FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

Posters

PUBLIC HEALTH & EPIDEMIOLOGY, OPAT & IPC – Poster Nos. 135-160

135
Preoperative MRSA screening in oncoplastic breast reconstruction

Abstract - 135

Poster 135

Preoperative MRSA screening in oncoplastic breast reconstruction

Yan Yu Tan, Jessica Chang, Kathryn Dickson, Mihir Chandarana, Soni Soumian, Sankaran Narayanan, Sekhar Marla
University Hospital of North Midlands, Stoke-on-Trent

Introduction: The importance of preoperative Methicillin-resistant Staphylococcus aureus (MRSA) screening has been well established. Guidelines recommend that all patients for oncoplastic breast reconstruction should be screened for MRSA and treated with topical suppression where positive. We present a closed loop audit on the rates of preoperative MRSA screening and treatment at our institution.

Methods: The first audit cycle included 138 patients who underwent therapeutic mammoplasty or skin- or nipple-sparing mastectomy with immediate implant reconstruction from January 2015 to January 2017. Electronic records were examined and data collected on presence and results of preoperative MRSA swabs, and details of any postoperative surgical site infections. Following this, we implemented a policy that all patients with a decision for oncoplastic surgery made at outpatient clinics should attend the pre-assessment unit the same day for MRSA swabs, the results of which should be checked by pre-assessment staff and escalated when required. The second audit cycle reviewed 35 patients from July to December 2017. Data was collected using the same methods and compared against the first audit cycle.

Results: In the first audit cycle, 8 patients (5.8%) had no record of preoperative MRSA swabs, of which 2 suffered infective complications but without evidence of postoperative MRSA infection. 1 of the 130 patients (0.8%) who had preoperative MRSA swabs had a positive result but received no treatment and subsequently suffered from postoperative MRSA surgical site infection. In the second audit cycle, all patients had preoperative MRSA screening, which were all negative.

Discussion: Implementing a same-day protocol for preoperative MRSA screening eliminates the delay between listing patients for surgery and preoperative assessment, and therefore reduces the potential for patients to fall between the cracks. This is a simple yet effective pathway that could be implemented in other breast units to improve rates of preoperative MRSA screening.

136
Analysis of vascular access device (VAD) infection incidence in NHS Lothian

Abstract - 136

Poster 136

Analysis of vascular access device (VAD) infection incidence in NHS Lothian

Omome Etomi1, Donald Inverarity2, Janathan Danial2, Luke Tysall2
1Croydon Univeristy Hospital Trust, Greater London. 2NHS Lothian, Edinburgh

Introduction: Many patients admitted to hospital will require a form of venous access. Vascular access devices (VAD) are associated with complications including infection. NHS Lothian aims to reduce VAD associated infection incidence within its patient population. Key interventions include the introduction of an educational package to promote best practice, mandating ANTT training across medical and nursing staff.

Methods: Positive blood culture results obtained from Hickman and PICC lines extracted from the laboratory information management system (Apex). Data analysed to establish the incidence of infective episodes after de-duplication of data. Further retrospective analysis performed to provide local descriptive epidemiology.

Results: We identified 127 total number of infectious episodes in the trust in 2017. The main burden of infection was based in the haematology and oncology services with 79% of all episodes managed by Adult and paediatric haematology/oncology combined. 40% of all isolated micro-organisms were Coagulase negative staphylococci, 23% were non-lactose fermenting gram negative bacilli, 14% were lactose fermenting. Of the yeasts isolated (6%) Candida glabrata was the most frequently isolated. There was an 8% all cause mortality at 30 days. The average length of hospital stay was 15 days (range 1 to 149 days) from a positive result taken from a VAD. A further VAD was required in 38% of all patients with an infectious episode. 41% of all lines removed within 24 hours of positive culture but of the lines not removed 14% cases had a relapse of infection with the same organism within 14 days of the initial positive result. Successful salvage of line was achieved in 37% of episodes.

Discussion: Host related factors such as immunocompromised status are significantly implicated given the high numbers of episodes from haematology/oncology, representing that this inherently high risk patient group are susceptible to significant morbidity and at high risk of poor outcomes. Furthermore, we were able to provide data to support targeted efforts within these clinical departments prior to rollout across the trust. Given that coagulase negative staphylococci were the most frequent isolates, promoting best practice at the points of insertion, line management, routine care and sampling are areas that can be targeted in the prevention of infection thereby addressing the healthcare provider-related factors contributing to the risk of developing VAD associated infection. A Post-intervention analysis planned to help assess the intervention’s impact. The importance of staff training cannot be underestimated and strategies of the trust to improve the care of VAD whilst promoting best practice are in line with the epic3 national guidelines for preventing Healthcare-Associated infections.

137
Infection control issues arising in the care of a patient with yellow fever: a UK hospital’s experience

Abstract - 137

Poster 137

Infection control issues arising in the care of a patient with yellow fever: a UK hospital’s experience

Charlotte Patterson, Michael Jacobs
Royal Free Hospital, London

Introduction: There is an ongoing outbreak of yellow fever in Brazil and other parts of Latin America and it remains endemic in many parts of Africa. Despite this, there had been no imported cases into the UK since the 1930s. As a result, clinical teams had very limited experience of dealing with infected patients in a resource rich setting as no staff currently working had seen yellow fever in the UK in their lifetimes. No guidance existed for the multiple issues that arose with regards to infection control in the care of our two patients with yellow fever and urgent advice was required. Here, we discuss infection control issues relating to the care of our patients with yellow fever.

Methods: We issued infection control advice addressing the concerns from staff involved in our patients’ care. This was done based on discussion between doctors at the Rare and Imported Pathogens Lab (RIPL), the Royal Free Hospital (RFH), the infection control team (ICT) and a literature search. The issues addressed first were those raised by staff. Subsequently a more thorough approach was taken and full guidance issued.

Results: One of the main concerns raised was vaccination and what to do in the event of an exposure incident. Fortunately no staff had a significant exposure event (such as a needlestick injury) during our patients’ care. Other issues that arose were dialysis equipment cleaning, laboratory handling of samples, after death care of the bodies and repatriation. Staff were advised that infection prevention rests fundamentally on the use of standard precautions to avoid sharps injuries and mucosal splashes. This applies to both the clinical and laboratory setting. The decision was made that the only staff who would require vaccination were those who may be involved in potential surgery. Other staff involved in care would not be vaccinated. Dialysis equipment was handled as per the hospital policy for hepatitis B patients. After death, the patients’ bodies was double bagged and repatriated as required.

Discussion: Formal guidelines are needed in the UK on infection control issues relating to the care of a patient with yellow fever. Despite the rarity of yellow fever in the UK, it is possible there will be more cases in the future. Clear guidance is essential for the safety of staff involved in the care of these patients.

138
The impact of an online microbiology referral service on departmental workload and on efficiency savings

Abstract - 138

Poster 138

The impact of an online microbiology referral service on departmental workload and on efficiency savings

Faisal Bin-Reza, Christi Atkinson, Justin Edwards, Mustafa Awad-el-kariem
Basildon & Thurrock University Hospital, Basildon

Introduction: To develop an automated intranet based referral service for clinical microbiology advice requests from hospital clinicians that provides a robust audit trail, and complies with information governance legislation

Methods: The trust intranet site was created using “concrete5 “, an Open Source

Content Management System (CMS). This allows users to create content using fixed pre-programmed blocks. The microbiology department utilised this technology to create an online referral form using a “form block”. This is presented in Figure 1.

Patient’s clinical details are mandatory fields, as the data remains within the Trust system, it complies with information governance requirements.

Once the form is submitted it generates an e-mail to a shared mailbox, which all microbiologists have access to. The output e-mail is presented in Figure 2. The form is for use during working hours only.

The microbiology online portal was launched on 26th September 2017. The service was advertised in the preceding two weeks using the ward pharmacists to distribute fliers on each ward.

Results: The average number of referrals via the secretaries dropped from 64 to 6.6 per week . On average each telephone referral would take 10 minutes of secretarial time.

Efficiency Savings in Secretarial Time:
Average number of calls reduction per week = 64-6.6 = 57.
Number of minutes saved = 57.4 x 10 = 574 (per week
Number of hours saved = 9 hours 34 minutes (per week)

This translated into increased productivity in other areas of the pathology secretaries workload, with clinic letter turnaround times improving.

Following the change, the average number of total referrals received (using figures from november 2017 onwards – once new system had been embedded) increased by 56.3% to 100.2 referrals per week.

The Microbiology online service has been demonstrated to be the most popular online submission tool within the trust intranet system using usage figures from the Trust’s intranet usage statistics.

Discussion: The switch to an electronic referral system has increased accessibility by clinical staff to the microbiology team, as demonstrated by the increase in requests. The consultant microbiologists were able to use their time more effectively and to establish better interactions with the various clinical teams delivering timely microbiology advice, with manageable interference with their other duties. Similar benefits have been demonstrated elsewhere with other disciplines online referral services(1). Furthermore, this has had a positive impact on anti-microbial stewardship. Ward pharmacists have utilised the system to query antibiotic prescriptions, which have led to interventions by the microbiologists. The subsequent conversations with clinical teams have led to increased contemporaneous teaching opportunities with junior medical staff regarding their anti-microbial prescribing. 

The use of the structured form has led to an improvement in the information provided prior to a discussion taking place, and facilitates referrers having a clear synopsis of the patient’s condition. This improves the efficacy of the subsequent conversation and reduces the transcription errors (when the referral came through the secretarial support team). This has too been the experience of other disciplines(2).

The improved use of secretarial time is particularly important with the current resource limitations within NHS structures presently. The automation of processes allow skill sets to be focused on priority tasks without a negative impact on service provision and improved efficiencies.

  1. The effect of an online referral system on referrals to bariatric surgery. Doumouras AG, Anvari S, Breau R, Anvari M, Hong D, Gmora S. Surg Endosc. 2017 Dec;31(12):5127-5134.
  2. A web-based referral system for neurosurgery–a solution to our problems? Choo MC, Thennakon S, Shapey J, Tolias CM. Br J Neurosurg. 2011 Jun;25(3):384-7.

