Infection Prevention and Control in Primary Care Mary Hanrahan RGN, RM, MSc Nursing

1. Infection Prevention and Control in Primary CareMary Hanrahan RGN, RM, MSc Nursing

2. Provide overview and update on.... • Conditions • SA / MSSA / MRSA / • CA MRSA • Clostridium difficile • ESBL’s • Norovirus • Influenza (Pandemic) • Practices / Health Care Environment • Hand Hygiene • PPE • Sharps • Decontamination / Reprocessing of equipment for minor surgery & other procedures • Specimen Sampling

3. The waiting ..... • The Adults... • Public health messages – leaflets / posters • Environmental furnishing & cleaning... • Choice of furniture • Cleaning solutions and frequencies.

4. waiting cont’d ....... • The Kids…. • Ideally clean solid toys between each patient contact and weekly with detergent and water, dried and wiped with70% alcohol wipe • Clean soiled toys between each patient contact ..... • Soft toys should be lost and never found again. • Clinical Practice & Waste • Use and disposal of sharps • Location of sharps boxes • Disposal of nappies • Blood and body fluid spills • Other spills

5. Many children in a waiting room setting may have or are incubating a community acquired infection e.g. RSV, rota virus, infected skin lesions, chicken pox • Children more susceptible than adults • Many have not developed immunity to common infectious fevers • Sicker children less likely to play with the toys • ‘Kid Incubators’ – not yet unwell will be attracted to toys.

6. The treatment room...... • Surfaces – ledges • Medical equipment • Waste • Hand hygiene facilities • Decontamination between patients

7. Staphylococcus aureus Found in nose of • 30% of healthy people • Can live on skin and in dust 11 days on a plastic patient chart > 12 days on a laminated tabletop - 9 days on a cloth curtain • SA - Clinically can cause boils, abscesses, wound infections, septicaemia & food poisoning • Susceptible patients - Burns, Post Surgery, Existing Skin conditions • MRSA meticillin resistant staphylococcus aureus • Screening for MRSA • MRSA decolonisation for patients pre op / post discharge

8. MRSA in the GP surgery! • A patient with chronic leg ulcer attends the surgery to have ulcer redressed – last laboratory report from an ulcer swab has identified – MRSA what actions do you take? • A patient attends the surgery with a letter from a local hospital stating that the patient has been given a date for elective orthopaedic surgery requiring implant their preop screen denotes MRSA carrier – what actions do you take?

9. Primary Care Decolonisation – Oilatum Plus – Active substance - Triclosan Hospital Decolonisation - Stellisept MED Active substance and concentration in 100 g: 1.0 g Didecyldimonium chloride This raw material is from the quaternary ammonium group (quats) • Quats are positively charged polyatomic ions with catalytic properties • Quats act by disrupting the cell membrane and proteins

10. PLV -SA • Panton-Valentine Leukocidin (PVL) – toxin produced by <2% of S aureus. • Causes recurrent skin and soft tissue infections – can be invasive e.g. necrotising haemorrhagic pneumonia – in otherwise health young people. • Investigate in – recurrent boils/abscesses • Nec SSTI, CA Nec H Pn. • Standard swabs include anterior nares • Rx – usual SA addition of Clind if PVL SA suspected.

11. Spore forming bacterium - 'normal' bacteria in the gut of up to 3% of healthy adults, more common in babies - rarely causes problems. • People over 65 years are more susceptible. • Antibiotic use. • Bowel surgery. • Immunocompromised.

12. Surveillance centre data Clostridium difficile2008

13. Antimicrobial Management Prescribing practices must adhere to guidance, be systematic and embedded in practice, take cognisance of patients hx Alert antimicrobials limited duration Targeted audit of use of ‘alert’ antibiotics Referral procedures to hospital

14. Risk Factors re Antibiotic therapy High Risk Broad spectrum antibiotics Cephalosporins Clindamycin Medium Risk Ampicillin Amoxycillin Co-trimoxazole Macrolides Tetracyclines Low Risk Aminoglycosides Metronidazole Rifampicin Vancomycin Fluroquinalones

15. Laboratory Specimens • Fresh is best! To avoid false negatives, transport to lab within 24 hours. • Over 24 hours- should be refrigerated at 4C. • Over 48 hours- should be frozen at -20C

16. ESBL-Producers • First described in 1980s, new class emerged early 2000s • Mostly E. Coli / Klebsiella • Resistant to penicillins and cephalosporins • Cross-resistance with other antibiotic classes • Can be difficult to treat → only 1 oral antibiotic • Colonise large bowel • Concept of ‘high risk’ areas less relevant • Large community reservoir (nursing homes)

