Guidance for General Practice SAMPLE · Preventing Infection Workbook 8 2. Infection prevention and...

Guidance for General Practice

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Name

Job Title

Preventing

Infection

Workbook Guidance for General Practice

3rd Edition

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Contents Page Indicate sectionsto be completed

1. Introduction 4

2. Infection prevention and control 5

3. Standard precautions 10

4. Hand hygiene 11

5. Personal protective equipment 17

6. Sharps management 21

7. Blood and body fluid spillages 25

8. Waste management 26

9. Laundry 30

10. Decontamination of equipment 32

11. Isolation 36

12. Environmental cleanliness 38

13. Aseptic technique 41

14. Specimen collection 45

15. Venepuncture 49

16. Clostridium difficile 52

17. MRSA 57

18. PVL - Staphylococcus aureus 61

19. MRGNB 65

20. CPE 67

Commentary 71

Key references 72

Notes and reflection 73

Certificate of completion 75

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Contents Page Indicate sectionsto be completed

1. Introduction 4

2. Infection prevention and control 5

3. Standard precautions 10

4. Hand hygiene 11

5. Personal protective equipment 17

6. Sharps management 21

7. Blood and body fluid spillages 25

8. Waste management 26

9. Laundry 30

10. Decontamination of equipment 32

11. Isolation 36

12. Environmental cleanliness 38

13. Aseptic technique 41

14. Specimen collection 45

15. Venepuncture 49

16. Clostridium difficile 52

17. MRSA 57

18. PVL - Staphylococcus aureus 61

19. MRGNB 65

20. CPE 67

Commentary 71

Key references 72

Notes and reflection 73

Certificate of completion 75

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Preventing Infection Workbook

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1. Introduction As a community NHS Infection Prevention and Control (IPC) Team

based in North Yorkshire, our aim is to support the diversity of

health and social care providers in promoting best practice in

infection prevention and control. Now in its 3rd Edition, this

Workbook: Guidance for General Practice complements a range of

educational infection prevention and control resources which can

be viewed at:

www.infectionpreventioncontrol.co.uk

This Workbook is intended to be the foundation for best practice for

infection prevention and control. By applying the principles within

the Workbook you will demonstrate commitment to high quality

care and patient safety. It is aimed at all staff working in a General

Practice, this includes not only front-line clinical staff, but all staff

groups including receptionists and cleaning staff. Your manager

can indicate on page 3 which sections you should complete based

on your role and duties. All staff should be aware how to access

your organisation’s Infection Prevention and Control Policies.

The Workbook has been designed to be undertaken in stages.

This will allow you to complete the ‘Test your knowledge’ questions

before moving on to the next section. On completion, your

manager will check that you have achieved 100% competency in

your infection prevention and control knowledge and then sign the

‘Certificate of completion’. You should keep the Workbook as

evidence of learning and as an on-going reference guide to provide

you with easily accessible advice for day-to-day care of patients.

The Workbook is evidence-based and includes latest national

guidance. Completion of this Workbook also helps your General

Practice demonstrate compliance with the Health and Social Care

Act 2008: Code of Practice on the prevention and control of

infections and related guidance and Care Quality Commission

requirements in relation to infection prevention and control training.

Dr Jenny Child

Director of Infection Prevention and Control/Consultant Microbiologist

Harrogate and District NHS Foundation Trust

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2. Infection prevention and control The Health and Social Care Act 2008: Code of Practice on the

prevention and control of infections and related guidance (The

Code of Practice), Department of Health, July 2015, states

“Good infection prevention (including cleanliness) is essential

to ensure that people who use health and social care services

receive safe and effective care”.

Infection prevention and control is a key priority for the

Department of Health, reinforced with the standards set out in

The Code of Practice and the Care Quality Commission (CQC)

requirements. Infection prevention and control spans the five

key questions the CQC will be asking about your service:

Are you safe? Are you effective?

Are you caring?

Are you responsive? Are you well-led?

An infection occurs when micro-organisms (germs) enter the

body and cause damage. These micro-organisms can come

from a variety of sources and often take advantage of a route

into the body provided by a wound or an invasive medical

device, e.g. catheter. Some infections can reach the

bloodstream (bacteraemia), causing serious or life threatening

infection and can result in death.