139
Awareness and understanding amongst a university student population of a community pharmacy public health campaign in Scotland aimed at encouraging the responsible use of antibiotics

Abstract - 139

Poster 139

Awareness and understanding amongst a university student population of a community pharmacy public health campaign in Scotland aimed at encouraging the responsible use of antibiotics

Antonella P. Tonna1, Anita E. Weidmann1, Ina Donat1, Jacqueline Sneddon2, Alison Cockburn3, Derek Stewart1
1School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen. 2Health Improvement Scotland, Glasgow. 3NHS Lothian, Western General Hospital, Edinburgh

Introduction: Antimicrobial resistance (AMR) is acknowledged to be one of the most significant threats to patient safety globally. Educating the general public on the appropriate and responsible use of antibiotics is essential to address this issue. European Antibiotic Awareness Day (EAAD) is a European public health initiative held annually, aiming to raise awareness on how to use antibiotics in a responsible way ensuring their effectiveness for the future. NHS Scotland has supported EAAD with resources since 2009 and from 2015, the campaign included posters and leaflets targeting the public displayed in all community pharmacies.

Aim: To explore the awareness and understanding amongst a university student population of this national campaign.

Methods: A questionnaire was developed using the EAAD resource, a World Health Organization led study, and general literature on evaluation of communication campaigns. The final questionnaire comprised: demographics; exposure to media campaign; awareness, knowledge and understanding of campaign; and student recommendations on how the campaign may be enhanced. Question types were a combination of closed, 5-point Likert scales and open response items. The draft questionnaire was reviewed for face and content validity before piloting with academic and non-academic staff in the university of study. The final version of the questionnaire was formatted electronically to allow easy distribution and anonymity of all responses. All students in all courses (undergraduate and postgraduate) in one Scottish university were emailed a link to the questionnaire, followed by two reminders. Data were collected over a 5 week period from November 2017. Data were analysed using SPSS version 21. Relevant ethical approvals were in place prior to data collection.

Results: 1358 responses were received of which 1143 (84%) were resident in Scotland. 73% were undergraduate students, and 63% female. Responses were received from all nine university schools, with the highest number of respondents from schools relating to business studies (23%, n=315)l and pharmacy/life sciences (24%, n=320) . 52 respondents (4.5%) had heard of EAAD and were predominantly healthcare students. 31 (2.7%) were familiar with posters advertising safe use of antibiotics as part of the EAAD campaign; awareness was mainly through posters in the local pharmacy. A higher proportion of respondents (24%, n=287) from healthcare related courses agreed to a key message from the campaign to seek self-care advice at their local pharmacy if they had symptoms of coughs or colds. The majority of respondents who thought that antibiotics should always be prescribed when suffering from a cold were studying a non-healthcare related course (5.4%, n=72). 881 respondents (77%) were not aware that their behaviour in taking antibiotics may influence future effectiveness. Few respondents (7%, n=79) provided their opinion on more effective ways of raising public awareness of appropriate use of antibiotics with social media (3%, n=35) being the main choice.

Discussion: The research indicates that the majority of respondents were not aware of EAAD, had not seen the community pharmacy posters and had little understanding of why antimicrobial resistance is important. Those who had good awareness where more likely to be studying a healthcare related subject suggesting that AMR is covered within the curriculum or they are more receptive to health-related campaigns. The low response rate is a limitation of the study; however representation from all schools was obtained in the final cohort. Current approaches need to be revised for more effective dissemination of the EAAD message amongst the general public.

140
Once daily dosing of Tigecycline to facilitate outpatient parenteral antibiotic therapy (OPAT)

Abstract - 140

Poster 140

Once daily dosing of Tigecycline to facilitate outpatient parenteral antibiotic therapy (OPAT)

Hui Chin1, Stephen Hughes2, Katie Heard2, Nabeela Mughal2,3,4, Luke Moore2,3,4
1University College London Universities. 2Chelsea & Westminster NHS Hospitals, London. 3North West London Pathology at Imperial College Healthcare NHS Trust. 4National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London

Introduction: Tigecycline is increasingly being used to treat complicated skin and soft tissue infections [cSSTI], intra-abdominal infections [cIAI] and off-label bone and joint infections [BJI], typically where resistant organisms or polymicrobial infections are identified. The licensed dose for tigecycline is 100mg stat loading dose by intravenous administration, followed by 50mg every 12 hours. However, the long half-life (36 hours) and prolonged post-antibiotic effect of tigecycline suggest that once daily administration with appropriate dosed tigecycline should provide adequate antimicrobial activity in vivo. To investigate the impact of this dosing strategy, a retrospective observational study was undertaken in a single London Teaching hospital of all patients who had received once-daily intravenous tigecycline via an established OPAT service.

Methods: All adult patients that received once daily tigecycline (>3 days) between Jan-2016 and Jun-2018 were reviewed. Electronic patient records were used to identify patients treated and collect treatment related outcomes. Treatment outcomes were defined by the OPAT multidisciplinary team at the end of each individual treatment course and grouped as a)Complete cure (completed course of tigecycline in line with recognised international guidelines and/or resolution of infection), b)Treatment failure (premature cessation of tigecycline due to adverse effects or non-response of infection to antibiotic) and c)Failure due to disease progression (disease progressed which required alternative aggressive treatment although there was response to infection)

Results: A total of 18 cases among 17 unique patients were identified. Female patients were more common (56%), average age was 62 years (range 44-85 years) and a high prevalence of patients with a documented previous antibiotic allergy (42%) were included. Average treatment duration was 36 days with a total of 648 bed-days saved by the OPAT service.

Overall treatment ‘complete cure’ was 83% in this cohort. A high treatment success was evident across multiple clinical indications (BJI / cSSTI 5 of 6 cases [83%], IAI 5 of 6 cases [83%], gynaecological / urological infections 2 of 3 [67%] and hepatobiliary infections 3 of 3 cases [100%]). Enterobacteriales (n=13), Enterococcus spp. (n=6) and S. aureus (n=4) were the most commonly implicated pathogens. Polymicrobial infections were present in the majority of cases (56%). A high proportion of resistant pathogens were isolated, including ESBL/AmpC (10 patients) & NDM (1 patient) Enterobacteriales, and glycopeptide resistant Enterococcus spp. (4 patients).

Complications of treatment include nausea and vomiting (22% of cases; none requiring treatment withdrawal). A delayed rash (five weeks into therapy) developed in one patient but this was not re-challenged and persisted with subsequent beta-lactam therapy and may not relate to the tigecycline therapy. Transient increases in amylase were evident in two patients, but neither patient required withdrawal of treatment as amylase did not exceed the two-fold lab increase (>180iu/L) or develop any signs of drug-related pancreatitis.

Discussion: In this study, tigecycline administered once daily facilitated out-patient treatment with a high rates of treatment success (83%). The main adverse events related to the once daily administration was nausea/vomiting (22%), comparable to what was reported in the product’s datasheet (21%), and was managed by antiemetic or alteration of infusion speeds. No pancreatic related complications were identified.

With extensive antimicrobial coverage, including MRSA, VRE and ESBL/CRO coverage, tigecycline provides clinicians with a valuable option for treatment of chronic infections where oral options are unavailable or first-line therapy is precluded by allergy or drug-resistance.

141
Transmission of a new Klebsiella pneumoniae CG 258 with dual carbapenemases (KPC and OXA48) via flexible gastroscope

Abstract - 141

Poster 141

Transmission of a new Klebsiella pneumoniae CG 258 with dual carbapenemases (KPC and OXA48) via flexible gastroscope

Surabhi Taori, Jeevani Kumarage, Kirstin Khonyongwa
King’s College Hospital NHS Foundation Trust, London

Introduction: A new strain of Klebsiella pneumoniae with dual carbapenemases KPC and OXA 48 (KP-DG) belonging to ST 512 (CG 258) panresistant to aminoglycosides and resistant to ceftazidime–avibactam has been reported recently at our Trust. An outbreak of this organism in a surgical intensive care unit (ITU) was brought under control in 2017 by strict control measures, regular screening and removal of a persistently colonised sink. We report further transmission of this strain into another ITU via a contaminated flexible gastroscope and control measure to halt further transmission.

Methods: KP-DG in bronchial washings and blood cultures of a patient in a ward unrelated to the original outbreak triggered an investigation. A flexible gastroscope was found to be the common factor between a previously colonised patient and the new case. All contacts of the gastroscope were screened. Gastroscope was tested for colonisation. The Trust implements routine screening for CPE colonisation in all intensive care units and high risk areas

Results: The Gastroscope was found coloniosed with KP-DG. Audits of gastroscopy revealed breaches in best practice. Onward ward transmission was detected as well. Three patients were affected of which two developed bacteraemia. Routine screening helped identify cases early on. Hydrogen peroxide vapour decontamination, strict IPC precautions including mandatory isolation rooms for colonised patients, high level awareness and discontinuation of the gastroscope helped prevent further spread

Discussion: Rapid transmission of the organism and the inherent limitations of high level decontamination of flexible endoscopes remain a concern. Multidrug resistant CPE, virulent sequence types such as CG 258 and flexible endoscopy associated infections are on the rise. There is an urgent need to develop methods for sterilisation of flexible endoscopes and encourage their widespread use.

142
Cost of controlling a Candida auris outbreak in the UK

Abstract - 142

Poster 142

Cost of controlling a Candida auris outbreak in the UK

Surabhi Taori, Iain Hayden, Kirstin Khonyongwa, Nergish Desai
King’s College Hospital NHS Foundation Trust, London

Introduction: An outbreak of Candida auris occurred between July 2016 and February 2017 at a tertiary care centre in London. Key interventions included regular screening, strict isolation and increased frequency of environmental decontamination including hydrogen peroxide vapour, creating high level of awareness by teaching sessions, regular outbreak meeings at ward and administrative level and replacing reusable equipment with disposable variants, chlorhexidine biopatches for IV lines. The cost of controlling an outbreak of Candida auris is not yet reported in literature.

Methods: We calculated the cost of the outbreak for factors including additional length of stay, antifungal treatment, cleaning and econtamination, consumables, patient screening and staff time. Loss of income (an indirect cost) due to cancelled procedures could not be calculated. Actual and opportunity costs were defined. Cost to control maintain control after the outbreak was over were calculated separately.

