Surgical Site Infection Prevention and Treatment of Surgical Site Infection
Healthcare Associated Infection · Surgical Site Infection Surgical site infection (SSI) is one of...
Transcript of Healthcare Associated Infection · Surgical Site Infection Surgical site infection (SSI) is one of...
Health Protection Scotland
Healthcare Associated Infection
Annual Report 2017
Publication date
DD May 2018
Health Protection Scotland
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Health Protection Scotland is a division of NHS National Services Scotland.
Health Protection Scotland website: http://www.hps.scot.nhs.uk
Published by Health Protection Scotland, NHS National Services Scotland, Meridian Court,
5 Cadogan Street, Glasgow G2 6QE
First published May 2018
© Health Protection Scotland 2018
Reference this document as:
Health Protection Scotland. Healthcare Associated Infections. Health Protection Scotland,
2017.
Health Protection Scotland, Glasgow 2018 [Report]
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Health Protection Scotland
NHS National Services Scotland
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Tel: +44 (0) 141 300 1100
Email: [email protected]
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Contents
Contents ................................................................................................................................. 2
Acronyms ............................................................................................................................... 5
NHS board abbreviations ................................................................................................... 8
Executive Summary ............................................................................................................... 9
Main Points .......................................................................................................................... 10
Surgical Site Infection .......................................................................................................... 14
Epidemiological Data ........................................................................................................ 14
Caesarean Section ........................................................................................................... 14
Hip Arthroplasty ................................................................................................................ 17
Quality Improvement and Interventions to Reduce SSI .................................................... 20
Healthcare Associated Infections in Intensive Care Units .................................................... 22
Quality Improvement and Interventions to Reduce HCAI in ICUs .................................... 23
Clostridium difficile Infection ................................................................................................. 24
Epidemiological Data ........................................................................................................ 24
Molecular Epidemiological Data ....................................................................................... 27
Antimicrobial Use and Resistance .................................................................................... 28
CDI Mortality ..................................................................................................................... 29
Quality Improvement and Interventions to Reduce CDI.................................................... 30
Staphylococcus aureus Infection ......................................................................................... 32
Epidemiological Data ........................................................................................................ 32
Antimicrobial Resistance .................................................................................................. 37
Quality Improvement and Interventions to Reduce SAB................................................... 37
MRSA Acute Admission Screening in Scotland ................................................................ 38
Gram-negative Bacteraemia ................................................................................................ 40
Gram-negative Bacteraemia ............................................................................................. 40
Escherichia coli Bacteraemia (ECB) ................................................................................. 41
Development of Surveillance and Interventions to Reduce E. coli Bacteraemia .............. 45
Antimicrobial Resistance in Gram-negative Bacteraemia ................................................. 47
Urinary Tract Infection .......................................................................................................... 49
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National UTI Programme .................................................................................................. 49
National Catheter Passport .............................................................................................. 49
National Hydration Campaign ........................................................................................... 50
Controlling Antimicrobial Resistance in Scotland ................................................................. 52
Carbapenemase-Producing Organisms ............................................................................... 55
Epidemiological Data ........................................................................................................ 55
Quality Improvement and Interventions to Reduce ........................................................... 57
Carbapenem Producing Organisms ................................................................................. 57
Information Leaflets .......................................................................................................... 59
Research .......................................................................................................................... 59
Prescribing ....................................................................................................................... 59
Prevention of Healthcare Associated Bloodborne Viruses ................................................... 60
National Sharps Injuries Prevention Project ..................................................................... 60
Sharps Injuries and Occupational BBV Exposures ........................................................... 60
Sharps Device Data.......................................................................................................... 62
Incidents Associated with BBV Infected Healthcare Workers ........................................... 63
Quality Improvement and Interventions to Reduce BBVs ................................................. 64
Neonatal Units ..................................................................................................................... 65
Neonatal Microbiological Screening ................................................................................. 65
Guidance .......................................................................................................................... 65
Development of Guidance .................................................................................................... 67
Respiratory Protective Equipment (RPE) ......................................................................... 68
NIPCM Website – A-Z ...................................................................................................... 68
HAI Compendium of Guidance ......................................................................................... 68
Hand Hygiene ................................................................................................................... 69
Alcohol Based Hand Rub (ABHR) Proxy Measure ........................................................... 69
Cystic Fibrosis Guidance .................................................................................................. 70
Hospital Outbreaks and Incidents ........................................................................................ 71
Current and Emerging Threats (CET)/Horizon Scanning ................................................. 73
Norovirus Outbreaks ............................................................................................................ 74
Epidemiological Data ........................................................................................................ 74
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Norovirus Reporting System ............................................................................................. 75
Infection Control in the Built Environment and Decontamination ......................................... 77
The Built Environment ...................................................................................................... 77
Decontamination .............................................................................................................. 77
Roles and Responsibilities ............................................................................................... 77
Assessment of Financial Impact Protecting Time for Standard Discharge Cleans ........... 78
Infection Prevention and Control Team (IPCT) Audit Tools and Processes: National
Monitoring Tool ................................................................................................................. 78
Alternative Approaches to Equipment and Environmental Decontamination .................... 78
New Technologies for Equipment and Environmental Decontamination .......................... 79
Pathogen Survival Review ................................................................................................ 80
Management of Dental Unit Water Lines (DUWLs): Recommendations for Clinical
Practice ............................................................................................................................ 80
Guidance; Clinical Management of Endoscopy Rinse Water Results .............................. 80
Future Work ...................................................................................................................... 81
List of Tables ........................................................................................................................ 82
List of Figures ...................................................................................................................... 82
Appendices .......................................................................................................................... 84
Appendix 1 – Background Information.............................................................................. 84
Appendix 2 – Publication Metadata .................................................................................. 84
Appendix 3 – Early Access Details ................................................................................... 99
Appendix 4 – HPS and Official Statistics ........................................................................ 100
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Acronyms ABHR Alcohol Based Hand Rub
AMR Antimicrobial Resistance
AMRHAI Antimicrobial Resistance and Healthcare Associated Infections
AMT Antimicrobial Management Team
AMU Antimicrobial Use
AST Antimicrobial Susceptibility Testing
BBV Bloodborne Virus
BSI Bloodstream Infection
CARS Controlling Antimicrobial Resistance in Scotland
CAUTI Catheter Associated Urinary Tract Infection
CET Current and Emerging Threats
CDI Clostridium difficile Infection
CJD Creutzfeldt-Jakob Disease
CRA Clinical Risk Assessment
CMO Chief Medical Officer
CNO Chief Nursing Officer
CPE Carbapenemase-producing Enterobacteriaceae
CPO Carbapenemase Producing Organism
CRI Catheter-Related Infection
CR-BSI CVC-Related Bloodstream Infection
CVC Central Vascular Catheter
DARC Defra Antimicrobial Resistance Coordination
DCU Dental Chair Unit
DDD Defined Daily Doses
DUWLs Dental Unit Waterlines
ECB Escherichia coli Bacteraemia
ECDC European Centre for Disease Prevention and Control
ECOSS Electronic Communication of Surveillance in Scotland
ESBL Extended Spectrum Beta-lactamase
ESPAUR English Surveillance Programme for Antimicrobial Utilisation and Resistance
EUCAST European Committee on Antimicrobial Susceptibility Testing
FMT Facilities Monitoring Tool
GCU Glasgow Caledonian University
GJNH Golden Jubilee National Hospital
HAI Healthcare Associated Infection
HBV Hepatitis B Virus
HCAI Healthcare Associated Infection
HCV Hepatitis C Virus
HCW Healthcare Worker
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HDL Health Department Letter
HEI Healthcare Environment Inspectorate
HIIAT Healthcare Infection Incident Assessment Tool
HIV Human Immunodeficiency Virus
HPS Health Protection Scotland
HPTs Health Protection Teams
ICBED Infection Control in the Built Environment and Decontamination
ICU Intensive Care Unit
IDHC Infectious Diseases of High Consequence
IPC Infection Prevention and Control
IPCT Infection Prevention and Control Team
ISD Information Services Division
KPC Klebsiella pneumoniae Carbapenemase
KPI Key Performance Indicator
MDR Multidrug Resistant
MDROs Multidrug Resistant Organisms
MRSA Meticillin Resistant Staphylococcus aureus
MSSA Meticillin Sensitive Staphylococcus aureus
NCP National Catheter Passport
NDC National Distribution Centre
NDM New Delhi Metallo-Beta-lactamase
NES NHS Education for Scotland
NHS National Health Service
NICU Neonatal Intensive Care Unit
NIPCM National Infection Prevention and Control Manual
NNU Neonatal Unit
NP National Procurement
NPGO National Policies, Guidance and Outbreaks
NWTC National Waiting Times Centre
PCR Polymerase Chain Reaction
PDS Post Discharge Surveillance
PEP Post Exposure Prophylaxis
PHE Public Health England
PHWCAMU Pig Health and Welfare Council AMU
PIS Prescribing Information System
PN Pneumonia
PNE Patient Notification Exercise
PPE Personal Protective Equipment
PPS Point Prevalence Survey
PVC Peripheral Vascular Catheter
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PWID People Who Inject Drugs
QIT Quality Improvement Tools
RPE Respiratory Protective Equipment
SAB Staphylococcus aureus Bacteraemia
SAPG Scottish Antimicrobial Prescribing Group
SEPA Scottish Environment Protection Agency
SGHSCD Scottish Government Health and Social Care Directorate
SHAIPI Scottish Healthcare Associated Infection Prevention Institute
SHPN Scottish Health Protection Network
SICPs Standard Infection Control Precautions
SICSAG Scottish Intensive Care Society Audit Group
SIRN Scottish Infection Research Network
SIUP Semi-invasive Ultrasound Probe
SLWG Short Life Working Group
SMR Scottish Morbidity Records
SMRSARL Scottish MRSA Reference Laboratory
SMVN Scottish Microbiology and Virology Network
SOE Significant Occupational Exposure
SONAAR Scottish One Health AMR and AMU Report
SPI Structure and Process Indicator
SPSP Scottish Patient Safety Programme
SSHAIP Scottish Surveillance of HAI Programme
SSI Surgical Site Infection
SSIRS Surgical Site Infection Reporting System
SSSCDRL Scottish Salmonella, Shigella and Clostridium difficile Reference Laboratory
SULSA Scottish Universities Life Sciences Alliance
SUTIN Scottish UTI Network
TBP Transmission Based Precautions
TOBDs Total Occupied Bed Days
TWOC Trial Without Catheter
UKAP UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses
UTI Urinary Tract Infection
WHO World Health Organisation
WTE Whole Time Equivalent
VAD Vascular Access Device
VAP Ventilator Associated Pneumonia
VIM Verona Integron-encoded Metallo-beta-lactamase
VRE Vancomycin Resistant Enterococci
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NHS board abbreviations
AA Ayrshire & Arran LN Lanarkshire
BR Borders LO Lothian
DG Dumfries & Galloway NWTC National Waiting Times Centre
FF Fife OR Orkney
FV Forth Valley SH Shetland
GGC Greater Glasgow & Clyde TY Tayside
GR Grampian WI Western Isles
HG Highland
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Executive Summary
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Main Points
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Surgical Site Infection
Surgical site infection (SSI) is one of the most common Healthcare Associated Infection
(HCAI), estimated to account for 16.5% of inpatient HCAI within NHSScotland.1 A
systematic review of impact of SSI on health care costs and patients outcomes in 2017
showed that SSI can have serious consequences for patients with the resulting negative
outcomes such as longer recovery periods, additional surgical intervention and readmission,
loss of earnings, suffering, and some cases result in death.2 SSIs are estimated on average
to double the cost of treatment, mainly due to the resultant increase in length of stay.3
Epidemiological Data
Health Protection Scotland (HPS) coordinate the SSI national surveillance programme that
is mandatory across all NHS boards in Scotland. All NHS boards are currently required to
undertake surveillance for caesarean section, hip arthroplasty, large bowel and vascular
procedures as per the mandatory requirements of HDL 2006 (38) and HAI DL( 2015) 19.4;5
SSI surveillance is conducted according to the HPS SSI surveillance protocol.6
Caesarean Section
Caesarean sections are routinely carried out within 14 NHS boards across Scotland. A total
of 16,900 caesarean sections were performed in Scotland during 2017 with 232 SSI being
reported to HPS. Caesarean section surveillance is carried out during the patient’s inpatient
stay and post discharge surveillance (PDS) is carried out by community midwives until day
10 post operative. During 2017 there were 29 (12.5%) SSIs diagnosed during the inpatient
stay, with 87.5% of SSI (n=203) being diagnosed following discharge from hospital using
post discharge surveillance methods.
The incidence of inpatient SSI was 0.2% (95% CI: 0.12 to 0.25) and the overall SSI
incidence including the PDS period to day 10 was 1.4% (95% CI: 1.21 to 1.56). The
incidence of overall SSI to day 10 decreased between 2013 and 2017 (year on year
decrease if 4.1%, p=0.04) (Figure 1). There was no change between 2016 and 2017 in the
inpatient and overall SSI incidence to day 10 (p=0.32).
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Figure 1: Incidence of SSI following caesarean section procedures in Scotland (inpatient and PDS to day 10), 2013 to 2017.1
1. Source of data is Surgical Site Infection Reporting System (SSIRS).
The annual incidence of SSI following caesarean section for each NHS board is presented
in a funnel plot (Figure 2).
The incidence in NHS Fife was above the 95% confidence upper limit in 2017. The funnel
plot analysis incorporates the full year’s data; as a result, some NHS boards may be above
the 95% confidence interval upper limit in the annual funnel plot but not in the quarterly
funnel plots (for full details please refer to Appendix 2 – Publication Metadata). NHS boards
are monitored on a quarterly basis, for more information refer to published quarterly
epidemiological data.
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Figure 2: Funnel plot of SSI incidence (per 100 caesarean section procedures) for all NHS boards in Scotland in 2017. 1, 2
1. Source of data is Surgical Site Infection Reporting System (SSIRS). 2. NHS Shetland and NHS Western Isles overlap.
The majority of SSIs which occurred following caesarean section surgery were superficial
(n= 198). A total of 12 (41.4%) deep or organ space SSI were reported during inpatient
phase of the SSI surveillance (Figure 3).
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Figure 3: Proportion of SSI following caesarean section procedures (inpatient and PDS to day 10) in Scotland by SSI type, 2017.1
1. Source of data is Surgical Site Infection Reporting System (SSIRS).
Hip Arthroplasty
Hip arthroplasty procedures are carried out routinely across 14 NHS boards in Scotland. A
total of 8,616 procedures were recorded through the hip arthroplasty SSI surveillance
programme during 2017. Hip arthroplasty SSI surveillance is carried out during the patient
inpatient stay and readmission surveillance is carried out until day 30 post operative. SSI
were reported in 54 cases of which 29.6% (n= 16) were diagnosed during the inpatient stay
and the remainder were identified on readmission to hospital in the 30 days following the
procedure (n=38).
The inpatient incidence of SSI was 0.2% (95% CI: 0.11 to 0.30) and the overall incidence of
SSI was 0.6% (95% CI: 0.48 to 0.82). The incidence of SSI for inpatient and readmission to
day 30 remained stable between 2013 and 2017 (p=0.25) (Figure 4). There was no
significant change between 2016 and 2017 in the inpatient and overall SSI incidence to day
30 (p=0.90).
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Figure 4: Incidence of SSI following hip arthroplasty procedures in Scotland (inpatient and readmission to day 30), 2013 to 2017.1
1. Source of data is Surgical Site Infection Reporting System (SSIRS).
The annual incidence of SSI following hip arthroplasty for each NHS board is presented
through funnel plot (Figure 5). No NHS board incidence was above the 95% confidence
upper limit in 2017. The funnel plot analysis incorporates the full year’s data; as a result,
some NHS boards may be above the 95% confidence interval upper limit in the annual
funnel plot but not in the quarterly funnel plots (for full details please refer to Appendix 2 –
Publication Metadata). NHS boards are monitored on a quarterly basis, for more information
refer to published quarterly epidemiological data.
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Figure 5 Funnel plot of SSI incidence (per 100 hip procedures) for all NHS boards in Scotland in 2017.1
1. Source of data is Surgical Site Infection Reporting System (SSIRS).
The proportion of SSI that were deep and organ space identified post discharge was higher
for hip arthroplasty than for caesarean section however these data are not comparable due
to different post discharge methods of case ascertainment; only SSI where the patient is
readmitted to hospital are captured post discharge following hip arthroplasty thus the
proportion of more severe SSI will be higher (Figure 6). The number of SSI following hip
arthroplasty is small therefore these data should be interpreted with due caution.
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Figure 6 Proportion of SSI following hip arthroplasty procedures (inpatient and readmission to day 30) in Scotland by SSI type, 2017.
1. Source of data is Surgical Site Infection Reporting System (SSIRS).
Quality Improvement and Interventions to Reduce SSI
HPS monitor the SSI incidence within each NHS board on a quarterly basis. Whilst national
surveillance systems do not replace the need for local surveillance, these data and quarterly
publications ensure that outcomes from the national SSI surveillance programme are
shared widely allowing Infection Prevention and Control staff, hospital managers and clinical
staff access to local and national data for improvement.
Since 2016 reporting of SSI surveillance data has been included within the commentary on
quarterly epidemiological data. This publication includes quarterly reporting on the
mandatory programmes for Clostridium difficile infection (CDI), Escherichia coli bacteraemia
(ECB), Staphylococcus aureus bacteraemia (SAB) in addition to SSI in Scotland. Local SSI
data continues to be available on the surgical site infections reporting system (SSIRS) for
NHS boards to use for reporting their own data. NHS Boards also have access to SSI
surveillance reports and indicators within NSS Discovery at board level. This method of
reporting has many benefits to NHS boards allowing them to compare their patients’
outcome with Scottish overall and other NHS Boards.
