Healthcare-Associated Infections in England:2008-2009 Report
Christine McCartney Executive lead for the HPA Healthcare-Associated Infection and Antimicrobial Resistance ProgrammeForeword – Christine McCartneyHealthcare-associated infections (HCAIs) are ‘everyone’s responsibility’ and soall those involved in reducing HCAIs are to be congratulated as this annualreport highlights dramatic decreases in HCAIs reported through the mandatorysurveillance scheme. Encouraging though this is, patients continue to contractmeticillin-resistant Staphylococcus aureus (MRSA) bacteraemia, Clostridiumdifficile, and other HCAIs that may not have such a high profile, so we can notafford to be complacent. Working towards zero tolerance of preventableinfections the Health Protection Agency remains vigilant gathering timelysurveillance data, providing diagnostic and reference microbiology services toassist the NHS, providing expert proactive advice and support at local,regional and national levels, as well as participating in and shaping researchand development.Highlights• Dramatic decreases in HCAIs reported through the mandatory surveillance scheme.• Launch of norovirus surveillance in December 2008.• Growth of the Clostridium difficile Ribotyping Network (CDRN).• Successful conference and launch of the DVD An introduction to infection control in care homes.HeadlinesThere were 36,097 Clostridium difficile infections reported in England in2008/09 (patients aged two years and over), which represents a 35% fall on the55,499 total for 2007/08. There is CDRN evidence that this decrease is due inparticular to successful control of ribotype 027.Figures on MRSA bloodstream infections showed there were 2,933 casesreported in England in 2008/09. This represents a 34% fall on the 4,451 totalfor 2007/08 and a 54% fall on the 6,383 cases reported in 2006/07.There have been statistically significant reductions in the rate of inpatient andreadmission surgical site infections between 2004 and 2008 in hip prosthesis(1.6% to 0.7%), knee prosthesis (0.9% to 0.5%), open reduction of long bonefracture (2.5% to 1.3%) and hip hemiarthroplasty (4.4% to 2.3%).These figures are national statistics collected on behalf of the Department ofHealth and published on the HPA website (www.hpa.org.uk).
Mandatory surveillance of MRSA bacteraemiaIn September 2008 the HPA published results showing the NHS had met its50% reduction target as compared with the 2003/04 baseline levels. Sincethe start of MRSA bacteraemia surveillance in April 2001 there has been a62% decrease in the cases of MRSA bacteraemia reported to the HPA(comparison based on April to June 2001 vs January to March2009 data).Data for the past year continues to show these infections mainly afflict theelderly (mean patient age is 69 ± 20 years), men (65% of patients), andthose with either predisposing morbidities (e.g. renal failure, diabetes,immunosuppression) or medical procedures (e.g. surgical interventions,central or peripheral intravenous lines). Patients attending for electivemedical procedures are estimated to account for less than 10% of allaffected patients.Since October 2005 when the HPA introduced a web-enabled data capturesystem to collect MRSA bacteraemia data on a patient basis (previously,cases were reported at an aggregate acute trust level), the largest declineamong the three patient populations has been the 69% reduction in thenumber of cases diagnosed three or more days after presentation athospital (Figure 1). From October to December 2005 this patientpopulation accounted for 65% of MRSA infections, but now (January toMarch 2009) accounts for just 52% of MRSA infections. However, there havealso been substantial decreases of 47% and 45% respectively amongpatients diagnosed within two days of admission and those diagnosed atnon-acute trust facilities during this time period.The HPA introduced patient record tracing in March 2009. Further researchmay be warranted into identifying predisposing risk-factors and MRSAstrains among patients suspected of being infected at non-acutetrust facilities. Figure 1. MRSA bacteraemia, by patient presentation 2,500 Three or more days after admission Within two days of admission Non-acute cases 2,000 Reports of MRSA bacteraemia 1,500 1,000 500 0 Oct/05- Apr/06- Oct/06- Apr/07- Oct/07- Apr/08- Oct/08- Mar/06 Sep/06 Mar/07 Sep/07 Mar/08 Sep/08 Mar/09
