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Health Protection Scotland

Healthcare Associated Infection

Annual Report 2017

Publication date

DD May 2018


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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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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

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can be made at the first opportunity.

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use.

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NHS National Services Scotland

Meridian Court

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Glasgow G2 6QE

Tel: +44 (0) 141 300 1100

Email: [email protected]

http://www.hps.scot.nhs.uk/

mailto:[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


Molecular Epidemiological Data ....................................................................................... 27

Antimicrobial Use and Resistance .................................................................................... 28

CDI Mortality ..................................................................................................................... 29

Quality Improvement and Interventions to Reduce CDI.................................................... 30

Staphylococcus aureus Infection ......................................................................................... 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


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



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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


9

Executive Summary


10

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.

http://www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx



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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


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


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


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.


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.

http://www.nssdiscovery.scot.nhs.uk/


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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).

http://www.hps.scot.nhs.uk/resourcedocument.aspx?resourceid=3491


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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


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.


29

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%)


30

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:


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.



31

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




32

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


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


33

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.




34

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






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



35

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


36


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


37

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,



38

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.


39

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


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

http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/healthcare-associated-infections/online-short-courses.aspx




40

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.


41

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.


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.




42

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






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



43

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


44

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


45

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



46

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.

http://www.hps.scot.nhs.uk/haiic/sutin.aspx

http://www.hps.scot.nhs.uk/haiic/sutin.aspx


http://www.hps.scot.nhs.uk/pubs/detail.aspx?id=3464


47

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


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.


48

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).



49

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:


50

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.


51

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


Figure 26 Healthy Pee Poster



52

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.

http://www.who.int/campaigns/world-antibiotic-awareness-week/en/

https://antibiotic.ecdc.europa.eu/en

https://antibiotic.ecdc.europa.eu/en



https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf

http://www.nipcm.hps.scot.nhs.uk/media/1365/2017-06-19-appendix-13.pdf


53

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.

http://www.sulsa.ac.uk/

http://www.scotlandshealthyanimals.scot/

http://agriscot.co.uk/

http://www.scotlandshealthyanimals.scot/farmers-livestock-owners/biosecurity-disease-avoidance/additional-guidance-for-specific-species-of-animals/poultry/poultry-hub/





54

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).



55

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.


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).


56

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


57

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.


58

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.


59

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).





60

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


61

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).


62

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).


63

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,

https://www.gov.uk/government/groups/uk-advisory-panel-for-healthcare-workers-infected-with-bloodborne-viruses

https://www.gov.uk/government/groups/uk-advisory-panel-for-healthcare-workers-infected-with-bloodborne-viruses


64

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).

https://www.gov.uk/government/collections/bloodborne-viruses-bbvs-in-healthcare-workers

https://www.gov.uk/government/collections/bloodborne-viruses-bbvs-in-healthcare-workers



65

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.


66

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).



67

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.


68

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.

http://www.hps.scot.nhs.uk/haiic/haicompendium.aspx


69

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.

http://www.e-bug.eu/


70

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




71

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


72


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


73

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).



74

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.


75

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


76


An infographic to accompany Norovirus of the HCAI Annual Report is available to

download (please click on icon).

Figure 34 HPS Norovirus activity dashboard1



77

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


78

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

http://www.hps.scot.nhs.uk/guidelines/detail.aspx?id=3418%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20

http://www.hps.scot.nhs.uk/haiic/decontamination/resourcedetail.aspx?id=3396


79

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




80

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



81

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).



82

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


83

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


84

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


85

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



Gram Negative bacteraemia:

Case data source: Electronic Communication of Surveillance in Scotland (ECOSS) Enhanced Surveillance Web Tool



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)


86

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



Carbapenemase-Producing Organisms: 31/01/2018

Antibiotic use in acute hospitals numerator: 28/03/2018

Antibiotic use in acute hospitals denominator: 15/03/2018


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)


Norovirus Outbreaks: 03/01/2018

Hospital HCAI Outbreaks and Incidents: 03/01/2018

Neonatal Units: 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:


87

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



Carbapenemase-Producing Organisms: None

Prevention of Healthcare Associated Bloodborne Viruses: None


Norovirus Outbreaks: None

Hospital HCAI Outbreaks and Incidents: None

Neonatal Units: 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


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.






Escherichia coli bacteraemia:

Details provided in quarterly publication





88




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.


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


Concepts and

definitions

Statistical significance:

Where the text refers to a change in the data this denotes statistical significance.




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.



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/




https://www.whocc.no/ddd/definition_and_general_considera/


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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).





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).


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.


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




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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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.





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.


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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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:


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.





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.






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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.


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


Completeness



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.







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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.








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.


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





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Comparability



Healthcare Associated Infections in Intensive Care Units: Data comparable to

equivalent data collected by other European countries where the ECDC protocol is utilised.

