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  • Healthcare Associated Infection

    Annual Report 2013

  • Health Protection Scotland is a division of NHS National Services Scotland.

    Health Protection Scotland website:

    Citation for this document: Health Protection Scotland. Healthcare Associated Infection Annual Report 2013. Health Protection Scotland, Glasgow 2014 [Report]

    Published by Health Protection Scotland, Meridian Court, 5 Cadogan Street, Glasgow G2 6QE

    First published May 2014

    Health Protection Scotland 2014

    Health Protection Scotland has made every effort to trace holders of copyright in original material and to seek permission for its use in this document. Should copyrighted material have been inadvertently used without appropriate attribution or permission, the copyright holders are asked to contact Health Protection Scotland so that suitable acknowledgement can be made at the first opportunity.

    Health Protection Scotland consents to the photocopying of this document for professional use.All other proposals for reproduction of large extracts should be addressed to:

    Health Protection ScotlandMeridian Court5 Cadogan StreetGlasgow G2 6QETel: +44 (0) 141 300 1100


  • i

    Table of ContentsAcronyms and Abbreviations iv

    Foreword 1

    Surgical Site Infection 3

    Healthcare Associated Infections in Intensive Care Units 8

    Clostridium difficile Infection 10

    Staphylococcus aureus Infection 14

    Escherichia coli Bacteraemia 20

    Urinary Tract Infections 22

    Carbapenemase-producing Bacteria 25

    Norovirus Outbreaks 28

    Hospital HAI Outbreaks and Provision of Support to Boards 30

    Hand Hygiene 32

    Development of Infection Prevention and Control Guidance 33

    Decontamination 35

    References 37

  • ii

    List of FiguresFigure 1: Incidence of SSI following caesarean section procedures in Scotland (inpatient and PDS to day 10), 2009 to 2013 4

    Figure 2: Proportion of SSI following caesarean section procedures (inpatient and PDS to day 10) in Scotland by SSI type, 2013 4

    Figure 3: Incidence of SSI following hip arthroplasty procedures in Scotland (inpatient and readmission to day 30), 2009 to 2013 5

    Figure 4: Proportion of SSI following hip arthroplasty procedures (inpatient and readmission to day 30) in Scotland by SSI type, 2013 5

    Figure 5: Annual CDI incidence rates in patients aged 65 and 15-64 years in Scotland per 100 000 bed days (2007 to 2013) 10

    Figure 6: Incidence rates of S. aureus, MRSA and MSSA bacteraemias in Scotland per 100 000 total AOBDs (four rolling quarters with 95% confidence intervals), April 2005 to December 2013 15

    Figure 7: Mupirocin use in primary and secondary care in Scotland, 2009 to 2012 16

    Figure 8: Percentage resistance to mupirocin (high level and low level) in MRSA bacteraemia isolates in Scotland, 2009 to 2012 17

    Figure 9: Carbapenemase producers reported in Scotland by AMRHAI (PHE) 26

    Figure 10: Number of wards closed on a Monday morning due to presumed or confirmed norovirus in Scotland by season, 2008 to 2014 29

    Figure 11: Types of outbreaks (number of events) reported to HPS during 2013 31

  • iii

    List of TablesTable 1: Incidence rates in Scottish ICUs by HAI type, 2012 9

    Table 2: Scottish PCR ribotypes isolated from mild, moderate or severe CDI cases (snapshot), or from severe cases and/or outbreaks between 2012 and 2013 12

    Table 3: Resistance (%) in E. coli urinary isolates from January 2012 - September 2012 and January 2013 - September 2013 23

  • iv

    Acronyms and AbbreviationsAMR Antimicrobial ResistanceAMT Antimicrobial Management TeamAOBDs Acute Occupied Bed DaysBSI Bloodstream InfectionCARS Controlling Antimicrobial Resistance in ScotlandCEL Chief Executive LetterCDI Clostridium difficile InfectionCI Confidence IntervalsCRA Clinical Risk AssessmentCNO Chief Nursing OfficerCPE Carbapenemase-producing EnterobacteriaceaeCRI Catheter-Related InfectionCR-BSI CVC-Related Bloodstream InfectionCVC Central Vascular CatheterEARS-Net European Antimicrobial Resistance Surveillance NetworkECDC European Centre for Disease Prevention and ControlECOSS Electronic Communication of Surveillance in ScotlandEMRSA Epidemic Meticillin Resistant Staphylococcus aureusESBL Extended Spectrum Beta-lactamaseEuSCAPE European Survey on Carbapenemase-producing EnterobacteriaceaeHAI Healthcare Associated Infection