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Quarterly exception reports are issued to boards where the incidence of SSI is higher than
expected based on the national data. Any NHS board issued with an exception report will be
asked to provide HPS with a board action plan outlining measures they will be taking to
reduce the incidence of SSI. During 2017 there were two exception reports issued for
Caesarean section procedures from different boards. HPS supported the boards with the
analysis of their local data and on both occasions the boards reported high BMI as a
continuing risk. HPS will continue to support local boards and are currently developing the
Discovery platform to enable monitoring of risks factors among SSI cases.
The 7th edition SSI surveillance protocol implemented April 1st 2017 included the new
mandatory procedures: large bowel and vascular. It is a requirement that new procedures
(large bowel and vascular procedures) are conducted using standard surveillance.
Reporting of new mandatory procedures data has been carried out locally and quarterly
epidemiological reports have been issued to each NHS board for improvement purposes
and will be included within the commentary on quarterly epidemiological data once robust
data have been provided by NHS boards.
The 7th edition SSI surveillance protocol also included the collection of structure and
process indicators (SPIs) to provide data for quality improvement. HPS support and
encourage collaboration between NHS boards to facilitate data collection.
An infographic to accompany Surgical Site Infection of the HCAI Annual Report is
available to download (please click on icon).
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Healthcare Associated Infections in Intensive Care Units
The Scottish Point Prevalence Survey (PPS) carried out in 2016 found that one in nine
intensive care unit (ICU) patients had an HCAI at the time of survey (11.4%, 95% CI: 7.2 to
17.5) and that the prevalence of HCAI in ICU patients was higher compared with patients
receiving care in general wards, such as those in medical wards (11.4% versus 4.0%,
p<0.001) and surgical wards (11.4% versus 6.5%, p=0.03).1 Patients cared for in ICU are
particularly vulnerable to infection due to their multiple co-morbidities and the extrinsic risk
factors such as surgical procedures and invasive devices to which they are exposed.
Therefore, patients in ICU are considered to be a priority for HCAI surveillance and
prevention programmes.
During 2016, 21 adult ICUs collected data for this surveillance programme, in accordance
with the national mandatory surveillance requirements. (Data from 2017 are not yet
available for publication in this report. These data will be published as part of the annual
Scottish Intensive Care Society Audit Group report of data in August, 2018). All data were
collected in accordance with the European Centre for Disease Prevention and Control
(ECDC) protocol for Surveillance of Healthcare-Associated Infections in Intensive Care
Units. Data relating to bloodstream infection (BSI), central vascular catheter (CVC) related
infection (CRI), CVC-related bloodstream infection (CR-BSI) and pneumonia (PN) were
collected.7 The cardiothoracic unit at Golden Jubilee National Hospital (GJNH) began
contributing data to the national surveillance programme in 2016 and the ICU at Ayr
Hospital did not contribute data during this period. Therefore, the case-mix has altered since
2015 and this has impacted on the ability to make year on year comparisons of data
contributed during 2016. Where year on year comparisons have been made, these must be
interpreted with caution.
Data were collected from 8,449 patients and in total 253 infections were reported from 232
patients (2.7%, 95% CI: 2.4 to 3.1). Of the infections, 50.6% were PN, 39.5% were BSI and
9.9% were Local and General CRI. Figure 7 shows the incidence of ventilator associated
pneumonia (VAP), BSI and CR-BSI from 2011 to 2016. The data indicate that there has
been no change in the incidence of BSI or CR-BSI between 2015 and 2016. Analysis of
VAP rates show that there has been an increase between 2014 and 2016 (26.7% change
year on year, p=0.002). With regards to the change in the units contributing to the dataset,
this significant increase is evident when GJNH and Ayr Hospital data are excluded from the
2014 to 2016 datasets and is therefore not attributable to these changes in the patient
population.
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The factors influencing an increase in VAP are not clear but may include local changes to
units contributing to the dataset which may result in an altered case-mix, better reporting of
VAP, a true increase in infection or changes in practice. Further analysis of data is in
progress to identify the potential reasons for this increase and validation of these
surveillance data will provide additional insight into this change.
1. Source of data is Scottish Intensive Care Society Audit Group
Quality Improvement and Interventions to Reduce HCAI in ICUs
HPS and the Scottish Intensive Care Society Audit Group (SICSAG) continue to work in
partnership to reduce HCAI in the critical care setting. Quality Indicators for Critical Care in
Scotland ensure that HCAI surveillance is carried out in all ICUs and HPS supports the
evidence content of the critical care infection prevention bundles for VAP and CVC.
From 2018, surveillance in ICU will facilitate the collection of clinically defined pneumonia
which do not meet the ECDC case definitions. This will provide a measure of clinically
defined disease which can be used to support local improvement and infection prevention.
An infographic to accompany HCAI in Intensive Care Units of the HCAI Annual
Report is available to download (please click on icon).
Figure 7 Incidence rates of BSI, VAP and CR-BSI for 2011 to 2016.
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Clostridium difficile Infection
Clostridium difficile infection (CDI) is an important healthcare associated infection, which
causes diarrhoea in the patient and contributes to a significant burden of morbidity and
mortality. Prevention of CDI is therefore essential and an important patient safety issue.
Mandatory surveillance of CDI in Scotland has been carried out in patients aged ≥65 years
since October 2006. This was extended to include patients aged 15-64 years in April 2009.
Full details of the methods may be obtained from the CDI surveillance protocol:
http://www.hps.scot.nhs.uk/haiic/sshaip/resourcedetail.aspx?id=678
Epidemiological Data
During 2017, there were 1,369 cases of CDI in patients aged ≥15 years in Scotland
compared to 1,399 in 2016.
The annual incidence rate in patients ≥15 years in 2017 was 30.1 per 100,000 population
compared to 30.8 per 100,000 population in 2016. There was a decreasing year on year
trend of 6.8% in the incidence rate between 2013 to 2017 ([p<0.001]) (Figure 8), continuing
the decline in CDI rates in patients ≥15 years observed since 2010.
CDI data is reported as part of the HPS Quarterly Epidemiological Commentary (that
also publishes epidemiological trends of ECB, SAB and SSI). In this publication the burden
and trends of CDI are reported using two categories:
Healthcare associated infection by NHS board of laboratory. This is a CDI patient
with onset of symptoms at least 48 hours following admission to a hospital or up to
twelve weeks after discharge from a hospital (see Methods & Caveats).
Community associated infection by NHS board of residence for the case. This is a
CDI patient with onset of symptoms while outside a hospital and without discharge
from a hospital within the previous 12 weeks – or with onset of symptoms within 48
hours following admission to a hospital without stay in a hospital within the previous
12 weeks.
In 2017 the incidence rate of healthcare associated CDI for Scotland was 15.5 per 100,000
total occupied bed days (TOBD), while the incidence rate of community associated CDI was
7.4 per 100,000 population. Figure 9 shows that the change in the incidence rate for
healthcare associated CDI between 2015 and 2017 accounts for most of the decline in the
overall incidence rates among patients aged ≥15 years over the same period, with little
change among community associated CDI cases. This suggests that key interventions in
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the healthcare setting continue to be effective in this area, though the rates appear to be
levelling out.
In funnel plot analyses of CDI incidence rates for 2017 (comparing NHS boards to each
other adjusted for hospital activity/population of health board of residence), NHS Ayrshire &
Arran and NHS Greater Glasgow & Clyde were above the 95% confidence interval upper
limit in the funnel plot for healthcare associated CDI (Figure 10). There were no NHS boards
above the 95% confidence interval upper limit among community associated cases (Figure
11). The funnel plot analysis incorporates the full year’s data; as a result, some NHS boards
may be above the 95% confidence interval upper limit in the annual funnel plot but not in the
quarterly funnel plots (for full details please refer to Appendix 2 – Publication Metadata).
NHS boards are monitored on a quarterly basis, for more information refer to published
quarterly epidemiological data.
Figure 8 Line graph of CDI incidence rate in all patients aged ≥15 years per 100,000 population for Scotland, 2013 to 2017.1
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & National Records of Scotland (NRS) population estimates.
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Figure 9 Incidence rates of healthcare associated (per 100,000 TOBD) and community associated (per 100,000 population) CDI in patients aged ≥15 years, 2015 to 2017.1
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & Total occupied bed days: Information Services Division ISD(S)1/ National Records of Scotland (NRS) population estimates.
Figure 10 Funnel plot of CDI incidence rates (per 100,000 TOBD) in healthcare associated infection cases among patients aged ≥15 years for all NHS boards in Scotland in 2017.1
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & Total occupied bed days: Information Services Division ISD(S)1.
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Figure 11 Funnel plot of CDI incidence rates (per 100,000 population) in community associated infection cases among patients aged ≥15 years for all NHS boards in Scotland in 2017.1
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & National Records of Scotland (NRS) population estimates.
Molecular Epidemiological Data
As part of the epidemiological surveillance of CDI, the Scottish Salmonella, Shigella and
Clostridium difficile Reference Laboratory carry out polymerase chain reaction (PCR)
ribotyping of subsets of C. difficile isolates (under the snapshot programme (to monitor the
background strain distribution) and severe cases and/or outbreaks typing programme).
In 2017, the most common PCR ribotypes circulating in Scotland were 002 (10.6%), 005,
015 and 078 (all 9.4%), whereas 005 (12.2%), 002 (11.8%) and 078 (10.9%) predominated
among severe cases and/or outbreaks. Other common PCR ribotypes included 014, 020,
and 023. Those designated ‘others’ include PCR ribotypes each of which have a frequency
<3% (Table 1). Previously predominant PCR ribotypes 001, 027 and 106 remain at low
levels in Scotland. This suggests that interventions put in place to reduce CDI in Scotland
continue to be successful in controlling these hospital epidemic types. The same major
ribotypes predominate in the rest of the UK, where there has also been a large decline in
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types 001, 106 and 027.8 However, 027 remains a common ribotype found in Europe, as
well as types 014, 001, and 078.9
Table 1 Scottish PCR ribotypes isolated from mild, moderate or severe CDI cases (snapshot), or from severe cases and/or outbreaks between 2016 and 2017.
Type
Snapshot 2016
n
Snapshot 2016
%
Snapshot 2017
n
Snapshot 2017
%
Clinical 2016
n
Clinical 2016
%
Clinical 2017
n
Clinical 2017
%
002 32 10.4 36 10.6 42 16.0 27 11.8
005 23 7.5 32 9.4 28 10.6 28 12.2
014 33 10.7 31 9.1 18 6.8 13 5.7
015 22 7.1 32 9.4 21 8.0 16 7.0
020 20 6.5 22 6.5 13 4.9 19 8.3
023 19 6.2 14 4.1 14 5.3 8 3.5
078 26 8.4 32 9.4 20 7.6 25 10.9
106 7 2.3 13 3.8 6 2.3 7 3.1
Others 126 40.9 129 37.8 101 38.4 86 37.6
Total 308 341 263 229
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS)
Antimicrobial Use and Resistance
The use of any antibiotic, especially the use of particular broad spectrum antibiotics (e.g. co-
amoxiclav, fluoroquinolones and cephalosporins), is known to be a key risk factor for CDI.
Optimisation of antibiotic prescribing through minimisation of unnecessary use and
reduction of inappropriate use of broad spectrum antibiotics are key elements of the
antimicrobial stewardship programme co-ordinated by the Scottish Antimicrobial Prescribing
Group (SAPG).
Most infections encountered in primary care are treated empirically, that is, where the
prescriber has no definitive information on the organism or its antibiotic susceptibility. To
support clinicians in primary care to optimise antibiotic use, SAPG and NHS board
Antimicrobial Management Teams (AMTs) have developed treatment policies to provide
clinicians with advice on antibiotic choice and duration of treatment. They are intended to
optimise antibiotic use through reducing unnecessary use of broad spectrum antibiotics.
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In 2017, the rate of prescribing in primary care of the broad spectrum antibiotics co-
amoxiclav, fluoroquinolones, and cephalosporins altogether was 0.16 items per 1,000
inhabitants per day, 10.8% lower (p<0.001) than 2013. This reduction suggests clinicians
are following local prescribing policies.
The use of broad spectrum antibiotics (cephalosporins, clindamycin, co-amoxiclav and
fluoroquinolones) in acute hospitals was 387.8 defined daily doses (DDD) per 1,000
occupied bed days, 16.2% higher (p<0.001) than in 2013 (data from NHS Shetland are
incomplete for this period and have been excluded). Initially, the priority for Scottish
stewardship programmes was to optimise antibiotic prescribing through reducing the use of
broad spectrum antibiotics associated with an increased risk of CDI. These antibiotics
became known collectively in Scotland as the ‘4Cs’. AMTs successfully engaged clinicians
with a ‘4C’ focussed stewardship programme to reduce the use of these antibiotics. While
CDI remains an important HCAI, the infection landscape has changed and the threat from
drug resistant infections, in particular those due to multidrug resistant (MDR) Gram-negative
bacteria, has become an additional priority for clinicians managing patients with, or at risk
of, infection. There is a need to balance the benefits of early antibiotic treatment in
suspected sepsis with CDI prevention and interventions to preserve the effectiveness of
antibiotics against Gram-negative drug resistant infection.
The Scottish Government is committed to developing a single national medicines formulary
for Scotland to deliver consistency, equity and value for money. SAPG and the Scottish
Microbiology and Virology Network (SMVN), have commenced work to deliver a national
guidance template for hospital antibiotic prescribing. This work may enable the removal of
redundant and unnecessary antibiotics from some regimens together with the increased use
of narrower spectrum antibiotics; this strategy is consistent with the Chief Medical Officer’s
(CMO’s) ‘Realistic Medicine’ approach.
To date, all isolates of C. difficile have been reported susceptible to metronidazole and
vancomycin, the two antibiotics used to treat CDI. However, resistance to other commonly
used antibiotics continues to be common among the Scottish C. difficile isolates, which has
been suggested to give C. difficile an advantage to spread in healthcare environments.
Cefotaxime (98.5%) and clindamycin (96.9%) resistance remained high among all ribotypes
isolated.
CDI Mortality
There was no discernible trend in the 30-day all-cause mortality in CDI patients between
2012 and 2016 (p=0.17) (Figure 12). In 2015, 30-day mortality was 16.9% compared to
15.3% in 2016 (p=0.26). The data are within the 30-day all-cause mortality range (3%-38%)
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reported by various studies from the UK, Europe and North America, though there is
heterogeneity in terms of methods used and reporting.10-12
Figure 12 Line graph of CDI 30-day all-cause mortality (%) among patients aged ≥15
years in Scotland, 2012 to 2016.1
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & National
Records of Scotland (NRS) mortality records.
Quality Improvement and Interventions to Reduce CDI
In 2017, HPS published a new edition (No 6 2017 edition) of the SHPN “Guidance on
Prevention and Control of Clostridium difficile Infection (CDI) in Health and Social Care
Settings in Scotland” which provides easily accessible advice covering key aspects of
prevention and control of CDI. The guidance is available from:
http://www.hps.scot.nhs.uk/haiic/sshaip/resourcedetail.aspx?id=184
This latest version (following Scottish Health Protection Network (SHPN) methodology for
development of guidelines) provides a standardised evidence-based approach to diagnosis,
prevention and control, and treatment of CDI to help staff deliver safe care and support the
reduction of CDI in their organisation.
Key aspects of the new guidance include monitoring and treatment of CDI in children (under
15 years old); clarification of the roles and responsibilities for GPs and Health Protection
Teams; revision of recommendations for patient assessment for CDI cases in care homes
and those receiving care at home; consensus opinion on the role of asymptomatic carriers
and probiotics for prevention/treatment of CDI; and updated information on the use of faecal
microbiota transplantation for the treatment of CDI.
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Over the coming year, HPS will be initiating projects to assess and evaluate the burden of
recurrent CDI in Scotland, as well as review evidence related to asymptomatic carriage of
CDI and the potential impacts in the healthcare setting.
HPS continues to support local NHS boards in response to any indication that local quality
improvements and reduction strategies are not being reflected in the rates of CDI within that
NHS board. Collaboration with European partners also continues in terms of harmonisation
of surveillance, which is crucial for monitoring trends and benchmarking.
An infographic to accompany Clostridium difficile of the HCAI Annual Report is
available to download (please click on icon).
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Staphylococcus aureus Infection
Staphylococcus aureus (S. aureus) was identified as the second most common causative
organism in the most recent Scottish Point Prevalence Study.1 S. aureus bacteraemia
(SAB) is a serious systemic form of infection which leads to increased morbidity and
mortality and requires exposure to antimicrobial therapy to treat.
Scotland has had a mandatory meticillin resistant S. aureus (MRSA) bacteraemia
surveillance programme since 2001,13 publishing quarterly reports14 of the numbers and
rates of MRSA bacteraemias. The programme was extended to include meticillin sensitive
S. aureus (MSSA) bacteraemias in 2006 and in 2014 to include enhanced SAB
surveillance.4;5 Full details of the surveillance methods may be found in the protocol.15
Epidemiological Data
During 2017, there were 1,574 cases of SAB reported in Scotland, 76 (4.8%) were MRSA
bacteraemias and the remaining 1,498 (95.2%) were MSSA bacteraemias. This compared
to 1,599 of which 88 (5.5%) were MRSA and 1,511 (94.5%) were MSSA in 2016.
