ADVISORY COMMITTEE ON ANTIMICROBIAL RESISTANCE & HEALTHCARE-ASSOCIATED INFECTION Eighteenth Meeting on 2nd February 2012
Room 136B;137B, Skipton House, 80 London Road, London SE1 6LH 10.00 –
Meeting Minutes List of attendance Members
Professor Jonathan Cooke (JC)
Professor Barry Cookson Professor Peter Hawkey
Professor Alison Holmes Professor David Leaper Dr Cliodna McNulty
Professor Mark Wilcox (MW) Mr Martin Kiernan
Dr Naomi Stanton – by phone Dr Peter Wilson Dr Alan Johnson Dr Julie Robotham Secretariat DH Sponsors Ms Sally Wellsteed Ms Claire Boville Invited Observers Dr Lorna Willocks (LW) Scotland Northern Ireland
Invited Speakers Dr David Livermore HPA (agenda item 3)
Invited experts Mr Peter Sellars University of West London
In attendance Ms Sharon Lecount Welcome, introductions, apologies, declarations of interest The Chair welcomed Claire Boville (DH), Professor Heather Loveday (University of West London), Bharat Patel (HPA), Theresa Lamagni (HPA), Russell Hope (HPA), Liz Sheridan (HPA) and explained their reason for attendance. All were thanked in advance for their input. Apologies were received from Dr Alexander Crighton, Dr William Tong and Paula Mansell (CQC) and Dr Paul Cook (FSA) Session on HCAI Surveillance ECDC HCAI Point Prevalence Survey The committee was reminded that the data were confidential and not for wider dissemination as they were provisional and incomplete. The final data set was expected in mid February and data from England, Scotland and Wales would be published in April. Northern Ireland and the Republic of Ireland were carrying out the survey in May-June. The final report was due to be published on 4th April to align with Scotland and Wales. The European report would be ready by autumn 2012 for Antibiotics Awareness Day in November 2012. The survey was carried out in September-October 2011. It was the fourth national healthcare associated infection point prevalence survey and the first antibiotic prescribing PPS. The aims and objectives were to raise awareness of HCAI infections and antimicrobial usage and to build epidemiological capacity. More than 400 staff had been trained in basic epidemiology practices. The speaker advised the committee that the methodology and definitions in this study differed slightly from previous surveys. Helics definitions had been used where possible. Unlike the 2006 survey this one also included the independent sector, paediatric and neonatal wards and mental health trusts. The average size of the participating organisation was 525 beds as compared to 309 last time. The speaker reported that the survey data appeared to be broadly similar to other data sources. It was noted that overall prevalence of HCAIs had decreased, with marked reductions in S aureus and C difficile infections being seen. E. coli accounted for the largest number of infections and it was clear that a significant proportion of these were healthcare associated. It was noted that high levels of pneumonia were reported and this may be an area to explore further as laboratory diagnosis is limited in this area. Around a third of patients were on antibiotics, with up to 6 antibiotics per patient being recorded and an average of 1.1 Members asked if the inclusion of independent sector hospitals and paediatrics had skewed the results but this was thought to be unlikely given the small numbers involved. The Chair thanked the presenter and recognised the hard work that the HPA and health service had put into this work. Surgical Site Infections Surveillance
A total of 150,000 operations from 361 hospitals and 81 independent sector organisations are included in surveillance which accounts for 20% of all surgery recorded in HES. Staphylococcus aureus was the most common cause of infections but Enterobacteriaceae are increasing. It was felt that information on the antibiotics used would help interpret these data and it was suggested that data from the PPS may be useful in this regard. Other risk factors such obesity and diabetic control during the operation were also identified as areas of relevance.