.





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.


ECDC report on Antimicrobial resistance surveillance in Europe https://ecdc.europa.eu/en/publications-data/antimicrobial-resistance-surveillance-europe-2016





Carbapenemase-Producing Organisms: Public Health England report on Carbapenem resistance https://www.gov.uk/government/collections/carbapenem-resistance-guidance-data-and-analysis




https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report

https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report


https://ecdc.europa.eu/en/publications-data/antimicrobial-resistance-surveillance-europe-2016

https://ecdc.europa.eu/en/publications-data/antimicrobial-resistance-surveillance-europe-2016


https://www.gov.uk/government/collections/carbapenem-resistance-guidance-data-and-analysis

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)


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


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

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385300/EoN_2014_-_FINAL_CT_3_sig_occ.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385300/EoN_2014_-_FINAL_CT_3_sig_occ.pdf

https://www.gov.uk/government/statistics/norovirus-national-update

http://www.nipcm.scot.nhs.uk/resources/literature-reviews/development-process/

http://www.nipcm.scot.nhs.uk/resources/literature-reviews/development-process/


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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

http://hpswebsite/about/confidentiality.aspx


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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.

http://www.isdscotland.org/


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(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.

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(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.

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http://www.sehd.scot.nhs.uk/mels/HDL2006_38.pdf


http://ecdc.europa.eu/en/activities/surveillance/hai/about_hai-net/pages/icu.aspx

http://ecdc.europa.eu/en/activities/surveillance/hai/about_hai-net/pages/icu.aspx

http://www.gov.uk/government/publications/clostridium-difficile-ribotyping-network-cdrn-report

http://www.gov.uk/government/publications/clostridium-difficile-ribotyping-network-cdrn-report


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(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

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(19) Scottish Government. MRSA Screening CNO (F3604568). 2011 http://www.sehd.scot.nhs.uk/publications/DC20110223MRSA.pdf

(20) Scottish Government Health Department. MRSA Key Performance Indicators. CNO(2013)01. Scottish Government Health Department 2013 April 24 [cited 2017 Sep 1];Available from: URL: http://www.sehd.scot.nhs.uk/cmo/CNO(2013)01.pdf

(21) Centers for Disease Control and Prevention (CDC). Gram-negative Bacteria Infections in Healthcare Settings. Centers for Disease Control and Prevention (CDC) 2011 January 17 [cited 2017 Sep 27];Available from: URL: https://www.cdc.gov/hai/organisms/gram-negative-bacteria.html

(22) Department of Health. UK Five Year Antimicrobial Resistance Strategy 2013 to 2018. Department of Health 2013 September 10 [cited 2015 Jul 2];Available from: URL: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf

(23) Public Health England. MRSA, MSSA, Gram-negative bacteraemia and CDI: quarterly report. Public Health England 2018 March 8Available from: URL: https://www.gov.uk/government/statistics/mrsa-mssa-and-e-coli-bacteraemia-and-c-difficile-infection-quarterly-epidemiological-commentary

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http://www.sehd.scot.nhs.uk/mels/HDL2001_57.htm

http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248


http://www.gov.uk/government/statistics/mrsa-mssa-and-e-coli-bacteraemia-and-c-difficile-infection-30-day-all-cause-fatality

http://www.gov.uk/government/statistics/mrsa-mssa-and-e-coli-bacteraemia-and-c-difficile-infection-30-day-all-cause-fatality

http://www.sehd.scot.nhs.uk/publications/DC20110223MRSA.pdf

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http://www.cdc.gov/hai/organisms/gram-negative-bacteria.html

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http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf

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(26) European Centre for Disease Prevention and Control. Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer. ECDC 2011 [cited 2016 Apr 4];Available from: URL: http://www.ecdc.europa.eu/en/publications/Publications/110913_Risk_assessment_resistant_CPE.pdf

(27) Health Protection Scotland. Toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae in Scottish acute setting. HPS 2016 May 31 [cited 2016 Jun 1];Available from: URL: http://www.hps.scot.nhs.uk/haiic/amr/publicationsdetail.aspx?id=55186

(28) Public Health England. Carbapenemase-producing Enterobacteriaceae: early detection, management and control toolkit for acute trusts. Gov uk 2014 June 19 [cited 2016 Apr 1];Available from: URL: https://www.gov.uk/government/publications/carbapenemase-producing-enterobacteriaceae-early-detection-management-and-control-toolkit-for-acute-trusts

(29) Health Protection Scotland. Toolkit for managing carbapenemase-producing Enterobacteriaceae (CPE) in Scottish non-acute care settings. Health Protection Scotland 2017 September 29 [cited 2017 Oct 2];Available from: URL: http://www.hps.scot.nhs.uk/haiic/amr/resourcedetail.aspx?id=3347

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