17. ESBL Producers • Most frequently causes UTI, which can progress to bacteraemia • Outbreaks have occurred • Risk factors and transmission mechanisms under investigation • Has been detected on: • Staff hands /Equipment (stethoscopes, electronic thermometers, USS probes/gel) /Cockroaches • Patient long-term colonisation known

18. Aetiology • Norovirus 80% • Few particles to cause illness • 2-3 days incubation with high attack rate ( 40% or more) • Spread by person – person • Aerosol dissemination when vomiting • Environmental contamination • Water & food • Secondary foodborne spread

19. Signs and Symptoms • Vomiting, but not always • Diarrhoea • Nausea • Abdominal cramps • Headache • Myalgia • Chills & fever

20. Control of an outbreaks in an NH • 2 or more cases - Report • Stop people traffic / admissions • Signage / Information Leaflets • Isolate symptomatic patients • Dedicated nursing staff for symptomatic patients • Focus on hand hygiene / type of alcohol gel PPE laundry & clinical waste management environmental cleaning • Obtain specimens • Documentation • Apply the 48 / 72 hour rule

21. Known outbreak of Norovirus in community what actions do you take in the surgery? • Discourage attendance at the surgery. • Known symptomatic patients wait is segregated area. • Send sample – vomitus best if necessary. • Pay particular attention to cleaning of toilet and wash hand basin used by symptomatic patients. • Do not overstock toilet area.

22. Pandemic InfluenzaModes of transmission For planning purposes it is assumed that a pandemic strain of influenza will have a similar transmission, communicability, and inactivation properties as “routine” seasonal influenza Influenza is well established to be transmitted from person-to-person through close contact

23. Modes of transmission influenza The most likely routes of transmission are large droplet and direct and indirect contact Airborne, or fine droplet transmission, may also occur Brankston et al (2007) Transmission of influenza A in human beings. Lancet Infect Dis. Apr; 7 (4); 257-65

24. Past Pandemics in the 20th Century Global Deaths 1918 H1N1 Spanish Flu >50 million 1957 H2N2 Asian Flu 1-2 million 1968 H3N2 Hong Kong Flu 700,00

25. Unusual Features of the 1918 Influenza Pandemic 3 successive waves within ~ 9 months Unexpectedly high mortality at all ages Paradoxical mortality: low in wave 1, high in waves 2 & 3 in young/healthy, in elderly Severe bronchopneumonia; cyanotic collapse Caused by a novel H1N1 virus

26. Staff Roles of Responsibilities and systems of working Lead person to ensure infection control issues are maintained Plan – separation/early triage Flu/non-flu patients - Cohort area large number of patients with flu symptoms - Consider entrance/exit - Consider flu/non-flu clinic - Antivirals Home visit teams Communication staff/public

27. Prevention of transmission Standard Infection Control Principles and Droplet Precautions are the principal infection control strategies which should be rigorously followed. In certain circumstances these control measures may need to be augmented with higher levels of respiratory protection

28. Prevention of transmission Hand hygiene Containment of respiratory secretions Separation or cohorting of patients Restriction of ill workers and visitors Education of staff, visitors, and patients Personal protective equipment

29. Personal protective equipment for care of patients with pandemic influenza

30. Prevention of transmission Aerosol generating procedures nebulisers, intubation = FFP3 mask Fit check carried out each time masks worn Seal tightly to the face (clean shaven skin) Change if breathing becomes difficult / damaged distorted or a face fit can not be achieved Eye protection – if there is a likelihood of exposure to body fluids

31. Within the surgery identify Cohort Area – know where to segregate waiting patients to nebulise patients if required to decontaminate equipment following use to dispose of equipment to dispose of infected materials - tissues

32. Telephone triage (less seriously ill reduces crowding) Access to hand washing facilities Removal of toys/soft furnishings /magazines Lidded tissue/waste bines in the areas

33. Infection Control ProceduresStandard Infection Control principles/ Droplet precautions (Surgery/Home Visits) Hand hygiene Sinks – adequate stocks of soap and towels Hand sanitiser at points of patient care Designated Entrance/Exits with sanitisers Consider alcohol hand sanitizer for home visits Hand contact surfaces – clean regularly when designated room is in use

34. Respiratory Etiquette Cover mouth with disposable tissues coughing, sneezing wiping and blowing noses Dispose of used tissues Wash hands Crowded waiting areas – symptomatic patients wear masks