Infection prevention and control means doing everything

possible to prevent infection from both developing and

spreading to others. Understanding how infections occur and

how different micro-organisms, such as bacteria, viruses and

fungi, spread is essential to preventing infection.

Healthcare associated infection

The term healthcare associated infection (HCAI) refers to

infections associated with the delivery of healthcare in any

setting, e.g. hospital, GP surgery, care home, in a

patient’s own home, dental surgery or health centre.

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Vaccines Vaccines can prevent transmission of disease from person-to-

person by both patients and staff. Staff should be aware of their

immune status in accordance with the guidance Immunisation

Against Infectious Disease (The Green Book) Chapter 12.

Correct storage of vaccines is essential to maintain their efficacy. If

vaccines are not stored correctly they may lose their effectiveness.

Over time vaccines naturally biodegrade and storage out of

temperature may hasten the loss of potency. This may result in the

vaccine failing to create the desired immune response, thereby

providing poor protection. Practices should ensure vaccines are

stored in line with the guidance in The Green Book or local Vaccine

Cold Chain Policy.

FACT

Every year there are over 300,000 cases of healthcare

associated infection (HCAI) in England and it is estimated that 1

in 3 are preventable.

It is estimated that infections cause 5,000 deaths a year and

contribute to another 15,000 (National Audit Office 2009).

HCAIs are estimated to cost the NHS approximately £1 billion a

year and £56 million of this is estimated to be incurred after

patients are discharged from hospital.

Antimicrobials It is important to ensure appropriate antimicrobial use to optimise

patient outcomes and to reduce the risk of antimicrobial resistance.

General Practice prescribing accounts for 80% of NHS antibiotic

use and this antibiotic use must be both necessary and appropriate.

Antibiotics should not be prescribed for viral infections.

The Antimicrobial stewardship: systems and processes for effective

antimicrobial medicine use (NICE Guidance NG15, August 2015)

recommends that GPs and nurse prescribers “should support the

implementation of local antimicrobial guidelines and recognise their

importance for antimicrobial stewardship”.

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The chain of infection

The spread of micro-organisms from

their source to a person is frequently

referred to as the ‘chain of infection’

which is made up of six links. Each

link represents one of the six

elements required to spread infection.

Each link of the chain must be present for an infection to

occur.

To break the chain requires the removal of just one of the six

links. With good infection prevention and control practice

(standard precautions) applied at all times and in all

healthcare settings, a link in the chain can be broken which

will prevent the spread of infection.

Organism Micro-organisms (bacteria, viruses, fungi), e.g.

Clostridium difficile, MRSA, Norovirus.

Reservoir A reservoir for the micro-organisms (where the

infection comes from), e.g. people, animals, food,

contaminated equipment or surfaces.

Portal of exit The way in which micro-organisms leave the body,

e.g. coughing, diarrhoea, blood, exudate (wound

discharge).

Means of

transmission

The way in which micro-organisms are transmitted,

e.g. hands, equipment, airborne, injection, ingestion.

Portal of entry The way in which micro-organisms enter the body,

e.g. mouth, nose, urinary tract, exposed wounds,

including cuts and grazes, needlestick injury.

People at risk A person’s susceptibility to infection is determined

by their age, well-being, level of immunity, invasive

devices and any medical interventions.

Organism

Means of transmission

Reservoir

Portal of

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Chain of infection

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4. Hand hygiene Hand hygiene refers to the process of hand decontamination

where there is physical removal of dirt, blood, body fluids and

the removal or destruction of micro-organisms from the hands.

Hands may become contaminated by direct contact with a

patient, handling equipment and contact with the general

environment.

Hand hygiene is the single most important way to prevent the

spread of infection. Hands may look visibly clean, but micro-

organisms are always present, some harmful, some not.

Evidence suggests that many healthcare professionals do not

perform hand hygiene as often as is required or use the

correct technique.

Evidence and national guidance identifies that effective hand

hygiene results in significant reduction in the carriage of

potential pathogens (harmful micro-organisms) on the hands.