Results: Amounts are in British Pound sterling.

Costs for controlling the outbreak
Additional length of stay amounted to £510,340.00 (actual)
Screening patients at risk £225,632.00 (actual and ooportunity)
Staff costs – MDT meetings, Medical Microbiologists; IPCN; and Surveillance time £97,771.53 (actual and opportunity)
Antifungal treatment of infected patients £74,346.00 (actual)
Additional cleaning – Hydrogen peroxide fogging £5,085.00 (opportunity)
Additional disposable consumables £16,908.59 (actual)

Total £930,083.12

Cost for maintaining control ( per month)
Screening samples £52,712.00 (actual and opportunity)
Additional disposable Consumables £2,550.00 (actual)

Total £55,262.00

Discussion: An outbreak of Candida auris lasting 8 months can cost more than £1 million to control. Sustaining control can cost up to 55,000 per month but can vary with the screening strategy employed.

143
Avoiding readmissions from OPAT: how old is too old?

Abstract - 143

Poster 143

Avoiding readmissions from OPAT: how old is too old?

Nicholas Norton, Elinor Moore, Sian Coggle
Addenbrooke’s Hospital, Cambridge

Introduction: In response to increased pressure on inpatient beds there has been an expansion in Outpatient Parenteral Antibiotic Therapy (OPAT) services. Outpatient treatment is an attractive option, particularly for patients with bone and joint infections where antimicrobial resistance may mandate 6 weeks or more of treatment with an intravenous agent. Readmission is an acknowledged risk of OPAT treatment and places further demand on resources as well as distress to patients and relatives. Careful selection of patients is therefore required to reduce readmission rates.

Methods: To determine whether age is a significant risk factor for readmission we carried out a retrospective analysis of the electronic records of all 2539 patients who had received OPAT at Addenbrooke’s hospital in the years 2012 to 2017. The risk of readmission per patient day of OPAT was calculated for each age group.

Results: In total there were 43175 patient days of OPAT in the period 2012-2017. 272 patient episodes ended with readmission corresponding to a readmission rate of 10.7%. Analysis of the distribution of age among patients readmitted versus all patients showed a skew toward older patients compared to all patients (median age 65 vs 60, p=0.00002, Mann-Whitney U test). The overall rate of readmission per patient day was 0.77%. Examination of readmission rates per age group showed increasing risk of admission with age; patients aged 90 and above had a markedly increased risk of readmission, 2.3% per day on OPAT, approximating to an 96% chance of readmission during a 6 week course of OPAT.

Discussion: Overall our data show readmission rates similar to patients managed in other ambulatory settings. The high rate of readmission in patients over the age of 90 suggests we should be cautious in offering OPAT treatment to patients in this age group. In particular it is noteworthy that patients who require prolonged courses of IV treatment in this age group have a risk of readmission approaching 100%. This information is of value not only in understanding how to meet the needs of older patients within an OPAT service but also in communicating with patients and carers to manage expectations.

144
Assessing the safety profile and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) for upper limb cellulitis in a tertiary referral Plastic Surgery Centre

Abstract - 144

Poster 144

Assessing the safety profile and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) for upper limb cellulitis in a tertiary referral Plastic Surgery Centre

Tanmay Kanitkar1,2, Katie Heard1, Dinesh Aggarwal2,1, Nabeela Mughal3,2,1, Luke Moore3,2,1
1Chelsea & Westminster NHS Foundation Trust, London. 2Imperial College Healthcare NHS Trust, London. 3Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London

Introduction: Outpatient parenteral anti-microbial therapy for lower limb cellulitis is well recognised and established. The safety, utility and cost-effectiveness of this same approach for upper limb cellulitis needs to be evaluated. In the context of a tertiary referral upper limb plastic surgery centre in central London, we conducted a retrospective observational study of patients referred to an Ambulatory OPAT service for anti-microbial management of their upper limb cellulitis.

Methods: A retrospective analysis of the upper limb cellulitis patient cohort referred to an ambulatory care service for OPAT was undertaken. Patients accessing this service for upper limb cellulitis specifically were identified; the antibiotic choice and duration of treatment, the efficacy and safety of treatment (30-day re-admission, 30-day and 90-day mortality) were identified. The total cost of running the OPAT service and equivalent inpatient cost was calculated using actual figures.

Results: During the study period (01 Jan 2017 to 31 Dec 2017), 20 patients were referred to ambulatory care for further management of upper limb cellulitis, 18 of whom were treated via the OPAT service (90%). Two patients (10%) were discharged on oral antimicrobials and did not require OPAT. The mean age of this cohort was 49 years, comprised of 12 male (60%) and eight female patients (40%).

The mean white cell count (x10^9/L) on presentation was 11.8 (range 3.9-20.8) and CRP (mg/L) 67.9 (range 0.8-376.3). End of therapy inflammatory markers were not universally captured, as clinical response (resolution of pain, erythema, oedema) was used to assess need for continued intravenous antibiotic therapy. No patients underwent imaging outside of four trauma patients. Only one patient had a causative organism identified (Staphylococcus aureus), the others remaining culture negative.

The mean total duration of antimicrobials after assessment in the emergency department was 12.1 days (range 7-37), with mean 2.7 days given via ambulatory care (range 0-8), and then follow on oral antimicrobials for mean 8.1 days (range 4-28). 18/18 patients who underwent OPAT received intravenous ceftriaxone as the choice of antimicrobial agent. As follow on oral regimes, 13/20 patients (65%) received flucloxacillin, and 3/20 (15%) received clindamycin, with 2/20 (10%) receiving co-amoxiclav. Four patients (20%) had received preceding oral antimicrobials from primary care. No patients died (at 30 or 90 days) or were re-admitted. One patient had a possible allergic reaction to flucloxacillin, which was safely managed without readmission and a change of antimicrobial agent.

The OPAT service for this cohort costs 17% (£1845) of the equivalent inpatient cost (£10600). Additional earnings for doctor-led reviews of OPAT patients accrued £9500.

Discussion: Ambulatory outpatient parenteral antimicrobial therapy is a safe and cost-effective mechanism to administer antimicrobials for those patients with upper limb cellulitis who had clinically failed preceding oral antimicrobials or in whom the initial attending physician had decided parenteral antimicrobials were indicated. No significant adverse events were identified in this study cohort. Our economic evaluation suggests this approach is capable of achieving significant cost-savings, through improved use of inpatient bed-use, patient-flow and additional financial reward for ambulatory care services.

However, it is apparent there is a need for clearer pathways for ambulatory patients with upper limb cellulitis. Specifically, there should be capture of inflammatory markers at the start and the end of therapy, an attempt at microbiological diagnosis made (may be limited in those with no overt skin breaks), and a risk stratification needs to be developed to identify those in whom imaging would aid surgical management. Antimicrobial management including choice, dose and duration needs to be protocoled. As a result of this observational study a policy is being developed to address these issues and improve patient care.

145
Impact and efficiency of microbiologist-attendance at multidisciplinary team meetings and dedicated antimicrobial advice ward rounds within a hospital antimicrobial stewardship programme

Abstract - 145

Poster 145

Impact and efficiency of microbiologist-attendance at multidisciplinary team meetings and dedicated antimicrobial advice ward rounds within a hospital antimicrobial stewardship programme

Ashley Whittington, Surjo De, Preet Panesar, Stephen Morris-Jones
University College London Hospitals

Introduction: Antimicrobial Stewardship (AMS) programs comprise multiple activities however it is unclear which of these are the most effective and efficient. Two well established components of our hospital’s AMS program are attendance of surgical Multidisciplinary Team meetings (MDTs) by infection specialists and a weekly ward round (WR) of surgical inpatients receiving antimicrobials. We wished to determine whether the WR or the MDT attendance was a more effective and time efficient AMS intervention. We then introduced the most effective activity onto a surgical ward that did not currently have a regular infection liaison service and assessed its effectiveness. We hypothesised that MDT attendance would be more time efficient and lead to more interventions being enacted by the patients’ clinical team as MDTs involve direct discussion between infection specialists and the senior surgical team.

Methods: As part of our 665 bed teaching hospitals’ established AMS activity a consultant clinical microbiologist attends a weekly upper GI Surgical MDT giving advice as requested and performs a weekly WR of a 62 bed mixed surgical specialty (mainly GI and hepatobiliary) ward. The WR comprises a notes review of all patients receiving antimicrobials with recommendations documented in the notes. Bedside patient reviews and discussion with the patient’s surgical team is performed at the discretion of the consultant. Over a 3 month period an independent observer recorded the interventions advised on the WR and MDT. Notes were later reviewed to ascertain if interventions were subsequently enacted. An intervention was defined broadly as any change to antimicrobial prescription, advice to obtain further cultures, perform further imaging and finally if an infection control recommendation was made. Following this a weekly identical WR was then introduced on the Head and Neck/ENT surgical ward which previously did not have direct AMS intervention.

Results: Fifteen patients were reviewed in MDT with interventions advised in 11 (73%). Of 106 patients reviewed on the WR a similar proportion, 81 of 106 (76%) had interventions advised. MDT interventions were enacted less frequently with 8 of 11 (73%) interventions enacted verses 61 of 81 (81%) on the WR (p=0.03). Reviews in both settings took a similar amount of clinical time averaging 9.1 mins and 9.2 mins for the MDT and WR respectively. Thus the WR was more efficient with each enacted intervention taking 14.7 mins versus 17.1 mins for the MDT. The 61 interventions enacted on the WR included 20 cessations of antimicrobials, 26 course length reductions and 8 iv to oral switches. A total reduction of 185 days of antibiotic administration was advised with 147 day reduction achieved. The most common intervention not enacted was advice to stop antibiotics, 9 of 19 (47%) of non enacted interventions. As the WR was a more effective intervention we introduced a new identical WR to Head and Neck (H&N) surgery. The H&N WR had a trend towards interventions being more commonly recommended (36 interventions in 41 patients reviewed, p=0.12) however interventions were less frequently enacted (20 of 36 interventions enacted, p=0.03).