Mandatory surveillance of Clostridium difficileThe mandatory surveillance of Clostridium difficile began in January 2004for patients aged 65 years and over, and was ‘enhanced’ in April 2007 toinclude patient-level data for all patients aged two years and over.Since April 2007 there has been a 50% reduction in the number of cases ofC. difficile reported for all patients aged two years and over (comparisonbased on April to June 2007 vs January to March 2009). The highestreduction (54%) is observed among patients testing positive three or moredays after admission (Figure 2). Significant reductions of 41% and 47%respectively have also been observed for patients testing positive within twodays of admission and patients testing at non-acute trust facilities.There have been no changes this past year (compared with the previousyear’s data) in mean patient age (74 ± 17 years), with 80% of casesaffecting those aged over 64 years of age, and a majority of cases afflictingwomen (58% of patients). Furthermore, the increased number of casesobserved between January and March 2009 as compared with the previousquarter is consistent with the seasonality that was evident during theprevious year.As over 40% of cases are observed among patients diagnosed within twodays of admission or diagnosed at non-acute trust facility, comprehensiveinfection control should include initiatives by a range of non-acute trustfacilities. As part of a national strategy to reduce these infections by 30% infinancial year 2010/11, the HPA has been identifying affected patients’responsible primary care organisations (PCO) to help these organisationsimplement suitable infection control initiatives. Figure 2. Clostridium difficile, by patient presentation (all patients aged 2 years and over) 12,000 Three or more days after admission Within two days of admission 10,000 Non-acute cases Reports of C. difficile 8,000 6,000 4,000 2,000 0 Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Jun/07 Sep/07 Dec/07 Mar/08 Jun/08 Sep/08 Dec/08 Mar/09
Surveillance of surgical site infectionSurgical site infections (SSIs) account for 15% of all HCAIs, are associatedwith considerable morbidity and estimated to at least double the length ofhospital stay. There is evidence that the care provided before and after theoperation is critical in minimising the risk of SSI and that feeding back dataon rates of SSI to the surgical team contributes to reductions in rates ofinfection. The HPA established the SSI Surveillance Service (SSISS) in 1997 toenable hospitals to compare their rates of SSI against a benchmark rate andto use the data to improve the quality of patient care. Hospitals are able tochoose from 14 categories of surgical procedures. Basic demographics arecollected on each patient who has a procedure in the category undersurveillance. Patients are then followed up during their hospital stay for SSIsthat meet the standard case definitions and, since July 2008, SSIs thatoccur in patients readmitted to hospital. SSISS is currently undertaking astudy to evaluate methods of post-discharge surveillance.During 2008, 251 hospitals collected data on 94,750 surgical procedures.These included 196 NHS and 55 independent sector hospitals. A total of1,191 SSIs were detected, with readmission SSIs comprising 30% of thistotal. The proportion of SSIs detected in readmissions is higher in thoseprocedures with a shorter length of post-operative stay. The rate of SSIvaries between categories, reflecting differences in likelihood of microbialcontamination at the operative site. In over 4,500 SSIs reported since 2004Staphylococcus aureus was the causative organism for 38% of all SSIs, ofwhich 59% were due to a methicillin-resistant strain.Since the mandatory surveillance of SSI following orthopaedic surgerystarted in April 2004 the rate of SSI has decreased significantly (p<0.001) inhip prosthesis, knee prosthesis and hip hemiarthroplasty. Figure 3. Rate of SSI (detected during inpatient stay and at readmission) by surgical category, with number of operations shown above each bar, 2008 12% Readmission SSI 2,499 10% Inpatient SSI % operations infected 8% 396 6% 348 4% 1,614 4,212 3,089 6,184 904 2% 1,354 765 1,261 34,702 37,422 0% Knee prosthesis Hip prosthesis long bone fracture Spinal surgery Abdominal hysterectomy femur Reduction of long bone fracture Hip hemiarthroplasty Coronary artery bypass surgery Vascular surgery Limb amputation Small bowel surgery Large bowel surgery Open reduction of Repair of neck of