Effective hand hygiene decreases the incidence of healthcare

associated infection (HCAI) leading to a reduction in patient

morbidity (disease) and mortality (death).

There are two categories of micro-organisms present on

the skin of the hands

Transient bacteria are found on the surface of the skin.

They are called ‘transient’ as they do not routinely live on

the hands. They are transferred to hands after contact

with patients or the environment and are easily removed

by routine handwashing with liquid soap and warm

running water.

Resident bacteria are found on the hands in the deep

layers and crevices and live on the skin of all people.

They play an important role in protecting the skin from

harmful bacteria and are not easily removed by routine

handwashing with liquid soap and warm running water.

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Facial protection

A face visor or safety glasses should be worn when there

is a risk of splashing of blood and/or body fluids to the face

and eyes to prevent infection. Reusable equipment should

be decontaminated after each use (see page 32).

A splash resistant surgical mask should be worn when

there is a risk of splashing of blood and/or body fluids to

the nose or mouth. Masks may be required to be worn on

other occasions, e.g. in the event of pandemic flu.

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White Clinical tasks, e.g. wound dressing

Yellow Cleaning of treatment and minor operation rooms

Blue Cleaning of general areas, e.g. consulting rooms

Red Cleaning of sanitary areas

Green Cleaning of kitchen areas

Order for putting on PPE Order for removing PPE

Pull apron over head and fasten at back of waist.

Secure mask ties at back of head and neck. Fit flexible band to nose bridge.

Place eye protection over eyes.

Extend gloves to cover wrists.

Grasp the outside of the glove with opposite gloved hand, peel off. Hold the removed glove in the gloved hand. Slide the

fingers of the ungloved hand under the remaining glove at the wrist and peel off.

Unfasten or break apron ties. Pull apron away from neck and shoulders lifting over head, touching inside of the apron only. Fold or roll into a bundle.

Handle eye protection only by the headband or the sides.

Unfasten the mask ties—first the bottom, then the top. Remove by handling ties only.

Clean your hands before putting on and after removing PPE.

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Procedure following a splash or inoculation injury In the event of a splash injury to eyes, nose or mouth

1. Rinse affected area thoroughly with copious amounts of running

water.

In the event of a bite or skin contamination

1. Wash affected area with liquid soap and warm running water, dry

and cover with a waterproof dressing.

In the event of a needlestick/sharps injury

1. Encourage bleeding of the wound by squeezing

under running water (do not suck the wound).

2. Wash the wound with liquid soap and warm

running water and dry (do not scrub).

3. Cover the wound with a waterproof dressing.

In all cases

4. Report the injury to your manager immediately.

If the injury is caused by a used sharp or sharp of unknown

origin, splash to non-intact skin or mucous membrane or a bite

has broken the skin

5. Immediately contact your GP or Occupational Health department.

Out of normal office hours, attend the nearest Accident and

Emergency (A&E) department.

6. If you have had a needlestick or sharps injury from an item which

has been used on a patient (source), the doctor in charge of their

care may take a blood sample from the patient to test for hepatitis

B, hepatitis C and HIV (following counselling and agreement of

the patient).

7. At the GP Practice/Occupational Health/A&E department:

A blood sample will be taken from you to check your hepatitis B

vaccination/antibody levels and you will be offered

immunoglobulin if they are low. The blood sample will be stored

until results are available from the patient’s blood sample. If the

source of the sharps injury is unknown, you will also have blood

samples taken at 6, 12 and 24 weeks for hepatitis C and HIV

If the patient (source) is known or suspected to be HIV positive,

you will be offered Post Exposure HIV Prophylaxis (PEP)

treatment. This should ideally commence within 1 hour of the

injury, but can be given up to 2 weeks following the injury

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7. Blood and body fluid spillages

A spillage of blood or body fluids, e.g. urine, may contain

micro-organisms, so it should be dealt with promptly. Dealing

with a spillage may expose staff to infection, therefore,

appropriate personal protective equipment (PPE) should be

worn and standard precautions followed.