    HAIRT Healthcare Associated Infection Reporting TemplatesHAITF HAI Task ForceHCW Healthcare WorkerHDU High Dependency UnitHDL Health Department LetterHEI Healthcare Environment InspectorateHELICS Hospitals in Europe Link for Infection Control through SurveillanceHIIAT Hospital Infection Incident Assessment ToolHPS Health Protection ScotlandICU Intensive Care UnitIPC Infection Prevention and ControlIPCT Infection Prevention and Control TeamISD Information Services DivisionKPI Key Performance Indicator

  • v

    MDR Multidrug ResistantMRSA Meticillin Resistant Staphylococcus aureusMSSA Meticillin Sensitive Staphylococcus aureusnCoV Novel CoronavirusNDM New Delhi Metallo-Beta-lactamaseNHS National Health ServiceNNU Neonatal UnitsNWTC National Waiting Times CentreOPCS Office of Population Censuses and SurveysPCR Polymerase Chain ReactionPDS Post Discharge SurveillancePHE Public Health EnglandPPS Point Prevalence SurveyPVC Peripheral Vascular CatheterPVL Panton-Valentine LeukocidinQIT Quality Improvement ToolsRPE Respiratory Prtotective EquipmentSAPG Scottish Antimicrobial Prescribing GroupScotMARAP Scottish Management of Antimicrobial Resistance Action PlanSEHD Scottish Executive Health DepartmentSGHSCD Scottish Government Health and Social Care DirectorateSICPs Standard Infection Control PrecautionsSICSAG Scottish Intensive Care Society Audit GroupSIGN Scottish Intercollegiate Guideline NetworkSIRN Scottish Infection Research NetworkSMRSARL Scottish MRSA Reference LaboratorySMVN Scottish Microbiology and Virology NetworkSPSP Scottish Patient Safety ProgrammeSSHAIP Scottish Surveillance of HAI ProgrammeSSI Surgical Site InfectionSSSCDRL Scottish Salmonella, Shigella and Clostridium difficile Reference LaboratoryTBP Transmission Based PrecautionsUTI Urinary Tract InfectionWHO World Health OrganisationWSG Water Safety GroupWSP Water Safety PlansVAP Ventilator Associated Pneumonia

  • 1 1

    Foreword Healthcare associated infections (HAI) continue to represent a significant threat to patient safety in NHSScotland and to safe care, wherever that is delivered. The inpatient cost of HAI originating in NHS acute care hospitals was estimated during a study

    carried out in 2013 and reported to be 137 million with an additional 318 172 bed days required in order to care for patients with HAI, the equivalent of a large teaching hospital occupied for a year. The burden outside of acute hospitals is currently unknown, but with the integration of health and social care, can be anticipated to be a public health concern based on initial work by Health Protection Scotland (HPS) in care homes and other settings.

    Over the last decade, significant reductions in the incidence of HAI, monitored by the mandatory surveillance systems, have been reported. However this report indicates that, for the second year in a row, these rates of infection continue to plateau. Last year we reported a plateau for the first time in key HAI types. This years data present similar findings wherein the incidence of surgical site infection following hip arthroplasty and caesarean section surgery, S. aureus infection bacteraemia had not changed significantly in 2013 compared with 2012. Reductions in C. difficile infection in the over 65 years age group continue, but not in under 65 years.

    Collaborative work with the Scottish Intensive Care Society Audit Group (SICSAG) has resulted in continuing success in the reduction of HAI occurring in some of the most vulnerable hospital patients in the Intensive Care Unit (ICU). The reported rates of bloodstream infection and ventilator associated pneumonia have decreased year on year since 2010. A project to describe the organisms responsible for HAI in ICU patients will be undertaken in 2014 further informing the agenda to reduce HAI.

    HPS activities over the last year have focused on improving the understanding of the current epidemiology of key HAI types with: enhanced surveillance, record linkage, and collaborations with the National Reference Laboratories. The findings from these studies will come to fruition in the coming year enabling HPS to support the NHS and beyond in designing new interventions to reduce risk and to ensure that interventions are targeted to populations most at risk, wherever in healthcare that may be.

    HPS continued to provide outbreak and incident support to boards via the Chief Nursing Officers national framework algorithm. In total, 49 outbreaks and incidents were reported to HPS. The intelligence obtained in the support of these outbreaks and incidents is used to develop a knowledge base that can be used to better prevent, prepare for and control outbreaks in the future in an intelligent and evidence based way.

    Evidence based infection prevention and control practice is essential in ensuring safe care. Building on the publication of Chapter One of the National Infection and Control Manual, Standard Infection Control Precautions (SICPs), Chapter Two of the manual was launched in April 2014. The Transmission Based Precautions (TBPs) are intended for frontline staff in the management of infections that are suspected or known to be due to an infectious agent or disease. The National Manual is a practice guide to be used by all staff and provides the best approach to mini


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