successful recovery. The Infection Prevention and Control Team may recommend that a Post Infection Review (PIR) is completed to identify any critical points and contributory factors, and determine whether any preventative action(s) and improvement action(s) can be undertaken to reduce or control incidents of HCAI [see Infection Prevention and Control Assurance - Standard Operating Procedure 18 (IPC SOP 1) - Undertaking a Post Infection Review and Infection Prevention and Control Assurance - Standard Operating Procedure 4 (IPC SOP 4) - Reporting Incidents of Infection to PHE or the Local Authority]. Multi-resistant gram negative bacteria (MR-GNB) Page 8 of 15 Version 1.0 July 2016

MR-GNB remain uncommon in a mental health/ learning disability environment therefore the review of cases as/when they occur may assist in any future case management. Outbreaks/periods of increased incidence of MR-GNB In the unlikely incident of a period of increased incidence of MR-GNB involving patients and or staff, the Infection Prevention and Control Team will convene an Outbreak Management Group if deemed necessary [see Infection Prevention and Control Assurance - Standard Operating Procedure 5 (IPC SOP 5) - Management and Recognition of Outbreaks of Communicable Infection/Disease]. Where there is evidence of MR-GNB transmission and acquisition, the advice of the Consultant Microbiologist will be sought. Where do I go for further advice or information? Infection Prevention and Control Team Physical Health Matron Your Service Manager, Matron, General Manager, Head of Nursing, Group Director Your Group Governance Staff Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust s Mandatory and Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies. Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy Data Protection Act and Freedom of Information Act Please refer to overarching policy. Multi-resistant gram negative bacteria (MR-GNB) Page 9 of 15 Version 1.0 July 2016

Appendix 1 Recommendations for the control of specific MDR-GNB Specific MDR-GNB Control Measures Duration for control measures Multi-resistant Acinetobacter baumanii Extended spectrum beta-lactamase producing organisms (ESBL-producers) Multi-drug resistant Pseudomonas aeruginosa Carbapenem Resistant Enterobacteriaceae (CRE) Glycopeptide Resistant Enterococci (GRE) Vancomycin Resistant Enterococci (VRE) New Delhi Metallo-beta lactamase 1 (NDM-1) 1. Infection risk assessment MUST be completed - see IPC SOP 14 along with an evaluation of the measures already in place. (Also see flow chart in appendix 2 of this document). 2. Staff must inform the Infection Prevention and Control Team promptly of any patient admitted with a previous history of MDR-GNB carriage. 3. Initially treat as colonised - therefore isolation recommended The Infection Prevention and Control Team to advise following completion of a risk assessment - see IPC SOP 6. 4. Standard and transmission based infection control precautions to be implemented without delay- see IPC SOPs 1 and 2. 5. Effective hand hygiene before and after contact with the patient and their environment by all healthcare staff see Hand Hygiene policy 6. Correct use of Personal Protective Equipment PPE by all healthcare staff see IPC SOP 1. 7. Enhanced daily environmental/equipment cleaning with 1000ppm available chlorine solution - see IPC SOP 7. 8. Change bed linen, towels and personal clothing daily treat as infected linen - see IPC SOP 1. 9. Judicipus antimicrobial treatment use by the Clinical Team with input from the Consultant Microbiologist. 10. Education of staff including all healthcare workers and cleaning staff in relation to MR-GNB should be intensified. *Please note MRSA is covered in a stand-alone procedure see IPC SOP 19: Alert organisms MRSA (Meticillin Resistant Staphylococcus Aureus) For the duration of their admission unless otherwise advised by the IPCT Multi-resistant gram negative bacteria (MR-GNB) Page 10 of 15 Version 1.0 July 2016

Appendix 2 Flow Chart for MDR-GNB Admission and Screening Patient admitted to the Trust in-patient unit. Ask the following questions for patient with Infection Risk Assessment Score of 6 or more: Has patient been transferred directly from a healthcare facility abroad? Has patient been an inpatient in a hospital abroad within the last 12months? Has patient a previous history of colonisation or infection with CRE/CRO/MERS CoV Has patient been an inpatient in a UK hospital known to have had problems with the spread of CRE/CRO/ MERS CoV NO YES Follow normal admission processes Isolate patient in single-room with en-suite facility (within 2hrs) Instigate infection prevention and control precautions (Standard and Transmission based precautions see IPC SOPs 1, 2 and 6) Seek advice from IPCT and Consultant Microbiologist Take screening swabs/microbiology samples as advised by the IPCT or Microbiologist Patient to be excluded from communal groups/therapies until advised otherwise by the IPCT or Microbiologist Patient should remain in isolation until 3 negative consecutive screens, taken 48hrs apart or as advised by the Microbiologist or IPCT. All screening specimens Negative x 3 No further actions NO YES Inform patient of infection/carrier status Continue all precautions and screening as advised by the IPCT Flag patient records (Infection Risk Warning) Review clinical management including use of antimicrobials and invasive devices e.g. whether required. Good communications in clinical area while an inpatient and with GP and other care providers on discharge/transfer Multi-resistant gram negative bacteria (MR-GNB) Page 11 of 15 Version 1.0 July 2016

