Title: Multi-Resistant Acinetobacter Directorate: Infection Control Responsible for review: Ref:1337 Classification: Guideline Due for Review:23/03/2015 Document Control Infection Control Ratified by: Dr S Hoque, Director of Infection Prevention &Control Liz Childs, Director of Nursing & Patient Experience Care & Clinical Policies Sub-Group (TSDHCT) Applicability: All Practitioners CONTENTS Section Page 1. Introduction 2. Purpose 3. Scope 4. Responsibilities 5. Process of monitoring the effectiveness of this policy 6. Education and Training 7. Risk Factors for Acinetobacter 8. Treatment and Management 9. Screening of Patients 10. Discharge or Transfer of Patients 1. INTRODUCTION Acinetobacter baumanii is found in hospital environments and is capable of surviving for long periods in the environment and is relatively resistant to usual cleaning methods and drying. This is the main multi-resistant type of Acinetobacter but there are other types that are not antibiotic resistant. Large numbers of A. baumannii infections have recently been reported among military casualties repatriated from war zones in Iraq and Afghanistan. The working party guidance on the control of multiresistant Acinetobacter defines; multi-resistant Acinetobacter, as “isolates that are resistant to any aminoglycoside e.g. gentamicin and to any third generation cephalosporin e.g. cefotaxime”. 2. PURPOSE The purpose of this document is to provide staff with clear guidance on the actions they must take in order to prevent transmission of infection. 3. SCOPE 1 This policy applies to all employees of South Devon Healthcare Foundation Trust and Torbay and Southern Devon Health and Care NHS Trust including people holding honorary contracts, bank and agency staff, locums, trainees and students. Each member of staff has a personal responsibility to ensure they comply with these guidelines. 4. RESPONSIBILITIES 4.1 All Employees 4.1.1 To ensure they are aware and adhere to the guidelines, and have read and understood them which will enable them to carry out their work according to the Trust’s guidelines. 4.1.2 Attend all relevant training 4.2 Line Managers/Heads of Department 4.2.1 It is the responsibility of the manager to ensure that the policy is fully implemented and that all staff members comply with this guidance. 4.2.2 To clarify issues for the staff member who does not understand any part of the guideline. 4.2.3 To make staff aware of any changes or revisions to the guidelines 4.2.4 To ensure new versions of the guidelines are made available to staff and to ensure superseded copies are removed from the ward/department 4.2.5 To ensure all staff members attend the relevant training, including updates at the required frequency. 5. PROCESS OF MONITORING THE EFFECTIVENESS OF THIS POLICY 5.1 Surveillance Programme Alert organism surveillance from routine clinical specimens, is the method of Surveillance 6. EDUCATION AND TRAINING 6.1 All new staff members will attend the South Devon Healthcare Foundation Trust or Torbay and Southern Devon Health and Care NHS Trust induction programme. Infection prevention and control is a mandatory topic on this session and a mandatory yearly update. 6.2 All Trust clinical staff members will undertake annual mandatory infection prevention and control update. During both sessions standard infection control precautions are emphasised aimed at minimising the risks of transmission of infection 2 7. 7.1 RISK FACTORS FOR ACINEOBACTER Principles a) Severe illness and prolonged hospital stay particularly in ITU, or burns units b) Presence of surgical and other wounds c) Broad spectrum antibiotics treatment d) Urinary and vascular catheters e) Mechanical ventilation f) Parental nutrition 8. TREATMENT AND MANAGEMENT a. Acinetobacter frequently causes colonization rather than invasive infection. Each patient should be assessed to distinguish between colonisation and infection to decide whether antimicrobial therapy and/or other interventions are necessary. This should be discussed with the infection control team b. Acinetobacter infection of the blood or urinary tract may be associated with intravenous and urinary catheters respectively and correct management often entails removal of the catheter. 8.1 CONTROL OF INFECTION The main routes of transmission between patients and health care workers are probably via hands, and/or environmental contamination. Acinetobacter may contaminate the environment around a patient and survive there for several days. Surfaces or equipment (including medical equipment) that comes into contact with staff hands may also become contaminated. These environmental sites are potentially secondary sources for cross-infection. 8.2 HAND HYGIENE Effective hand hygiene is the most important measure to prevent and control the spread of antimicrobial resistant organisms. Hands should be decontaminated between each patient contact, including after wearing gloves, whether or not the patient is known to be colonized or not. If hands are soiled they should be decontaminated using soap and water. Hands that are physically clean, in-between patients and patient activities alcohol gel can be used 8.3 PERSONAL PROTECTIVE EQUIPMENT 8.3.1 A risk assessment must be undertaken before each patient care activity to assess the need for PPE. 8.3.2 Single use gloves and aprons must be worn when dealing with all patients body fluids in accordance with Standard Infection Control Precautions 8.3.3 Single use gloves and aprons must also be used for close patient environment contact for example bed making, moving and handling patient, cleaning room area and patient equipment 3 8.3.4 Hands must be washed after using gloves 8.4 PATIENT ISOLATION 8.4.1 Ideally, patients colonized or infected should be source isolated in single rooms. However, where there are larger patient numbers and insufficient isolation rooms, patients should be cohorted in bays on the open ward. Contact the Infection Prevention & Control Team (IPCT) for assistance if considering cohort in the bay. 8.4.2 Ensure that multi-resistant Acinetobacter is documented in the patient’s medical and nursing notes. Record the date of onset, frequency of symptoms and bed location. This is important for risk assessment and surveillance/monitoring purposes 8.4.3 Side rooms, should have adjoining toilet facilities. 