Other healthcare infections 

Some basic facts about Healthcare Associated Infections including what they are, how they are spread and treated, and what measures are needed to minimise the risk to yourself and others.

 

The information here refers to nosocomial infections.  Nosocomial infections occur as a result of treatment in a hospital or a healthcare facility, but are secondary to a patient's original condition.  With care many nosocomial infections can be avoided, with attention to hand-hygiene, strict aseptic technique, the right training and information, and the rigour now adopted by many healthcare facilities, we hope this will serve as a guide to help reduce the risk of becoming infected and to make a good recovery.

Vancomycin-resistant Staphylococcus aureus (VRSA)

This relates to a potentially new strain of Staphylococcus aureus, which could be Vancomycin resistant.  This would indicate the mutation of a strain which is resistant to what is currently considered to be the last line of defence when others have failed.  There is currently research being done into newer drugs.

Community acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA)

These infections can cause the same type of infections as other strains of Staph.  Studies have found that CA-MRSA is more likely to cause skin and soft tissue infections and that healthcare associated MRSA (HA-MRSA) is more likely to be found in sputum, urine and wounds.  Most CA infections are skin and soft tissue infections such as abscesses/boils or cellulitus.  The most serious form of CA MRSA infection causes necrotising fasciitis (commonly known as "flesh-eating bacteria") a severe, rapidly progressing and life threatening skin infection.  Early detection of this is of paramount importance.

PVL Staphylococcus aureus

Panton Valentine Leukocidin (PVL) is a toxic substance produced by some strains of Staphylococcus aureus which is associated with an increased ability to cause disease. The incidence is low at present but it is important healthcare professionals and the public are aware of the infections it can cause and the precautions which should be taken.

 

PVL can be produced by both methicillin sensitive and methicillin resistant strains of S. aureus . Most of the PVL-positive S. aureus strains identified in the UK are sensitive to many antibiotics.

How common is PVL S. aureus?

The PVL toxin is carried by less than 2% of S. aureus and can be carried by both MRSA (methicillin resistant Staphylococcus aureus ) and MSSA (methicillin sensitive Staphylococcus aureus ).

 

The Health Protection Agency (HPA) are aware of isolated cases in the community across the United Kingdom (UK). Microbiology laboratories across the UK are vigilant and have been requested to send any suspicious samples to the HPA for further analysis.

What are the symptoms?

Infections caused by PVL strains of S. aureus normally cause cellulitis (inflammation of layers under the skin) and pus-producing skin infections (eg abscesses, boils and carbuncles).  However, they can, on very rare occasions, lead to more severe invasive infections, such as septic arthritis, bacteraemia (blood poisoning) or necrotising pneumonia (a severe, life-threatening form of pneumonia).

Why do people get PVL S. aureus infections?

Not all patients with PVL S. aureus will suffer an infection. When these occur they are usually associated with the presence of other risk factors such as overcrowding, skin abrasions resulting from close contact sports such as wrestling or rugby, or using contaminated articles such as sharing towels, razors, poor hand hygiene and damaged skin from other conditions such as eczema.

What should people do to protect themselves?

The risk to the general public of becoming infected with PVL S. aureus is small but it is always good practice to maintain appropriate hygiene measures which include proper cleansing and disinfection of cuts and minor wounds. Wounds should be covered with a bandage until healed and individuals should avoid contact with other peoples' bandages and lesions.

 

If the infection spreads or recurs go to your GP or Accident and Emergency for further investigation and/or treatment. Such spreading infection should not be ignored.

 

Other simple measures are regular bathing/showering, regular changing of linen and underwear, hand washing, avoiding sharing personal items (eg toothbrushes, face cloths, towels) and keeping wounds covered.

 

Chances of contracting all types of S. aureus infections are reduced by maintaining good hand hygiene and not sharing personal items. In shared facilities (for instance, in gyms) it is good practice to use liquid soap and disposable towels, to place a towel on the bench before sitting, and to ensure the facilities are cleaned frequently and that there is good ventilation to the locker room and showers.

Is this a new type of MRSA?

No, PVL-producing strains of S. aureus have been seen in the UK before. In the 1950s and 1960s PVL methicillin sensitive S. aureus were common in hospitals, but are not common currently. It is thought that PVL-positive MRSA have evolved from strains such as these. The small numbers of PVL cases reported have usually been in the community rather than a hospital setting.

Can people die from it?

Infection with PVL-producing strains of S. aureus normally causes skin infection, but can occasionally cause more severe infections. The HPA is aware of seven deaths in England and Wales associated with PVL-positive MRSA over the last two years (this includes the two recently reported at a hospital in the West Midlands ). Most of these were unrelated to hospital care.