Discussion: An infection specialist led WR of surgical patients receiving antimicrobials leads to a significant number of successful patient interventions, reducing antimicrobial usage. Attendance at MDT meetings was a less time efficient AMS activity as recommendations were less commonly followed despite MDTs involving discussion and review with senior decision making clinicians. However, the H&N WR led to interventions which were less frequently enacted. This suggests long established AMS activities are more effective possibly as closer working relationships between infection and surgical specialities are built over time.

146
Rapid access Infectious Diseases Clinic at the Royal Victoria Infirmary Hospital, Newcastle

Abstract - 146

Poster 146

Rapid access Infectious Diseases Clinic at the Royal Victoria Infirmary Hospital, Newcastle

Victoria Parris, Ewan Hunter
Royal Victoria Infirmary, Newcastle

Introduction: The Department of Infection and Tropical Medicine at the Royal Victoria Infirmary (RVI), Newcastle runs a registrar led rapid access infectious diseases clinic (RAID). This enables urgent (typically same day) review of patients with suspected or confirmed infectious diseases who are not expected to require inpatient admission but can not wait until routine outpatient infectious diseases (ID) review. Every weekday afternoon there are three appointments into which patients can be booked; referrals are accepted via telephone by the on-call ID registrar.

Methods: A retrospective data analysis of patients attending RAID between 1st January and 30th April 2018 was undertaken to understand clinic utilisation and patient flow through the service.

Results: 87 patients were seen in 104 appointments, with 55.9% of all available clinic appointments used. Median patient age was 33 years (IQR 20.5, range 18-88), 58.6% were male. The majority of referrals were from General Practitioners (GPs) (25.3%), followed by the RVI emergency department (ED) (15%) and patients discharged from the RVI ID ward requiring early review (15%). 9 patients (10.3%) self-referred, all of whom were already under active ID follow up. Overall, 45 patients (51.7%) were referred from sources within the Trust and 38 (43.7%) were external referrals.

Among the 87 patients, 29 (33.3%) were returned travellers, and 38 (43.7%) were already known to the ID service. There was a wide variety of reason for referral, most frequently fever (29.8%), and requirement for a blood test (16%). Of those referred for a blood test, 35.7% (5 of 14) required a repeat malaria film. 2 patients were reviewed as they felt unwell after discharge from the RVI ID ward. 

Among all 104 appointments, 46.1% had further follow up in a consultant ID clinic arranged, 36.5% were discharge from the ID service, 8.7% had further RAID clinic follow up, and 8.7% were admitted to the ID ward. For the 14 patients that were seen more than once in RAID clinic, 70.6% (12 of 17) of repeat appointments was for a blood test, of which 58.3% (7 of 12) was for a malaria film.

Discussion: The RAID model enables early assessment, diagnosis and treatment by an infection specialist. Demand for specialist opinion is highlighted by a third of referrals being unwell returned travellers. Care is streamlined; direct referral from GPs avoids presentation to the ED or Acute Medical Unit, referrals from ED results in transfer of care to an appropriate provider, patients already known to ID avoid re-routing via other services, and patients requiring inpatient care are admitted to the most appropriate setting. Use of RAID for early re-assessment of patients discharged from the ID ward supports earlier ward discharge.

Blood testing represented a large proportion of RAID use: 16% of referrals, and 70.6% of repeat RAID appointments. Opportunities for task shifting could improve use of clinic time.

147
Spatial dynamics of ground-level malaria prevention; tackling severe paediatric malaria in Sierra Leone through motorcycle mapping and community empowerment

Abstract - 147

Poster 147

Spatial dynamics of ground-level malaria prevention; tackling severe paediatric malaria in Sierra Leone through motorcycle mapping and community empowerment

Edward Monk1,2, Ka-Ping Yee3, Rupert Allan3, Ivan Gayton3
1Manchester University NHS Foundation Trust. 2Nixon Memorial Methodist Hospital, Segbwema, Sierra Leone, 3Missing Maps, London

Introduction: Malaria is a leading cause of paediatric death in Sierra Leone. Rurally, bed net distribution is advertised through vehicle-mounted announcements with ticket distribution at village level. These tickets are subsequently exchanged in person for bed nets at Primary Health Units (PHUs) during ‘Wel Bodi’ week: the final destination of bed net distribution is unrecorded. Records at Nixon Memorial Methodist Hospital in Segbwema, Njaluahun chiefdom, Kailahun district, Sierra Leone, were hand-searched in May 2017 and rarely resulted in reliable inpatient origin or primary diagnosis documentation. We report the implementation of an innovative public health tool from July 2017, designed to serve the staff of Nixon Memorial Methodist Hospital and the students of its affiliated nursing school, and example its utilisation through the design of a malaria primary prevention project throughout Njaluahun chiefdom that is currently in progress.

Methods: Local community members were recruited and trained to survey the 1,950 villages in the 11 chiefdoms served by Nixon Memorial Methodist Hospital, using OpenDataKit and OsmAnd. Surveyors were paired with local motorcycle drivers to reach all villages identified by satellite imaging and ascertain each community’s definition of their village’s name/names (including alternative spellings), district, chiefdom and section. The main outcomes were a comprehensive map (OpenStreetMap) and ‘Gazetteer’ production to ascertain patient origin on hospital arrival through a step-wise record of patient origin, linked to true GPS coordinates. Improved coding was addressed by implementing a specially designed ‘stamp’, added to clinical notes on patient arrival by the hospital registrar in order to 1) focus the clinician’s attention to identify a primary diagnosis in relation to the patient’s presentation, 2) provide a standardised area to record the primary diagnosis and 3) allow a platform for the hospital registrar to question illegible or ambiguous entries.

Ongoing: Bed net distribution will be mapped comprehensively from points of distribution in June 2019, using a Gazetteer (identical to that currently used in the hospital) at each of the 14 PHUs within Njaluahun chiefdom. This will allow village-level comparisons between severe malaria incidence in under-fives (currently being audited at Nixon Memorial Methodist Hospital) and the proportion of the under-five population receiving nets in the 134 villages of Njaluahun chiefdom, calculated from local surveying and satellite counts of dwellings/population-projections.

Results: Twelve months after initial implementation, patient origin is continuing to be recorded reliably and sustainably with ongoing stamp record of primary diagnosis and minimal external influence. Villages with multiple names, or the same name are being successfully coded to GPS coordinates. A ‘dashboard’ has been designed and implemented to visualise diagnoses both spatially and temporally in a manner accessible to end-users (hospital staff and nursing school students). The initial mapping effort has also provided a proof of concept, allowing the development of a methodology ´playbook´ of workflows and product-modelling. This has been utilised in further humanitarian efforts in both Tanzania and Uganda.

Discussion: The hospital´s nursing school (with a student-body of 300) continues to provide community outreach services, including drives combating malaria, across Njaluahun chiefdom. Recording village-level bed net distribution and paediatric severe malaria caseload offers this organisation, participating in community outreach, a tailored dataset to ask “why is this village having paediatric cases of severe malaria”. We intend for this dataset to not only direct community outreach project planning but also stimulate public health and primary prevention discussion within the nursing school student body, strengthening understanding that can be taken with community nurse graduates as they relocate within the country for their future roles. In addition to this, multiple sub-Saharan communities are benefiting from our proof of concept, utilising Android technology now widely available across the continent.

148
Hospital-associated influenza transmission and its management in a UK teaching hospital

Abstract - 148

Poster 148

Hospital-associated influenza transmission and its management in a UK teaching hospital

Ben Warne1, Mark Reacher2, Lucy Reeve2, Iain Roddick2, David Williams3, Monica Galiano3, Nicholas Jones1, Kyriaki Ranellou1, Silvana Christou1, Callum Wright1, Ashley Popay2, Clare Sander1, Maria Zambon3, Hamid Jalal1
1Cambridge University Hospitals NHS Foundation Trust. 2Field Service, National Infection Service, Public Health England, Cambridge. 3National Infection Service, Public Health England, Colindale, London

Introduction: Seasonal influenza is a major cause of morbidity. However, its impact and potential for transmission in secondary care are poorly understood. In this study we combine clinical, epidemiological and genomic data to investigate the burden of influenza-associated morbidity and the extent of transmission within a UK teaching hospital. We also describe changes in clinical practice implemented in response to suspected nosocomial outbreaks.

Methods: All patients attending Cambridge University Hospitals with influenza A detected by PCR between August 2016-April 2017 were included. An epidemiological investigation was conducted in parallel with genetic analysis of samples to develop independent evidence of transmission pathways. Algorithms were developed to interrogate ward movement data to detect co-location of a potentially infectious patient with a susceptible one. A ward-time cluster was defined as a sequence of two or more patients on the same ward where there was an overlap of the intervals of infectiousness and of susceptibility. Genome sequencing was attempted using RNA extracted directly from samples. Whole and partial genome sequences were included in phylogenetic analyses to infer transmission networks. Ward movement, prescribing and laboratory data were derived from electronic records for all confirmed influenza cases for 2016-17 and compared to a second cohort from August 2017-May 2018. Further clinical data were manually abstracted, including judgement of whether infection was community- or hospital-acquired based on symptom duration and length of stay at time of swabbing.

Results: In 2016-17 influenza A was diagnosed in 326 patients, median age 76 years. Of these, 313 (96.0%) were admitted to hospital; 98/313 (31.3%) infections were acquired during the admission. All-cause mortality during the admission was 10.2%; 11/32 deaths were associated with hospital-acquired influenza.

The majority of inpatients (58.8%) were linked in 33 ward-time clusters. Whole genome sequences were available for 180/313 samples and partial genomes for a further 29 samples. Using whole genomes, 64.4% of isolates were phylogenetically linked within 22 putative clusters; this rose to 73.8% within 31 clusters using partial genomes. Combining epidemiologic and genomic data demonstrated that 43/61 (70.5%) hospital-acquired cases fell within 7 transmission networks (range 2-22 patients) across 10 wards. Additionally, we identified clusters imported into hospital, including transmission in 3 outpatient units and 3 care homes.