Spillage kits

An appropriate spillage kit should be used for the spillage,

e.g. blood, urine or vomit. There are two types of spillage kits

available; one for blood and one for urine and vomit. The two

types differ because of the disinfectant or concentration

required for dealing with a blood spillage rather than urine or

vomit. It is, therefore, essential that you use the correct

spillage kit to appropriately deal with the spillage.

Always ensure:

The manufacturer’s instructions are followed

The spillage kit is in date as expired contents

may not be effective

The spillage kit is suitable for use on soft surfaces if

required

Waste is disposed of as infectious waste (see page 28)

It’s a fact

5,164 people were diagnosed with HIV in the UK in 2016.

Test your knowledge Please tick the correct answer True False

1. Spillage kits, if out of date, will still be as

effective.

2. PPE should always be worn when dealing

with body fluids.

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Waste stream guide for General Practice

Colour * Description

Yellow

stream

Waste classified as infectious Waste contaminated with body fluids from a patient with a known or suspected infection which poses a potential infection risk and there are

also medicines or chemicals present. Examples are:

Anatomical wastes and tissue samples preserved in hazardous chemicals

Medicines, medicinally-contaminated syringes, medicated dressings

Contaminated dressings that contains an active pharmaceutical, e.g. ibuprofen

Diagnostic kits contaminated with potentially infectious body fluids and chemical reagents (this does not include sticks from dip tests)

Orange

stream

Waste classified as infectious Waste contaminated with body fluids from a patient with a known or suspected infection, but no contamination with medicines or chemicals. Examples are:

Contaminated PPE (gloves, aprons, etc.)

Contaminated dressings that do not contain an active pharmaceutical

Very small pieces of tissue

Syringe bodies contaminated with body fluids, but not medicines

Purple

stream

Waste classified as hazardous Waste consisting of, or contaminated with, cytotoxic and/or cytostatic medicines. Examples are:

Medicine containers with residues of cytotoxic or cytostatic medicines (bottles, infusion bags or syringe barrels)

Items contaminated with cytotoxic or cytostatic medicines, e.g. swabs

Used sharps from treatment using cytotoxic or cytostatic medicines

Yellow

and black

stream

Waste classified as offensive (non-hazardous) Waste from patients with no known or suspected infection which may be contaminated with body fluids. Examples are:

Gloves, aprons

Dressings (including blood stained)

Empty non-medicated infusion bags

Blue

stream

Waste classified as non-hazardous medicinal waste (non-cytotoxic or cytostatic). Examples are:

Unused medicines in original packages

Part empty containers containing residues of medicines

Empty medicine bottles

Black

stream

Includes items normally found in household waste. Examples are:

Newspapers

Food waste

Paper towels

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To further reduce any micro-organisms, where possible,

uniforms or clothing should be tumble dried and/or ironed.

Always wash hands after placing uniforms or clothing in

the washing machine.

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Note

Fabric hand towels should not be used in General Practice

by staff or patients as they can harbour micro-organisms

which can be transferred from person-to-person.

It’s a fact

Micro-organisms can transfer from contaminated to

uncontaminated fabrics during a wash cycle.

The laundering process works by physical removal of dirt,

inactivation by increased temperature and chemical

inactivation by detergents containing activated oxygen

bleach.


1. Fabric pillow cases can be used and

washed weekly.

2. It is best practice to wash uniforms

separately from household laundry.

3. If fabric curtains are used, they should be

professionally laundered at least every six

months.

4. Tumble drying and ironing further reduces

the amount of micro-organisms on fabric.

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10. Decontamination of equipment Cleaning, disinfection and sterilisation is known as

decontamination. Safe decontamination of reusable medical

equipment after use on a patient is an essential part of

routine infection control to prevent the transmission of

infection.

1. Cleaning - for items used on intact skin and

non-infectious patients

Cleaning is essential before disinfection or sterilisation is

carried out. Detergent wipes or neutral detergent, warm

water and single use cloths should be used for the

cleaning of any reusable medical equipment, e.g.

examination couch, pillow case, stethoscope, doppler, that

has been in contact with intact skin (for example skin

which has no breaks, grazes, cuts).