What decontamination methods can be used on people, wards, clothing etc?

As with any kind of S. aureus , thorough hand washing and drying, or use of alcoholic hand rubs if hands are not visibly soiled, have been shown to be the most important measures in reducing cross-infection in both the community and the hospital.

 

The environment must be kept clean and dry. Whilst in hospital, patients may have to be nursed in side-rooms or in a special ward and visitors may be asked to wear gloves and aprons.  Before going home visitors are advised to wash their hands or use an alcoholic hand rub even if hands are not visibly soiled.

Who can PVL-positive MRSA affect?

PVL-producing strains are more commonly contracted in the community and generally affect previously healthy young children and young adults - this contrasts with the so called 'hospital-associated MRSA' strains which do not usually produce PVL and are more commonly associated with wound infections and blood-poisoning in elderly or severely ill hospitalised patients.  At the moment PVL-MRSAs are not common in the UK hospital setting.

Can PVL-MRSA and PVL-MSSA be treated?

Yes, both types of PVL producing S. aureus can be treated. It is important to diagnose infection early. Infections caused by many antibiotic-sensitive varieties of PVL- S. aureus are usually successfully treated with antibiotics such as some types of penicillin and erythromycin. PVL-MRSA is resistant to antibiotics of the methicillin-class (eg flucloxacillin) and occasionally other antibiotics such as erythromycin. Isolates seen in this country are usually susceptible to many other antibiotics such as tetracycline, ciprofloxacin, rifampicin, trimethoprim and fusidic acid. Effective treatment is therefore readily available.

What infection control measures can be used to stop the spread of PVL-positive MRSA?

The infection control measures used to prevent the spread of PVL-positive MRSA are the same as for any type of MRSA infection.  Standard infection control measures are effective and the most important first line of defence.  In healthcare settings, measures include early diagnosis and treatment of cases, barrier nursing, and sometimes investigation of close contacts.

Is PVL-producing MRSA more dangerous than other strains seen in the UK and elsewhere?

 

While PVL-producing MRSA can cause more serious infection, we have no evidence to suggest it is more dangerous than some other types of MRSA. Indeed, some previous and more recent data suggests that the PVL gene may not be the main virulence factor even in PVL strains. PVL-positive MRSA has not been shown to spread more rapidly than any of the usual hospital-associated MRSA organisms. However, we will continue to monitor the situation.

Should patients be worried?

 

There is no indication that current PVL-positive MRSA strains are more transmissible than other MRSA strains. Persons with recurrent skin infections - spreading inflammation (cellulitis), boils and abscesses - should seek medical advice. Standard treatment and infection control measures are highly effective.

What is the Health Protection Agency doing to ensure that PVL-positive MRSA does not become more widely spread?

 

At a local level, our Health Protection Units provide advice on infection control measures in the event of an incident or outbreak, as they do with other infectious diseases.

Eradication of S. aureus organisms is not possible, because there are no vaccines and patients are often not sufficiently immune after an infection. At least a third of people carry S. aureus as part of their normal bacterial flora, living on their skin or mucous membranes and causing no harm. However, when infection with such strains occurs, basic infection control measures are effective in preventing spread and available antibiotics are effective against them.

 

The Agency has published information to enable GPs and clinicians to recognise potential cases early and to then ensure that laboratory confirmation is obtained, treatment initiated early and infection control and hygiene advice implemented.  For DOH guidance on PVL infections visit: 

http://www.dh.gov.uk/en/AboutUs/MinistersAndDepartmentLeaders/ChiefMedicalOfficer/%0bFeatures/DH_4133761

GRE -  Glycopeptide-resistant enterococci

 

Enterococci are bacteria found in the faeces of human and many animals, and they commonly cause urinary tract infections and wound infections as well as bacteraemia, and occasionally endocarditis and meningitis.  Enterococci frequently colonise open wounds and skin ulcers.  Minor infections can be treated by common antibiotics.  However, only aminopenicillins, or teicoplanin and vancomycin are reliably effective against serious enterococcal infections.  Enterococcus faecalis and enterococcus faecium have emerged as leading nosocomial pathogens in recent years.  Enterococci are amongst the most antibiotic resistant bacteria isolated from humans.  GRE, and in particular Vancomycin-resistant enterococci (VRE) have emerged as major nosocomial pathogens as they are typically resistant to multiple antimicrobials and treatment is extremely difficult, often limited to linezolid.