In response to influenza transmission, programmes of staff education and reviews of influenza management were undertaken prior to the 2017-18 winter, when 763 further influenza cases were identified (48.9% influenza A, 51.1% influenza B). Isolation of patients on admission rose from 50% of influenza cases in 2016-17 to 79% in 2017-18. Median time from admission to sample collection for community-acquired cases fell from 9.7 to 5.2 hours. Median time from admission to first antiviral dose fell from 45.2 to 10.1 hours.

Discussion: We have demonstrated that influenza is an important but poorly recognised cause of morbidity and mortality in secondary care. A substantial proportion of influenza cases were acquired during the patient admission and are therefore likely to be amenable to changes in infection control measures. We have demonstrated that better use of existing resources can lead to considerable improvement in patient management.

Combining genomic and epidemiologic approaches provides a powerful and tractable tool for assessing influenza transmission, a critical step in guiding infection control practices. However, these approaches also highlight the complexity of transmission: their individual use can over-estimate patient clustering, while combined they reveal gaps in networks, which may represent asymptomatic or untested patients, healthcare workers and hospital visitors.

Although we have studied a single centre, similar transmission is likely to occur throughout secondary care. Responding to this problem requires the engagement of many disciplines, utilising a range of approaches to better understand, manage and prevent transmission.

149
Audit of the effectiveness of clinical advice provided for patients with bloodstream infection at a District General Hospital

Abstract - 149

Poster 149

Audit of the effectiveness of clinical advice provided for patients with bloodstream infection at a District General Hospital

Martha Purcell1, Bruce Stewart1,2
1Surrey and Sussex Healthcare NHS Trust, Redhill. 2Frontier Pathology NHS Partnership, Redhill

Introduction: Bloodstream infection is a serious medical condition. Patients require prompt assessment, including taking of blood cultures and treatment with appropriate antibiotics. Blood culture results are communicated by telephone to clinical staff on the wards daily by the microbiology consultant or registrar. Microbiology advice is important as it guides antibiotic treatment and can provide valuable information concerning the source of the patient’s infection. Prompt and accurate advice from microbiology should result in optimisation of the patient’s treatment and outcome. It should also result in narrowing the spectrum of antibiotic treatment, thereby promoting better antimicrobial stewardship. The content and quality of the information provided to clinical teams are rarely assessed. Additionally, it is unclear how the advice provided is documented, interpreted and enacted by clinical teams on the wards. 

Aims:

1) To assess the content and clinical effectiveness of microbiology advice provided for patients with bloodstream infections. 

2) To assess the documentation and clinical effectiveness of action taken on the wards in response to the microbiology advice given. 

3) To identify areas for improvement in order to develop a set of quality standards for improved clinical practices in relation to the principles of managing sepsis and good antimicrobial prescribing. 

Methods: Electronic microbiology records and clinical case notes for positive blood culture results over a 1-month period were reviewed.

Results:

  • 116 de-duplicated consecutive cases of positive blood culture over a 1-month period were studied. 54 cultures yielded significant organisms requiring anti-microbial treatment and 43 of these initial Gram films were phoned to the clinical team.
  • 53% of initial positive results (Gram film) were communicated on the day of positivity, but more accurate assessment of how quickly a positive result was communicated (in hours) was not possible with available LIMS data. 
  • 3% of those positive results that were not communicated on the day of positivity were later found to be clinically relevant. 
  • 77% of telephoned initial positive results were correctly documented by the clinical teams in the case-notes.
  • In 42% of significant cases, empirical antibiotic choice (selected by Trust antibiotic policy) was appropriate on the basis of the confirmed culture result. 
  • For cases where empirical antibiotic choice was not effective, microbiology advice to optimise therapy was provided in 65% before ID and sensitivities were available and in 30% after final results were confirmed. 
  • Only 75% of opportunities to narrow the spectrum of treatment were taken.
  • Where antibiotic management optimisation was advised by microbiology, the clinical teams documented and carried out the required change in 80%. 
  • 11% of patients were physically reviewed by the microbiology service to ensure a definitive treatment plan was documented in the notes. 

Discussion:

  • The Trust’s current antibiotic policy may not provide effective treatment guidance for the empirical management of patients with sepsis/suspected bloodstream infection – this requires review.
  • While telephone advice did optimise therapeutic choice in a large proportion, there were missed opportunities for communicating clinically relevant initial results and narrowing treatment regimens. 
  • Telephone advice including communication of results and optimisation of therapeutic choice did not always translate into documented optimisation of management in all cases. 
  • Microbiology ward review of a greater proportion of cases would raise the proportion of patients with a documented definitive treatment plan. 

Quality Improvement Actions:

1) Define a care pathway and set of quality standards for optimal communication, documentation, microbiology review and treatment planning. 

2) Agree an improvement target for narrowing of treatment regimens. 

3) Further work is needed to optimise the time taken between the availability of positive results in laboratory and the communication of results to the clinical team in order to optimise management of patients with bloodstream infection.

150
The impact of the Antimicrobial Stewardship Team on facilitating discharge via referral to the outpatient parenteral antimicrobial therapy (OPAT) service

Abstract - 150

Poster 150

The impact of the Antimicrobial Stewardship Team on facilitating discharge via referral to the outpatient parenteral antimicrobial therapy (OPAT) service

Gagandeep Gohlar
Farhana Butt, London

Introduction: The antimicrobial stewardship (AMS) team play a significant role in the promotion of safe and effective use of antimicrobial therapies in secondary care. The AMS team also play an active role in identifying and reviewing patients that can be managed in the ambulatory care setting via the outpatient parenteral antimicrobial therapies (OPAT) pathway to facilitate early discharge and reduce length of stay (LOS). Traditional OPAT referral pathways include Accident & Emergency (A&E) to avoid admissions to inpatient wards.

OPAT treatments are limited to once daily regimens, administered by intravenous infusions or continuous elastomeric infusion pumps. Commonly used agents within the OPAT setting include ceftriaxone, ertapenem, teicoplanin, and tazocin or flucloxacillin via a continuous infusion pump.

The aim of this single centre study was to focus on the impact of the AMS team on the OPAT service in facilitating early discharge, reducing LOS and bed-day savings for the trust.

Methods: Intervention data for interventions made by the AMS team was collected at the single centre site, West Middlesex University Hospital (WMUH) from April 2017 to July 2018. Prospective OPAT-related intervention data was collected using an electronic intervention data collection tool on AMS ward rounds. Information collected included patient age, gender, ward, responsible team, antimicrobial(s) prescribed and route of administration, indication for therapy, microbiological cultures and clinical advice provided by the AMS team. Patients were followed up in the weekly OPAT multi-disciplinary meeting following discharge, to review and monitor response to therapy. Patients that were not discharged following OPAT review were followed up retrospectively to identify reasons for non-ambulation as well as to de-escalate therapy regimens to narrow spectrum antimicrobials where possible.

Results: During the timeframe for audit, a total of 1098 AMS interventions were made, of which 57 were OPAT reviews (5%). Of the 57 patients considered for OPAT, 37 patients (65%) were successfully ambulated in the OPAT setting. The remaining 20 patients (35%) completed their full treatment course on the ward and were de-escalated to narrower agents where possible (80%), were switched to appropriate oral therapies (15%) or were palliated (5%). 38% of patients were ambulated using a continuous infusion pump to deliver conventional multiple daily dosing regimens over 24 hours. The average age of referred patients was 60 years old (range 23 – 89 years) and 70% were male.

Referral to the OPAT service by the AMS team facilitated discharge for 37 patients, resulting in 608 bed days saved. An additional 245 bed days could have been saved based on anticipated treatment durations, if the remaining 16 patients that were suitable for intravenous therapy had been discharged via OPAT.

Deep seated infections requiring prolonged intravenous therapy included collections (n=4), hepato-biliary (n=4), infective endocarditis (n=2), osteomyelitis (n=7) and CNS infections (n=3). One patient failed therapy for a liver abscess and was re-admitted for drainage, prior to re-ambulation. There was also a high incidence of resistant organisms grown in cultures, including MRSA (n=3) and ESBL E.coli (n=6), necessitating intravenous therapy options only. 30 of the 37 patients reviewed had positive microbiology results to target therapy.

Discussion: The impact of this single centre review demonstrates the important role of the AMS team in identifying and preparing patients for OPAT via the ambulatory care setting. Patient discharge was facilitated using non-conventional administration methods such as continuous infusion elastomeric pumps in place of multiple daily dosing regimens where targeted therapy was warranted in infections requiring prolonged therapy. The AMS team contributed to the treatment of infections requiring prolonged treatment durations in an outpatient setting, leading to a reduced LOS and expected risks of acquiring healthcare associated infections (HAIs), and ultimately improving patient experience and quality of life.

151
Infection control lessons learnt due to cross infection with an extremely-drug resistant Acinetobacter in a modern intensive care unit

Abstract - 151

Poster 151

Infection control lessons learnt due to cross infection with an extremely-drug resistant Acinetobacter in a modern intensive care unit

Kirsten MacGregor1, Fiona Hammond2, Samantha Matthews2, Elizabeth Darley1
1Severn Pathology Infection Sciences, Bristol. 2Infection Prevention and Control, North Bristol NHS Trust

Introduction: North Bristol NHS Trust (NBT) is a 1000 bed hospital with referral centres for trauma and burns and has a 4 ward, 48-bed ICU with each bed in a single room which was opened in 2016. In 2018 cross infection of a extremely drug resistant strain of Acinetobacter baumanii (XDR-AB) occurred between 2 patients necessitating closure of two intensive care unit (ICU) wards.

Extremely resistant organisms are not endemic at NBT but are identified on infection screens of patients returning to NBT from hospitals abroad. Previously there has been no case of cross infection of an extremely drug resistant Gram-negative organism between patients in NBT.

Methods: We describe the clinical setting and management of this outbreak, as well as the subsequent reflections and clinical lessons learnt, from the perspective of the trust’s medical microbiology and infection prevention and control teams.

Results: Patient A was transferred from a Greek ICU to NBT ICU for ongoing neurosurgical care. They were colonised on admission with an XDR-AB in multiple surface screens though never from sterile sites. From admission the patient was managed in strict isolation as per the hospital’s infection control policy.