Between 2013 and 2017, there has been no change in the overall incidence of SAB in
Scotland (p=0.69). When looking at the trends of MRSA and MSSA during this period there
has been a year on year decrease of 17.3% (p<0.001) in MRSA rate however there has
been no change in the MSSA annual incidence rate (p=0.18). The annual incidence of SAB
for Scotland in 2017 was 29.1 per 100,000 population, with no significant change from the
previous year (p=0.66). The annual incidence rates of MRSA and MSSA bacteraemia in
2017 were 1.4 per 100,000 population and 27.7 per 100,000 population, respectively.
Neither of these incidence rates have changed between 2016 and 2017 (p=0.35 and
p=0.81, respectively).
Patient outcome data has been linked (all cause mortality at 30 days) with SAB case data
for all MRSA and MSSA bacteraemias reported by HPS between 2012 and 2016. This
showed there was no change in the proportion of people dying within 30 days of acquiring
an MRSA or MSSA bacteraemia (p=0.91 and p=0.50 respectively) over this time period. In
2016, the 30-day mortality was 31.8% for MRSA bacteraemias and 17.9% for MSSA. These
figures are comparable to those reported by Public Health England (PHE) for the period
2016/17.16
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1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & National Records of Scotland (NRS) mortality records.
Figure 13 describes the national incidence rates of MRSA, MSSA and SAB. The historic
decline in the incidence rates of MRSA and MSSA seen in the initial stage of surveillance
then changed to show a plateau in MSSA and overall SAB rate but with a continued
decrease in MRSA rate.
SAB data is reported as part of the HPS Quarterly Epidemiological Commentary (that
also publishes epidemiological trends of CDI, ECB and SSI). In this publication the burden
and trends of SAB are reported using two categories (see Methods and Caveats):
Healthcare associated infection by NHS board of aspiration. Cases are categorised as healthcare associated when the case has had contact with healthcare either in hospital or while receiving care in the community.
Community associated infection by NHS board of residence of the case. Cases are categorised as community associated when the case has had no known contact with healthcare.
Figure 13 Incidence rates of S. aureus, MRSA and MSSA bacteraemias (per 100,000 population) in Scotland: 2013 to 2017.
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In 2017, there were 1,047 (66.5%) healthcare associated cases of SAB reported in Scotland
with a rate of 16.7 per 100,000 total bed days. The remaining 527 (33.5%) were community
associated with a rate of 9.8 per 100,000 population.
In funnel plot analyses of SAB incidence rates for 2017 (comparing NHS boards to each
other adjusted for hospital activity/population of health board of residence), NHS Greater
Glasgow & Clyde and NHS Lanarkshire were above the 95% confidence interval upper limit
in healthcare associated cases, however NHS Dumfries & Galloway, NHS Highland and
NHS Lothian were below the 95% confidence interval lower limit (Figure 14). No NHS board
was above the 95% confidence interval upper limit for community associated cases (Figure
15). The funnel plot analysis incorporates the full year’s data; as a result, some NHS boards
may be above the 95% confidence interval upper limit in the annual funnel plot but not in the
quarterly funnel plots (for full details please refer to Appendix 2 – Publication Metadata).
NHS boards are monitored on a quarterly basis, for more information refer to published
quarterly epidemiological data.
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & Total
occupied bed days: Information Services Division ISD(S)1.
Figure 14 Funnel plot of SAB incidence rates (per 100,000 TOBD) in healthcare associated infection cases for all NHS boards in Scotland in 2017.1
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1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & National Records of Scotland (NRS) mid-year population estimates.
2. NHS Orkney and NHS Shetland overlap.
In the healthcare associated cases over a third reported a device related entry point
(vascular access device (VAD) or device other than VAD) that led to the SAB (Figure 16).
The other common known entry point was skin and soft tissue infection (19.4%). For some
cases (23.7%) it is not possible to identify the entry point of the bacteraemia. For community
associated cases the most common known entry points were skin and soft tissue infection
(30.2%), people who inject drugs (PWID) (15.2%) and respiratory infection (9.3%) (Figure
17). It was not possible to establish entry point in 38.9% of the community associated
cases.
Figure 15 Funnel plot of SAB incidence rates (per 100,000 population) in community
associated infection cases for all NHS boards in Scotland in 2017.1, 2
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1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS)
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS).
Figure 16 Pie chart of SAB healthcare associated cases (n=1,047) for Scotland in 2017 by Entry point.1
Figure 17 Pie chart of SAB community associated cases (n=527) for Scotland in 2017 by Entry point.1
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Antimicrobial Resistance
Mupirocin is used for nasal decolonisation of MRSA. Resistance to mupirocin is
phenotypically categorised as low-level resistance and high-level resistance. Treatment with
mupirocin is unlikely to be effective in the presence of high-level mupirocin resistance, and
there are concerns that low-level resistance will also lead to nasal decolonisation failure.
The resistance results presented here are only for bacteraemia-related isolates, as
submission of S. aureus bacteraemia isolates to the Scottish MRSA Reference Laboratory
(SMRSARL) is mandatory. During 2017, there were no mupirocin high level resistant
isolates observed in MRSA isolates, this compares to 3/88 (3.4%) in 2016. Low level non-
susceptibility in 2017 was observed in 1/76 MRSA isolates (1.3%), similar to the proportion
observed in 2016 1/88 (1.1%). Data should be interpreted with caution as numbers are
small.
Quality Improvement and Interventions to Reduce SAB
Research and Surveillance
HPS continues to support local NHS boards with local and national quality improvements
and reduction strategies. Outputs from the enhanced surveillance are shared quarterly with
the short life working group (SLWG), local infection prevention and control teams (IPCT)
and HAI Policy Unit for management and improvement purposes. The reports are being
displayed through NSS Discovery. Further developments have been carried out on ECOSS
web tool to allow boards to analyse their local data in real time.
The enhanced data have provided an evidence base for development of healthcare quality
improvements and interventions to reduce SAB. The risks in adults and children highlighting
the differences when the data is broken down by origin have been published in the Journal
of Hospital Infection and describe the types of devices associated with healthcare
associated SAB and highlighting that improvement plans should not only focus on hospitals
but be wider to target reductions in SAB with community origin.17;18
The enhanced data set has been linked as part of the Scottish Healthcare Associated
Infection Prevention Institute (SHAIPI) and is using genome sequencing to analyse strain
patterns in conjunction with risk factors to identify any association between community and
hospital acquired SAB. This research is ongoing and combined with a SAB case control
study working with colleagues at Glasgow and St Andrews Universities this will enable
future focussed interventions to target SAB. A better understanding of the specific clinical
epidemiology of MSSA bacteraemias may lead to interventions to reduce these infections,
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which now represent the majority of all SAB in Scotland. HPS will continue to work with
specialities where patient populations, through the inventions and treatment they receive,
are at risk of acquiring a SAB to develop improvement plans for reduction of bacteraemia.
MRSA Acute Admission Screening in Scotland The Scottish national MRSA acute hospital admission screening programme identifies
patients who are colonised or infected with MRSA, ensures that they are identified
early and are managed effectively to prevent transmission of MRSA to other patients. A
national MRSA screening policy has been in place in Scotland since March 2012.19 This
clinical risk assessment (CRA) based screening policy identifies a subset of patients at high
risk of MRSA colonisation or infection on admission to hospital who are then tested for
MRSA. This method of screening reduces the number of patients who require to be
laboratory tested for MRSA and allows high risk patients to be pre-emptively isolated whilst
the results of the test are awaited.
Uptake of the application of the CRA is a level 3 HAI Key Performance Indicator (KPI).20
During 2017 85% of eligible admissions to Scottish acute hospitals were risk assessed in
line with national MRSA screening policy. This remains below the KPI of 90% however
reflects a 3.5% increase (p<0.001) from 2016 where compliance was 82%.
Whilst the CRA KPI system was designed to measure uptake of CRA at a Scottish level on
an annual basis, uptake at board level continues to be monitored each quarter to identify
boards with uptake below the minimum level required. HPS continues to work with NHS
boards to provide support in facilitating ongoing improvement with uptake. In 2017 this
included the development of run charts to display the KPI uptake data by month, over time.
These run charts will be an enhanced form of feedback to boards, who will receive a chart
for their board, and for the national uptake each quarter.
Figure 18 below shows Scotland’s MRSA screening uptake by month up from April 2013 to
the end of December 2017.
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Figure 18 Scottish MRSA Screening Uptake by month of admission. April 2013 to December 2017.1
1. Source of data is MRSA screening KPI tool.
Research
The Scottish Infection Research Network (SIRN) funded a research study to identify the
barriers and drivers to the implementation of acute hospital admission screening, the results
and recommendations of which were finalised in January 2018 by Glasgow Caledonian
University (GCU). HPS will take forward the findings and recommendations from this study
to develop a best practice guide; use data from the KPI measurement tool to enhance
feedback to boards using quality improvement methodologies (including run charts, see
Figure 18, at the local and national level); and will work with NHS Education for Scotland
(NES) to promote the online learning module for multidrug resistant organism (MDRO) HAI
screening (covering both carbapenamase-producing enterobacteriaceae (CPE) and MRSA),
which was launched in January 2017 (and can be accessed via the following link:
http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/healthcare-
associated-infections/online-short-courses.aspx.
An infographic to accompany Staphylococcus aureus Infection of the HCAI Annual Report is
available to download (please click on icon).
Median
90% Target
60%
65%
70%
75%
80%
85%
90%
95%
100%
Scre
enin
g U
pta
ke (
%)
Month of admission
SAB Chapter: MRSA Acute Admission SAB Chapter: MRSA Acute Admission SAB Chapter: MRSA Acute Admission
Quarterly feedback
Targeted feedback
Enhanced feedback
CPE Pilot
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Gram-negative Bacteraemia
This chapter comprises:
Gram-negative bacteraemia (Escherichia coli, Klebsiella oxytoca, Klebsiella
pneumoniae, Pseudomonas aeruginosa, and Acinetobacter spp),
E. coli bacteraemia (ECB) enhanced surveillance,
Antimicrobial resistance (AMR) data for Gram-negative bacteraemia (E. coli, K.
pneumoniae, and P. aeruginosa).
Gram-negative Bacteraemia
Gram-negative bacteria are an important cause of serious infections in healthcare and
community settings.21 The most recent PPS showed that two-fifths of all reports of infection
in a adult patients in acute healthcare settings (40.4%, 114/282) and almost all patients in
non-acute healthcare settings (94.4%,17/18) were caused by Gram-negative bacilli.1
Gram-negative bacteraemia is, therefore, a priority, and as such is monitored as an
indicator of the impact of the ‘UK Five Year Antimicrobial Resistance Strategy (2013-
2018)’.22
E. coli was the most common cause of Gram-negative bacteraemia in Scotland in 2017
followed by K. pneumoniae and P. aeruginosa.
Figure 19 Incidence (per 100,000 population) of Gram-negative bacteraemia due to the most commonly reported pathogens within Scotland, 2013 to 2017.1
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & National Records of Scotland (NRS) mid-year population estimates.
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Escherichia coli Bacteraemia (ECB)
In Scotland, E. coli is a frequent cause of bacteraemia in community and healthcare
settings. E. coli bacteraemia develops usually as a complication of other infections,
including urinary tract infection (UTI), surgery and use of medical devices including urinary
catheters and vascular access devices.
Epidemiological Data
During 2017, there were 4,763 cases of ECB in Scotland compared to 4,802 in 2016. The
annual incidence of ECB for Scotland in 2017 was 88.1 per 100,000 population with no
change from the previous year (p=0.69). The incidence rate in England was 74.6 per
100,000 population for the year 2017.23 There was an increasing year on year trend of 1.5%
in the incidence of ECB in the period 2013-2017 (p=0.002) (Figure 19). Although there still
was an upward trend in ECB incidence from year 2013 to year 2017, the annual increase is
less than previous (1.5% vs. 3.9% between 2012 and 2016). This reflects a historical
change as the rate has not increased in the last 2 years when comparing to the previous
year (i.e. 2017 vs. 2016).
In 2016, the 30-day all-cause mortality was 15.2%. The corresponding mortality rate for
England for the period 2016/17 was 14.7%.16 ECB case data reported by HPS between
2012 and 2016 demonstrated a 2.5% decrease in the proportion of people dying within 30
days of acquiring an ECB (p=0.02).
ECB data are reported as part of the HPS Quarterly Epidemiological Commentary which
also includes epidemiological trends of SAB, CDI and SSI). In this publication the burden
and trends of ECB are reported using two categories (see Methods and Caveats):
Healthcare associated infection by NHS board of aspiration. Cases are categorised as healthcare associated when the case has had contact with healthcare either in hospital or while receiving care in the community.
Community associated infection by NHS board of residence of the case. Cases are categorised as community associated when the case has had no known contact with healthcare.
In 2017, the rate of healthcare associated ECB for Scotland was 35.0 per 100,000 bed days
and the rate of community associated infections was 47.5 per 100,000 population.
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In funnel plot analyses of ECB incidence rates for 2017 (comparing NHS boards to each
other adjusted for hospital activity/population of health board of residence), four NHS boards
were above the 95% confidence interval upper limit in healthcare associated cases: NHS
Ayrshire & Arran, NHS Lanarkshire, NHS Shetland, and NHS Tayside (Figure 20); and three
NHS boards were above the 95% confidence interval upper limit in community associated
cases; NHS Ayrshire & Arran, NHS Greater Glasgow & Clyde, and NHS Lanarkshire (Figure
21). The funnel plot analysis incorporates the full year’s data; as a result, some NHS boards
may be above the 95% confidence interval upper limit in the annual funnel plot but not in the
quarterly funnel plots (for full details please refer to Appendix 2 – Publication Metadata).
NHS boards are monitored on a quarterly basis, for more information refer to published
quarterly epidemiological data.
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & Total
occupied bed days: Information Services Division ISD(S)1. 2. NHS Ayrshire & Arran and NHS Tayside overlap.
Figure 20 Funnel plot of ECB incidence rates (per 100,000 TOBDs) for healthcare associated cases for all NHS boards in Scotland in 2017.1,2
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1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & National
Records of Scotland (NRS) mid-year population estimates.
The enhanced surveillance component of the national surveillance programme captures
detailed clinical information through local case reviews. These additional data on all cases
of ECB help identify where the bacteraemia occurred as well as the primary infection and/or
healthcare procedures that are thought to have contributed to the development of
bacteraemia.
In 2017 around half of the cases of ECB reported were ‘community associated’ (Figure 22)
i.e. the case has had no known contact with healthcare prior to developing an ECB.
Figure 21 Funnel plot of ECB incidence rates (per 100,000 population) for community associated cases for all NHS boards in Scotland in 2017.1
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1. Source of data is derived from the Electronic Communication of Surveillance in Scotland system (ECOSS).
A third of cases of ECB reported had a lower urinary tract infection as their primary infection
that may have led to the bacteraemia (Figure 23). Other common primary infections
included: hepatobiliary infections (19.5%), pyelonephritis (7.8%) and those associated with
urinary catheters (7.7%). For some cases (15.0%) it was not possible to establish the
source of the ECB or identify the entry point of the bacteraemia.
Figure 22 Pie chart of ECB cases (n=4,763) for Scotland in 2017 by origin of infection.1
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1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS).
Development of Surveillance and Interventions to Reduce E. coli
Bacteraemia
The importance of ECB demands a reliable surveillance programme in order to monitor
trends in incidence rates to inform strategic planning, target interventions and develop
quality improvement initiatives. Mandatory surveillance commenced in April 2016. HPS will
work in collaboration with NHS laboratories to gain further intelligence into historical trends.
The ECB enhanced surveillance dashboard has now been launched on NSS Discovery, an
NHS information system that provides approved users with access to a range of
comparative healthcare information to support performance and quality improvement in
health boards across Scotland. Presentation of ECB data on Discovery has replaced the
conventional enhanced ECB surveillance report and enables NHS boards to identify and
investigate exceedences, and focus in on particular sources, devices and procedures. This
information can highlight areas for improvement to guide the best use of national resources
(e.g. Scottish Urinary Tract Infection Network) and facilitate the establishment of
collaborative professional groups to target the implementation of quality improvement and
preventative measures both locally and nationally.
The most recent Scottish Point Prevalence Survey further highlighted that the types of
healthcare associated infection occurring in Scottish hospitals are associated with a large
Figure 23 Pie chart of ECB cases (n=4,763) for Scotland in 2017 by primary infection.1
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burden of prescribing to treat community acquired infections in hospital.1 Measures to
reduce the risk of infection that can be applied to both community and hospital settings
would reduce the risk of all infections in all care settings. The Health and Social Care
Integration agenda and the 2020 vision for healthcare delivery in Scotland aim to integrate
health and social care with a focus on prevention and supported self management. Given
the changes to the way care will be delivered in the future, it is necessary to develop a
broader public health system-wide approach that also focuses on minimising the risk of
developing infection before admission to hospital. A system-wide approach has the potential
to reduce community acquired infections and the associated prescribing; the risk of
antimicrobial resistance; reduce the need for hospital admission for infections and reduce
the risk of patients developing a severe infection.
Urinary tract infections are very common in the community and may lead to E. coli entering
the person’s bloodstream to cause a bacteraemia. The establishment of interventions in
primary care is key to reducing the occurrence of hospital admissions due to ECB. The
national Gram negative bacteraemia programme works in partnership with the Scottish
Urinary Tract Infection Network (SUTIN) and SAPG to underpin quality improvement
activities in the prevention and management of urinary tract infections. One recent SUTIN
initiative is the introduction of the National Urinary Catheter Passport (NCP). The purpose
of this quality improvement tool is to facilitate the provision of seamless care for people with
urinary catheters as they move through the various pathways of health and social care but
more importantly, it is a means of encouraging self-management of their device in a way
which will reduce the risk of complications such as catheter associated urinary tract infection
(CAUTI).
