SURF Workshop

Healthcare associated infection service users' research forum

Thursday 8 May 2014
Egyptian Room, London Art House

There were three very interesting speakers at the workshop giving an insightful view of the challenges facing healthcare providers in terms of the emerging threats from multi-drug resistant bacteria. The scenarios are worrying but the efforts being made to research solutions are being stepped up with ministries in the UK, Europe and USA giving antimicrobial resistance the full attention it deserves. The threat is greater where countries have no regulation of antibiotic use, and a global approach is needed.

Outbreaks of antimicrobial resistant bacteria in the hospital environment - surveillance and monitoring

Dr Olga Tosas Auguet from the Centre for Clinical Infection & Diagnostic Research, King's College London & Guy's & St Thomas' NHS Foundation Trust, gave an overview of the project on the surveillance and monitoring of outbreaks of antimicrobial resistant bacteria in the hospital environment.

Antimicrobial resistant bacteria can be carried on the skin or in the environment, but this may not necessarily mean a person gets infected, but there is a risk if their immunity is compromised, and a risk to other patients.

Targeted tracking has the advantage of dealing with antimicrobial resistant bacteria, taking the necessary preventative measures to stop them spreading, including making sure the appropriate antibiotic treatment and interventions are carried out expediently, benefiting all patients in a unit or ward where there may be a problem.

In terms of the definition of an outbreak, for the purposes of this project, it can be just a few cases that may be significant in terms of needing to implement specific interventions or protocols. The 'outbreak' would be more than what you would normally expect in any population or geographical area, or in this case ward or hospital.

This approach is important as antimicrobial resistance is developing much faster than we can develop new antibiotics and there is no standardised system for hospitals to detect outbreaks. There is a focus on specific infections such as MRSA, MSSA and E.coli, but the range of antimicrobial resistant bacteria is much wider and needs to be tracked. Antimicrobial resistance can spread between bacterial species and render hospitals' antibiotics as ineffective on some strains of bacteria.

The aim of the project is to provide near real time detection, provide alerts and to develop protocols to deal with antimicrobial resistant outbreaks, data on antimicrobial resistant species is collated by laboratories through the NHS electronic infection control tracking system and an algorithm will be used to identify problem antibiotic resistant species and the response to controls.

Emergence and detection of multidrug resistant gram negative bacteria Dr Jon Otter, Centre for Clinical Infection & Diagnostic Research, King's College London & Guy's & St Thomas' NHS Foundation Trust

Is the end of the antibiotic era nigh?

Gram-negative bacteria are resistant to multiple drugs and are increasingly resistant to most available antibiotics. These bacteria have built-in abilities to find new ways to be resistant and can pass along genetic materials that allow other bacteria to become drug-resistant.

Gram-negative infections include those caused by Klebsiella, Acinetobacter, Pseudomonas aeruginosa, and E. coli, as well as many other less common bacteria.

Inconsistencies can affect individual hospitals, and the broader community because patients are frequently transferred between hospitals and long-term care facilities, furthering spread.

Multidrug-resistant gram-negative bacteria (MDR-GNB) is a growing problem that is more difficult to detect and treat than the more commonly known MRSA (methicillin-resistant Staphylococcus aureus). The USA are experiencing more cases and the CDC have issued some pretty grim headlines. Although the UK have relatively fewer reports of these multi-resistant bacteria, because of the difficulty in treating people who become infected with these organisms, the mortality rate can be as high as 50% if carbapenim resistance is involved.

No single test can determine whether bacteria are multidrug-resistant, diagnosis determines whether or not a patient requires contact precautions.

Jon, posed the question "What do you do with patients who are colonised with MDR bacteria - isolate them indefinitely - probably, yes."

Looking at Europe Greece has a high proportion of multi-drug resistant bacteria compared to other regions, this is largely due to unregulated use of antibiotics.

Public Health England has launched a toolkit for hospitals to detect, manage and control antibiotic-resistant bacterial infections caused by carbapenemase-producing Enterobacteriaceae (CPE).

The use of many different types of antibiotics in hospitals creates evolutionary pressures that encourage the development and spread of antibiotic resistant bacteria. This process is a natural consequence of the use of antibiotics and cannot be stopped, only managed.

Enterobacteriaceae are a group of bacteria carried in the gut of all humans and animals. While they are usually harmless they may sometimes spread to other parts of the body such as the urinary tract or into the bloodstream where they can cause serious infections.