Patient B, who had not been abroad, was admitted to ICU from home with colitis 9 days after patient A’s admission. A wound swab from day 10 of patient B’s admission cultured an identical XDR-AB to that in patient A. Patient B subsequently cultured the XDR-AB in multiple screens and one blood culture. Patient A and B were admitted to completely separate wards of the ICU, with separate care teams.

When the cross infection was identified the two ICU wards where Patient’s A and B were cared for were closed. The other two wards remained open. All patients in all 4 ICU wards were then screened twice weekly for the XDR-AB. No further cases were identified.

The XDR-AB was resistant to all aminoglycosides, beta-lactams, quinolones, and colistin. Only tigecycline had a susceptible MIC of 0.5mg/L. DNA sequencing confirmed the isolates were identical.

An outbreak meeting was called. Investigations identified that both patients had surgery under the same surgical team in the same theatre consecutively. Patient A was operated on first and the theatre deep-cleaned appropriately afterwards. The surgical team then reviewed both patients consecutively on ICU, adhering to infection control practices.

After deep cleaning of the two affected ICU wards, and no further patients identified with XDR-AB on repeated screening of all ICU patients, the unit was fully reopened. Both patients subsequently died on the unit from non-infective causes.

Discussion: No single breach of policy could be identified which was likely to have resulted in the cross infection. It was felt that the most likely source must have been around the time of the surgical procedures or subsequent review on the ICU by the surgical team. An in depth review of theatre cleaning procedures by the infection control team revealed that though staff understood the deep clean policy, there was some confusion about individual responsibilities for aspects of cleaning amongst theatre team members. This may have led to an incomplete deep clean. Further educational sessions were delivered to ensure all theatre staff understood their roles in the deep clean of theatre suites.

This outbreak was an isolated and unexpected event. Though we considered the hospital policy for managing patients with multi drug resistant organisms to be comprehensive and effective, a failure of understanding of all aspects of the policy may have lead to inadvertent breaches, with the potential to cause cross infection with an almost untreatable organism.

152
Efficacy of teicoplanin in the outpatient parenteral antibiotic therapy (OPAT) setting

Abstract - 152

Poster 152

Efficacy of teicoplanin in the outpatient parenteral antibiotic therapy (OPAT) setting

Helena Wickham1, Hannah Dabrowski1, Michael Marks1,2, Jon Underwood1, Surjo De3, Sarah Logan1, Gabriele Pollara1,4
1Infection, University College London Hospitals. 2Clinical Research, London School of Hygiene and Tropical Medicine. 3Clinical Microbiology, University College London Hospitals. 4Infection & Immunity, University College London

Introduction: Intravenous antibiotics are increasingly administered in outpatient settings to reduce length of inpatient admissions, reduce costs and increase patient satisfaction. Teicoplanin can be administered once daily, making it highly compatible with Outpatient Parenteral Antibiotic Therapy (OPAT) services. Although evidence supports its use in skin and soft tissue infections (SSTI), limited data exists on its efficacy in the OPAT setting. Where this has been previously assessed, teicoplanin was associated with a surprisingly high (25%) clinical failure rate, and with inferiority to ceftriaxone, another commonly used once daily antibiotic in OPAT.

We present a large case series seeking to address whether teicoplanin use in OPAT is more effective than previously reported and how it compares with ceftriaxone.

Methods: We reviewed the records of patients being treated by the OPAT team at University College London Hospitals between January 2015 and February 2018. Data were extracted from the elCID database for patients who received at least 3 days of teicoplanin or ceftriaxone as part of their OPAT treatment for SSTI, bone and joint infections, and endovascular infections. These diagnoses made up 88% of all indications for teicoplanin prescriptions in the OPAT service.

The primary outcome was clinical failure, defined by the National Outcome Registry System (NORS) (http://opatregistry.com/) as progression or non-response of infection despite OPAT, resulting in admission, surgical intervention or death for any reason.

Results: We identified 134 eligible episodes of teicoplanin-related OPAT care, of which 108 (81%) did not involve any administration of ceftriaxone during the episode of care. The majority (70%) of teicoplanin courses were less than 30 days in duration and causative organisms were predominantly represented by Gram positive bacteria. During this time, there were 216 eligible episodes of OPAT care associated with ceftriaxone use that did not also involve teicoplanin administration. Adverse events (AE) were rare for both antibiotics (3 AE for Teicoplanin (2.2%) and 7 AE for ceftriaxone (3.2%)).

Teicoplanin was associated with clinical failure in 6 out of 108 cases (5.5%) whereas ceftriaxone was associated with clinical failure in 7 out of 216 cases (3.2%). There was no statistical difference in failure rate between the antibiotics in either univariate or multivariate analysis controlling for duration of antibiotics and underlying clinical condition.

Discussion: Data collected prospectively from our cohort of patients demonstrate teicoplanin to be a viable drug in the OPAT setting. Notwithstanding the methodological limitations of our study design, the clinical failure rate associated with teicoplanin was low and not significantly higher than ceftriaxone, in contrast to previous reports. We conclude that teicoplanin in OPAT is safe and effective, supporting its continued use in UK OPAT centres and consideration for its introduction where it is not currently being offered.

153
The use of outpatient parenteral antimicrobial therapy in patients with non-cystic fibrosis bronchiectasis: a retrospective and prospective audit

Abstract - 153

Poster 153

The use of outpatient parenteral antimicrobial therapy in patients with non-cystic fibrosis bronchiectasis: a retrospective and prospective audit

Rory Kennedy
Univeristy of Manchester, University of Plymouth

Introduction: Bronchiectasis incidence and prevalence has risen over the last decade. Severe, recurrent or resistant infection in bronchiectasis may necessitate intravenous antimicrobials. Outpatient parenteral antimicrobial therapy (OPAT) is a formal method of providing intravenous antibiotics outside of the inpatient setting, associated with high patient satisfaction and cost saving. OPAT is known to reduce admissions by avoiding inpatient administration of intravenous antimicrobials, but it is unclear whether this provides a long-term reduction in admissions.

We aimed to establish:

  • Whether there was a change in unplanned all-cause inpatient admissions after OPAT (primary aim).
  • The adverse events experienced by the OPAT bronchiectasis population.
  • To describe the microbiological and antimicrobial resistance profile of sputa isolates.
  • To prospectively assess any change in healthcare related quality of life (HRQoL) scores after OPAT.

Methods: The OPAT service in Wythenshawe Hospital, Greater Manchester, set up in January 2015, was retrospectively audited. Adults with a diagnosis of bronchiectasis between 1st July 2015 to 30th June 2017 were included. Patients without a CT diagnosis were included, and CT data was recorded. Patients were excluded if they had previously had an OPAT appointment or received intravenous antimicrobials via the outpatient respiratory service. Data was collected for the year before and after first OPAT appointment, from the hospital electronic patient record and OPAT database, generated through routine clinical practice.

Patients were prospectively studied, between April and August 2018, using the St George’s respiratory questionnaire (SGRQ). This was completed at the initial OPAT appointment and 2 weeks after antimicrobial course completion.

Results: In 2 years, 73 patients started OPAT for bronchiectasis, 87% had a CT confirmed diagnosis. Women accounted for 61.6% of patients, the mean age was 64.6 years (standard deviation 15.1). The most common antimicrobial regimen was ceftazidime and tobramycin (39.7%). Pseudomonas aeruginosa was cultured in 60% of patients in the year before OPAT.

The mean number of all-cause inpatient admissions per year before OPAT was 1.18 (95% confidence interval (CI) 0.78 – 1.57) and 1.12 after OPAT (95% CI 0.79 – 1.46). The mean difference was 0.053, which was not significant (p=0.738).

In the year after OPAT, 4/73 patients (5.5%) died. One patient suffered from Staphylococcus epidermidis bacteraemia 5 months after line removal and 5/73 patients (6.8%) suffered from an intravenous access complication leading to a change in their line. No patients suffered Clostridium difficile infection.

In the 44 patients who had cultured P. aeruginosa before OPAT, 21 (47.7%) were culture negative for P. aeruginosa for 1-year post OPAT. In the year after OPAT, 11 patients isolated Pseudomonas spp resistant to an antimicrobial used during OPAT.  

In the prospective study, the SGRQ was completed by 8 patients before and after OPAT. 7 patients (87.5%) had a reduction in SGRQ score greater than the clinically significant difference of 4 points. The mean reduction in SGRQ score after OPAT was 13.13 points (95% CI 3.27-22.98), p=0.016.

Discussion: No significant benefit in admission reduction could be found in the year after OPAT. Use of OPAT has shown sustained P. aeruginosa suppression rates of close to 50%.

The rise in resistance was concerning, however the most frequent resistance was to piperacillin/tazobactam, in 7 isolates. Only one patient developing resistance had been treated with piperacillin/tazobactam, so this seems unlikely to represent in vivo resistance developing.

The significant decrease in SGRQ may be indicative of a clinical benefit of OPAT in non-CF bronchiectasis. The sample size was too small to stratify by microbiology, antimicrobials used or demographics. We are collecting data on a larger population to enable this.

154
Structured collaborative multi-disciplinary IPC approach to reduce healthcare associated (HCAI) methicillin sensitive Staphylococcus aureus (MSSA) bloodstream infection

Abstract - 154

Poster 154

Structured collaborative multi-disciplinary IPC approach to reduce healthcare associated (HCAI) methicillin sensitive Staphylococcus aureus (MSSA) bloodstream infection

Hloniphani Mpofu, Julie Samuel
The Newcastle Upon Tyne Hospitals NHS Foundation Trust

Introduction: Staphylococcus aureus (S. aureus) is a type of bacteria that is commonly found on the skin and anterior nares of healthy individuals. It is associated with pathogenic infection in patients with wounds and invasive devices.

At Newcastle hospitals we have set a target of reducing Methicillin Sensitive Staphylococcus Aureus (MSSA) bacteremia by 10% across all directorates.

During the month of March 2016 there was a significant increase in incidences of MSSA bacteraemia within Cardiothoracic Intensive Care Unit (ITU). Measures were put in place to investigate the cause of this increase.