In April 2017, stakeholders asked if SUTIN would host a Hydration Campaign which would
support the reduction of Gram negative bloodstream infections such as ECB. Using a
collaborative approach, a suite of educational posters and leaflets for raising awareness
was produced to support the hydration campaign.
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Antimicrobial Resistance in Gram-negative Bacteraemia
AMR is the ability of microbes (bacteria, viruses, fungi and parasites) to withstand the
effects of antimicrobials (chemical agents used to suppress or kill microbes). Multidrug
resistance among Gram-negative bacteria is a threat to public health and patient safety and
consequently higher healthcare costs, increased length of stay in hospitals, treatment
failures, and increased mortality.
The proportions of ECB non-susceptible (resistant or intermediate) to commonly used
antibiotics were generally stable over the last five years; however, resistance to some
antibiotics was consistently high over this period (Figure 24).
Figure 24 Proportions of ECB non-susceptible to indicated antibiotics (fluoroquinolones, aminoglycosides, 3rd-generation cephalosporins, piperacillin/tazobactam and carbapenems) 2013 to 2017.1
1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS)
Susceptibility in K. pneumoniae Bacteraemia
Susceptibility among K. pneumoniae bacteraemia has remained unchanged over the last
five years except for piperacillin/tazobactam where non-susceptibility was 19.1% (154/805)
in 2017 and has shown a non-linear increase (7.7%, p=0.004) over the last five years.
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Susceptibility in P. aeruginosa Bacteraemia
P. aeruginosa is intrinsically resistant to a broad range of antimicrobials and any additional
acquired resistance limits the therapeutic options for treatment of serious infections.
Antimicrobials that remain susceptible include ceftazidime, ciprofloxacin, gentamicin,
meropenem and piperacillin/tazobactam. Non-susceptibility to these agents has remained
stable since 2013 except for piperacillin/tazobactam where a year on year decrease has
been observed (16.5%, p=0.004).
An infographic to accompany the Gram-negative bacteraemia of the HCAI Annual Report is available to download (please click on icon).
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Urinary Tract Infection
Urinary Tract infection (UTI) is the most prevalent HCAI within adult inpatient care in
Scotland.1 The recent Scottish PPS found that UTI accounted for almost a quarter of all
HCAI (24.5%) with half of those patients having a urinary catheter in place within one week
of infection onset. Within non-acute hospitals, UTI represented 58.8% of all HCAIs, and
again half of those patients had a urinary catheter within one week of infection onset. The
recently published Healthcare Associated Infections in Long-term Care (HALT) study within
Scotland found that UTI accounted for approximately a third of all HCAI (31.0%) within the
52 care homes that contributed to the survey.24 Thus there is a significant burden of UTI
across health and social care settings, much of which results in preventable secondary
bloodstream infections and sepsis.
National UTI Programme
Recognising this burden of potentially preventable UTI and Catheter associated UTI
(CAUTI); the Scottish UTI Network (SUTIN) was established in 2015 by HPS. The aim of
SUTIN is to achieve a strategically cohesive approach to all strands of UTI reduction work,
ensuring there is shared learning from all outputs by all stakeholders. The SUTIN board
includes representatives from a wide range of stakeholders across health and social care
with a shared interest in UTI reduction. An important part of their role as board members
has been to act as a conduit between the network and their various professional bodies.
Communication methods are varied with a SUTIN webpage within the HPS website as well
as updates via social media tweets. In addition the quarterly SUTIN newsletter provides a
platform for communicating UTI reduction strategies with contributions from Network Board
members. The newsletter is also published on the HPS website with SUTIN board members
providing links to this from within their organisational websites.
National Catheter Passport
The need for a National Catheter Passport (NCP) was identified by SUTIN and developed in
2017. The purpose is to provide seamless care for people with urinary catheters as they
move across various health and social care settings. More importantly it provides a means
of encouraging self-management of their device in a way which reduces risk of
complications such as CAUTI. A short life working group (SLWG) which included members
from across health and social care including urology and bladder and bowel specialists
developed the NCP which was then tested in 15 different settings and locations across
Scotland. This booklet is held by the individual with the catheter and provides essential
information regarding:
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Reason for catheter insertion
Catheter care – hand hygiene, care of leg bag
Troubleshooting information
Expected removal date / Trial without catheter (TWOC)
Clinical care details – including catheter maintenance
A whole system approach to implementation has been recommended; following the patient
journey through the various health settings to their own home (Figure 25).
Collaboration with National Procurement (NP) and National Distribution Centre (NDC) has
enabled the NCP to be made available free at the point of use; when ordered with catheters
via the PECOS system. Alternative distribution methods are being explored for those not
using PECOS.
Evaluation of the NCP in terms of patient outcomes in both acute hospitals and care homes
will follow during 2018/19. The feasibility of using proxy measures to provide quantitative
analysis via available registry data is being explored as well as measuring qualitative
outcomes in terms of patient and healthcare staff feedback.
National Hydration Campaign
During April 2018, SUTIN initiated a National Hydration Campaign which aims to convey the
public health benefits of good hydration in terms of UTI prevention. Collaborating on a
SLWG with national organisations including NES, Care Inspectorate, Scottish Care, NHS24,
Figure 25 National Catheter passport.
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Scottish Antimicrobial Prescribing Group and Scottish Government, this campaign will
support other national health programmes where good hydration can be beneficial e.g.
reduction in falls and pressure ulcers as well as frailty, delirium and acute kidney injury.
Campaign materials include posters, leaflets and a visual reusable fluid record chart. These
are grouped together: those suitable for acute settings, care at home and care home
settings; and those to be used in the public facing part of the campaign. Specific posters
were designed to be placed in all of Scotland’s community pharmacies, with accompanying
leaflets. This is to encourage the public to make positive choices in terms of hydration and
also to raise awareness of the dangers of dehydration (Figure 26)
An infographic to accompany Urinary Tract Infection of the HCAI Annual Report is
available to download (please click on icon).
Figure 26 Healthy Pee Poster
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Controlling Antimicrobial Resistance in Scotland
The Controlling Antimicrobial Resistance in Scotland (CARS) programme aims to provide a
strategic response to AMR, ensuring Scotland is better equipped to control AMR now and in
the future.
AMU/AMR Surveillance
In November 2017, during World Antibiotic Awareness Week and ahead of European
Antibiotic Awareness Day, HPS published the Scottish One Health Antimicrobial Use
and Antimicrobial Resistance Annual Report (SONAAR).25 Consistent with the
recommendations of the ‘UK Five Year Antimicrobial Resistance Strategy(2013-2018)’22
and the ‘One Health’ ethos, the report included surveillance information on antimicrobial use
(AMU), AMR in humans, and AMR in animals.
As part of national AMR surveillance improvement measures, in 2009 HPS developed an
automated alert system to monitor unusual AMR phenotypes among emerging organisms.
These organism/antibiotic combinations are important to monitor either because resistance
is so rare that a report of resistance warrants prompt investigation to confirm its validity, and
if confirmed, further characterisation of the organism, or because a significant change in
resistance patterns will impact on clinical management of cases. This system, which reports
weekly, allows early identification, confirmation and reporting of such resistance to NHS
boards. In June 2017, in conjunction with the Scottish Microbiology and Virology Network
(SMVN), HPS produced the ‘Resistant bacteria (exceptional phenotypes) -’ list published in
the ‘National Infection Prevention and Control Manual Appendix 13’. This list was used
to update the national antimicrobial alert monitoring system for Scotland in August 2017.
The CARS team has been working with the HPS Public Health Microbiology team to
improve public health microbiology data to ensure provision of all antimicrobial sensitivity
data to Electronic Communication of Surveillance in Scotland (ECOSS).
Research Facilitation
Funded by the Scottish Government and commissioned by HPS, CARS has supported GCU
to produce a suite of reports which provide insights on the drivers, pressures and
behaviours underpinning clinical decisions to prescribe antimicrobial drugs in primary and
secondary care, treatment expectations in patients, and the level of understanding and
awareness of AMR among veterinarians and companion animal owners.
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The Scottish Universities Life Sciences Alliance (SULSA) is a strategic alliance between
eight Scottish Universities that aims to advance Scotland’s research and innovation in life
sciences. CARS is working in collaboration with SULSA and other partners to develop a two
day AMR research conference at the University of Strathclyde, 26th to 27th April 2018.
In addition, CARS has facilitated AMR research in Scotland including collaborations with
academic partners on a number of projects including investigation of the risk factors, health
outcomes, and genetic characteristics of resistant organisms.
Control of AMR in Animal Health
Scotland’s Healthy Animals website was formally launched at AgriScot on 15th
November 2017, providing an important platform for promotion of guidance on disease
avoidance and antibiotic stewardship to the wider animal health community.
Scotland’s Poultry Hub is a ‘go to’ resource that was developed for poultry keepers,
especially smallholders, signposting guidance and helpful up-to-date information on keeping
poultry healthy so as to avoid the need to treat disease. This resource is hosted on the
Scotland’s Healthy Animals website and it is envisaged that this platform will be utilised
as a trusted ‘one-stop shop’ of disease avoidance and antimicrobial stewardship information
and guidance for all animal keepers and their veterinarians.
The CARS Scottish Veterinary Antimicrobial Stewardship Group aims to optimise
antimicrobial stewardship and prescribing in veterinary practice by drawing together
representation from all veterinary sectors (including pigs, poultry, cattle, sheep, horses,
companion animals, exotics, fish and aquaculture) and from veterinary nursing.
Guidance for Countryside and Leisure has been drafted as part of the Scotland’s Healthy
Animals website. This offers guidance on responsible countryside access and prevention of
spread of infectious diseases throughout the countryside as well as avoiding bringing home
infections with the potential to infect people.
Engagement and Education
The Scottish Antimicrobial Prescribing Group (SAPG), and the Scottish Microbiology and
Virology Network (SMVN)/Antimicrobial Susceptibility Testing (AST) Group are key groups
for the successful delivery of control of AMR in Scotland. CARS is furthering joint working in
relation to a number of initiatives including, with SAPG on antifungal stewardship, dental
stewardship, and with the SMVN on improvements to AMR surveillance.
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CARS has engaged with stakeholders, including Directors of Public Health and Consultants
in Public Health, Animal Health Practitioners, and Environmental Health (Scottish
Environment Protection Agency (SEPA) and Royal Environmental Health Institute of
Scotland (REHIS)) to promote the need to focus on AMR and inappropriate prescribing and
build capacity for the control of AMR across the ‘One Health’ landscape.
In addition, CARS has worked closely with counterparts in PHE e.g. the English
Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Oversights
Group, the Department for Environment, Food and Rural Affairs (Defra), Antimicrobial
Resistance Coordination (DARC) Group, and the Pig Health and Welfare Council AMU
(PHWCAMU) Subgroup. The Animal Health team held a ‘One Health’ shared professional
stewardship pilot event in Orkney in September and a complementary joint professional
stewardship initiative in NHS Lanarkshire in March. The aim of these initiatives was to
promote “on the ground” activities to control AMR with clinical and veterinary prescribers
working together to understand their local prescribing and AMR problems, to develop
solutions, and influence cultural change in the ‘One Health’ context.
Following consultation with educators in Scottish veterinary schools and in veterinary
nursing and, with input from the Scottish Veterinary Antimicrobial Stewardship Group, a
preliminary template has been drafted to gather information about educational challenges
for veterinarians and veterinary nursing trainees and their educators for presentation to the
Veterinary Schools Council AMR Group. The initiative aims to develop long-term
relationships with educators to help to identify and agree knowledge gaps and share best
practice to support teaching of antimicrobial stewardship and AMR to students of veterinary
medicine and veterinary nursing.
An infographic to accompany Controlling Antimicrobial Resistance in Scotland
(CARS) of the HCAI Annual Report is available to download (please click on icon).
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Carbapenemase-Producing Organisms
Carbapenems are very broad-spectrum antibiotics which are used almost exclusively in the
hospital setting for the treatment of suspected or confirmed multi-resistant Gram-negative
infections. The emergence and spread of carbapenemase-producing organisms (CPOs)
(including the carbapenemase-producing Enterobacteriaceae (CPE), and non-fermenting
bacteria) is of particular concern as these organisms can inactivate carbapenem antibiotics,
which leaves few therapeutic options for infections due to CPOs. CPOs have been reported
worldwide in healthcare and community settings, with increased intercontinental travel
contributing to their spread.
Epidemiological Data
In Scotland, CPO isolates are derived from a range of screening and clinical specimens
including urine, respiratory and blood isolates. A total of 108 CPO isolates were reported
from the Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI)
Reference Unit, Public Health England (PHE) and the Scottish AMR Satellite laboratory, in
2017, compared to 73 isolates reported in 2016. There was a year on year increase (39.3%,
p<0.001) in the incidence of CPO (2013 to 2017), from 0.4 per 100,000 population in 2013
to 2.0 per 100,000 population in 2017. There was also an increase since 2016 (47.9%,
p=0.01) when the incidence was 1.4 per 100,000 population. This increase is temporally
associated with improved awareness of CPO, continued CPE screening – 44.4% of CPOs
were from specimens taken for screening for colonisation in 2017 compared with 19% in
2015 – and the launch of the Scottish AMR Satellite Reference service in 2017. Figure 27
shows the number of CPO isolates by enzyme type (2003 to 2017).
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1. Source of data is ECOSS, Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit Public Health England (PHE) and the Scottish AMR Satellite Laboratory.
In 2017, the most frequently isolated enzyme was OXA-48 like enzymes (34.3%; n=37)
followed by NDM (New Delhi Metallo-beta-lactamase) (27.8%; n=30) and VIM (Verona
Integron-encoded Metallo-beta-lactamase) (16.7%; n=18).
Table 2 shows the number of CPOs by organism type and enzyme since 2003.
Enterobacteriaceae account for 83.8% (n=315) of all CPOs reported between 2003 and
2017.
Figure 27 Number of CPO isolates by enzyme type reported in Scotland by AMRHAI (PHE) and the Scottish AMR Satellite laboratory (2003 to 2017).1
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Table 2 Carbapenemase-producers by organism and enzymes reported in Scotland by AMRHAI (PHE), 2003 to 2017.1
Species IMI IMP KPC NDM OXA-
48 VIM
IMP + NDM
NDM + OXA-48
GES-5
NDM + IMP
VIM + IMP
Mixed All
enzymes
Enterobacter 2
2
Enterobacter cloacae
3 7 15 6 3 28
1 63
Enterobacter sp. 1 3 2 1 6
13
Escherichia coli 1 1 43 40 6
1
1 93
Klebsiella oxytoca 6
6
Klebsiella pneumoniae
40 24 29 14
4
111
Klebsiella sp. 5 9 4
1
19
Proteus mirabilis 1 1
2
Providencia rettgeri
1
1
Providencia stuartii
2
2 1
5
Total Enterobacteriaceae
3 9 61 84 83 64 2 7 0 0 1 1 315
Acinetobacter baumannii
4
4
Acinetobacter indicus
1
1 2
Citrobacter freundii
2 1 1 1 4
9
Pseudomanas fluorescens
3
3
Pseudomonas aeruginosa
7
1
29
1
1 39
Pseudomonas putida
1
1
Pseudomonas stutzeri
1
1
Unknown 1
1
2
Total non-fermenting bacteria
0 12 1 8 2 34 0 1 1 1 0 1 61
Total CPO 3 21 62 92 85 98 2 8 1 1 1 2 376
1. Source of data is ECOSS, Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit Public Health England (PHE) and the Scottish AMR Satellite Laboratory.
Quality Improvement and Interventions to Reduce
Carbapenem Producing Organisms
Measures to prevent and control outbreaks of CPOs, in hospitals and other settings,
include: active surveillance, isolation and contact precautions of suspected and confirmed
cases, education of staff, and the prudent use of antimicrobials.26 Additional measures are
needed to control CPEs in hospitals due to the high risk of transmission in this setting; thus
admission screening comprising a clinical risk assessment with follow up testing and
isolation of those identified as at higher risk, is required.
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In May 2016, HPS published the “Toolkit for the early detection, management and control of
carbapenemase-producing Enterobacteriaceae in Scottish acute settings”.27 This document
was adapted from the PHE acute trust toolkit28 following consultation with, and contributions
from, an expert CPE Screening Short Life Working Group (SLWG) which helped to ensure
that the toolkit was fit for purpose. In September 2017, the “Toolkit for managing
carbapenemase-producing Enterobacteriaceae (CPE) in Scottish non-acute care settings”
was published.29 This toolkit was adapted from the PHE toolkit for CPE in non-acute and
community settings.30
The acute admission screening toolkit provides guidance on the two-step clinical risk
assessment (CRA) based screening policy, which identifies a subset of patients at high risk
of CPE colonisation, who are then tested for CPE carriage/infection. The development of
the toolkit followed the joint Chief Medical Officer (CMO)/Chief Nursing Officer (CNO)/Chief
Pharmacy Officer letter to NHS boards published in June 2013,31 describing the emerging
threat from CPE and the requirements for an acute hospital admission screening
programme for CPE. In March 2017, the Chief Nursing Officer issued a new letter to
reinforce the mandatory policy requirement for screening in NHS boards across Scotland.32
At the final meeting of the CPE Screening SLWG in May 2016, a range of options for
measurement of compliance with CPE screening was presented. There was consensus that
the current MRSA screening tool should be amended to include a module for the additional
collection of data on compliance with CPE CRA-screening. In order to test the feasibility of
the expansion of the existing MRSA screening KPI tool, a pilot study was undertaken
between April and June 2017. This pilot found that the expansion of the current KPI tool to
include a CPE module was feasible and required only minimal additional resources. The
results from the pilot data collection, from 12 participating boards, indicated that uptake of
CPE CRA was sub-optimal at 72.8% (ranging from 31.9% to 95.0%). (It should be noted
that one quarter is not representative of annual compliance, nor is there the same evidence
base upon which to set an effective target, as with the MRSA KPI).