As length of hospital stay decreases post discharge surveillance is becoming more important and had been strengthened. The speaker felt it was likely that less serious infections were underestimated but it was not clear if this was clinically significant. The HPA team would like to make the administration of surveillance more efficient and include susceptibility data. They planned to identify user needs later in 2012. It was noted that caesarian section surveillance had been piloted. The speaker felt that including this in the programme would double throughput for HPA. While some NHS trusts were supportive of this work others had signalled that it would result in a significant addition to the NHS’s workload and may not be feasible. ARHAI members noted that hip and knee surgery currently account for the bulk of the number of operations and the percentage of operations covered in some other categories was low. It was not clear that the programme was focused on the areas of greatest clinical need. Given the finite resources available, members felt that there was a case for refocusing some of the effort. It was agreed that customers needs should be established to help inform prioritisation and that doing less in some areas should be considered. The HPA explained that they regularly review surveillance priorities and welcomed ARHAI’s contribution to this process. ARHAI would give further consideration on the best way to provide advice on ensuring maximal returns for investment in surveillance.
Mandatory Surveillance of MRSA and MSSA Bacteraemia The speaker noted that surveillance had shown a very significant decline in MRSA bacteraemia. A range of interventions was introduced to control MRSA and it is not clear which of these had been the most effective but it was believed that a significant proportion of MRSA infections were device associated. One area being considered to improve MRSA surveillance was typing of MRSA strains submitted to HPA to help determine the origin of infections. There was no clear association between high MRSA and MSSA levels, for example London had high MRSA levels but below average MSSA infections. Enhanced surveillance of MSSA bacteraemias had been introduced to investigate these data better. Surveillance had shown that most cases are not trust apportioned and clear regional differences exist. MSSA generally increased with age but there was a significant number of cases in the under ones. Only a third of cases had the voluntary risk factor fields completed and increased completion of these fields would help identify interventions to reduce MSSA. Members noted that the data indicated that skin and soft tissue infection and lines were the top two causes. Evidence from the New England Journal of Medicine and other sources indicated that targeted MSSA screening reduced infection rates and was cost effective. In light of this, members felt MSSA screening offered a potential opportunity to reduce serious MSSA infection and agreed that the introduction of MSSA screening should be more formally evaluated. If the ongoing NOW project showed scope for more specific targeting of MRSA screening it may be possible to introduce MSSA screening with little extra burden and deliver significant clinical benefit. Members suggested that there may be merit in linking data with other data sets such as HES, this may help identify the risk factors for MSSA infections and typing could be valuable.
Introducing MSSA screening and decolonisation could also increase mupiricin resistance but members felt this was unlikely if screening was targeted and lab base 2 would show if problems start to emerge.
E. coli, C. difficile GRE & Cosurv Due to time constraints this presentation focused on E. coli. E. coli mandatory surveillance started in June 2011 and aimed to find out why E. coli bacteraemias were increasing and identify interventions to reverse this trend. The speaker commented that initial analyses had shown significant regional variation, most infections were present on admission and about a third were likely to be HCAI. Only about a third of records had risk factor information and over 40% were associated with UTIs and catheterisation. It was hoped that completion of the voluntary fields would increase once the PPS was published and it was apparent that E. coli was the major cause of bacteraemias It was noted that HPA had plans to link the data with HES and lab-base 2. Unfortunately, it was not feasible to collect information on antibiotic use before admission but the results of the PPS may provide useful information. The committee considered that a large amount of data had already been collected and was keen to mine it effectively to inform decisions on appropriate interventions to reduce E. coli bacteraemias. The HPA was asked to provide more detailed analyses for the next meeting. Some members felt that there may be issues around recording of urinary catheter use and the forthcoming NICE review of the primary and community care infection control guidance may help improve practice. It should be routine practice to question if a catheter is needed and if present the clinical notes should explain why and when it should be removed. Some members felt that there was also a need for better training in catheter use. It was noted that information on catheter use was collected in the NHS Safety Thermometer data set and it was felt that this might provide a lever to improve practice. The role of pressure ulcers as a cause of bacteraemias was also identified. It was noted that the Department of Health was undertaking work to develop a pressure ulcer care bundle and it was agreed that the Committee would be provided with more information about this as members may be able to help increase awareness and implementation. The committee agreed with the HPA recommendation that mandatory E. coli surveillance data should be collected for at least a year to see if there was any seasonal variation but after that the value of continued collection should be re-examined. ACTIONS