2. Disinfection - follows cleaning, for items used on

non-intact skin, mucous membranes, body fluids,

known or suspected infectious patients

Disinfectants are not effective if dirt or visible soiling is

present.

Disinfectants can be in the form of wipes or as chlorine

releasing tablets, liquids or granules. Some products

There are 3 levels of decontamination

1. Cleaning Is a process which physically removes dirt,

blood, body fluids and many micro-organisms.

2. Disinfection Is a process to remove or kill pathogenic

(disease causing) micro-organisms using an

antimicrobial agent.

Is a process for the complete destruction or

removal of all micro-organisms.

3. Sterilisation

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11. Isolation Dedicated isolation treatment rooms are not required in

General Practices, but General Practices are expected to

implement reasonable precautions when a patient is

suspected or known to have a transmissible infection.

Using standard precautions reduces the risk of the

transmission of infection. However, patients with specific

infections who may be a risk to others, e.g. a child with

chickenpox or measles, should be segregated so that the risk

of infection to other patients in waiting or communal areas is

minimised. Where possible, arrangements should be made

to see these patients in their own home or in a separate area

of the practice away from other patients.

Preparation

Refer to your local policy on Isolation.

The designated room or area should be clutter free with

wipeable surfaces and only the equipment required for the

consultation. Avoid areas with carpets if possible.

A risk assessment should be undertaken for the personal

protective equipment (PPE) required, e.g. disposable

apron and gloves. The routine wearing of masks is usually

not required, however for certain

infections, e.g. Pandemic Influenza

or new emerging infections, national

guidance should be followed.

PPE should be worn, applied and

removed correctly (see page 19).

Ensure hand hygiene facilities are available, e.g. wall

mounted liquid soap, paper hand towels, alcohol handrub.

A foot pedal operated lidded waste bin with liner should be

available and waste disposed of as infectious waste.

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12. Environmental cleanliness Cleanliness is an integral part of infection prevention and

control of the General Practice environment. Cleanliness

helps reduce the incidence of healthcare associated

infections and ensure patient confidence. All staff, and in

particular cleaning staff, play an important role in improving

the quality of the environment and maintaining standards.

To facilitate effective cleaning of the environment, surfaces

should be damage and clutter free, smooth and wipeable.

The environment should be well maintained and in a good

state of repair.

The environment should be routinely cleaned in line with

the National Patient Safety Agency (NPSA) Guidance on

specifications for cleanliness in primary care.

Cleaning schedules should be used. Staff should sign and

date when each activity is completed.

National colour coding scheme All General Practices are recommended to adopt the national

colour code for cleaning materials (see below). All cleaning

items, e.g. cloths, mops, buckets and disposable aprons,

should be colour coded.

Red Blue

Green Yellow

Kitchens. Treatment and minor operation rooms.

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13. Aseptic technique An aseptic technique is used to carry out a procedure in a

way that minimises the risk of contaminating an invasive

device or contaminating a vulnerable area (see below), where

introducing micro-organisms may increase the risk of

infection.

When to use an aseptic technique

The following are some examples of when an aseptic

technique should be used (please note that this is not an

exhaustive list).

Dressing wounds healing by primary intention, e.g.

surgical wounds, or when dressing burns.

Suturing wounds.

Inserting an invasive device, e.g. urinary catheter.

Vaginal examination using instruments, e.g. insertion of

IUCD.

Minor surgery procedures.

Dressing deep wounds that lead to a cavity or sinus.

If a patient is immunosuppressed, diabetic or at high risk of

infection.

Principles of aseptic technique Reduce activity in the immediate area where the

procedure is to be undertaken.

Keep the exposure of a susceptible site to a minimum.

Ensure appropriate hand hygiene

prior to the procedure.

Wear a disposable apron and sterile

gloves.

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1. Specimens awaiting collection should be

stored in a rigid container that can be

decontaminated.

2. Recent antibiotic history should be

included with the clinical information.

3. Specimens should be sent to the laboratory

as soon as possible and within 24 hours.

4. Swabs should be moistened when taking a

wound swab if the wound is dry.

Remember

Specimens must be labelled correctly, including relevant

clinical details and any recent antibiotic history.

Specimens should be sent as soon as possible and within

24 hours.