Clostridium difficile Ribotyping Network (CDRN) The Clostridium difficile Ribotyping Network (CDRN, formerly the CDRNE) has expanded to eight regional laboratories in England and Northern Ireland. CDRN provides ribotyping and enhanced DNA fingerprinting to identify cross-infection, reduce transmission, optimise management of outbreaks and determine the epidemiology of C. difficile. In 2008/09 CDRN processed 4,682 faecal samples from 190 healthcare facilities (~100% increase over 2007/08) about one out of every eight or nine C. difficile cases in England were examined by CDRN. Marked changes in ribotype prevalence in 2008/09 occurred, with a striking decrease in C. difficile 027, and ‘compensatory’ increases in the other main types (Table 1). There were clear regional differences in ribotype prevalence e.g. ribotype 027 was the commonest in each region except the North East (ribotype 001, 20.0% vs ribotype 027, 12.6%; p<0.001). Figure 4 demonstrates shifting ribotype prevalences since CDRN(E) was introduced. There was a significant association between all cause mortality and ribotype 027 (OR = 1.9; p<0.001). Notably, there was an increase from 9.6% to 12.5% in the proportion of (toxin positive) faecal samples that are C. difficile culture-negative. This may reflect more false positive samples that have tested locally as ‘toxin positive’ (see HPA guidance at www.hpa.org.uk). Susceptibility testing of over 1,000 C. difficile isolates has shown more evidence of emergence of reduced susceptibility to metronidazole with some institutional clustering. Table 1. Changing prevalence of most common Clostridium difficile Figure 4. Prevalence of 10 most common ribotypes in ribotypes detected by CDRN in 2007/08 and 2008/09 England by quarter (April 2007 to March 2009) Riboty pe 07/08 (n,%) 08/ 09 ( n,%) Prevalenc e Prevalence of 10 most common ribotypes in England by quarter change (%) (Apr 2007 - Mar 2009) 027 1152 (55.3%) 1468 (36.1%) - 19.2% 700 106 270 (13.0%) 517 (12.7%) - 0.3% 027 600 106 001 181 (8.7%) 297 (7.3%) - 1.4% 500 Sporadic Number of ribotypes 002 57 (2.7%) 231 (5.7%) + 3.0% 014/020* 57 (2.8%) 218 (5.4%) + 2.6% 001 400 002 015 50 (2.4%) 215 (5.3%) + 2.9% 015 078 37 (1.8%) 144 (3.5%) + 1.7% 300 078 005 29 (1.4%) 118 (2.9%) + 1.5% 200 005 023 21 (1.0%) 109 (2.7%) + 1.7% 023 026 5 (0.2%) 87 (2.1%) + 1.9% 100 014 The top 10 most prevalent ribotypes are shown i.e. those 0 with >2% prevalence in 2008/09. In 07/08 and 08/09, 7.2%9 41 43 45 47 49 51 01 03 05 07 09 11 13 15 17 19 21 23 25 0 1 2 3 4 5 6 7 8 9 and 8.1%, respectively, of all isolates were designated as Weeks sporadic i.e. these were not one of the commonly recognised Quarter (April 2007 - March 2009) ribotypes. * Data for ribotypes 014 and 020 are combined.
Surveillance of norovirus Norovirus is the commonest cause of cases and outbreaks of gastrointestinal disease in the UK. The majority of outbreaks of norovirus reported to the HPA occur in healthcare-associated settings such as hospitals and residential care homes. A prospective study of gastrointestinal disease outbreaks in three NHS hospital trusts in the county of Avon in 2002/03 found that 63% of the outbreaks were confirmed due to norovirus. Resulting staff absence due to illness and bed-days lost due to ward closures was estimated to cost the NHS around £115 million in that year. For 2009, the HPA launched a new surveillance scheme called Hospital Norovirus Outbreak Reporting. Infection control teams in acute hospitals enter and access data directly via a secure web enabled database at www.hpa-bioinformatics.org.uk/noroOBK/. Reporting to the scheme is voluntary; therefore the reported figures are an underestimate of the true number of outbreaks of norovirus in hospitals in England and Wales. To encourage participation the system was designed to be a resource for infection control staff and to provide real-time local outbreak information. The system supplements the data collected as part of routine laboratory report surveillance (Figure 5). From January to March 2009 there were 262 outbreaks reported from 43 trusts (Table 2). A total of 82% of outbreaks resulted in some form of ward closure, with 2,814 patients and 747 staff reported to have been affected as part of these outbreaks, and over 4,000 bed-days were lost. Table 2. HPA Hospital Norovirus Outbreak Reporting: Figure 5. Seasonal