Appendix 3 Example of a Proforma Letter to GP/other Healthcare Provider Date: Dear Doctor/Healthcare Professional RE (insert patient s full name and NHS Number): The patient named above was recently an in-patient on Ward. During their hospitalisation, this patient was diagnosed as having a Multi Resistant Gram Negative Bacteria (MR-GNB) (specify organism): and was treated with: Antibiotic Dose Route Start date Duration of treatment We are therefore writing to inform you that there is a small chance following discharge/transfer that: Your patient could relapse with the infection or Remain colonised with the organism for a significant period of time. If the patient requires re-admission to a healthcare facility in the future please inform them that your patient previously had an infection/colonisation with this organism. Yours sincerely, Multi-resistant gram negative bacteria (MR-GNB) Page 12 of 15 Version 1.0 July 2016

Author: XXX Department: XXX Ref.No: XXX Issue Date: XXX Review Date: XXX What happens if I am admitted to a hospital again in the future? You may be given a single room and screening swabs may be taken and sent to the laboratory. If these swabs are found to be clear you may be moved into the general ward where you can mix freely with other patients. Appendix 4 Multi-Resistant Gram Negative Bacteria (MR-GNB) Infection prevention and control is everyone s responsibility. Patients and visitors all have an important role to play in preventing the spread of healthcare associated infections. Information for patients and Information for patients and carers If you require further advice or information, please contact the Trust s Infection Prevention and Control Team or a member of the ward/department staff. Multi-resistant gram negative bacteria (MR-GNB) Page 13 of 15 Version 1.0 July 2016

What are Multi-resistant gram-negative bacteria (MR-GNB)? Bacteria or germs are found on everyone, both inside and outside the body. Gram-negative bacteria are germs that are often found living naturally in the human gut. For many reasons a small number of these bacteria can become resistant to the antibiotics that they may have been sensitive to in the past. This may mean that some of the traditional antibiotics are no longer effective for treating infections caused by these germs. Multi-resistant Gram-negative bacteria is a term covering many different bacteria, including Escherichia coli (ESBL) and many others. It does not include MRSA. Sometimes they are referred to as Extended-spectrum Beta lactamases which is shortened to ESBL. How did I get it? Gram-negative bacteria can be passed from person-to-person directly or indirectly via contamination of hands or objects and can then be introduced into the mouth, wounds or other entry sites into the body. They can also be acquired from another part of your own body. Currently this is found most often in the long-term care or in the critical care settings. The problem is usually first identified, however, when an individual presents to hospital and a specimen of urine, blood or a wound swab is submitted to the microbiology lab to be tested. Do these germs always cause infection? No, people can often carry the bacteria without causing any harm (called colonisation ) but sometimes may lead to infection. What infections do MR-GNB cause? Most commonly Multi-resistant Gram-negative bacteria are detected in the urine. However they may also be found in other sites such as respiratory tract and wounds. How can the spread of these bacteria be prevented? People in hospital are more at risk of infections because their body defences are weakened by illness, surgery, medication and the presence of invasive devices like drips and urinary catheters. Patients with positive sputum samples who are coughing and patients with exfoliative skin conditions and positive wound swabs have the greatest risk of spreading the infection. Patients with Multi-resistant Gram-negative bacteria are usually transferred to a single room. Healthcare staff involved in direct care will wear gloves and a plastic apron whilst in the room to reduce the risk of transferring bacteria to other patients. The prevention of spread of the bacteria relies mainly on everyone having good hand hygiene practices, particularly after using the toilet or caring for wounds or devices such as urinary catheters. Your room will be cleaned daily and any Multi-resistant equipment that gram is used negative on multiple bacteria patients (MR-GNB) will be cleaned after each Page use. 14 of 15 Version 1.0 July 2016 Can it be treated? People who are simply colonised (have no symptoms of infection) with the bacteria do not require antibiotic treatment. In most people these antibiotic resistant bacteria will disappear on their own over time. However, despite being resistant to many of the usual antibiotics, be reassured that treatment options are still available if an infection should occur. Will I have to stay in hospital? People may not have to stay in hospital until the infection is cleared up. You will be able to go home when your general condition allows regardless of whether you are still carrying the bacteria or not. Can I have visitors? It is very unlikely that visitors or relatives will be affected. However all visitors should use the sanitizing gel on entering and leaving the ward. Visitors should not sit on the bed and should not visit if they are unwell or have diarrhoea or vomiting. You should make sure that you wash your hands before eating and after using the toilet. Visitors should not go and visit any other patients on the ward (unless they speak to a staff nurse first). What about my laundry? Personal laundry should be bagged and kept in your room for relatives/friends to collect as soon as possible. Items should be washed separately from the rest of your families laundry in the usual way with normal detergents ideally on a hot wash (60 C or above if the material will withstand the temperature). Hands must be washed with soap and water after handling your personal soiled linen. What happens when I go home? The presence of the bacteria (which may disappear quite naturally) should not affect you or your family at home. Usual personal hygiene and household cleaning is sufficient and there are no restrictions to activities or visitors. If you have a wound and it becomes red, swollen or oozes, or if you develop a fever then please contact your GP as usual. Your GP will be informed via your discharge documentation of the type of infection / colonisation you have had. Good hand hygiene is the most important way to prevent the spread of Clostridium difficile Posters showing the best way to wash your hands are available at the hand wash sinks.

Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-COI-POL-05-22 New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Control of Infection Executive Director of Nursing, AHPs and Governance Infection Prevention and Control Team Infection Prevention and Control Committee May 2016 Month/year SOP was approved July 2016 Next review due July 2019 Disclosure Status B can be disclosed to patients and the public Review and Amendment History Version Date Description of Change 1.0 July 2016 New Procedure established to supplement Infection Control Assurance Policy Multi-resistant gram negative bacteria (MR-GNB) Page 15 of 15 Version 1.0 July 2016