The screening tool has now been redeveloped as a multi-drug resistant organism (MDRO)
acute admission screening tool, and national data collection to monitor the uptake of the
clinical risk assessment for both MRSA and CPE began on 1st April 2017, and will be
monitored on a quarterly basis.
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Information Leaflets
Standardised national staff, patient and public information leaflets to complement the acute
and non-acute toolkits on CPE screening and management are available on the HPS
webpages. An educational electronic module on HAI screening (covering both CPE and
MRSA) for all staff was launched in January 2017 (and can be accessed via the following
link: http://www.nes.scot.nhs.uk/education-and-training/by-theme-
initiative/healthcare-associated-infections/online-short-courses.aspx).
The purpose of these materials is to support frontline staff and ensure patients can make
informed decisions about consenting to screening.
Research
The SIRN sponsored research study carried out by GCU to identify the barriers to, and
drivers of, the implementation of acute hospital admission screening included a CPE
screening staff and patient acceptability study, the results and recommendations of which
were finalised in January 2018. HPS will implement the findings and recommendations from
this study to develop a best practice guide; use data from the KPI measurement tool to
enhance feedback to boards using quality improvement methodologies; and will work with
NES to develop the online learning module for MDRO HAI screening.
Prescribing
The challenge for preservation of antibiotics in acute hospitals is to safely reduce antibiotic
use to minimise selection pressure for AMR, while maintaining positive outcomes for
patients. An additional focus for the antimicrobial stewardship programme coordinated by
the Scottish Antimicrobial Prescribing Group is optimisation use of very broad spectrum
antibiotics such as carbapenems which are vitally important for the treatment of suspected
or confirmed MDR infections. In 2017, SAPG developed and implemented a quality
improvement programme to optimise carbapenem use.
In 2017, the use of carbapenems in acute hospitals* was 19.5 defined daily doses (DDD)
per 1,000 occupied bed days, 1.8% lower (p<0.001) than in 2013.
*data from NHS Shetland are incomplete for this period and have been excluded.
An infographic to accompany Carbapenemase-producing organisms of the HCAI
Annual Report is available to download (please click on icon).
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Prevention of Healthcare Associated Bloodborne Viruses
The delivery of healthcare provides a context where both bloodborne virus (BBV) (human
immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV)) infected
subjects (potential sources of infection) and susceptible subjects (potential recipients) are
mixed and concentrated in a confined place. Transmission of BBVs can occur after
exposure of staff to infected patient blood or body fluids, or exposure of patients to infected
staff, blood or body fluids. Patient-to-patient transmission of BBVs from both diagnostic and
therapeutic practices may also occur, following infection control breaches.
National Sharps Injuries Prevention Project
NHS employers are required by law to take a comprehensive approach to ensure that the
risk from sharps injuries is adequately assessed and appropriate control measures are in
place.33 HPS supports NHS boards to meet their obligation to evaluate the implementation
of control measures through the surveillance of occupational sharps injuries occurring in
Scotland, and the collation of data on the transition to the use of safer sharps devices by
NHS Scotland. This provides site-specific trend data and national comparison data to:
monitor the incidence of occupational exposures among healthcare workers (HCWs) and changes over time
monitor exposure outcomes and assess the impact of interventions such as post exposure prophylaxis (HIV and HBV) or disease treatment (HCV)
monitor the circumstances surrounding occupational exposures, including the use of safer sharps devices
evaluate the impact of safer sharps devices on sharps injuries
inform local and national prevention strategies to reduce the number of sharps injuries sustained, and thus reduce the risk of contracting a BBV occupationally
Sharps Injuries and Occupational BBV Exposures
The latest information on sharps injuries collated by HPS relate to those reported in 2016.
The interval between the occurrence of the injury and publication of the data reflects the
delay in collation of the data, which occurs six months after the last day a HCW could have
potentially been exposed in 2016. This is to ensure that complete information on a
seroconversion event associated with an injury is available.
In 2016, 2,368 occupational exposure incidents were reported by 17 NHS boards
(employing 100% of applicable NHS staff in Scotland), see Figure 28. Sharps-related
injuries accounted for 2,068 (87%) of these incidents, giving a rate of 1.9 sharps injuries per
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100 whole time equivalent (WTE) staff. This rate has reduced from the rate of 2.1 sharps
injuries per 100 WTE staff in 2015 (p<0.01).
Figure 28 Occupational exposure incidents by exposure type, all Scotland, 2016.1
1. Source of data is voluntary anonymous returns from Occupational Health services and Health & Safety leads in health and applicable special boards in NHS Scotland.
Of all 2,368 occupational exposure incidents, 87 HCWs were considered to have sustained
a significant occupational exposure (SOE) (i.e. the source was known to be infected with a
BBV); of these, 79% (n=73) involved HCV infected sources. No HCWs are known to have
acquired a BBV infection following an occupational exposure in 2016. In total since 2010,
seven occupational related seroconversions (all HCV) have been reported in Scotland.
Analysis of SOEs by procedure phase and staff group highlights that over half of the
exposures occur while performing a clinical procedure (n=41/74, 55%) and that doctors and
nurses are the most at risk of sustaining an SOE, accounting for 84% (n= 62/74) of all
injuries; however, while clinicians most frequently report exposures as having occurred
during the procedure, nurses report exposures being sustained at all stages of the
procedure, including after disposal (Figure 29).
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Figure 29 Significant Occupational Exposures by procedure phase and occupational group, all Scotland, 2016*.1
1. Source of data is voluntary anonymous returns from Occupational Health services and Health & Safety leads in health and applicable special boards in NHS Scotland.
Safer sharp devices have been designed with in-built safety features that aim to prevent or
minimise the risk of accidental injury and have been shown to be an effective way to reduce
HCW-related sharps injuries.34-36 Analysis of the SOEs, where the safety status of the
sharp device was reported, revealed that 62% of exposures (n=24/39) involved a safer
sharp device. Of the 17 exposures reported to have occurred post-procedure, eight were
safer sharp devices indicating either issues with training in the use of the devices or faults in
the design or function of the devices.
Sharps Device Data
Safer sharps devices purchased and distributed via the National Distribution Centre (NDC),
as a proportion of total sales of all types of sharp devices, has increased from 30% in 2013
to 63% in 2016 (p<0.01).
Non-sharp alternative devices, such as filter straws, which can be used instead of
hypodermic needles for medication withdrawal from ampoules, can also be used as
substitutes for traditional sharps. Purchasing of non-sharp alternative devices has also
increased over the same time period (p<0.01) (Figure 30).
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Figure 30 Sales of sharp devices and non-sharp alternatives, all Scotland, 2013 to 2016.1
1. Source of data is NHS National Procurement.
In 2016, there were eight sharp device product families (blood collection needles, IV
cannulae, hypodermic needles, insulin syringes with needles, lancets, scalpels, syringes
with needles and winged infusion sets); two of these (scalpels and syringes with needles)
do not have safer alternatives available from National Procurement.
Incidents Associated with BBV Infected Healthcare Workers
HPS works with Health Protection Teams (HPTs) in NHS boards to support the public
health response following the identification of a HCW infected with one or more BBVs. In
line with guidance from the UK Advisory Panel for Healthcare Workers Infected with
Bloodborne Viruses (UKAP) (https://www.gov.uk/government/groups/uk-advisory-
panel-for-healthcare-workers-infected-with-bloodborne-viruses), NHS boards are
required to undertake a number of steps to determine if patients have been put at risk of
infection and whether they should be traced, notified and offered testing: a patient
notification exercise (PNE). In 2017, HPS supported NHS boards to undertake two risk
assessments related to the identification of BBV infected HCWs. Both of the assessments
were referred to UKAP who did not recommend a PNE for either.
In 2017, Public Health England (PHE), in conjunction with HPS, released ‘Integrated
guidance on the management of healthcare workers infected with bloodborne viruses (HIV,
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hepatitis B and/or hepatitis C). The guidance can be found online at:
https://www.gov.uk/government/collections/bloodborne-viruses-bbvs-in-healthcare-
workers. A set of quick reference guides for the management of common situations are
also available on the website. While the guidance is intended primarily for use by
occupational health services in the UK, it also provides up-to-date, evidence-based
recommendations intended to reduce the risk of HCW-to-patient transmission of BBVs.
Additional information is, for the first time, included about arrangements for a PNE.
Quality Improvement and Interventions to Reduce BBVs
The prevention of BBV infections occurring as a consequence of healthcare requires a
comprehensive approach that includes education and training, surveillance, reporting and
management of sharps injuries including post exposure prophylaxis , use of safer sharp
devices, HBV immunisation, advocacy of Standard Infection Control Precautions (SICPs),
monitoring and evaluating the implementation of policies, guidance and recommendations
and their impact.
The measures that will demonstrate effective health outcomes in relation to continued
compliance with guidance/policies for reducing BBV infection risk events and managing
BBV infected HCWs include:
Trends in sharps injuries and significant occupational exposures.
Increasing use of safer sharp devices where reasonably practical
Prompt management of incidents (BBV infected HCWs, acute BBV infections
associated with receipt of healthcare and reported infection prevention and control failures).
An infographic to accompany Prevention of Healthcare Associated Bloodborne
Viruses of the HCAI Annual Report is available to download (please click on icon).
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Neonatal Units
The 2016 Scottish PPS found the prevalence of HAI in Neonatal Intensive Care Unit (NICU)
babies was 8.1% (95% CI: 4.3 to 14.7) (9/111 babies); the prevalence of HAI in all neonates
was 5.0% (95% CI: 2.9% to 8.5%) (12/240 babies).1 In 2017, the HPS Neonatal Unit (NNU)
Infection Prevention Health Protection Programme was created with the aim of preventing
HAI in NNUs. The programme aims to provide national oversight and coordination across
NHS organisations to ensure a joined up and integrated approach to the prevention of HAI
(including BSI/sepsis) in neonates. A short-life working group (SLWG) chaired by a
consultant neonatologist was established to allow collaboration and consultation with
stakeholders from NNUs across NHSScotland to ensure consensus with all programme
aims and outcomes.
Neonatal Microbiological Screening
A national survey of routine screening practises in NHSScotland NNUs was conducted in
2015; this was repeated in 2017. Both surveys identified variation in the organisms
screened for, the body sites screened and when screening was performed in neonates.
In 2017 HPS presented an options appraisal based on a review of the published literature
and microbiological data from boards to identify evidence to support and inform a national
policy for routine neonatal microbiological screening. In consultation with the NNU SLWG
three options were considered:
1. Maintain the status quo (all decisions on screening are made at the local level)
2. Develop a universal screening policy across NHSScotland
3. Develop a clinical risk-based screening policy across NHSScotland
The consensus was to adopt option 3 and work has begun to develop a clinical risk-based
screening policy which will be piloted in 2018 to ensure feasibility and cost-benefit.
Guidance
Quality Improvement Tools (QITs)
HPS have begun the development of Quality Improvement Tools (QITs) to ensure
recommendations for practice in this patient group are evidence-based and consistent
across NNUs in NHSScotland. In November 2017, HPS published a QIT for preventing
infection when inserting and maintaining a neonatal central vascular catheter (CVC). Two
further neonatal QITs are planned for publication in 2018, one for the prevention of infection
when inserting and maintaining peripheral vascular catheters (PVCs) in neonates and one
for preventing ventilator associated pneumonia (VAP) in neonates.
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Management of Outbreak/Incidents in NNU
HPS have been working on the production of guidance for managing incidents/outbreaks in
neonatal units. This guidance will be finalised in 2018 for inclusion in the National Infection
Prevention and Control Manual (NIPCM).
An infographic to accompany Neonatal Units of the HCAI Annual Report is available
to download (please click on icon).
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Development of Guidance
National Infection Prevention & Control Manual
The National Infection Prevention and Control Manual (NIPCM)37 continues to evolve from
its inaugural chapter, Chapter 1: Standard Infection Control Precautions (SICPs) in 2012,
followed by Chapter 2: Transmission Based Precautions (TBPs) in 2013/14.
The updates this year have included
Revising Chapter 2 (TBPs) to reflect setting specific guidance for example hospital, primary
care and care home settings. This also required a revision of Appendix 11: Aide memoire
for optimal patient placement and Respiratory Protective Equipment (RPE) for infectious
agents whilst a patient in hospital.
In April 2017 Chapter 3: Healthcare Infection, Incidents, Outbreaks and Data Exceedance
was published having aligned the content of the chapter with the revised ‘Management of
Public Health Incidents: Guidance on the roles and responsibilities of NHS led incident
management teams (2017)’,38 with the aim of promoting consistency in the management
and reporting of healthcare infection incidents and outbreaks across all healthcare settings
in Scotland. This chapter is supported by a scientific literature review.
The literature review process ensures that the ethos of the NIPCM is consistent with the
original methodology and that practice recommendations remain applicable and evidence
based. The methodology for producing the NIPCM and its associated literature reviews and
tools was updated to reflect revisions and additions to search strategies.
In 2017, five of the scientific literature reviews that underpin Chapter 2 of the NIPCM were
updated. These were: Definitions of Transmission Based Precautions; Management of care
Equipment and Environmental Decontamination (previously two separate reviews);
Respiratory Protective Equipment (RPE); and Surgical Masks.
A new literature review was also published in April 2017 regarding personal protective
equipment (PPE) for infectious diseases of high consequence (IDHC); this review was
developed using the NIPCM methodology and was used to inform PPE competency
frameworks which are available as resources associated with the NIPCM.
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Respiratory Protective Equipment (RPE)
The Scotland wide Respiratory Protective Equipment (RPE) group continues to support the
development of guidance and provide expert opinion. This has included supporting the
production of two competency frameworks for PPE for IDHC. These frameworks are
underpinned by a systematic literature review and are intended as resources to support the
assessment and recording of staff competency in the use of PPE for infectious disease
threats such as pandemic influenza and viral haemorrhagic fevers. These were made
available on the resources section of the NIPCM from April 2017.37
An annual survey of RPE was completed again in 2017; the survey gathers intelligence from
NHS Boards on the types of RPE in use and is used to inform NHSScotland pandemic
preparedness and provide information for procurement and resilience teams in Scotland.
NIPCM Website – A-Z
During the development of Appendix 11 ‘List of infectious agents and/or diseases that
require transmission based precautions (TBPs) in addition to SICPs’ consideration was
given to providing further information on individual pathogens/infectious agents.
A web-based ‘A-Z of pathogens’ was developed and added to the NIPCM website in April
2017; providing a summary of the infectious agent/disease; incubation period; infectivity;
transmission route; notifiable status; and supporting materials including specific guidelines,
leaflets.
HAI Compendium of Guidance
The HAI Compendium is a directory of national and international guidance and supporting
materials relevant to infection prevention and control in Scotland
(http://www.hps.scot.nhs.uk/haiic/haicompendium.aspx).
New content for the Compendium is sourced via scientific alerts and national and
international organisational websites on a monthly basis. Stakeholders are updated on
these changes on a quarterly basis through the production of a summary report for the
National Policies, Guidance and Outbreaks (NPGO) Steering and Consensus Group. An
annual review of the content of the compendium, including hyper/web-links is undertaken.
During 2017, work commenced on moving the pathogen/disease specific guidance and
supporting materials from the Compendium to the A-Z.
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Hand Hygiene
HPS continued to support the 5th of May WHO ‘SAVE LIVES: Clean your hands campaign’.
In 2017 the theme was ‘Fight antibiotic resistance – it’s in your hands’. This year the
campaign focuses on healthcare associated sepsis ‘It’s in your hands – prevent sepsis in
health care’. In support of this HPS have published this annual report to align with this date.
In May 2017 HPS joined infection control colleagues from Glasgow Caledonian University
School of Health and Life Sciences to deliver a hand hygiene teaching event at a local
Glasgow primary school that highlighted the importance of hand hygiene to children of
primary school age (4-11). Throughout the day an overview of e-bug material that provides
an interactive way of learning about antimicrobial resistance was provided to pupils and
teachers.
In addition HPS held a local event within Meridian Court that promoted good hand hygiene
practice to all National Services Scotland Staff. The event highlighted that hand hygiene
remains central to preventing antimicrobial resistance in healthcare and community. Tweets
were made throughout the day to promote both events.
Alcohol Based Hand Rub (ABHR) Proxy Measure
HPS have been working in collaboration with National Procurement since 2014 utilising
purchasing data for alcohol based hand rub (ABHR) and soap products distributed by the
National Distribution Centre (NDC). This collaboration has established a commodity
indicator for hand hygiene which has been validated in volunteer NHS boards and is
suitable for use as a national proxy measure for hand hygiene compliance in NHSScotland
(similar to that of other European countries).
Product data was available for all but three NHS boards which were excluded from the
national proxy measure calculation. The results of the validation study indicate that the
national average ABHR consumption for 2016 was 17.0 litres per 1,000 bed days, which
equates to 17 hand hygiene opportunities taken per bed day. These results were published
in the Journal of Hospital Infection in October 2017 as part of a study which validated the
hand hygiene proxy measure.39 This usage is lower than the European average of
23.9L/1,000 bed days reported in the 2012 European PPS and the 2016 Scottish PPS
measure of 33.5L/1,000 bed days.1;40 The Point Prevalence Surveys and the proxy measure
use different methods for data collection and included all NHS boards so are not directly
comparable; the 2016 proxy measure for ABHR consumption is however, comparable to the
2015 measure of 17.5L/1,000 bed days.
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Cystic Fibrosis Guidance
In response to an identified gap in existing national guidance, HPS have undertaken work to
develop evidence-based infection prevention and control guidance to prevent infection in
people with cystic fibrosis.