1. A small focused sub group to consider the options and benefits of MSSA screening would be set up and report back to ARHAI later in 2012. This would take account of the scientific literature on this issue and the DH funded study on MRSA screening 2. HPA would feed ARHAI comments into their routine reviews of SSI and other surveillance priorities. ARHAI to provide further advice on surveillance priorities and obtaining the best return for investment in surveillance. 3. HPA would undertake more detailed analyses of the E. coli data and report back at the next meeting. This information will help determine effective interventions. 4. DH would contact colleagues working on pressure sores to investigate how ARHAI could assist with implementation of this care bundle. 5. DH to investigate what information on catheter use is included in the NHS Safety Thermometer data set Horizon Scanning The speaker highlighted the following developments: OXA-48 carbapenemase - As projected at the previous meeting the unrest in North Africa had resulted in th eimportation of more cases of OXA-48. Klebsiella pneumoniae with OXA- 48 were referred to ARML from 6 of 50 transferred patients. There was no significant spread within the multiple NHS hospitals that cared for the patients but underscores the risk of transmission and raises the question of what admission screening or cohorting is required for such patients. A novel multi-resistant acinetobacter strain was also imported with at least 8 patients; but this was no more resistant than strains already circulating in the NHS. Amoxicillin-clavulanate. Breakpoints defining antibiotic susceptibility were previously set by the British Society for Antimicrobial Chemotherapy, which had higher values (32+16 mg/L) for coamoxiclav in uncomplicated urinary infections than for other body sites (the drug concentrates in the urine). BSAC has now participated in EUCAST’s harmonisation process for breakpoints and EUCAST does not have high urinary breakpoints, saying that all isolates, regardless of source should be graded against a single breakpoint of 8+2 mg/L. The result is that labs, gradually adopting updated EUCAST-BSAC breakpoints are finding that their rate of co-amoxiclav resistance in urinary ‘coliforms’ jumps from c. 10% to c 40% with the combination appearing little better than unprotected amoxicillin. There is considerable scepticism since treatment failures were not widespread with the old higher urinary breakpoint, but, if followed, the advice looks set to lead to the loss of co-amoxiclav for lower UTIs. BSAC are in contact with EUCAST on this. Discussion: Members felt that there were important implications arising from the change in breakpoints for GP guidance on UTIs and additional advice for GPs may be needed. As a first step it was agreed to approach the Chair of the British Society of Antimicrobial Chemotherapy Working Party to inform him of ARHAI’s concerns and to discuss the way forward. Action secretariat to contact Robin Howe BSAC. Telavancin - this novel lipoglycopeptide, was licensed by EMA in 2011 for treatment of adults with nosocomial pneumonia (NP) including ventilator associated pneumonia, known or suspected to be caused by meticillin-resistant Staphylococcus aureus (MRSA)…. ‘ where it is known or suspected that other alternatives are not suitable’. It follows that the drug can only be used if vancomycin, teicoplanin and linezolid have all been considered and rejected. In short, there is no potential for a market and Astellas, who had taken the drug through Phase III, pulled out and handed it back to the discoverer,. Fully ceftriaxone-resistant N. gonorrhoeae. Following an earlier case in Japan another has been reported in France (Unemo M et al. Antimicrob Agents Chemother. 2011 Dec 12. epub). Update on pseudomonas contamination and draft guidance The committee was reminded that this issue had been discussed in March 2011. Since then the Department had commissioned a report on pseudomonas and developed an action plan to implement its recommendations. Some of these actions had been brought forward following the Northern Ireland outbreaks in augmented care units in order to strengthen the guidance and advice to healthcare providers. It was recognised that Pseudomonas aeruginosa was difficult to eradicate and contamination of water outlets was multifactorial, for example influenced by tap design, organic carbon content of water and clinical practice. It was also apparent that contamination was more prevalent than previously believed. It was also noted that there were no specific standards for pseudomonas in hospital water systems and the risk of appeared to be particularly associated with augmented care and burns units. The committee felt a proportionate approach was required as pseudomonas only accounts for 2-3% of paediatric bacteraemias.