Streptococcus Pneumoniae

 

This gram-positive bacterium colonises the nasopharyngeal mucosal epithelium and is a major cause of community-acquired pneumonia (CAP), invasive pneumococcal disease (IPD) and bacteria meningitis.  Individuals principally affected are those at the extremes of age (children and elderly), individuals without a functioning spleen, and immuno-compromised patients.  Many strains of S. pneumoniae have become resistant to some of the antibiotics used to treat pneumococcal infections, and resistance to penicillin is common in some parts of the world.

 

For more information on Streptococcal Infections see the Health Protection Agency website http://www.hpa.org.uk/infections/

Acinetobacter species

 

Acinetobacter is a type if bacterium carried by 25% of healthy people and is readily isolated from many sources in the environment, including drinking and surface waters, soil, sewage and various food types.  There are at least 25 different Acinetobacter species, though it is mainly Acinetobactor baumannii that causes infections in hospital patients.  Such infections can include skin and wound infections, urinary tract infections, pneumonia and bacteraemia.  These "hospital-adapted" strains of Acinetobacter are often resistant to antibiotics and may be difficult to treat and eradiate, for example from intensive care units, strains resistant to carbapenems have been reported in UK hospitals, leaving polymixin as the only licensed antibiotic available for treatment.

Extended-Spectrum beta-lactamase (ESBL) producing Escherichia coli

 

ESBL- producing E. Coli are antibiotic resistant strains of E.Coli.  Although E. Coli normally reside harmlessly in the gut, it is one of the most common bacteria causing infections in humans - particularly urinary tract infections, (UTIs)- in the community as well as hospitals.  These infections can sometimes progress to cause more serious infections such as blood poisoning which can be life threatening.  ESBL strains of E. Coli produce an enzyme called extended-spectrum beta-lactamase (ESBL) which makes them resistant to antibiotics and the infections harder to treat.  Most ESBL-producing E.coli are resistant to cephalosporins, penicillins, fluroquinolones, trimethoprim, tetracycline and some other antibiotics, leaving very limited options for oral treatment in the community.  In many instances, only oral antibiotics (nitrofurantoin and fosfomycin) and a very limited group of intravenous antibiotics remain effective.  Most ESBL-producing E.coli infections occur in people with other underlying medical conditions and in elderly people.  Patients who have been taking antibiotics or who have been previously hospitalised are mainly affected.  Further research is needed to look at risk factors associated with different strains of ESBL-producing E.coli and how they are transmitted between patients and in community settings.

Norovirus

 

Noroviruses are a group of viruses that are the most common cause of gastroenteritis in England and Wales and estimated to affect between 6000,000 and one million people in the UK each year. Although relatively mild, norovirus gastroenteritus can occur at any age as prior infections do not elicit long-lasting immunity.  The incubation period is usually 24 to 48 hours and symptoms last 12 and 60 hours.  The symptoms can include the sudden onset of nausea followed by projectile vomiting, and watery diarrhoea.  Some people may have a raised temperature, headaches and aching limbs.  The majority of people make a full recovery however, some (usually the very young or elderly) may become very dehydrated and require hospital treatment.  Norovirus spreads very easily from one person to another and can be transmitted by contact with infected individual, by consuming contaminated food or water, or by contact with contaminated surfaces or objects.  As the virus is easily spread from one person to another and can survive in the environment for many days, outbreaks of norovirus gastroenteritis are common in semi-closed environments such as hospitals, nursing homes and schools.  The most effective way to respond to an out break is to isolate those infected for up to 48 hours, disinfect contaminated areas, institute good hygiene measures including hand-washing and provide advice on food handling.  There is no specific reason for norovirus, however it is a self-limiting infection and recovery occurs within one to two days

Candida species

 

The yeast Candida is the most common cause of opportunistic mycoses worldwide.  It is a member of the normal flora of the skin, mouth,vagina and stool, and it is commonly found in the environment, particularly on leaves, flowers, water and soil.  The genus Candida includes around 154 species, of which 6 are most frequently isolated in human Candida infections including Candida albicans, Candida tropicalis, Candida glabata, Candida parapsilosis, Candida krusei and Candida lusitaniae.  Infections caused by Candida species are in general referred to as Candidiasis.  The clinical spectrum of Candidiasis is extremely diverse and almost any organ or system in the body can be affected.  It can cause either benign and frequent infections such as oral and vaginal candidiasis or more serious problems such as life-threatening invasive infections in immuno-compromised hosts. 
C albicans is the most pathogenic and most commonly encountered species and accounts for 60% of all Candida infections.  It can grow as a biofilm on artificial surfaces including medical implant devices such as catheters, prostheses, artificial valves and joints, and dentures.  Several anti-fungal drugs are effective against candidiasis, of which the most effective is fluconazole.  The emergence of strains of C albicans resistant to fluconazole increases the difficulty in treating the infection and necessitates the use of other anti-fungal drugs that are less effective or have damaging side effects (eg amphotericin)

 

Ref: BMA guide for Healthcare Associated Infections Feb 2006

Pseudomonas aeruginosa

 

A pseudomonas infection is caused by a bacterium, Pseudomonas aeruginosa, and may affect any part of the body. In most cases, however, pseudomonas infections strike only persons who are very ill, usually hospitalised.