8.4.4 Patients should be allocated their own specific equipment e.g. commode, moving and handling equipment, wash bowls and blood pressure cuffs. Where possible single patient use equipment should be used and disposed of as clinical waste on patient discharge or discontinuation of isolation precautions. 8.4.5 If patient is to be isolated a clear explanation should be provided to both the patient and their visitors. Ensure that visitors are aware of the additional precautions they will have to take. Visitors for patients on the main ward areas will not be expected to wear aprons or gloves unless they are attending to the patient e.g. helping to wash patients. Aprons should be disposed of at the patients’ bedsides. 8.4.6 In critical care, visitors will be asked to wear aprons whilst with the patient. Also in critical care there will be use of a closed tracheal suction system for all patients receiving mechanical ventilation. 8.4.7 If unable to nurse the patient in a side room they should be nursed next to the hand washing sink in the bay area 8.4.8 The following standard infection control precautions should be adhered to:      8.4.9 Wash hands before and after each contact with the patient and his/her environment and after using the toilet, bedpan or commode Wear disposable plastic apron and gloves when disposing of faeces, handling soiled linen, when in contact with exudates and any body fluids Protective clothing should be disposed of as clinical waste immediately the task is completed. Ensure the patient environment is clean and dust free. Strict attention must be paid to the cleaning of the patient’s surrounding environment with particular attention to high and low surfaces. The room should be full cleaned daily Change bed linen and discard in red alginate bags Acinetobacter can contaminate stock items stored in a patient’s room. Following a patient’s discharge any items should be decontaminated adequately (Bioquell™ only in SDHFT) or disposed of. All unused disposable items such as packets of swabs, syringes, and needles should be discarded (unless the stock is decontaminated with 4 (Bioquell™ only in SDHFT). Stocks of these items should be kept to a minimum to prevent wastage. 8.5 ENVIRONMENTAL CLEANING The direct patient environment should be cleaned daily with Actichlor plus 5,000ppm in the acute Trust and according to individual cleaning guidelines in Community Hospitals, taking special attention to horizontal surfaces and dust collecting areas. These include bed rails, curtain rails, beds, tables, ventilators, sinks, doorknobs and telephones. Electrical equipment that generates static need particular attention by nursing staff 8.6 OUTBREAK OF ACINETOBACTER Where there is more than one patient on the same unit/ward an outbreak team will be convened and an investigation undertaken. Case definition will be agreed and dates of admission and discharge ward and bed locations of all infected/colonised patients documented. Patient movement should be restricted. A cluster of multi-resistant Acinetobacter cases will require a root cause analysis to help identify and address the factors contributing to acquisition and transmission. This would be led by the appropriate Directorate lead for risk management with infection control input 8.7 TERMINAL CLEANING 8.7.1 Refer to Terminal cleaning of a ward following an outbreak of infection (Policy 1161) 9. SCREENING OF PATIENTS Screening of patients to identity colonised patients is recommended during outbreaks. Screening sites include the nose, throat, perineum and any wounds, sputum, tracheostomy sites and faeces or rectal swabs. This will only be done on the advice of the IPCT. 10. DISCHARGE OR TRANSFER OF PATIENTS It is the responsibility of the clinical team responsible for the patient to inform the receiving clinical and infection control team of the patient’s multi-resistant Acinetobacter status. This needs to happen before the transfer takes place. References Working Party Guidance on the Control of Multi-Resistant Acinetobacter Outbreaks Report of the joint working party 2006. Last reviewed: 24 July 2008. K.J. Towner. Acinetobacter: an old friend, but a new enemy. JHI 2009; 73:355-363 Department of Health (2008) The Health and Social Care Act 2008: Code of Practice for health and social care on the prevention and control of infections and related guidance London DoH 5 Department of Health (2007) Saving Lives: A delivery programme to reduce Healthcare Associated Infection including MRSA. London DoH Allen D, Hartman B. Acinetobacter Species. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases Philadelphia: Churchill Livingstone, 2000: 2339-2344. Urban C, Segal-Maurer S, Rahal JJ. Considerations in control and treatment of nosocomial infections due to multidrug-resistant Acinetobacter baumannii Clinical Infectious Diseases 2003; 36(10):1268-1274. 6 7 8