Title: Ref:1337 Classification: Guideline

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
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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
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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
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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
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(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
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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.
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