 

P. aeruginosa is a rod-shaped organism that can be found in soil, water, plants, and animals. Because it rarely causes disease in healthy persons, but infects those who are already sick or who have weakened immune systems, it is called an opportunistic pathogen. Opportunistic pathogens are organisms that do not ordinarily cause disease, but multiply freely in persons whose immune systems are weakened by illness or medication. Such persons are said to be immunocompromised. Patients with AIDS have an increased risk of developing serious pseudomonas infections. Hospitalised patients are another high-risk group, because P. aeruginosa is often found in hospitals. Infections that can be acquired in the hospital are sometimes called nosocomial diseases.

 

Of the two million nosocomial infections each year, 10% are caused by P. aeruginosa. The bacterium is the second most common cause of nosocomial pneumonia and the most common cause of intensive care unit (ICU) pneumonia. Pseudomonas infections can be spread within hospitals by health care workers, medical equipment, sinks, disinfectant solutions, and food. These infections are a very serious problem in hospitals for two reasons. First, patients who are critically ill can die from a pseudomonas infection. Second, many Pseudomonas bacteria are resistant to certain antibiotics, which makes them difficult to treat.

 

P. aeruginosa is able to infect many different parts of the body. Several factors make it a strong opponent. These factors include:

 

  • the ability to stick to cells
  • minimal food requirements
  • resistance to many antibiotics
  • production of proteins that damage tissue
  • a protective outer coat

 

Infections that can occur in specific body sites include:

 

  • Heart and blood. P. aeruginosa is the fourth most common cause of bacterial infections of the blood (bacteraemia). Bacteraemia is common in patients with blood cancer and patients who have pseudomonas infections elsewhere in the body. P. aeruginosa infects the heart valves of intravenous drug abusers and persons with artificial heart valves.
  • Bones and joints. Pseudomonas infections in these parts of the body can result from injury, the spread of infection from other body tissues, or bacteraemia. Persons at risk for pseudomonas infections of the bones and joints include diabetics, intravenous drug abusers, and bone surgery patients.
  • Central nervous system. P. aeruginosa can cause inflammation of the tissues covering the brain and spinal cord (meningitis) and brain abscesses. These infections may result from brain injury or surgery, the spread of infection from other parts of the body, or bacteraemia.
  • Eye and ear. P. aeruginosa can cause infections in the external ear canal--so-called "swimmer's ear" - that usually disappears without treatment. The bacterium can cause a more serious ear infection in elderly patients, possibly leading to hearing problems, facial paralysis, or even death. Pseudomonas infections of the eye usually follow an injury. They can cause ulcers of the cornea that may cause rapid tissue destruction and eventual blindness. The risk factors for pseudomonas eye infections include: wearing soft extended-wear contact lenses; using topical corticosteroid eye medications; being in a coma; having extensive burns; undergoing treatment in an ICU; and having a tracheostomy or endotracheal tube.
  • Urinary tract.  Urinary tract infections can be caused by catheterisation, medical instruments, and surgery.
  • Lung. Risk factors for P. aeruginosapneumonia include: cystic fibrosis; chronic lung disease; immunocompromised condition; being on antibiotic therapy or a respirator; and congestive heart failure. Patients with cystic fibrosis often develop pseudomonas infections as children and suffer recurrent attacks of pneumonia.
  • Skin and soft tissue. Even healthy persons can develop a pseudomonas skin rash following exposure to the bacterium in contaminated hot tubs, water parks, whirlpools, or spas. This skin disorder is called pseudomonas or "hot tub" folliculitis, and is often confused with chickenpox. Severe skin infection may occur in patients with P. aeruginosa bacteraemia. The bacterium is the second most common cause of burn wound infections in hospitalised patients.

Causes and symptoms

P. aeruginosa can be sudden and severe, or slow in onset and cause little pain. Risk factors for acquiring a pseudomonas infection include: having a serious illness; being hospitalised; undergoing an invasive procedure such as surgery; having a weakened immune system; and being treated with antibiotics that kill many different kinds of bacteria (broad-spectrum antibiotics).