A gap analysis of the NIPCM against infection prevention and control guidance published on
behalf of the Cystic Fibrosis Foundation41 and guidance on Mycobacterium abscessus
infection prevention and control guidance published by the Cystic Fibrosis Trust42 revealed
that both contained recommendations in addition to those outlined in SICPs and TBPs. HPS
have started reviewing recent scientific evidence, and a short life working group has been
established to contribute to development of the guidance. The guidance, which is due to be
published in 2018, will include recommendations for the prevention and control of infection
in adult, paediatric and neonatal patients in both inpatient and outpatient healthcare
settings, as well as recommendations for home and community settings, for example
schools.
An infographic to accompany Development of Guidance of the HCAI Annual Report is
available to download (please click on icon).
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Hospital Outbreaks and Incidents
HPS continue to support and work with IPCTs and HPTs in the management of incidents
and outbreaks. All NHS boards are required to assess outbreaks and incidents using the
Healthcare Infection Incident Assessment Tool (HIIAT). Mandatory HIIAT Green (non-
norovirus) reporting for NHS boards was introduced in April 2016; providing a more robust
epidemiological picture of incidents and outbreaks across acute healthcare in NHSScotland.
In 2017, a total of 167 outbreaks and incidents were reported. This compares with 121
reports in 2016. The mandatory HIIAT Green data collection commenced in April 2016,
therefore a full 12 months of data was not available for 2016.
Figure 31 shows that 167 outbreaks and incidents were reported. Of these 14 (8.4%) were
assessed as red, 18 (10.8%) as amber and 134 (80.2%) as green. One (0.6%) had no
HIIAT completed.
Figure 31 All outbreaks and Incidents reported in 2017 by HIIAT assessment (n=167).1
1. Data are reported directly to HPS by NHS boards
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1. Data are reported directly to HPS by NHS boards
Figure 32 shows the number of incidents and outbreaks by infection category for all 167
incidents and outbreaks reported by NHS boards in 2017. These incidents and outbreaks
occurred in a variety of care settings including intensive care, surgical units, paediatrics,
care of the elderly and rehabilitation units.
Respiratory and gastrointestinal infections were reported as the greatest cause of incidents
and outbreaks: 93 (55.7%) of the total. Of the 69 (41.3%) respiratory infections reported, the
majority were influenza virus (36 [52.2%]). Of the 24 (14.4%) gastrointestinal infections
reported 14 (58.3%) were reported as Clostridium difficile. The majority of these incidents
were reported as HIIAT greens (73 [78.5%]) and all were effectively managed and
successfully resolved by NHS boards in a timely manner.
Figure 32 All incidents and outbreaks reported in 2017 by Infection category (n=167).1
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Those incidents and outbreaks reported as ‘colonisation’ i.e. no infection present, but
potential for cross transmission to occur included Carbapenemase Producing
Enterobacteriaceae (CPE) (n=4), Serratia marcescens (n=3), Acinetobacter baumannii
(n=2) Extended Spectrum Beta-Lactamase (n=1), Group A Streptococci (GAS)(n=1),
Meticillin Resistant Staphylococcus aureus (MRSA) (n=1), Stenotrophomonas maltophilia
(n=1) and Vancomycin Resistant Enterococci (VRE) (n=1). All of these colonisation
incidents were assessed as HIIAT green.
Current and Emerging Threats (CET)/Horizon Scanning The current and emerging threats (CET) report provides a continuous assessment of
HCAI/AMR threats in or to NHSScotland. This report includes a formalised risk assessment
and gap analysis to identify any need for additional guidance, tools or health protection
programmes (including surveillance) in NHSScotland. Every quarter, HCAI and AMR
‘threats’ identified in the published literature are assessed for relevance, summarised and
risk assessed. In addition, the CET report provides a summary of HIIAT assessed outbreaks
or incidents reported to HPS (Figure 31 and Figure 32). Threats that were risk assessed as
at least moderate and had no existing specific or related guidance were considered for the
production of new guidance, supporting tools or other preventative action. In 2017, nine
‘threats’ were identified in the literature; these included novel pathogens, novel antimicrobial
resistance modes and novel outbreak sources; four of the ‘threats’ had initially been
identified in the 2016/17 period. Of the nine threats identified, three were high risk threats
from Middles Eastern Respiratory Syndrome Coronavirus (MERS-CoV), plasmid-mediated
colistin resistance and plasmid-mediated fosfomycin resistance, the remaining six were
moderate risk threats from Candida auris, Mycobacterium chimaera, carbapenem resistant
Acinetobacter baumannii, Salmonella typhi resistant to 3rd generation cephalosporins and
seasonal respiratory illness with increased clinical impact (influenza).
As a result of the CET report, HPS highlighted and monitored the service risk from these
identified threats to IPCTs via the HPS National Policies, Guidance and Outbreaks (NPGO)
steering group and the ARHAI programme board. These were also reported to SARHAI for
national oversight and consideration.
An infographic to accompany Hospital Outbreaks and Incidents of the HCAI Annual
Report is available to download (please click on icon).
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Norovirus Outbreaks
Norovirus is a pathogen that predominantly has the highest prevalence during the winter
months – most often peaking between October and April. However NHS boards continue to
report norovirus outbreaks outwith the winter season. Consequently, it remains important
that all care settings remain fully prepared for norovirus outbreaks at all times aiming to
reduce, as far as possible, impact on services.
The popular ‘Stay at Home’ campaign was re-launched by HPS in partnership with Health
Scotland and the Scottish Government Health and Social Care Directorate (SGHSCD).
Radio sound bites produced by NHS Dumfries and Galloway were updated and re-issued
nationally. Regular communications and updates were provided to NHS boards via the HPS
Digest.
Epidemiological Data Due to the seasonality of norovirus these data are reported mid-year to mid-year. For
season 2016/17 there were a total of 89 wards closed with an additional 97 bays closed
giving a total of 186 closures. In comparison, for season 2015/16 there were a total of 127
wards closed with an additional 93 bays closed giving a total of 200 closures (Figure 33);
this may be due to lower activity, early detection of outbreaks and improved awareness in
care and community settings. In season 2016/17 47.8% (89) of closures due to norovirus
were ward closures, in comparison in the 2015/16 season 63.5% (127) of closures due to
norovirus were ward closures; this may be due to the reduction of ward closures reported
this season. Overall, bay closures continue to reduce service impact without compromising
patient safety during norovirus season.
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1. NB. This information represents prevalence of ward closures and not incidence of norovirus. 2. Data are reported directly to HPS by NHS boards
Norovirus Reporting System In October 2017, prior to norovirus season start 2017/2018, HPS launched a revised
reporting system to replace the Monday point-prevalence reporting. The new reporting
system captures all norovirus outbreaks within a hospital setting. It is anticipated that this
new incidence reporting will provide more robust data, thus assisting preparedness for
future seasons.
An interactive public facing dashboard has been developed to display these data (Figure
34). All stakeholders are now able to view norovirus data for NHSScotland; the dashboard
displays ward closures, bay closures, total number of patients affected and total number of
days closed due to norovirus.
Figure 33 Number of ward closures in Scotland reported via weekly point prevalence.1,2
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1. Data are reported directly to HPS by NHS boards
An infographic to accompany Norovirus of the HCAI Annual Report is available to
download (please click on icon).
Figure 34 HPS Norovirus activity dashboard1
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Infection Control in the Built Environment and Decontamination
Outbreaks and incidents related to the healthcare environment, reusable medical devices
and surgical instruments continue to be reported in the international literature.43-48 The
Infection Control in the Built Environment and Decontamination (ICBED) team continue to
review emerging technologies and infection control strategies for management of the
healthcare environment and decontamination of the patient environment and patient related
equipment.
The Built Environment
In 2017 the health protection decontamination programme widened its remit to incorporate
the built environment. The expanded programme will be responsible for delivery of infection
prevention interpretation of current technical guidance documents regarding the physical
environment in healthcare. The delivery of supporting documents for service users will detail
relevant guidance of the healthcare setting (including ventilation and water systems) for
each clinical area. The decontamination element of the programme will continue to support
NHSScotland with research and evidence for clinical decontamination practice for reusable
medical devices, patient equipment and the clinical environment.
The first clinical environment for review is the operating room for a general theatre. This
decision was reached following a national consultation with our stakeholders in 2017/18. A
question set for the theatre suite scientific literature review was developed and approved by
the expert steering group and work has commenced on the literature review for the
operating theatre area. The findings from this literature review will be published in May
2018.
Decontamination
Roles and Responsibilities
Over recent years, Healthcare Environment Inspectorate (HEI) reports46 have continued to
report on poor standards of cleaning. Defining roles and responsibilities for cleaning are key
to this. In 2017, HPS completed a targeted literature review and a survey of NHS boards to
provide an evidence base to define roles and responsibilities for equipment and
environmental decontamination. Evidence from the literature suggests when roles and
responsibilities are clearly defined this has a positive impact on standards of re-useable
patient equipment and environmental decontamination.49 National findings from an HPS
administered survey of NHS boards, confirmed roles and responsibilities are locally defined
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for the different types of cleans required outlined in the national infection control and
prevention manual (NICPM) although staff performing these roles vary sometimes within
and between boards. The summary report was published in December 2017 inclusive of a
flow chart as a simple measure to assist boards with identifying and implementing
responsibilities for cleaning. http://www.hps.scot.nhs.uk/guidelines/detail.aspx?id=3418
Assessment of Financial Impact Protecting Time for Standard Discharge
Cleans
Having time to clean has been highlighted as having an impact on standards of equipment
and environmental decontamination following HEI Inspections.46 In 2017, in support of
these concerns, the Scottish Government requested HPS assess the financial impact of
mandating the recommended minimum timings of 40 minutes to clean a general bedspace
and 60 minutes a specialist bedspace.50 Assessment was undertaken using board validated
timings for nurses and Health Facilities Scotland data for domestic cleaning timings.51 The
findings from this assessment will be presented to the Scottish Government in March 2018.
Infection Prevention and Control Team (IPCT) Audit Tools and
Processes: National Monitoring Tool
Following an options appraisal in May 2017 the SGHSCD requested the development of a
national monitoring tool plus enhancement of the current Facilities Monitoring Tool (FMT)
data platform to include FM monitoring and Standard Infection Control Precautions (SICPs)
monitoring. A review of NHS Board IPC audit tools was undertaken in 2017. Findings from
this showed a consistent approach across the boards in terms of audit criteria, however,
there was variation between the boards around methodology and approach to audit.
Following discussion with the SGHSCD, it was agreed HPS would produce a National IPC
Monitoring Framework for Audit to focus on audit methodology. A SLWG consisting of
members from every IPCT in Scotland has been convened in order to co-design and co-
produce the Framework. This work is due to be delivered by the end of September 2018.
Alternative Approaches to Equipment and Environmental
Decontamination
In 2017 HPS published the UK & International Review of Alternative Approaches to
Environmental and Equipment decontamination
http://www.hps.scot.nhs.uk/haiic/decontamination/resourcedetail.aspx?id=3396 which
identified the housekeeper as an additional support role involved in the decontamination of
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patient related equipment and the healthcare environment. A snapshot evaluation
undertaken within a Scottish health board that has employed housekeepers, on a cost
neutral basis, provided limited quantitative data to support the implementation of this role
nationally. However the qualitative data HPS obtained from senior charge nurses with
housekeepers was overwhelmingly positive.
The findings of both studies have prompted a request from SGHSCD for a more detailed
analysis of this housekeeper role including from recruitment and beyond. The current study
is evaluating ward audit scores for wards with and without housekeepers to evaluate
possible impact of the housekeeper role on cleanliness of the ward and reusable communal
patient equipment. In addition data collection is underway regarding how many times
nursing staff clean items of equipment in wards with and without housekeepers. A
comparison will be made as to whether the housekeeper reduces the time nurses spend on
routine cleaning whereby releasing time for care practices. The evaluation of the
housekeeper has been submitted to the Scottish Government for consideration in April
2018, followed later in the year with the recruitment evaluation.
New Technologies for Equipment and Environmental Decontamination
Antimicrobial surfaces are of increasing interest to the IPCTs for their biocidal potential.
Copper and its alloys are the most widely researched antimicrobial surface types. As such,
HPS carried out a literature to assess the scientific evidence for the effectiveness of
antimicrobial copper surfaces in healthcare settings which includes evidence on both copper
alloy surfaces and copper oxide impregnated surfaces. The review, published in August
2017
(http://www.hps.scot.nhs.uk/haiic/decontamination/resourcedetail.aspx?id=3313),
makes a number of graded recommendations and concludes that the use of antimicrobial
copper surfaces may be used to supplement standard cleaning practices where required in
healthcare settings at an additional cost.
Building on work previously undertaken reviewing the evidence for ten existing and
emerging decontamination technologies, in October 2017 HPS produced a paper bringing
together the reviews by summarising the results of the included studies with respect to
specific pathogens of relevance to the healthcare setting
(http://www.hps.scot.nhs.uk/haiic/decontamination/resourcedetail.aspx?id=3436).
This re-framing of 74 previously identified studies facilitated the development of
recommendations for the best methods of pathogen removal and destruction by presenting
the results in such a way as to allow the quality and quantity of studies and results for each
technology to be easily determined for specific bacterial, viral and fungal pathogens. Based
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on the evidence identified, the paper recommends that the use of UV and hydrogen
peroxide vapour disinfection systems can be considered as supplements to terminal
cleaning for specific pathogens in specific contexts. However, the significant logistical and
financial implications of their use must be taken into account.
Pathogen Survival Review
Contaminated surfaces contribute to the transmission of pathogens in healthcare settings,
with the potential for transmission dependant on the ability of pathogens to survive on
environmental surfaces. HPS carried out a literature review that builds on the results of a
previous review,52 by collating and summarising evidence from 80 experimental studies on
the maximum duration of survival on environmental surfaces of bacteria, viruses and fungi
that cause HAI. The review presents data indicating longer maximum survival times for
some pathogens, as well as data for a number of pathogens, including new and emerging
pathogens, for which survival data has only recently been published. The results indicate
that many pathogens can survive for long periods on environmental surfaces, and in the
absence of decontamination interventions, survival times can extend to weeks, months and
even years. The findings emphasise the importance of appropriate and adequate
decontamination to remove and destroy pathogens that can persist in the environment and
present a risk of cross-infection. The review has been submitted for peer-reviewed journal
publication this year.
Management of Dental Unit Water Lines (DUWLs): Recommendations for
Clinical Practice
Following heightened awareness of the infectious risk from contaminated dental unit water
lines (DUWLs),53 HPS responded to NHS Boards requests to provide guidance for
healthcare workers on the appropriate disinfection of DUWLs within the dental chair unit
(DCU) – a reusable medical device. In 2017/18, HPS undertook a review of extant literature
to understand the risks associated with DUWL for patients and staff to inform clinical
recommendations for practice. The evidence and recommendations was published in April
2018
(http://www.hps.scot.nhs.uk/haiic/decontamination/resourcedetail.aspx?id=3494)
Guidance; Clinical Management of Endoscopy Rinse Water Results
HPS produced a summary report (unpublished) on the Testing and Management of Final
Rinse Water within NHSScotland which found variation in practices relating to the testing
and management of final rinse water from endoscope procedures across the responding
boards. A data linkage study (2016) showed no potential clusters of infection associated
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with endoscope procedures nationally, concluding the risk of cross transmission of HCAI
following endoscope procedures was low. Additional data analysis is ongoing with the data
linkage and is expected to be published in July 2018.
With the findings that despite variation in management of rinse water results nationally and
the low risks of infection identified for endoscopy procedures guidelines have been
developed and will be published in May 2018 to standardise the clinical management of
rinse water results whereby reducing the risk of service disruption with washer disinfectors
out of commission whilst maintaining patient safety.
Future Work
In 2018, HPS will build upon the current programme of work on the built environment,
encompassing specialist advice on water and ventilation within acute hospital settings .
Future work for 2018 will also include: (1) a national estimation of time spent by nursing staff
cleaning reusable patient equipment; and (2) production of a national framework for
monitoring of the healthcare environment.
An infographic to accompany Infection Control in the Built Environment and Decontamination of the HCAI Annual Report is available to download (please click on icon).
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List of Tables
Table name
Table 1 Scottish PCR ribotypes isolated from mild, moderate or severe CDI cases (snapshot), or from severe cases and/or outbreaks between 2016 and 2017.
Table 2 Carbapenemase-producers by organism and enzymes reported in Scotland by AMRHAI (PHE), 2003 to 2017.1
List of Figures
Figure name
Figure 1: Incidence of SSI following caesarean section procedures in Scotland (inpatient and PDS to day 10), 2013 to 2017.1
Figure 2: Funnel plot of SSI incidence (per 100 caesarean section procedures) for all NHS boards in Scotland in 2017. 1, 2
Figure 3: Proportion of SSI following caesarean section procedures (inpatient and PDS to day 10) in Scotland by SSI type, 2017.1
Figure 4: Incidence of SSI following hip arthroplasty procedures in Scotland (inpatient and readmission to day 30), 2013 to 2017.1
Figure 5 Funnel plot of SSI incidence (per 100 hip procedures) for all NHS boards in Scotland in 2017.1
Figure 6 Proportion of SSI following hip arthroplasty procedures (inpatient and readmission to day 30) in Scotland by SSI type, 2017.
Figure 7 Incidence rates of BSI, VAP and CR-BSI for 2011 to 2016.
