Select Committee on Science and Technology Minutes of Evidence


APPENDIX 4

PROTOCOLS FOR ALERT ORGANISM SURVEILLANCE

STAPHYLOCOCCUS AUREUS

ORGANISM

  STAPHYLOCOCCUS AUREUS INCLUDING METHICILLIN RESISTANT STRAINS (MRSA)

ICD CODES

  A41.0

DISEASE (S) OR SYNDROME(S)

  STAPHYLOCOCCUS AUREUS SEPTICAEMIA/BACTERAEMIA

RATIONALE FOR SURVEILLANCE

Public health significance

  Frequent cause of morbidity in hospitals within the UK, particularly in patients suffering from burns, following surgery and those who are immunosuppressed. S. aureus infection may present in a variety of ways, including impetigo, cellulitis, abscesses, wound infections. The organism may also colonise an individual without evidence of infection or contaminate samples taken for microbiological examination.

Significance of antimicrobial resistance

  Frequently resistant to multiple antimicrobials. Limited alternative antimicrobials available. Other agents in development.

Potential transmissibility

  Transmitted readily on the hands of healthcare workers where standards of hygiene are suboptimal. Airborne transmission may also be important.

TRIGGER FOR SURVEILLANCE

  Common problem across UK. Surveillance of S. aureus bacteraemias, including those caused by MRSA should continue to be undertaken routinely.

RECOMMENDED TYPES OF SURVEILLANCE

  Comprehensive active case-based surveillance should be undertaken incorporating an alerting mechanism for variations against prescribed norm. In the event of outbreaks or clusters of disease enhanced surveillance or other detailed epidemiological investigation should be considered. (1)

RECOMMENDED CASE DEFINITION

  For surveillance purposes, cases should fulfil both clinical and microbiological criteria.

Clinical attributes

  Evidence of clinically significant infection. [To be agreed between users and service providers.]

Laboratory attributes

  Isolation of S. aureus from blood.

Case classification

Suspected:

  Meets laboratory attributes only. (2)

Confirmed:

  Meets clinical AND laboratory attributes.

  Antimicrobial susceptibility to Methicillin/Oxacillin:

    Undetermined.

    Susceptible.

    Resistant.

APPROPRIATE SPECIMEN

Specimen type:

  Blood.

RECOMMENDED SUSCEPTIBILITY TESTING

  Undertaken by all laboratories providing microbiology services to NHS patients.

Antimicrobials

  Methicillin/Oxacillin. (3)

Methodology

  [To be agreed between users and service providers.]

RECOMMENDED MINIMUM DATASET (4)

Case-based data

    —  Unique identifier capable of cross linkage with laboratory data.

    —  Age or date of birth and sex.

    —  Evidence of clinically significant infection. [To be agreed between users and service providers.]

    —  First episode of infection.

    —  Place of residence. (4)

    —  Health care facility and care group. (4)

    —  Where acquired: following admission to present hospital, other hospital or healthcare facility. (4)

Laboratory data

    —  Unique identifier capable of cross linkage with clinical data.

    —  Specimen date and type.

    —  Susceptibility to methicillin/oxacillin.

REQUIRED OUTPUTS

Local

  To be determined by each District Infection Control Committee.

Regional

  Confidential reports to SHAs, PCTs, NHS Trusts and RO as agreed with RDPH.

National

  Reports as agreed with DH.

PRINCIPAL USES OF DATA

    —  Detect and monitor outbreaks.

    —  Provide monitoring data to identify trends.

SPECIAL ASPECTS

  1.  This protocol describes the minimum surveillance required. Consideration will need to be given to other types of surveillance and the monitoring of particular strains of the organism. In particular, consideration will need to be given to ensuring that no duplication of activity arises with alert condition surveillance.

  2.  In the absence of clinical information it may be necessary to collect data on suspected cases, with the exclusion at laboratory level of positive results from clearly contaminated specimens and repeat specimens from the same episode of illness on an individual patient.

  3.  An agreed extension of antimicrobials to be tested may provide a robust contribution to surveillance of antimicrobial susceptibility.

  4.  Certain data elements may not be immediately available. However, it is essential that population based data are collected as soon as is reasonably practicable.

FURTHER INFORMATIONProposed surveillance definitions

WHO Recommended Surveillance Standards,

2nd Edition October 1999

Clostridium difficile

ORGANISM

  CLOSTRIDIUM DIFFICILE

ICD CODES

DISEASE (S) OR SYNDROME(S)

  CLOSTRIDIUM DIFFICILE ASSOCIATED DIARRHOEA

RATIONALE FOR SURVEILLANCE

Public health significance

  Infection by toxigenic strains of C difficile following a course of antibiotic therapy is a cause of significant morbidity and mortality. The most common presentation is self-limiting diarrhoea but more severe cases may result (in some individuals) in potentially fatal pseudomembranous colitis.

Significance of antimicrobial resistance

  The disease usually occurs in patients who have been treated with broad spectrum antimicrobials. The organism is resistant to many agents and its survival and spread is favoured by antibiotic use.

Potential transmissibility

  Spores of C difficile can contaminate the environment around an infected patient and persist for several months. Infection can be transmitted via healthcare staff and via fomites.

TRIGGER FOR SURVEILLANCE

  Potentially a problem across UK. Surveillance of C difficile should be a component of surveillance of diarrhoea in the healthcare context and should be undertaken routinely(1).

RECOMMENDED TYPES OF SURVEILLANCE

  Comprehensive active case-based surveillance should be undertaken incorporating an alerting mechanism for variations against prescribed norm. In the event of outbreaks or clusters of disease enhanced surveillance or other detailed epidemiological investigation should be considered.(1)

RECOMMENDED CASE DEFINITION (2)

Clinical attributes

  Diarrhoea and/or enterocolitis.