35. Hand Hygiene • Wash/Use alcohol rub • Expose forearms - bare below the elbow • 6 step technique + wrists • No jewellery • No false nails/nail polish • Hair - off face • Pedal bin

36. Hand Washing –When ! • When you come on duty, before & after breaks & before going home • Before & after patient contacts • Before & after aseptic technique/invasive procedure • Before contact with a susceptible site • After contact with blood, body fluid or excreta • After handling contaminated equipment/waste/laundry • Before & after contact with a patient on isolation precautions • Before serving meals & drinks

37. Advantages of Cleaning Hands with Alcohol-Based Hand Rubs • When compared to soap and water handwashing, alcohol-based hand rubs have the following advantages: • take less time to use • can be made more accessible than sinks • cause less skin irritation and dryness • are more effective in reducing the number of bacteria on hands • making alcohol-based handrubs readily available to personnel has led to improved hand hygiene practices

38. When not to use alcohol gels! D&V if your product is not active against causative virus C diff – alcohol hand gels do not kill spores Your skin - Moisturise at appropriate times!

39. Identify your highest risk activity in relation to the need for effective equipment decontamination! • Joint and soft tissue injections • Aspirations • Incisions • Excisions • Curetting • Cautery • Cryotherapy • Wound dressings

40. Guidance • Facilities to provide minor surgery – DH Health Building Note 46: General Medical Practice Premises. London DH • IC Guidance for General Practice IPS 2004 • Cooper T (2007) IC in General Practice. Primary Health Care 14 (6) 15-17. • Health Service Circular 2000 /032 - Guidance specific to equipment decontamination.

41. Effective management system to cover all aspect of decontamination cycle • Appropriate facilities • Equipment is fit for purpose, maintained, calibrated, monitored and validated. • Staff have appropriate training. • Single use items are not reused • Decontamination records are kept

42. Low risk Cleaning • Items in contact with intact skin. • Removal of accumulated deposits, by washing with a cleaning solution. This reduces the number of organisms and removes dirt, grease and organic matter. Medium risk Disinfection • Items that do not penetrate the • Partial removal or destruction of skin, but are in contact with organisms, except spores. This reduces mucous membranes or the number of organisms present. non-intact skin. • Low risk items contaminated with virulent organisms. High risk Sterilisation • Items in contact with broken skin/ • Complete removal or destruction mucous membranes, or introduced of all organisms including spores. into sterile body areas. Decontamination and re-processing of equipment Cleaning must always proceed disinfection and sterilisation. 5.7

43. Disinfection - 'the removal or destruction of harmful microbes, not usually including bacterial spores. (Maurer, 1974) • prEN ISO 15883-1) defines disinfection as 'reduction of the number of viable microorganisms on a product to a level previously specified as appropriate for its intended further handling or use'. • Disinfectant compounds are required to produce a 99.999% (log 5) reduction in bacterial population. Out of 100,000,000 1,000 survivors would remain.

44. Decontamination may use chemical disinfectants such as Milton or Hypochlorite. Choosing the type and concentration of a disinfectant depends on its effectiveness against specific pathogens. Hypochlorite tablets such as HAZ may also be used for Blood or body fluid spills. Actichlor Plus – combines disinfectant with detergent.

45. Actichlor Plus Actichlor Plus Detergent Action lifts grease and cleans Chlorine Disinfects and Sanitises Correct dilution: • Amount of available chlorine needed for the job • general environment 1,000ppm 1 tablet in 1 litre • blood spillage 10,000ppm 1 tablet in 100 ml The solution made up from the tablets will sanitise and clean at the same time.

46. STERILISATION in CSD • One means of decontamination is autoclaving. • A steam autoclave destroys organisms using saturated steam under pressure. • Autoclaving is used for sterilization of equipment as well as for decontamination of waste items. • When autoclaving is used to sterilize reusable items, they must be soaked, cleaned, and packaged prior to the process.

47. BTS and Sterilisation

48. vCJD • Effective cleaning prior to sterilization is of the utmost importance in reducing the risk of transmission of vCJD via surgical procedures • Single-use instruments? HSS(MD)15/99: variant Creutzfeldt-Jakob Disease (vCJD)

49. Equipment • Before buying check decontamination requirements with manufacturer • Use single use/single patient use equipment if possible • Have written protocols/guidelines from manufacturer & locally for decontamination • Have replacement policy

50. Specimen Taking • Swabs • Tissue • Pus • Wound Fluid/exudate • Irrigate