Figure 8 Line graph of CDI incidence rate in all patients aged ≥15 years per 100,000 population for Scotland, 2013 to 2017.1
Figure 9 Incidence rates of healthcare associated (per 100,000 TOBD) and community associated (per 100,000 population) CDI in patients aged ≥15 years, 2015 to 2017.1
Figure 10 Funnel plot of CDI incidence rates (per 100,000 TOBD) in healthcare associated infection cases among patients aged ≥15 years for all NHS boards in Scotland in 2017.1
Figure 11 Funnel plot of CDI incidence rates (per 100,000 population) in community associated infection cases among patients aged ≥15 years for all NHS boards in Scotland in 2017.1
Figure 12 Line graph of CDI 30-day all-cause mortality (%) among patients aged ≥15 years in Scotland, 2012 to 2016.1
Figure 13 Incidence rates of S. aureus, MRSA and MSSA bacteraemias (per 100,000 population) in Scotland: 2013 to 2017.
Figure 14 Funnel plot of SAB incidence rates (per 100,000 TOBD) in healthcare associated infection cases for all NHS boards in Scotland in 2017.1
Figure 15 Funnel plot of SAB incidence rates (per 100,000 population) in community associated infection cases for all NHS boards in Scotland in 2017.1, 2
Figure 16 Pie chart of SAB healthcare associated cases (n=1,047) for Scotland in 2017 by Entry point.1
Figure 17 Pie chart of SAB community associated cases (n=527) for Scotland in 2017 by Entry point.1
Figure 18 Scottish MRSA Screening Uptake by month of admission. April 2013 to December 2017.1
Figure 19 Incidence (per 100,000 population) of Gram-negative bacteraemia due to the most commonly reported pathogens within Scotland, 2013 to 2017.1
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Figure 20 Funnel plot of ECB incidence rates (per 100,000 TOBDs) for healthcare associated cases for all NHS boards in Scotland in 2017.1,2
Figure 21 Funnel plot of ECB incidence rates (per 100,000 population) for community associated cases for all NHS boards in Scotland in 2017.1
Figure 22 Pie chart of ECB cases (n=4,763) for Scotland in 2017 by origin of infection.1
Figure 23 Pie chart of ECB cases (n=4,763) for Scotland in 2017 by primary infection.1
Figure 24 Proportions of ECB non-susceptible to indicated antibiotics (fluoroquinolones, aminoglycosides, 3rd-generation cephalosporins, piperacillin/tazobactam and carbapenems) 2013 to 2017.1
Figure 25 National Catheter passport.
Figure 26 Healthy Pee Poster
Figure 27 Number of CPO isolates by enzyme type reported in Scotland by AMRHAI (PHE) and the Scottish AMR Satellite laboratory (2003 to 2017).1
Figure 28 Occupational exposure incidents by exposure type, all Scotland, 2016.
Figure 29 Significant Occupational Exposures by procedure phase and occupational group, all Scotland, 2016*.1
Figure 30 Sales of sharp devices and non-sharp alternatives, all Scotland, 2013 to 2016.1
Figure 31 All outbreaks and Incidents reported in 2017 by HIIAT assessment (n=167).1
Figure 32 All incidents and outbreaks reported in 2017 by Infection category (n=167).1
Figure 33 Number of ward closures in Scotland reported via weekly point prevalence.1,2
Figure 34 HPS Norovirus activity dashboard1
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Appendices
Appendix 1 – Background Information
The purpose of this report is to present the outputs of HPS health protection programmes to
reduce HCAI including surveillance and development of guidance and tools. This report
details the progress made by HPS to support the reduction of HCAIs in NHSScotland as
well as providing data to inform local and national HCAI reduction activities.
UK comparisons
Improved collaboration with the other UK nations has made comparisons and
standardisation across the UK a high priority for all four nations’ governments/health
departments. The changes introduced in the Scottish HAI surveillance, described here,
facilitate benchmarking of the Scottish data against those of the rest of the UK.
Appendix 2 – Publication Metadata
Metadata Indicator
Description
Publication title
Healthcare Associated Infection Annual Report 2017
Description This release provides information on Healthcare associate infection, in Scotland for the period January to December 2017 when this is not available, data from January to December 2016 has been used.
Theme Infections in Scotland
Topic Healthcare associated Infection
Infection prevention and Control
Format Online resource (PDF)
Data source(s)
Surgical Site Infection:
Case data source: Surgical Site Infection Reporting System (SSIRS)
Number of procedures denominator: Surgical Site Infection Reporting System (SSIRS)
Healthcare Associated Infections in Intensive Care Units:
Source of data is Scottish Intensive Care Society Audit Group
Clostridium difficile infection:
Case data source: Electronic Communication of Surveillance in Scotland (ECOSS)
Healthcare associated denominator: Total occupied bed days: Information Services Division ISD(S)1
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Community associated denominator: National Records of Scotland (NRS) population estimates
Antibiotic use in primary care numerator: Prescribing Information System (PIS) ISD
Antibiotic use in primary care denominator: National Records of Scotland (NRS) population estimates
Antibiotic use in acute hospitals numerator: Hospital Medicines Utilisation Database (HMUD) ISD. Includes only hospitals labelled as ‘General Hospitals (mainly acute)’ in HMUD.
Antibiotic use in acute hospitals denominator: Acute hospital occupied bed days (OBDs): Information Services Division (ISD). Sum of OBDs for all hospitals in numerator.
Staphylococcus aureus Infection:
Case data source: Electronic Communication of Surveillance in Scotland (ECOSS) Enhanced Surveillance Web Tool
Healthcare associated denominator: Total occupied bed days: Information Services Division ISD(S)1
Community associated denominator: National Records of Scotland (NRS) population estimates
Gram Negative bacteraemia:
Case data source: Electronic Communication of Surveillance in Scotland (ECOSS) Enhanced Surveillance Web Tool
Healthcare associated denominator: Total occupied bed days: Information Services Division ISD(S)1
Community associated denominator: National Records of Scotland (NRS) population estimates
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: ECOSS, Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit Public Health England (PHE) and the Scottish AMR Satellite Laboratory.
Antibiotic use in acute hospitals numerator: Hospital Medicines Utilisation Database (HMUD)
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ISD. Includes only hospitals labelled as ‘General Hospitals (mainly acute)’ in HMUD.
Antibiotic use in acute hospitals denominator: Acute hospital occupied bed days (OBDs): Information Services Division (ISD). Sum of OBDs for all hospitals in numerator.
Prevention of Healthcare Associated Bloodborne Viruses:
1) Voluntary anonymous returns from Occupational Health services and Health & Safety leads in health and applicable special boards in NHS Scotland.
2) NHS National Procurement.
Development of Guidance: N/A
Norovirus Outbreaks: NHS boards Infection Control Teams reported to HPS.
Hospital HCAI Outbreaks and Incidents: Healthcare infection incidents reported to HPS.
Neonatal Units: N/A
Infection Control in the Built Environment and Decontamination (ICBED): N/A
Date that
data are
acquired
Surgical Site Infection: 19/02/2018
Healthcare Associated Infections in Intensive Care Units: 27/02/2017
Clostridium difficile infection: 13/02/2018
Antibiotic use in primary care numerator: 28/03/2018
Antibiotic use in primary care denominator: 09/05/2017
Antibiotic use in acute hospitals numerator: 28/03/2018
Antibiotic use in acute hospitals denominator: 15/03/2018
Staphylococcus aureus Infection: 14/02/2018
Gram Negative bacteraemia: 19/03/2018 (with the exception of Escherichia coli bacteraemia)
Escherichia coli bacteraemia: 14/02/2018
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: 31/01/2018
Antibiotic use in acute hospitals numerator: 28/03/2018
Antibiotic use in acute hospitals denominator: 15/03/2018
Prevention of Healthcare Associated Bloodborne Viruses:
Voluntary anonymous returns from Occupational Health services and Health Safety leads in health and applicable special boards in NHS Scotland – collated in August 2017
National Procurement extracted data for 2013 to 2016 (inclusive)
Development of Guidance: N/A
Norovirus Outbreaks: 03/01/2018
Hospital HCAI Outbreaks and Incidents: 03/01/2018
Neonatal Units: N/A
Infection Control in the Built Environment and Decontamination (ICBED): N/A
Release date 04 May 2018
Frequency Annual
Timeframe of data and timeliness
The latest iteration of data is 05 May 2017, therefore 5 months in arrears
For the following chapters 2016 data has been reported:
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Healthcare Associated Infections in Intensive Care Units: These data have a delayed publication (1 year 4 month arrears) due to the requirement for HPS publication to follow and not preceed the Scottish Intensive Care Society Audit Group publication in August each year (8 months in arrears).
Prevention of Healthcare Associated Bloodborne Viruses: the delayed publication is due to BBV seroconversion data only being available 6 months post the last day of exposure in 2016 (i.e. 31st December 2016). While NP data is available up to the end of 2017, for comparison with sharps injury data this is only reported to the end of 2016
Continuity of data
Surgical Site Infection: None
Healthcare Associated Infections in Intensive Care Units: None
Clostridium difficile infection: None
Staphylococcus aureus Infection: None
Gram Negative bacteraemia: None
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: None
Prevention of Healthcare Associated Bloodborne Viruses: None
Development of Guidance: N/A
Norovirus Outbreaks: None
Hospital HCAI Outbreaks and Incidents: None
Neonatal Units: N/A
Infection Control in the Built Environment and Decontamination (ICBED): N/A
Revisions statement
These data are not subject to planned major revisions. However, HPS aims to continually improve the interpretation of the data and therefore analysis methods are regularly reviewed and may be updated in the future.
Revisions relevant to
this publication
Surgical Site Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Healthcare Associated Infections in Intensive Care Units: Following the identification of several errors in the processing of these data, revisions were made following the initial publication of data in August 2017. Minor errors were identified in infection numbers and denominators, resulting in small alterations to some rates. This did not alter the key messages of the report.
Clostridium difficile infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Staphylococcus aureus Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Gram Negative bacteraemia:
Escherichia coli bacteraemia:
Details provided in quarterly publication
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http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: None
Prevention of Healthcare Associated Bloodborne Viruses: There are no revisions to historical data. Commodity specialists identify and classify all sharps instruments available for purchase via National Procurement. New sharps devices including new safety versions and non sharp alternative products will be added by the National Procurement Product Specialist and incorporated into the data as applicable.
Development of Guidance: N/A
Norovirus Outbreaks: Revision to the way that data for norovirus has been collected during 2017. Until 2nd October 2017 data was collected on a point prevalence basis with only closures on a Monday being reported. From 2nd October 2017 data from all norovirus ward and bay closures were reported.
Hospital HCAI Outbreaks and Incidents:
In April 2016 the mandatory reporting of non-norovirus HIIAT greens was introduced, therefore this dataset has an additional three months of mandatory HIIAT green reporting.
Neonatal Units: N/A
Infection Control in the Built Environment and Decontamination (ICBED): N/A
Concepts and
definitions
Statistical significance:
Where the text refers to a change in the data this denotes statistical significance.
Surgical Site Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Healthcare Associated Infections in Intensive Care Units:
The surveillance data are collected in accordance with the European Centre for Disease Prevention and Control protocol for HAI Surveillance in ICU. Ventilator Associated Pneumonia: Patients who are ventilated are at increased risk of developing a VAP. CVC related infection/Bloodstream infections: Patients in intensive care often have a CVC in situ and are at increased risk of developing a CVC related infection, including bacteraemia.
Clostridium difficile infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Antibiotic use information in primary care presented as the number of items which represents the number of times an antibiotic appears on prescription.
Antibiotic use information in acute hospitals is presented as the number of defined daily doses
https://www.whocc.no/ddd/definition_and_general_considera/
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Staphylococcus aureus Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Gram Negative bacteraemia:
Gram-negative organisms including Enterobacteriaceae, (comprising amongst others Escherichia coli, Klebsiella oxytoca, and Klebsiella pneumoniae), and non-fermenters, (comprising amongst others Pseudomonas aeruginosa, and Acinetobacter spp.), cause serious infections including bacteraemia, pneumonia, meningitis, and surgical site infections (SSIs).
Gram-negative bacteraemia is a public health and clinical concern because of:
• the severity of infection, commonly occurring among vulnerable patients often at the extremes of life and/or with comorbidities,
• the large number of cases of Gram-negative bacteraemias each year, and high prevalence of Gram-negative infections,
• the association with receiving healthcare in community and healthcare settings.,
• their ability to become resistant to multiple classes of antibiotics, limiting treatment options.
For all antimicrobial susceptibility data published in this report, was aligned with the following definition:
A new case of bacteraemia is a patient from whom an organism has been isolated from the patient’s blood, and who has not previously had the same organism isolated from blood within a 14 day period (i.e. 14 days from date last positive sample obtained).
Escherichia coli bacteraemia:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms:
Carbapenems are broad spectrum antibiotics that are generally used in hospitals for the treatment of suspected or confirmed multi-drug resistant Gram-negative infections. They are often one of the few antibiotics left for treatment of these resistant infections. Important hospital acquired infection (HAI)/Healthcare Associated Infection (HCAI) -related Gram-negative organisms are; Enterobacteriaceae, (comprising amongst others E. coli, K. oxytoca, and K. pneumoniae), and non-fermenters, (comprising amongst others P. aeruginosa, and Acinetobacter spp.).
The emergence and spread of Gram-negative organisms which have acquired the ability to produce carbapenemase enzymes that inactivate carbapenem antibiotics, known as carbapenemase-producing organisms (CPOs), is increasingly concerning. CPOs have been reported globally with increased intercontinental travel and exposure to healthcare abroad contributing to their spread.
The genes that code for carbapenemase enzymes spread between and within bacterial species via plasmids or transposons, and are commonly associated with other resistance determinants; this means that bacteria resistant to carbapenems are invariably resistant to most other broad spectrum antibiotics, leaving little in the way of treatment options. CPOs
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produce beta-lactamase enzymes which inactivate carbapenems and other beta-lactam antibiotics such as the penicillin and cephalosporin classes of antibiotics.
Although the overall occurrence of carbapenem resistance in bacteraemia and UTIs is estimated to be low in Scotland but has been increasing over recent years. A national enhanced surveillance program for carbapenem resistance, with a focus on Gram-negative bacteria expressing acquired carbapenemases, was setup to improve understanding of the current situation across Scotland.
Probable case- A case is any person in Scotland with Gram-negative bacteria isolated from a clinical or screening specimen, where resistance is suspected to be caused by the expression of an acquired carbapenemase.
Confirmed case- A case is any person in Scotland with Gram-negative bacteria isolated from a clinical or screening specimen, where resistance is suspected to be caused by the expression of an acquired carbapenemase and with a reference laboratory confirmation of a CPO.
CPE CRA screening uptake- The national policy for CPE screening on admission to hospital states all acute admissions must undergo a clinical risk assessment followed by a swab screen to test for CPE. At present, the degree of implementation of the mandatory policy across boards is not known as screening uptake is not currently measured. The data reported is from the pilot data collection and calculates uptake of application of CRA as a percentage, from an audit sample of patient admissions (within the pilot dates).
Prevention of Healthcare Associated Bloodborne Viruses:
Safer sharp device: A medical sharp device which has been designed to incorporate a feature or mechanism that minimises and/or prevents the risk of accidental injury. Other terms include (but are not limited to) safety devices, safety-engineered devices and safer needle devices.
Sharps injuries: An injury caused by a sharp instrument or object such as a needle or scalpel, cutting or puncturing the skin. Other terms include percutaneous injury.
Significant occupational exposure: A percutaneous, mucocutaneous exposure or non-intact skin (abrasions, cuts, eczema) exposure to blood/other body fluids from a source that is known (or later found to be) positive for a bloodborne virus infection.
Development of Guidance: N/A
Norovirus Outbreaks:
Outbreaks of norovirus are defined as two or more linked cases associated with the same healthcare setting over a specified time period.
Hospital HCAI Outbreaks and Incidents:
Healthcare infection incidents reported to HPS.
Healthcare associated infection incidents are defined within chapter 3 of the National Infection Prevention and Control Manual as: An exceptional infection episode
• A single case of any serious illness which has major implications for others (patients, staff and/or visitors), the organisation or wider public health e.g. infectious diseases of high
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consequence such as VHF or XDR-TB.
A healthcare associated infection outbreak:
• Two or more linked cases with the same infectious agent associated with the same healthcare setting over a specified time period; or
• A higher than expected number of cases of HAI in a given healthcare area over a specified time period.
A healthcare infection exposure incident:
• Exposure of patients, staff, public to a possible infectious agent as a result of a healthcare system failure or a near miss e.g. ventilation, water or decontamination incidents.
A healthcare infection data exceedance:
• A greater than expected rate of infection compared with the usual background rate for that healthcare location
http://www.nipcm.scot.nhs.uk/chapter-3-healthcare-infection-incidents-outbreaks-and-data-exceedance/
Neonatal Units:
Neonates are defined as being under 28 days old, however, a large proportion of patients in NNUs will have been admitted at birth and will often have been born prematurely (<37 weeks gestation) and/or with life threatening conditions that require surgical or medical intervention resulting in increased vulnerability to infection. Patients in an NNU may be older than 28 days and therefore not technically neonates but would still be classed as such for the purposes of HPS guidelines, policy and tools.
Infection Control in the Built Environment and Decontamination (ICBED):
The built environment covers all aspects of the healthcare environment including healthcare premises, ventilation, water, physical layout/requirements, decontamination (reusable medical devices, equipment and environment). There is a wide variety of current technical guidance which applies to the built environment including Scottish Health Technical Memoranda (SHTM), Health Technical Memoranda (HTM) and Facilities/Health Planning notes. These guidance documents cover the engineering, control and technical aspects of the built environment, however the ICBED remit is to apply the Infection Prevention (clinical elements) to support the technical documents.