Stool specimen containers should be at least 1/4 full.

Note

Urine samples which are not sent to a laboratory should

be discarded into a toilet or sluice.

To ensure more micro-organisms are transferred to the

swab, if the wound is dry, moisten the swab with sterile

0.9% sodium chloride or sterile water before use.

It’s a fact

At least 23% of all infections are due to a urinary tract

infection (UTI).

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organisms and are difficult to clean.

Wear disposable gloves when undertaking venepuncture.

The wearing of gloves can help prevent acquiring a blood-

borne virus (BBV) if you sustain a needlestick injury.

During a needlestick injury, if gloves are worn, up to 86%

of the blood on the needle is wiped off by the glove

material, therefore, reducing the risk of acquiring a BBV.

Decontaminate the skin prior to venepuncture, using either

a 70% alcohol swab or a 70% alcohol with 2%

chlorhexidine swab. The area should be swabbed for 30

seconds to allow for the skin disinfection to be effective,

then allowed to air dry prior to inserting the needle to avoid

stinging.

Use sterile gauze to cover the puncture site, do not apply

pressure until the needle is fully removed.

Do not bend the patient’s elbow.

Dispose of the venepuncture needle

safely to reduce the risk of a sharps

injury to yourself or others.

Apply a sterile adhesive dressing to

the puncture site.

Note

Gently invert the tube to mix blood with

additives to prevent damage to blood cells.

The number of times a tube should be

inverted varies on the colour of the tube cap.

Always follow the manufacturer’s instructions.

Blood must be drawn in a specific order to avoid cross-

contamination of additives from one tube to another,

affecting laboratory results. Follow your blood collection

systems guidance for ‘the order of draw’.

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C. difficile awareness

There are a number of local initiatives across the country

where patients with C. difficile are provided with a ‘status

card’ which helps to alert care professionals of their C. difficile

status and to help make the correct

decisions about their treatment, particularly

antibiotics and anti-motility agents.

Communicate C. difficile status to any

receiving health and social care providers.

Advice for patients with C. difficile symptoms

If antibiotics are prescribed to treat C. difficile, it is

important to complete the full course.

Drink plenty of fluids to prevent dehydration.

Wash hands thoroughly after each episode of diarrhoea

with liquid soap and warm running water, especially before

preparing or eating food.

After an episode of diarrhoea, to reduce possible spread,

always close the toilet seat lid before flushing the toilet .

A separate towel should be used to dry hands and should

not be used by other people. It should be washed daily.

Alcohol handrub should not be used as it does not kill

C. difficile spores.

Clean surfaces in toilets and bathrooms at least daily, with

a household bleach in line with manufacturer’s instructions.

Wash soiled clothing or bedding separately as soon as

possible at the highest temperature advised on the label.

If possible, have a shower, bath or wash daily, as

C. difficile spores can be on other areas of the body.

Stay at home, do not visit friends, relatives, hospitals or

care homes, until free from symptoms for 48 hours and a

formed stool has been passed.

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MRSA infection

People can become infected with MRSA when the bacteria

enters the body and causes illness, e.g. abscess, boil, local

skin infection. It may cause serious illness, such as

septicaemia. Signs of infection include fever, redness, pain

and increased wound discharge. If infection is present,

antibiotic treatment should be prescribed and suppression

treatment considered.

MRSA screening

In accordance with Department of Health guidance, MRSA

screening is routinely undertaken by hospitals. If a MRSA

positive result is diagnosed after a patient has been

discharged from hospital, the General Practice may be

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How to take a nasal swab for MRSA screening

Wash hands and apply non-sterile gloves.

Place a few drops of either sterile 0.9%

sodium chloride or sterile water onto the swab

taking care not to contaminate the swab.

Place the tip of the swab inside the nostril at

the angle shown.

It is not necessary to insert the swab too far

into the nostril.

Gently rotate the swab ensuring it is touching

the inside of the nostril.

Repeat the process using the same swab for

the other nostril.

Place the swab into the container.

Dispose of gloves and wash hands.