Laboratory attributes

  Detection of toxin in stool and/or isolation of toxigenic C difficile.

Case classification

  Fulfils clinical AND laboratory definition.

APPROPRIATE SPECIMEN

Specimen type:

  Faeces.

RECOMMENDED TESTING

  Undertaken by all laboratories providing microbiology services to NHS patients.

Methodology

  Toxin detection and/or isolation. [To be agreed between users and service providers.]

RECOMMENDED MINIMUM DATASET

Case-based data

    —  Unique identifier capable of cross linkage with laboratory data.

    —  Age or date of birth and sex.

    —  Presenting signs (diarrhoea/toxaemia).

    —  First episode of infection.

    —  Place of residence.(3)

    —  Health care facility and care group.(3)

    —  Where acquired: following admission to present hospital, other hospital or healthcare facility.(3)

Laboratory data

    —  Unique identifier capable of cross linkage with clinical data.

    —  Specimen date and type.

REQUIRED OUTPUTS

Local

  To be determined by each District Infection Control Committee.

Regional

  Reports to SHAs, PCTs, NHS Trusts and RO as agreed with RDPH.

National

  Reports as agreed with DH.

PRINCIPAL USES AND ACTIONS OF DATA

    —  Detect and monitor outbreaks.

    —  Provide monitoring data to identify trends.

SPECIAL ASPECTS

  1.  This protocol describes the minimum surveillance required. Consideration will need to be given to other types of surveillance and the monitoring of particular strains of the organism. In particular, consideration will need to be given to ensuring that no duplication of activity arises with alert condition surveillance.

  2.  Alert organism surveillance for C difficile will usually be based on the identification of toxin in the stool rather than isolation of the organism.

  3.  Certain data elements may not be immediately available. However, it is essential that population based data are collected as soon as is reasonably practicable.

FURTHER INFORMATIONProposed Surveillance definitions

WHO Recommended Surveillance Standards,

2nd Edition October 1999

  Prevention and management of C difficile disease

DoH/PHLS Guidelines 1994

ENTEROCOCCUS (GLYCOPEPTIDE RESISTANT)

ORGANISM

ENTEROCOCCUS (GLYCOPEPTIDE RESISTANT)

ICD CODES

DISEASE (S) OR SYNDROME(S)

GLYCOPEPTIDE RESISTANT ENTEROCOCCAL BACTERAEMIA

RATIONALE FOR SURVEILLANCE

Public health significance

  Enterococci are part of the normal gut flora and can give rise to a number of clinical infections (urinary tract infections, bacteraemia, intra-abdominal infections, wound infections and, rarely, meningitis and respiratory tract infections). Although infections may arise from endogenous organisms, infection by glycopeptide resistant enterococci (GRE) most frequently arise in the healthcare context and can give rise to serious/fatal illness. GRE infection is uncommon at present but an emerging problem in some hospital units.

Significance of antimicrobial resistance

  Enterococci have a relatively wide intrinsic resistance to routinely available antimicrobials. In addition, the species also manifests a capacity to acquire resistance. The acquisition of glycopeptide resistance usually implies extensive antibiotic resistance. Generally these strains are of low virulence. However, they may cause serious invasive infection and have the potential to pass their resistances to S. aureus. Information on resistance will guide the management of cases, the effectiveness of infection control arrangements and inform prescribing policies.

Potential transmissibility

  High in health care setting.

TRIGGER FOR SURVEILLANCE

  In view of intrinsic resistance care-based surveillance should be undertaken routinely.

RECOMMENDED TYPES OF SURVEILLANCE

  Comprehensive active surveillance should be undertaken incorporating an alerting mechanism for variations against prescribed norm. In the event of outbreaks or clusters of disease enhanced surveillance or other detailed epidemiological investigation should be considered.

RECOMMENDED CASE DEFINITION

Laboratory attributes

  Isolation of GRE (1)

APPROPRIATE SPECIMEN

  All isolates, excluding screening samples and duplicates.

RECOMMENDED SUSCEPTIBILITY TESTING

  Undertaken by all laboratories providing microbiology services to NHS patients.

Antimicrobials

  Specified glycopeptides [To be agreed between users and service providers] (2)

Methodology

  [To be agreed between users and service providers]

RECOMMENDED MINIMUM DATASET

Case-based data

    —  Unique identifier capable of cross linkage with laboratory data

    —  Age or date of birth and sex

    —  Presenting signs (febrile)

    —  Place of residence (3)

    —  Health care facility and care group (3)

    —  Where acquired: following admission to present hospital or healthcare facility (3)

Laboratory data

    —  Unique identifier capable of cross linkage with clinical data

    —  Specimen date and type

    —  Susceptibility to specified glycopeptides

REQUIRED OUTPUTS

Local

  To be determined by each District Infection Control Committee.

Regional

  Reports to SHAs, PCTs, NHS Trusts and RO as agreed with RDPH.

National

  Reports as agreed with DH.

PRINCIPAL USES OF DATA

    —  Detect and monitor outbreaks.

SPECIAL ASPECTS

  1.  Differentiation from glycopeptide resistant forms of E. faecium and E. faecalis required.

  2.  A range of antimicrobials to be tested may provide a robust contribution to surveillance of antimicrobial susceptibility.

  3.  Certain data elements may not be immediately available. However, it is essential that population based data are collected as soon as is reasonably practicable.

FURTHER INFORMATION

  Proposed surveillance definitions

WHO Recommended Surveillance Standards, 2nd Edition October 1999.


 
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