Relevance and key
uses of the statistics
Surgical Site Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Healthcare Associated Infections in Intensive Care Units:
Output from the surveillance system is intended to support units in reducing HAI and preventing HCAI. The data are intended to be used locally for improvement and the data are also used nationally to measure trends at this level and to benchmark against other European countries.
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Clostridium difficile infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Staphylococcus aureus Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Gram negative bacteraemia: The outputs of the surveillance programme are intended to support the NHS boards in controlling and reducing the burden of Gram-negative bacteraemia.
Escherichia coli bacteraemia:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: Output from the surveillance system is intended to support units in reducing and preventing CPOs. The data are intended to be used locally for improvement and the data are also used nationally to measure trends at this level and to benchmark against other European countries.
Output from the CPE screening pilot data collection was primarily collected to test the feasibility amending the MRSA screening KPI collection protocol. The uptake figure may gave an indication of uptake, but this must be interpreted with caution, as the pilot covered only one annual quarter, and does not represent national uptake. The pilot will inform the development of a national data collection, and following roll out will allow a better assessment of the implementation of the CPE screening policy.
Prevention of Healthcare Associated Bloodborne Viruses: The data will facilitate compliance with H&S legislation and reduce BBV infection risk events and infections occurring as a consequence of healthcare interventions through i) monitoring the incidence of occupational exposures, among HCWs and changes over time ii) monitoring exposure outcomes and an assessment of the impact of interventions such as post exposure prophylaxis (HIV and HBV) or disease treatment (HCV) iii) monitoring the circumstances surrounding occupational exposures, including the use of safer sharps devices iv) evaluating the impact of safer sharps devices on sharps injuries and v) informing local and national prevention strategies to reduce the number of sharps injuries sustained, and thus reduce the risk of contracting a bloodborne virus (BBV) occupationally.
Development of Guidance: N/A
Norovirus Outbreaks: Norovirus Outbreak data is used to provide more robust data on norovirus outbreaks thus assisting preparedness for future seasons.
Hospital HCAI Outbreaks and Incidents: To identify risks or trends in the organisms, types of infection, procedures, patients, or medical specialities associated with healthcare infection incidents to inform the production of guidance, tools or policy to assist in preparing for, preventing, detecting and managing healthcare infection incidents.
Neonatal Units: N/A
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Infection Control in the Built Environment and Decontamination (ICBED): N/A
Key to NHS boards
AA = Ayrshire & Arran
BR = Borders
DG = Dumfries & Galloway
FV = Forth Valley
FF = Fife
GR = Grampian
GGC = Greater Glasgow & Clyde
HG = Highland
LN = Lanarkshire
LO = Lothian
NWTC = National Waiting Times Centre
OR = Orkney
SH = Shetland
TY = Tayside
WI = Western Isles
Accuracy Surgical Site Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Healthcare Associated Infections in Intensive Care Units: The data are collected within the Scottish Intensive Care Society Audit dataset. The HAI data are collected solely for the purpose of surveillance. Evidence from case note review validation indicate that units collect their data in a consistent way and an algorithm built into the electronic data collection system ensures that case definitions are applied consistently. However, it is likely that there is some level of under and over reporting from time to time.
Clostridium difficile infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Staphylococcus aureus Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Gram Negative bacteraemia: Gram negative bacteraemia data are the product of the Electronic Communication of Surveillance in Scotland (ECOSS). Participating laboratories routinely report all identifications of organisms, infection or microbiological intoxication and where possible the antimicrobial resistance data unless they are known to be of no clinical or public health importance. The collected data is used for the identification of single cases of severe disease, outbreaks, antimicrobial resistance patterns and longer term trends in the incidence of laboratory reported infections, enhanced surveillance, health protection, analytical and statistical use.
Escherichia coli bacteraemia:
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Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: CPO isolates are derived from a range of screening and clinical specimens including urine, respiratory and blood isolates submitted to the Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit Public Health England (PHE) and the Scottish AMR Satellite lab.
Data from the CPE screening CRA uptake pilot, is an audit of patient admission based on the sampling strategy for the MRSA screening KPI protocol, and subject to the same validation checks.
Prevention of Healthcare Associated Bloodborne Viruses: Validation of collated data includes assessing data completeness and quality. Sense check of expected codes, frequencies and patterns in the data, with resolution of any queries/data irregularities with the data originators.
Development of Guidance: N/A
Norovirus Outbreaks: Data is quality checked when it first comes in for accuracy and NHS boards are contacted if there are any data issues. The data is then added onto a spreadsheet holding all the 2018 figures. The data on this spreadsheet is checked again before being added to the Tableau file and any issues resolved.
Hospital HCAI Outbreaks and Incidents: HPS are aware that the healthcare infection incident assessment tool (HIIAT) is subjective and that there is variation in how NHSScotland boards assess and therefore report healthcare infection incidents.
Neonatal Units: N/A
Infection Control in the Built Environment and Decontamination (ICBED): N/A
Completeness
Surgical Site Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Healthcare Associated Infections in Intensive Care Units: The data are collected within the Scottish Intensive Care Society Audit dataset. The HAI data are collected solely for the purpose of surveillance. Previous data validation exercises have concluded that the HAI data reported have a high level of sensitivity and accuracy when validated against the case notes. However, it is likely that there is some level of under and over reporting from time to time.
Clostridium difficile infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
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Antibiotic use information in acute hospitals: data for NHS Shetland are incomplete for 2017 and all data on antibiotic use in NHS Shetland 2013-2017 have been excluded.
Staphylococcus aureus Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Gram Negative bacteraemia:
Escherichia coli bacteraemia:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: CPO isolates are derived from a range of screening and clinical specimens including urine, respiratory and blood isolates submitted to the Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit Public Health England (PHE) and the Scottish AMR Satellite lab.
Data from the CPE screening CRA uptake pilot, is an audit of patient admission based on the sampling strategy for the MRSA screening KPI protocol, and subject to the same validation checks.
Antibiotic use information in acute hospitals: data for NHS Shetland are incomplete for 2017 and all data on antibiotic use in NHS Shetland 2013-2017 have been excluded.
Prevention of Healthcare Associated Bloodborne Viruses: Data for 2016 was returned from 17 boards, representing 100% of the applicable NHS workforce. 16 boards were able to supply detailed data on significant occupational exposures, representing 91% of the applicable NHS workforce. Note, sharps incidents and occupational exposures are self-reported, thus open to bias. Sharp device data includes products distributed throughout Scotland via the National Distribution Centre and is through to represent the vast majority of products purchased.
Development of Guidance: N/A
Norovirus Outbreaks: NHS Boards only send in data when their ward has reopened so data is included in a retrospective way.
Hospital HCAI Outbreaks and Incidents: HPS are aware that the healthcare infection incident assessment tool (HIIAT) is subjective and that there is variation in how NHSScotland boards assess and therefore report healthcare infection incidents. The extent of variation in assessment and unreported incidents has not been fully quantified.
Neonatal Units: N/A
Infection Control in the Built Environment and Decontamination (ICBED): N/A
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Comparability
Surgical Site Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Healthcare Associated Infections in Intensive Care Units: Data comparable to
equivalent data collected by other European countries where the ECDC protocol is utilised.
.
Clostridium difficile infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Staphylococcus aureus Infection:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Gram Negative bacteraemia: Public Health England report on national data on antibiotic resistance https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report
Surgical Site Infection, Clostridium difficile infection, Staphylococcus aureus Infection and Gram Negative bacteraemia:
The funnel plot analyses incorporate the full year’s data; as a result, some NHS boards may be above the 95% confidence interval upper limit in the annual funnel plot but not in the quarterly funnel plots as the confidence limits are narrower.
For CDI, SAB and ECB only, the annual funnel plot analyses also include Q1 data on healthcare associated infection and community associated infection. The publication of healthcare associated infection and community associated infection data was introduced in Q2 2017; therefore, there is no corresponding Q1 funnel plot.
http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
ECDC report on Antimicrobial resistance surveillance in Europe https://ecdc.europa.eu/en/publications-data/antimicrobial-resistance-surveillance-europe-2016
Escherichia coli bacteraemia:
Details provided in quarterly publication http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx
Urinary Tract Infection: N/A
Controlling Antimicrobial Resistance in Scotland (CARS): N/A
Carbapenemase-Producing Organisms: Public Health England report on Carbapenem resistance https://www.gov.uk/government/collections/carbapenem-resistance-guidance-data-and-analysis
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ECDC report on Carbapenem resistance https://ecdc.europa.eu/en/surveillance-atlas-infectious-diseases
Prevention of Healthcare Associated Bloodborne Viruses: The data collected on sharps incidents and occupational exposures is comparable with that elsewhere in the UK (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385300/EoN_2014_-_FINAL_CT_3_sig_occ.pdf)
Development of Guidance: N/A
Norovirus Outbreaks: PHE produce a national norovirus surveillance report, however, reporting is voluntary and not comparable to Scottish data collected through mandatory reporting https://www.gov.uk/government/statistics/norovirus-national-update
Hospital HCAI Outbreaks and Incidents: N/A, reporting of all HCAI outbreaks is not mandatory elsewhere in the UK and comparable data are not published.
Neonatal Units: N/A
Infection Control in the Built Environment and Decontamination (ICBED): N/A
Accessibility It is the policy of HPS to make its web sites and products accessible according to published guidelines.
Coherence and clarity
All guidelines and resources are produced using a defined process which ensures clarity and coherence. http://www.nipcm.scot.nhs.uk/resources/literature-reviews/development-process/
Value type and unit of
measurement
Number of procedures and Surgical Site Infections and incidence per categories (per 100 procedures) for inpatients and post discharge surveillance.
Incidence Rate: Number of HAI (CR-BSI/VAP) per 1,000 device days (Ventilator days/CVC days) or Number of HAI per 1,000 patient (bed) days.
Healthcare associated cases and incidence rates (per 100,000 Total occupied bed days (TOBDs)) for Clostridium difficile infection, Escherichia coli bacteraemia & Staphylococcus aureus bacteraemia.
Community associated cases and incidence rates (per 100,000 population) for Clostridium difficile infection, Escherichia coli bacteraemia & Staphylococcus aureus bacteraemia.
Number of cases and incidence rates (per 100,000 population) for Gram negative bacteraemia. AMR data includes percentage non-susceptible for antibiotics/organism combinations.
Number of isolates, number of Carbapenemase-producers by organism and enzymes and incidence per 100,000 population.
Use of antibiotics per 1,000 occupied bed days (acute hospitals)
Use of antibiotics per 1,000 population per day (primary care)
CPE CRA Uptake % = no.patients/records where CRA was applied/all patients/records in audit
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sample.
Number and rate (per 100 WTE) of sharps related injuries per 100 WTE; number of significant occupation exposure. Volume (millions) sharps devices purchased.
Total number of reported incidents is counted, often reported as a proportion of the total by infection type or organism.
Disclosure The HPS protocol on Statistical Disclosure Protocol is followed.
Official Statistics
designation
Not Assessed
UK Statistics Authority
Assessment
Not Assessed
Last published
05 May 2017
Next published
May 2019
Date of first publication
25 May 2015
Help email [email protected]
Date form completed
20 April 2018
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Appendix 3 – Early Access Details
Pre-Release Access
Under terms of the "Pre-Release Access to Official Statistics (Scotland) Order 2008", HPS
is obliged to publish information on those receiving Pre-Release Access ("Pre-Release
Access" refers to statistics in their final form prior to publication). The standard maximum
Pre-Release Access is five working days. Shown below are details of those receiving
standard Pre-Release Access.
Standard Pre-Release Access:
Scottish Government Health Department
NHS Board Chief Executives
NHS Board Communication leads
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Appendix 4 – HPS and Official Statistics
About HPS
HPS is a division of NHS National Services Scotland which works at the very heart of the
health service across Scotland, delivering services critical to frontline patient care and
supporting the efficient and effective operation of NHS Scotland.
HPS was established by the Scottish Government in 2005 to strengthen and coordinate
health protection in Scotland. It is organised into three specialist groups with expertise
provided by a multi-disciplinary workforce which includes doctors, nurses, scientists and
information staff, all of whom are supported by core business and IM&T teams. The
specialist groups are:
Healthcare Associated Infections and Infection Control;
Blood Borne Viruses and Sexually Transmitted Infections, Immunisation, and
Respiratory and Vaccine Preventable Diseases;
Gastrointestinal and Zoonoses Travel, and Environmental Public Health.
Official Statistics
Our official statistics publications are produced to a high professional standard and comply
with the Code of Practice for Official Statistics. The Code of Practice is produced and
monitored by the UK Statistics Authority which is independent of Government. Under the
Code of Practice, the format, content and timing of statistics publications are the
responsibility of professional staff working within NHS National Services Scotland.
Our statistical publications are currently classified as one of the following:
National Statistics (ie assessed by the UK Statistics Authority as complying with the
Code of Practice)
National Statistics (ie legacy, still to be assessed by the UK Statistics Authority)
Official Statistics (ie still to be assessed by the UK Statistics Authority)
other (not Official Statistics)
Further information on NHS National Services Scotland’s statistics, including compliance
with the Code of Practice for Official Statistics, and on the UK Statistics Authority, is
available on the ISD website.
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Reference List
(1) Health Protection Scotland. National Point Prevalence Survey of Healthcare Associated Infection and Antimicrobial Prescribing 2016. Health Protection Scotland 2017 May 23 [cited 2017];Available from: URL: http://www.hps.scot.nhs.uk/pubs/detail.aspx?id=3236
(2) Badia J.M, Casey A.L, petrosillo N, et al. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. Journal of Hospital Infection 2017;96:1-15.
(3) Jenks P.J., Laurent M., McQuarry S., Watkins R. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. Journal of Hospital Infection 2014;86:24-33.
(4) Scottish Government. Healthcare Associated Infection (HAI) and Antimicrobial Resistance (AMR) Policy Requirements. DL(2015)19. 2015 http://www.sehd.scot.nhs.uk/dl/DL%282015%2919.pdf
(5) Scottish Executive Health Department. A revised framework for national surveillance of healthcare associated infection in Scotland.HDL(2006)38. Scottish Executive Health Department 2006 [cited 2015 Mar 26];Available from: URL: http://www.sehd.scot.nhs.uk/mels/HDL2006_38.pdf
(6) Health Protection Scotland. SSI surveillance protocol and resource pack 7th Edition. Health Protection Scotland 2017 [cited 2017];Available from: URL: http://www.hps.scot.nhs.uk/haiic/sshaip/resourcedetail.aspx?id=827
(7) European Centre for Disease Prevention and Control. ECDC surveillance of healthcare-associated infections in intensive care units (ICUs). European Centre for Disease Prevention and Control 2015 [cited 2015 Apr 2];Available from: URL: http://ecdc.europa.eu/en/activities/surveillance/hai/about_hai-net/pages/icu.aspx
(8) Public Health England. Clostridium difficile Ribotyping Network (CDRN) for England and Northern Ireland, 2013 to 2015. PHE 2018 [cited 2018 Mar 22];Available from: URL: https://www.gov.uk/government/publications/clostridium-difficile-ribotyping-network-cdrn-report
(9) Davies KA, Ashwin H, Longshaw CM, Burns DA, Davis GL, Wilcox MH. Diversity of Clostridium difficile PCR ribotypes in Europe: results from the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID), 2012 and 2013. Euro Surveill 2016 Jul 21;21(29).
(10) Hensgens MP, Goorhuis A, Dekkers OM, van Benthem BH, Kuijper EJ. All-cause and disease-specific mortality in hospitalized patients with Clostridium difficile infection: a multicenter cohort study. Clin Infect Dis 2013 Apr;56(8):1108-16.
(11) Mitchell BG, Gardner A. Mortality and Clostridium difficile infection: a review. Antimicrob Resist Infect Control 2012 May 30;1(1):20.
(12) Barbut F, Bouee S, Longepierre L, Goldberg M, Bensoussan C, Levy-Bachelot L. Excess mortality between 2007 and 2014 among patients with Clostridium difficile infection: a French health insurance database analysis. J Hosp Infect 2018 Jan;98(1):21-8.
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(13) Scottish Executive Health Department. A framework for national surveillance of healthcare acquired infection in Scotland. HDL(2001)57. Scottish Executive Health Department 2001 [cited 2014 Apr 8];Available from: URL: http://www.sehd.scot.nhs.uk/mels/HDL2001_57.htm
(14) Health Protection Scotland. The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland. Health Protection Scotland 2014 April 2Available from: URL: http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248
(15) Health Protection Scotland. Protocol for Enhanced Staphylococcus aureus bacteraemia surveillance. HPS 2016 [cited 2017 Mar 23];Available from: URL: http://www.hps.scot.nhs.uk/haiic/sshaip/resourcedetail.aspx?id=1732
(16) Public Health England. Thirty-day all-cause fatality subsequent to MRSA, MSSA and E. coli bacteraemia and C. difficile infection, 2016/17. Gov uk 17 A.D. August 16 [cited 2016 Apr 1];Available from: URL: https://www.gov.uk/government/statistics/mrsa-mssa-and-e-coli-bacteraemia-and-c-difficile-infection-30-day-all-cause-fatality
(17) Murdoch F, Danial J, Morris AK, Czarniak E, Bishop JL, Glass E, et al. The Scottish enhanced Staphylococcus aureus bacteraemia surveillance programme: the first 18 months of data in adults. J Hosp Infect 2017 Oct;97(2):133-9.
(18) Murdoch F, Danial J, Morris AK, Czarniak E, Bishop JL, Glass E, et al. The Scottish enhanced Staphylococcus aureus bacteraemia surveillance programme: the first 18 months of data in children. J Hosp Infect 2017 Oct;97(2):127-32.
(19) Scottish Government. MRSA Screening CNO (F3604568). 2011 http://www.sehd.scot.nhs.uk/publications/DC20110223MRSA.pdf
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