Complete patient details on the container and

specimen form. Request ‘MRSA screening’

under clinical details on the form. SAMPLE


64

Do not touch or squeeze boils or abscesses as this will

contaminate hands and can cause a deeper infection.

Wash hands regularly with liquid soap and warm running

water, e.g. after changing dressings, before and after

preparing food.

Use separate towels which should also be kept separately

from other towels to avoid contamination. Towels should

be washed frequently on a hot wash cycle, e.g. 60oC.

Regularly launder, vacuum and dust with a damp cloth all

rooms including personal items. A household detergent is

adequate for cleaning.

Clean the wash basin, taps and bath after use with a

regular household cleaning product and a disposable cloth.

Cover nose and mouth with a tissue when coughing or

sneezing. Immediately dispose of the tissue and then

wash hands with liquid soap and warm running water.

Avoid recreational settings/activities if lesions cannot be

adequately contained by dressings.

An advice sheet ‘PVL-SA Information for service users’ is

available at www.infectionpreventioncontrol.co.uk.

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1. PVL-SA can be either MRSA or MSSA.

2. PVL-SA can be spread by using shared

towels or shared items.

3. Carers with PVL-SA can work whilst they

have a lesion.

4. Patients should wash their hands after

changing their dressings.

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65 19

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19. MRGNB (Multi-resistant Gram-negative

bacteria) including extended-spectrum beta- lactamase (ESBL)

Bacteria commonly found in the bowel include E. coli,

Klebsiella, Pseudomonas, Enterobacter and Proteus. These

bacteria are referred to as Gram-negative bacilli (GNB) and

are part of our ‘good’ bacteria and are found in the

environment, in water and soil and can be part of transient

flora carried on the hands of staff and equipment.

Multi-resistant Gram-negative bacteria (MRGNB) are found

most frequently in patients who have received broad

spectrum antibiotics with diminished immunity.

Some MRGNB achieve antibiotic resistance by producing an

enzyme (extended-spectrum beta-lactamases or ESBL’s)

which can destroy/inactivate broad spectrum antibiotics, such

as cefuroxime and cefotaxime.

The genes that carry antibiotic resistance can spread to other

bacteria; therefore, the control of MRGNB requires

comprehensive infection control and antibiotic policies.

Routes of transmission

Direct spread via hands of staff and patients. The

importance of good hand hygiene before and after direct

patient contact is essential.

Equipment not appropriately decontaminated.

Environmental contamination.

Management of a patient colonised/infected with MRGNB

Communicate MRGNB status to any receiving health and

social care providers.

Patients colonised with MRGNB who do not have any

symptoms of infection do not require antibiotic treatment.

SAMPLE


68

endemic in many hospitals in the UK. Faecal screening, e.g.

rectal swabs or stool samples, on high risk patients for CPE

has been implemented nationally in hospitals resulting in

sporadic cases being identified. Screening is not routinely

required in a community setting.

Routes of transmission CPE can be passed to other patients by direct contact on

hands or through contaminated surfaces or equipment. CPE

can then be transferred into wounds or other body entry sites.

Risk factors for CPE Patients are at an increased risk of being colonised or

infected if they have a history of:

Hospitalisation abroad

Hospitalisation in a UK hospital with a high prevalence of

CPE

Previously confirmed as a case or contact of a case

Cosmetic or elective surgery abroad

Management of a patient colonised/infected with CPE The majority of people with CPE are colonised and do not

have any symptoms of infection and do not require antibiotic

treatment. The duration of colonisation is unknown, it may be

anything from a few days to indefinitely.

If a patient has clinical indications of an infection, e.g. causing

a UTI, wound infection, treatment should be discussed with

your local Consultant Microbiologist.

Colonisation with CPE is more common than infection.

Suppression treatment of the skin or gut are not

recommended. Attempts at eradication of Multi-resistant

Gram-negative bacteria (MRGNB) from the gut have not

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71

Commentary Congratulations, you have now completed the ‘Preventing

Infection Workbook: Guidance for General Practice’.

Your Manager will check that you have achieved 100%

competency in your infection prevention and control (IPC)

knowledge. If there are any sections in which you have not

achieved this, these sections should be revisited and the

‘Test Your Knowledge’ questions undertaken again. When

full competency has been achieved, the ‘Certificate of

completion’ will be signed by your Manager and should be

documented as evidence for CQC inspections.