Methods: Newcastle upon Tyne Hospitals NHS Foundation Trust (NuTH) standards stipulate the need to complete a Root Cause Analysis (RCA) for all HCAI MSSA bacteraemia. This is completed by a multi-disciplinary team (MDT), reviewing patients’ journey from the community and acute health care setting with the aim of identifying any lapses in care; the process also pinpoints lessons to be learned and acknowledging good practice.

The findings from the detailed analysis are then shared with other departments to improve the wider practice. Data collected from 50% completed MSSA bacteraemiae RCA within NUTH Cardiothoracic ITU identified invasive devices as the potential source of infection. We then convened an (MDT) meeting to agree an Action Plan to reduce HCAI MSSA bacteraemiae within the Unit. The MDT engaged with the “Plan, Do, Study, Act (PDSA)” approach which could be mirrored by other departments within the trust if successful.

The measures outlined below were implemented:

  • Ward staff policing the bed spaces with the aim of promoting adherence to all IPC measures including hand hygiene as per World Health Organisation (WHO) 5 moments of hand hygiene. Do’s and Don’t’s list
  • IV audit tool prepared by IPC Team
  • Department Matron, IPC link staff and IPC nurse to undertake device management audit, complete audit daily for the first week, twice weekly for two weeks, weekly for 3 months and progressing to random checks to ensure the standards are maintained and to identify lapses in practice in a timely manner .
  • All personnel undertaking ANTT procedures both Medical and Nursing to have their competencies re-assessed.
  • Hand hygiene champions to be cascade trainers
  • One to one meetings with senior medical and surgical staff
  • Strong emphasis on IPC in daily safety briefings

The Matron and IPC nurse met on a regular basis to discuss the progress and to review the Action Plan, based on the audit results..

Results: Between the period of February 2017 to March 2018 the department had no HCAI MSSA bacteraemias. A system to provide assurance was established with line management, where weekly audits were carried out to determine whether the implemented preventative measures were successful

Following the completion of the excercise, more than 60% of the staff had confidence in challenging bad practice. This collaborative working with the department was evidenced by staff adhering to all IPC measures.

Discussion: Securing high levels of engagement amongst the staff and promoting ownership was very useful in reducing HCA MSSA bacteraemia. There are however challenges when there is a high staff turnover where by continuous IPC interventions are essential in the reduction of HCAI.

155
Are current infection control and prevention methods effective in controlling transmission of Clostridium difficile infection in the inpatient population of a large teaching hospital? Using ribotyping to assess risk of patient to patient cross contamination

Abstract - 155

Poster 155

Are current infection control and prevention methods effective in controlling transmission of Clostridium difficile infection in the inpatient population of a large teaching hospital? Using ribotyping to assess risk of patient to patient cross contamination

Findlay Lowson1,2, Susan Gould1, Tim Neal3, Mike Beadsworth1
1Tropical and Infectious Diseases, Royal Liverpool and Broadgreen University Hospital Trust. 2University of Liverpool. 3Royal Liverpool and Broadgreen University Hospital Trust

Introduction: Clostridium difficile infection (CDI), is associated with increased mortality, morbidity and length of stay in hospital settings, this adversely affects patient flow, capacity, as well as the cost implications, including treatments. The Royal Liverpool and Broadgreen University Hospital Trust (RLBUHT), is a large teaching hospital with 850 in-patients. Since 2008/9, at the peak of the CDI epidemic RLBUHT has seen over 96% reduction in hospital associated CDI cases. The successful multi-disciplinary approach to case-finding, isolation and treatment also included a robust preventative campaign. As numbers of new cases have stabilised at between 30 and 40 annually, concerns exist that maintaining/motivating aggressive prevention and infection control procedures may lapse. To assess the on-going success of these policies, we reviewed all in-patient cases in 2017/2018 reviewing patient journeys with ribotypes to assess for any risk of patient to patient cross contamination.

Methods: All in-patients with CDI between 01/04/17 and 01/04/18 were reviewed to assess their journey through RLBUHT. All had been ribotyped, and as each patient was mapped, assessment was made to see if there was any evidence of cross contamination of those with identical ribotypes. Alongside mapping we describe the epidemiological character of each patient, including risk factors for developing CDI.

Results: Of the 44 in-patients identified, 39 were managed as in-patients, 24 were male, 20 were female, the median age was 74 (IQ range 14.5). Using electronic casenotes and dashboards we mapped the geographical route of every patient through their stay in RLBUHT. (Mapping illustrations will be included in the poster).

For those with identical ribotype we found no nodal interaction. All were isolated, 60% within the regional infection unit, 82% had recently received antibiotics.

Discussion: Reassuringly, despite the low numbers, current policies of infection control and prevention for CDI appear robust. It remains, however, vital to not only develop guidelines and policies for nosocomial infection, but to also challenge them to confirm that they are working.

Patient journey mapping is a useful tool for assessment of cross contamination risk, having ribotypes and also electronic records allows this method to be undertaken with relative ease.

156
Lessons learnt from a prolonged ventilation failure in a containment level 3 Mycobacterial Reference Laboratory

Abstract - 156

Poster 156

Lessons learnt from a prolonged ventilation failure in a containment level 3 Mycobacterial Reference Laboratory

Pretin Davda, Grace E Smith, Priti Rathod, Esther Robinson
Public Health England, Birmingham

Introduction: Many microbiology laboratories have a containment level 3 (CL3) facility to process Hazard Group 3 pathogens including Mycobacteria.

Each laboratory should have a documented risk assessment which includes a contingency plan in case of laboratory outage for whatever reason.

In June 2018, a national reference laboratory in the West Midlands had to put its contingency plan into action when there was a failure in the ventilation system preventing any negative pressure in its primary processing and reference CL3 laboratories. This ventilation failure lasted 6 weeks and we outline 

This reference laboratory provides two services:

  1. Providing primary processing of samples for many hospitals within the West Midlands. This involves acid fast bacili (AFB) staining, culturing specimens in both liquid and solid media and performing a Ziehl Neelsen (ZN) stain on positive culture samples.
  2. Identifying positive mycobacterial cultures using Whole Genome Sequencing (WGS) for isolates from laboratories in North and Central England.

Despite the prolonged laboratory failure, the reference laboratory was able to continue to provide a primary processing and WGS service, which continued to meet its turnaround time of 7 working days.

This was due to the successful implementation of the contingency plan which involved the use of supporting laboratories. 

Methods: A Gantt chart was created to oversee the management and timeline of the contingency plan during the laboratory outage and recovery period.

The contingency plan involved transporting all primary processing work to a nearby CL3 laboratory. The primary samples would be processed and stored there during the reference laboratory outage period.

Reference laboratory staff were also redistributed to this supporting laboratory to process the primary work with the aim of minimising disruption to the supporting laboratories daily work.

In addition, consumables and mycobacterial culture storage units were sent to the supporting laboratory as they did not have the capacity to manage the reference laboratories workload. 

Preparing samples for WGS requires heat killing the mycobacteria, which makes them save to be removed from a CL3 laboratory for DNA extraction and whole genome sequencing. 

Samples requiring WGS were sent to the mycobacterial reference laboratory that provides a diagnostic WGS service to the south of England (NMRS-S). To minimise the impact on NMRS-S’s workload, it was agreed that they would heat kill (and ZN if necessary) the cultures and send them back to the north and central reference laboratory who could then safely complete the DNA extraction and sequencing steps for WGS.

Band 7 staff at the west midlands reference laboratory underwent risk assessment and FFP3 mask fit testing to allow them to enter the CL3 laboratories to read previously incubated cultures.

All positive cultures were recorded onto a spreadsheet and a clinician triaged them to decide whether the culture needed to be sent to NMRS-S for ZN & heat killing. TB PCR was performed on primary specimens if after triaging it was felt to change patient management.

Once negative pressure was restored in the reference laboratory, samples at NMRS-S were returned for storing and archiving. Again, a tracker spreadsheet was made to account for the location on all samples.

Results: AFB results on primary samples were delayed by up to 48 hours because these samples required transporting to, booking in and processing at a contingency laboratory. 

WGS turnaround times were longer than normal but did not exceed the national target of 7 working days.

All specimens were logged on the tracking spreadsheets and Gantt charts with no missing specimens to date.

Discussion: This laboratory outage highlights why contingency planning is essential and complex and therefore requires forward planning. From informal discussions with laboratories, many do not have an agreed contingency plan.

157
Endocarditis in the 21st century: what, where and how?

Abstract - 157

Poster 157

Endocarditis in the 21st century: what, where and how?

Anda Samson
Hull & East Yorkshire Hospitals NHS Trust

Introduction: Previously audits showed an incidence in HEY of 35-40 definite or possible endocarditis cases per year. We suspected that this number was now larger given current patient numbers. Since the last endocarditis audit national guidelines for endocarditis prophylaxis and guidelines for antimicrobial treatment have changed. National drivers on the diagnosis and treatment of sepsis as well as a push for limitation of the use of antibiotics have notably changed practice. In the light of these changes, the aim of this audit was to assess whether the incidence of endocarditis has changed, and whether patients have been treated in compliance with existing guidelines. 

Methods: All patients with positive blood cultures between april1st, 2016 and march 31st, 2017 with Staphylococcus Aureus, Streptococci and Enterococci were identified. Electronic letters were reviewed. Notes of patients without an alternative explanation were studied in more detail. Additionally, notes of patients known to have had endocarditis in HEYHT were reviewed; these could be patients from other trusts treated at our hospital, or patients with a different micro-organism not captured by the original search

Modified DUKE criteria for endocarditis were used to establish definite/possible endocarditis, or to reject the suspicion of endocarditis. We further collected data on micro-organism, endocarditis site, complications, discussion in endocarditis MDT, imaging, treatment, surgery, and mortality. 