This can occur after an injury or via the use of medical devices such as urinary catheters or intravenous drips where the skin is punctures allowing the bacteria to get into the body.

CPE is the name given to some strains of gut bacteria that have developed the ability to destroy an important group of antibiotics call carbapenems, making them resistant to these drugs. Infections caused by CPE can usually still be treated with antibiotics, however treatment is more difficult and may require a combination of drugs or the use of older antibiotics to be effective.

Trusts have been mandated to report back on their implementation of the toolkit. Royal Free showed around 20% of admissions would meet the criteria for isolation - equating to £3m per annum. Public Health England will be doing a national randomised survey to assess prevalence.

SURF members asked "What will replace antibiotics?"

Some of the solutions include:

  • Looking at enzyme inhibitors to augment the activity of antibiotics
  •  Using cyclical antibiotic therapy, both on an individual basis and locally
  • Bacteria phage therapy, although this approach has not been thoroughly evaluated
  • Complementing the normal flora of the gut as an adjunctive therapy, using faecal transplant (crapsule), usually carried out as a last resort - preferable to having a colostomy for most patients

Jon said they would be carrying out an enhanced surveillance study for a month, to see who meets the screening trigger for CPE and who would need therapy.

Jon's presentation is available on his blogspot article "What does lab diagnosis of MDR-GNR have to do with SURFing?"

Using eye tracker technology as a research method
Professor Jonathan Stockdale, Institute for Practice, Interdisciplinary Research and Enterprise, University of West London.

Professor Stockdale had been working with Jenny Wilson at UCH to look at possible ways to use eye tracker technology in the hospital setting to study how we look at the environment and how this influences behaviours.

A film showed how the technology is used in sports science to research behaviour. Cristiano Renaldo wore the headgear to track eye movements whilst playing soccer in a controlled experiment. It showed the intuitive behaviour when a player attempts to tackle and take the ball, with Cristiano instinctively looking at the challenger's hip, knee and foot movements without thinking to optimise the response to being tackled. The other player's eye movements showed that he kept his eye on the ball, which was also intuitive, but meant he was always 'behind' in terms of reaction to the skilled player, giving little opportunity to retrieve the ball, giving a paradoxical meaning to the saying "keeping your eye on the ball"

Bio feedback is also assessed to test the body's reaction to situations and the complexity of tasks. Pupils dilate when there is less concentration, so it's possible to assess cognitive load.

Glasses with a camera and recording device were used to look at hospital signage in an experiment. The glasses were useful as it was possible to walk through the corridors with the surveillance being unobserved, giving a natural environment to see behaviours of people passing through. Hand gel stations were by-passed at the entrance, these were to one side. The stations were also not being used in the corridors. There was a suggestion that the red signage may be taken for something other than hand gel stations to passers-by, fire extinguishers and associated signage that could be something that you would normally walk past but not observe directly.

The technology could be applied to test what works or doesn't work in terms of success at hand hygiene at the point of care, looking at behaviours in a ward setting, and opportunities for hand hygiene, gloving etc, why don't we do this intuitively, what are the distractions?

Our experience shows however, that any recording of ward activity has met with resistance due to concerns over patient confidentiality, particularly in light of the personal care involved, so it is unlikely that this could be used in a real ward situation, but simulations are used in training by a lot of university teaching hospitals now, and the technology could be applied in this situation.

It could also be applied to researching patient interactions between doctors and patients with patient consent.

MRSA Action UK activity update to SURF

An update was given on our stakeholder partnership agreement with NICE where we will be assisting in promoting the recently reviewed infection prevention and control guidelines. We will be doing other promotional work, including signposting people to the guidelines at infection prevention study days that we attend and also conferences. NICE will provide the materials on request.

We are currently reviewing information on our website and have an audit to ensure we are meeting the Information Standard requirement to provide up-to-date balanced information for the public.

It has been nine years since we founded the charity, we are still getting similar types of enquiry from patients with concerns about healthcare associated infections, often not understanding the information given to them, or saying they have not received information, such as the diagnosis of the infection (saying they have an infection and they think it is MRSA) or saying they have MRSA but not understanding the difference between colonisation and infection. We get asked about pets too - can they catch it, or give it to us.

If you or someone you care about has been affected by a healthcare associated infection and you wish to discuss this with us, please contact us at

The information on this website is for general purposes only and is not a substitute for qualified medical care, if you are unwell please seek medical advice.

(c) MRSA Action UK 2014