 

Each of the infections listed above has its own set of symptoms. Pseudomonas bacteraemia resembles other bacteraemias, producing fever, tiredness, muscle pains, joint pains, and chills. Bone infections are marked by swelling, redness, and pain at the infected site and possibly fever. Pseudomonas meningitis causes fever, headache, irritability, and clouded consciousness. Ear infection is associated with pain, ear drainage, facial paralysis, and reduced hearing. Pseudomonas infections of the eye cause ulcers that may spread to cover the entire eye, pain, reduced vision, swelling of the eyelids, and pus accumulation within the eye.

 

P. aeruginosa pneumonia is marked by chills, fever, productive cough, difficult breathing, and blue-tinted skin. Patients with cystic fibrosis with pseudomonas lung infections experience coughing, decreased appetite, weight loss, tiredness, wheezing, rapid breathing, fever, blue-tinted skin, and abdominal enlargement. Skin infections can cause a range of symptoms from a mild rash to large bleeding ulcers. Symptoms of pseudomonas folliculitis include a red itchy rash, headache, dizziness, earache, sore eyes, nose, and throat, breast tenderness, and stomach pain. Pseudomonas wound infections may secrete a blue-green coloured fluid and have a fruity smell. Burn wound infections usually occur one to two weeks after the burn and cause discoloration of the burn scab, destruction of the tissue below the scab, early scab loss, bleeding, swelling, and a blue-green drainage.

 

Diagnosis

Diagnosis and treatment of pseudomonas infections can be performed by specialists in infectious disease.  Because P. aeruginosa is commonly found in hospitals, many patients carry the bacterium without having a full-blown infection.  Consequently, the mere presence of P. aeruginosa in patients does not constitute a diagnostic finding.  Cultures, however, can be easily done for test purposes.  The organism grows readily in laboratory media; results are usually available in two to three days.  Depending on the location of the infection, body fluids that can be tested for P. aeruginosa include blood, urine, cerebrospinal fluid, sputum, pus, and drainage from an infected ear or eye. X rays and other imaging techniques can be used to assess infections in deep organ tissues.

 

Treatment

 Medications

Because P. aeruginosa is commonly resistant to antibiotics, infections are usually treated with two antibiotics at once.  Pseudomonas infections may be treated with combinations of ceftazidime (Ceftaz, Fortraz, Tazicef), ciprofloxacin (Cipro), imipenem (Primaxin), gentamicin (Garamycin), tobramycin (Nebcin), ticarcillin-clavulanate (Timentin), or piperacillin-tazobactam (Zosyn).  Most antibiotics are administered intravenously or orally for two to six weeks. Treatment of an eye infection requires local application of antibiotic drops.

 

Surgery

Surgical treatment of pseudomonas infections is sometimes necessary to remove infected and damaged tissue. Surgery may be required for brain abscesses, eye infections, bone and joint infections, ear infections, heart infections, and wound infections. Infected wounds and burns may cause permanent damage requiring arm or leg amputation.

 

Prognosis

Most pseudomonas infections can be successfully treated with antibiotics and surgery. In immunocompromised persons, however, P. aeruginosa infections have a high mortality rate, particularly following bacteraemia or infections of the lower lung. Mortality rates range from 15 to 20% of patients with severe ear infections to 89% of patients with infections of the left side of the heart.

 

Prevention

Most hospitals have programs for the prevention of infections. Patients with cystic fibrosis may be given periodic doses of antibiotics to prevent episodes of pseudomonas pneumonia.

 

Minor skin infections can be prevented by avoiding hot tubs with cloudy water; avoiding public swimming pools at the end of the day; removing wet swimsuits as soon as possible; bathing after sharing a hot tub or using a public pool; cleaning hot tub filters every six weeks; and using appropriate amounts of chlorine in the water.

References:

'Code of Practice for the Prevention and Control of Healthcare Associated Infections in England' Department of Health 2006
National Patients Safety Agency 'Clean Your Hands Campaign'

'Cleaner Hospitals'  National Standards of Cleanliness for the NHS
NHS Estates 2001 Healthcare Cleaning Manual 2004

Reducing Risk of Infection From the use of Indwelling Devices
DOH 'Winning Ways Campaign' 2003
'Personal Protective Equipment ' Epic Project ' 2001

'Dress Code in Clinical Setting ' BMA February 2006 Report

The Safer Needles Network Initiative 'Safer Needles Now'

'Saving Lives' Department of Health 2005

Gale Encyclopedia of Medicine, December, 2002

Health Protection Agency

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

 (c) MRSA Action UK June 2008