comparison of laboratory reports preliminary data, January to March 2009 of norovirus (England and Wales) 500 2002/2003 I 2,499 Trusts reporting (N) 43 450 2003/2004 Outbreaks (N) 262 2004/2005 January 107 400 2005/2006 February 89 350 Laboratory Reports 396 2006/2007 March 66 300 Ward closed 215 2007/2008 (82%) 348 250 2008/2009 1,614 Laboratory confirmed 4,212 181 200 6,184 904 3,089 (69%) 150 65 1,261 Total Median (Range) Patients affected 2814 10 (2-34) 100 Staff affected 747 2 (0-21) 50Spinal surgery Abdominal hysterectomy femur Reduction of long bone fracture Hip hemiarthroplasty Coronary artery bypass surgery Vascular surgery Limb amputation Small bowel surgery Large bowel surgery Repair of neck of Bed days lost (N – 161) 4136 10 (0-173) 0 27 29 31 33 35 37 39 41 43 45 47 49 51 01 03 05 07 09 11 13 15 17 19 21 23 25 Weeks
Providing specialist advice and supportThe HPA has made a significant contribution to help trusts to control Clostridiumdifficile. It has deployed multidisciplinary specialist advisory teams at the request ofacute trusts to improve patient safety by raising awareness, providing advice, supportand training, and using site visits to demonstrate good practice at local, regional andnational levels. This has been achieved through direct engagement with NHS trustboards and executive groups, and frontline healthcare staff.The roll out of the MRSA Standard Package of Charts for use by health protection unitsand regions started in May 2008 and training for staff took place on 13 June 2008 inLondon, 20 June 2008 in Leeds and 24 June 2008 in Birmingham. This standardpackage, produced on a monthly basis, contains three data worksheets and 11 chartswithin an spreadsheet and is used to inform dialogue with NHS trusts. There are fourtypes of charts that are automatically generated from the data entered into the threedata worksheets. These are a ‘raw’ time series, a guidance or statistical process controlchart, a cusum (cumulative sum) of differences from the trajectory, and a comparativeincidence density chart. The first three types have been produced for the monthly,quarterly and annual data.In February 2009 the HPA produced a DVD featuring a series of short films designed togive care home staff an introduction to infection prevention and control. This trainingresource was produced in conjunction with the Department of Health and theInfection Prevention Society. It can be used to supplement existing infection controltraining in care homes and provides practical assistance to help comply with the newDepartment of Health code of practice.To complement the launch of the DVD a one-day conference was held on 21 May2009. The conference took place in London in partnership with the InfectionPrevention Society. The event was attended by 280 delegates from across the UKincluding care home managers and owners, infection prevention and controlspecialists, community nurses, representatives from primary care trusts and strategichealth authorities, leads on HCAI, regulators and health protection unit staff. Speakersfrom the Department of Health, Care Quality Commission and the National PatientSafety Agency highlighted the new code of practice and what it will mean for carehomes, including registration and compliance issues.
Health Protection AgencyHealthcare Associated Infection and AntimicrobialResistance Programme7th Floor Holborn Gate330 High HolbornLondon WC1V 7PPUnited KingdomTel: +44(0)20 7759 2817Fax: +44(0)20 8327 6633Email: firstname.lastname@example.orgWebsite: www.hpa.org.ukLinks to the dataMandatory MRSA bacteraemia:www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1191942169773Mandatory C. difficile:www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733750761CDRNE:www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1208417851521?p=1208417851521Norovirus:www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1191942172974?p=1191942172974Surgical Site Infection Surveillance Service:www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1191942150156?p=1191942150156Other useful linksPVL Staphylococcus aureuswww.hpa.org.uk/web/HPAwebFile/HPAweb_C/1218699411960Clostridium difficile infection: How to deal withthe problemwww.hpa.org.uk/web/HPAwebFile/HPAweb_C/1232006607827Download the care homes DVDwww.hpa.org.uk/carehomesdvdAugust 2009c Health Protection AgencyThis leaflet is printed on recycled content paper. Gateway no: 09/005