Results: A total of 57 cases of definite or possible endocarditis were identified; the majority was caused by MSSA. (fig 1) Of all patients with endocarditis, more than half had left-sided endocarditis. (fig 2) 

Fourteen out of fifty-seven patients did not have an abnormality on echocardiogram or did not have an echocardiogram. Thirteen patients underwent a transoesophageal echocardiogram. Five (40%) had an altered diagnosis after transoesophageal echocardiogram. Five patients underwent cardiac CT, there were no patients who underwent cardiac MRI, and six underwent PET-CT. PET helped change the diagnosis in at least 1 patient; 

Antibiotic treatment was largely started according to international guidelines, but only in 24 out of 57 patients these guidelines were followed throughout the treatment course. Reasons for straying from these guidelines were kidney dysfunction, liver impairment, facilitation of outpatient treatment, and compliance. Complications of endocarditis were common and varied as shown in table 1. Sixteen patients needed surgery, the majority of those had streptococcal endocarditis. Fifteen patients were IV Drug users, of whom 12 had MSSA endocarditis. Four of 15 IV drug users with IE died (27%) ; overall 15 of 57 patients (26%) with IE died.

Discussion: The frequency of IE seems increased indeed , though this may in part be due to a more rigorous audit methodology. 

Despite change in dental prophylaxis, there is no rise in streptococcal IE, which is consistent with international data

Given the frequent need to change antibiotics and frequent complications, the multidisciplinary endocarditis team is pivotal in managing this patient group

The role of imaging modalities that are available needs to be further explored and clarified

158
A retrospective review of 15 patients treated for malignant otitis externa in an OPAT setting in 2016-2017

Abstract - 158

Poster 158

A retrospective review of 15 patients treated for malignant otitis externa in an OPAT setting in 2016-2017

Tamara Mitchell, Katharine Cartwright, Elisabeth Ridgway
Sheffield Teaching Hospitals

Introduction: Malignant (necrotising) otitis externa is an invasive infection of the external ear canal. Although rare, increasing rates have been seen locally and nationally. Cases require prolonged courses of antibiotics with associated cost implications. Increasingly in Sheffield these patients are being managed in an OPAT setting avoiding prolonged inpatient stays. Understanding of how best to manage these patients remains limited, with only a few case series published and no guidelines available internationally for diagnosis, management and follow up. We conducted a retrospective review of cases in Sheffield to increase understanding of this cohort of patients in order to improve management.

Methods: Patients presenting to Sheffield Teaching Hospitals with malignant otitis externa over a one year period from August 2016 to July 2017 were identified from the ENT and OPAT databases. Clinical notes and laboratory results systems were interrogated.

Results: 15 patients were identified over this period, an increase on previous years. Risk factors were predominantly diabetes 9/15 (60%), however 3/15 (20%) had no identifiable risk factor other than age (mean age 74.3 (range 41-91). CRP at presentation was usually low 25.2 (range 1.7-78.7) with 5 (33.3%) having a CRP <10. 5 patients were diagnosed with bony involvement at initial presentation (33%). Pseudomonas aeruginosa was the predominant organism isolated in 11/15 patients (73.3%).

Most common antibiotic choice was piperacillin-tazobactam (73%); other regimes included ceftazidime/ based (+/- teicoplanin/metronidazole), meropenem, ciprofloxacin based (+ doxycycline, clindamycin or teicoplanin) and ceftolazone-tazobactam, Mean duration of treatment was 16 weeks (range 5-40); 8.8 weeks for limited soft tissue infection (range 8.5-9), 14 weeks for extensive soft tissue infection (range 5-21) and 22 weeks for bony involvement (range 8-40). Drug reactions were more common than expected in this patient group (33% of patients), which contributed to frequent readmissions following discharge to OPAT (53%).

4/15 (27%) patients had ongoing symptoms at 12 weeks. 12/15 (83%) patients ultimately achieved cure with no relapse at follow up, 1 achieved initial cure but had 2 subsequent relapses and 1 (7%) died due to uncontrolled MOE.

Discussion: Malignant otitis externa treatment requires prolonged courses of antibiotics which can be provided through OPAT shortening inpatient stays. However antibiotic reactions are common, and re-admissions frequent, requiring close collaboration between ENT, OPAT and microbiology. We designed a management flow chart to aid management of these complex patients.

159
Quality improvement: improving adherence to guidelines for urinary legionella antigen testing in a large teaching hospital

Abstract - 159

Poster 159

Quality improvement: improving adherence to guidelines for urinary legionella antigen testing in a large teaching hospital

Francesca Knapper, Susan Mcculloch, Mahableshwar Albur
Southmead Hospital, North Bristol NHS Trust

Introduction: A rare but important cause of pneumonia is Legionella pneumophila. This is a notifiable disease where source control and outbreak management essential.

The British Thoracic Society (BTS) guidelines state that patients with a high severity community acquired pneumonia (usually considered to be CURB score >2), specific risk factors, or during outbreaks should be tested for urinary legionella antigen. 

This quality improvement project sought to evaluate current testing practices and rationalise testing.

Methods: A random 100 patient sample from the first 4 months of 2016 were used as the baseline data collection. Data on the location, duration of stay, and diagnosis on discharge were collected retrospectively.

Prompts when ordering urinary legionella antigen tests were introduced in January 2017. This included a link to the BTS guidelines, an error message to reduce duplicate testing, removing testing from the GP panel, and a prompt to calculate the CURB-65 score before requesting. 

A repeat sample of 190 samples was reviewed from February 2017.  

Results: During the two time periods sampled there were no positive results. Initial data showed that 45% had a diagnosis of community acquired pneumonia (CAP) on discharge. Other diagnosis ranged from pulmonary embolism, infective exacerbation of COPD and influenza. 10% did not have a diagnosis associated with respiratory symptoms. 25% of patients were discharged from the emergency department (ED) prior to results being available. 1% patients had had a duplicate test, and 1% had been sent from General Practice. 2% of patients were tested over 14 days into their inpatient stay.

Following the implementation of changes to requesting 2% of patients from ED were discharged prior to results. 1% were duplicate tests, and no samples were sent from General Practice. Looking at the diagnosis on discharge there was a slight improvement from 45% with CAP to 53%. All requestors gave a CURB score on the request, 16% were for a CURB score of 1. 2.6% patients were tested over 14 days into their inpatient stay.

Discussion: Despite links to the BTS guidelines on the request and prompts tests were still be sent as duplicates and on patients who did not have a community acquired pneumonia. Challenging this at the point of request offers potential but clearly this is not fail safe. Delaying testing until admission from ED was one potential to try and reduce diagnostic uncertainty. Education and training is another important area that needs to be improved. Further work continues with a re-cycle planned. Hopefully this project can provide an insight into the challenges and potential solutions to rationalise and ensure appropriate testing. 

160
Monkeypox outbreak in Blackpool: clinical presentation, contact surveillance, post-exposure prophylaxis and outcomes

Abstract - 160

Poster 160

Monkeypox outbreak in Blackpool: clinical presentation, contact surveillance, post-exposure prophylaxis and outcomes

Peter Flegg1, Ruth Palmer1, Sharon Mawdsley1, Susan Richardson1, Susan Houldsworth1, Nick Harper1, Meera Chand2, Nick Phin2
1Blackpool Teaching Hospitals NHS Trust. 2Public Health England, London

Introduction: Monkeypox is a rare zoonotic infection, causing human disease similar to but usually milder than smallpox. Cases outside of Africa are extremely rare, with only one outbreak recorded in 2003 in the USA involving exposure to infected animals.

In September 2018 an adult male with monkeypox was admitted to Blackpool Victoria Hospital following recent travel from Nigeria. He gave a history of ingesting “bush meat” as well as contact with a possible human case of monkeypox. He was isolated using standard universal barrier precautions. This was escalated to full isolation with FFP3 respiratory precautions after a monkeypox diagnosis was suspected, and he was transferred to Liverpool Airborne High Consequence Infectious Disease Unit (HCIDU).

Two weeks later a secondary case of monkeypox was diagnosed in a female Health Care Worker who was based on the Blackpool isolation unit, despite having received post exposure prophylaxis (PEP) with smallpox vaccine one week earlier (one week after her exposure to the index case). She had dealt with contaminated bed linen and clothing from the index case. She was transferred to Newcastle Airborne HCIDU. This is the first documented instance of human to human transmission outside Africa.

Contact tracing and surveillance was instituted and PEP offered to those with significant exposure.

The local response to this small outbreak of monkeypox is discussed. This incident is still “live”, therefore the information presented here is provisional and may not reflect the final numbers and disposition of patients and contacts. Root cause analysis is underway to clarify the cause of secondary hospital transmission.

Methods: Contacts were categorised according to exposure risk (High, Intermediate, and Low) as defined by Public Health England (PHE).

Surveillance was co-ordinated by PHE and the NW Health Protection Team. Active surveillance was instituted for high and intermediate risk contacts for 21 days post contact (representing the maximal incubation period for monkeypox), consisting of daily text messaging of contacts to verify their health status.

Demographic and clinical data were recorded for those offered PEP, which consisted of a 3rd generation smallpox vaccine (IMVANEX®).

During surveillance, several contacts developed clinical illness which required either telephone or face-to-face clinical assessment. These outcomes were documented.

Results: Over 200 exposure contacts within the community and health service were monitored, including Hospital and Primary care staff, and Hospital inpatients.

Location of exposure for Health Care contacts (percentage):

Isolation Ward:                  38%

Acute Medical Unit:          22%

Accident & Emergency:   13%

Radiology:                             6%

Other:                                  21%

Offers of vaccination PEP to Hospital HCWs and inpatients:

Hospital HCW:          70 (uptake 59; 84%)

Inpatients:                   4 (uptake 4; 100%)

HPE instituted a system of both active and passive surveillance for all contacts, but many staff remained anxious about their health, particularly following their colleague’s acquired infection. Six HCWs required further ad hoc local clinical assessment, and numerous queries were fielded by the virologist, infection control teams and the ID physician.

Discussion: Considerable resources were required to manage this incident, which required multi-level collaboration between local, regional and national departments and agencies. The burden imposed in terms of organisational logistics and costs for our Trust has been significant.

Despite PEP, one HCW developed monkeypox following an exposure that was subsequently categorised as “high risk”, emphasising the importance of full protective isolation for any possible cases.

Monkeypox may present in a variety of clinical settings in primary and secondary care. Clinicians need to remain alert to its salient clinical features.

Trusts should ensure that the relevant National and local policies and guidelines are put in place to ensure any future UK monkeypox cases can be rapidly detected, isolated and managed.

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