When you apply this knowledge in practice, you will have the

fundamental skills in which to offer safe quality IPC care to

your patients.

This learning is intended to be the foundation for best

practice. If you apply the principles within this Workbook, it

will demonstrate commitment to quality care and supports the

principle that infection should be prevented wherever

possible.

Please keep this Workbook in an accessible place so that it

can be readily referred to on a day-to-day basis for safe

delivery of care to patients.

Remember infection prevention and control is

everyone’s responsibility and all staff should

receive annual IPC education

As a NHS Community Infection Prevention and Control Team, we

continually strive to ensure our advice is straightforward and patient

centred. We welcome feedback in which to improve any aspect of

our resources. Please do not hesitate to contact us at:

[email protected]

Co

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mailto:[email protected]


72

Key references Association of healthcare cleaning professionals (2013) Revised Healthcare Cleaning Manual

British Medical Association (May 2012) CQC Registration—What you need to know, Appendix B

Policies and Protocols Guidance for GP

Care Quality Commission Homepage [online]

Department of Health (July 2015) The Health and Social Care Act 2008: Code of Practice on the

prevention and control of infections and related guidance

Department of Health (2013) Health Technical Memorandum 07-01: Safe management of healthcare

waste

Department of Health (January 2009) Clostridium difficile infection: How to deal with the problem

Department of Health (1998) Guidance for clinical healthcare workers: protection against infection

with blood-borne viruses

Harrogate and District NHS Foundation Trust (December 2017) Community Infection Prevention and

Control Guidance for General Practice (IPC Policy Folder)

Health Protection Agency (November 2008) Guidance on the diagnosis and management of PVL-

associated Staphylococcus aureus infection (PVL-SA) in England 2nd Edition

Healthcare Commission (October 2007) Investigation into outbreaks of Clostridium difficile at

Maidstone and Tunbridge Wells NHS Trust

Terrence Higgins Trust [online]

Loveday HP, et al, epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England Journal of Hospital Infection 86S1 (2014) S1–S70

Medicines and Healthcare Products Regulatory Agency (April 2015) Managing Medical Devices

Guidance for healthcare and social services organisations

Mid Staffordshire NHS Foundation Trust (2013) The Report of the Mid Staffordshire NHS Foundation

Trust Public Inquiry volume 2: Analysis of evidence and lessons learned (part 2), Chaired by Robert

Francis QC 2013

National Audit Office [online]

National Institute for Health and Care Excellence (August 2015) Antimicrobial stewardship: systems

and processes for effective antimicrobial medicine use

National Institute for Health and Care Excellence (2012 updated 2017) Infection: prevention and

control of healthcare-associated infections in primary and community care Clinical Guideline 139

National Patient Safety Agency (August 2010) The national specifications for cleanliness in the NHS:

Guidance on setting and measuring performance outcomes in primary care medical and dental

premises

Public Health England (June 2015) Toolkit for managing carbapenemase-producing

Enterobacteriaceae in non-acute and community settings

Public Health England (2013 updated September 2014) Immunisation Against Infectious Disease

(The Green Book)

Royal College of Nursing (May 2018) Tools of the trade: RCN guidance for health care staff on glove

use and the prevention of contact dermatitis

Royal College of Nursing (February 2018) Freedom of Information Follow up Report on Management

of Waste in the NHS

Royal College of Nursing (November 2017) Essential practice for infection prevention and control

Royal College of Nursing (April 2014) The Management of waste from health, social and personal

care RCN guidance

Royal Marsden (March 2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedure 9th

Edition [online]

WHO (2010) Guidelines on drawing blood: Best practices in phlebotomy

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Written and produced by Community Infection Prevention and Control

Harrogate and District NHS Foundation Trust

Tel: 01423 557340

www.infectionpreventioncontrol.co.uk

March 2019

© Harrogate and District NHS Foundation Trust, Community Infection Prevention and Control 2019

SAMPLE

http://www.infectionpreventioncontrol.co.uk

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