After hearing the background on the Northern Ireland incidents and an introduction to pseudomonas and water systems The committee considered the need for enhanced surveillance, the HPA statement included in the interim guidance issued in Northern Ireland on lever taps and the draft DH “Dear colleague” letter and associated best practice advice. Members agreed that enhanced surveillance was useful when a problem was identified but local rather than national mandatory surveillance was the most suitable to identify what was happening in the hospital. Members agreed that elbow taps could be sensible when there is no risk of scalding but noted that some of these taps have reservoirs where water is at room temperature and there is the potential for biofilm to develop. They felt a local assessment was required and general recommendations were not appropriate. Maintenance as well as cleaning was important to reduce the risk of contamination and an engineering solution would be required to reduce the risk of contamination. Members noted that terminal filters had prevented transmission to patients when manufacturers instructions on fitting and maintenance were followed. However, some systems did not have sufficient water pressure to use filters. The use of ultra violet light in taps and other outlets was being investigated but there was limited evidence so far on efficacy. The committee proposed a number of changes to improve the presentation and content of the draft “Dear Colleague” letter. Chairs Report It was noted that some members were coming to the end of their terms and membership issues would need to be considered. The ARHAI Secretariat vacancy was out to advert and the chair reported that the ARHAI pharmacist had had a baby boy. The discussion on NICE guidance (paper 18-07) was deferred due to lack of time
It was noted that the ARHAI Supplement for the Journal of Antimicrobial Chemotherapy was nearing completion The Chair thanked the secretariat and the Department for their hard work on the committee but noted that resources were limited and prioritisation of the work programme was required.
The Chair explained that the Department had some support from the University of West London and they would help identify research priorities to inform ARHAI’s work programme Secretariat Report The ICU sub-group was considering what would be the best single surveillance indicator for HCAIs in Intensive Care Units, as a follow on from “Matching Michigan”. The consensus was it should be a measure of central line associated blood stream infections (CLABSI) as used in the original NPSA programme and an options appraisal was being developed. The chair reported that a short life ARHAI sub-group on Neonatal Intensive Care Units had been established to develop guidance on optimal management of acute HCAI outbreaks and longer term surveillance options. C.difficile sub-group – The testing guidance developed by ARHAI had been approved by ministers and the chair thanked members of the sub-group for their prompt turn around on this piece of work. C.difficile discussion paper – As there was no time to consider the discussion paper, members were asked to submit written comments. These would be collated and fed back to the Department. Action members to send comments to MW for collation Professional Education – Good progress had been made on developing generic competences and these would be completed shortly. The feasibility of doing further work to develop three tier (novice, practitioner and expert) competences would be considered later in the year. Antimicrobial Stewardship Group – It was agreed that antibiotic stewardship was the priority and it was important to establish the impact of Start Smart - then Focus and an audit to investigate this was being established. This involved input from both the public education and antimicrobial stewardship subgroups. Progress in obtaining hospital prescribing data from IMS had been made and members were asked to comment on the routine reports that would be the most useful. Action members to send JC suggestions for regular reports.
A number of iPhone apps were available for primary and secondary care formularies and these could help improve practice Plans for EAAD – The Committee accepted plans put forward by the Chair of the EAAD Advisory Group (CMc). These will include promoting the day through professional societies and other stakeholders, promoting ‘Start Smart then Focus’ through feedback of impact and launch of an antimicrobial stewardship in primary care (ASPIC) toolkit on the RCGP website.
Devolved Administration Updates – due to time constraints members were asked to send any queries via email. Action members to send any queries to LW Minutes of the meeting held on 31st May 2011
The minutes were agreed as an accurate record. Action Points These were reviewed Any other business Publication of the ARHAI/DARC report on ESBLs in the human and veterinary sectors was expected on 7th February 2012.
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