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Antibacterial resistance: Part 3

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Antibacterial resistance: Part 3

Welcome to the third and final instalment in our series of modules looking at the role of the pharmacy team in minimising antibacterial resistance. This series is based on the Centre for Pharmacy Postgraduate Education (CPPE) open learning programme Antibacterial resistance – a global threat to public health: the role of the pharmacy team, and is designed to give pharmacy technicians an overview and better understanding of this area of practice

Having discussed in previous modules how antimicrobial resistance develops and the role of pharmacy in protecting the use of antibiotics, we will now consider the importance of infection control and prevention.

Infection control

Effective infection prevention and control measures are key to stopping infectious diseases, including those caused by resistant organisms. Preventing the transmission of infection leads to reduced antimicrobial use, which helps to minimise antimicrobial resistance.

This is particularly important for community pharmacists and pharmacy technicians who handle bodily fluids, such as urine samples for chlamydia testing, or sharps handling for syringe and needle exchange.

Infection control is also important in the prevention of healthcare-associated infections (HCAIs) which result from medical care or treatment in hospitals, nursing homes or a patient’s own home. Two main HCAIs in the UK are Clostridium difficile (C. difficile) and MRSA.

Each year, the NHS standard contract sets an incidence number of C. difficile and MRSA infections that healthcare organisations must not exceed or they will be issued with a financial penalty. In primary and secondary care, infection control teams work alongside microbiologists or infection control doctors to train staff on infection control, monitoring outbreaks and policing the infection control policy.

Hand hygiene

Hand hygiene is the most important step in reducing the spread of infection. The use of soap and water to wash hands when patients are vomiting or have diarrhoea is critical. This is because C. difficile can release spores into the environment that are not susceptible to alcohol hand gel. While some alcohol gels are active against viruses, others are not. It is therefore very important to wash hands with soap and water when patients are affected by norovirus outbreaks.

Many healthcare professionals (HCPs) do not wash their hands correctly or apply alcohol gels as often as required. It is also important that HCPs dry their hands thoroughly, as wet surfaces transfer organisms more easily. It is also important to note that while alcohol gels and rubs are a soap alternative, they are not a soap substitute when hands are visibly dirty, potentially contaminated with bodily fluids or when caring for a patient who is vomiting or has diarrhoea, regardless of whether gloves are worn.

Handwashing facilities must be available and easily accessible in all patient areas, treatment rooms, sluices and kitchens. In clinical areas, sinks should have non-touch operated taps with liquid soap dispensers, paper towels and foot-operated bins. Alcohol gels must be available at the point of care in all primary and secondary care settings.

All healthcare staff have a responsibility to their patients to actively prevent cross-infection. This includes highlighting any lack of facilities to the appropriate person.

To help raise awareness of handwashing, you could:

  • Run a school competition to design a poster for clinical areas. This educates children and their parents
  • Each year, train staff in infection control
  • Ensure alcohol gel is available in all clinical areas, alongside posters.

Protective equipment

Wearing personal protective equipment is important to protect both the patient and the HCP from the risk of cross-infection.

Disposable gloves must be worn whenever there might be contact with blood, bodily fluids, mucous membranes or broken skin. Handwashing is still required before and after wearing gloves. If handling highrisk substances, gloves should be made of nitrile or latex, rather than polythene.

Aprons should be worn if a patient has a known infection or if there is a risk of contaminating the HCP’s clothing with blood or bodily fluids. Eye protection and masks are required if there is a risk of blood or bodily fluids splashing the face. Masks are also necessary if the infecting organism is airborne.

Handling and disposal

The main health risk when handling sharps is a needlestick injury that results in infection with hepatitis B, hepatitis C or HIV. The risk of infection depends on the patient – i.e. whether they’re infected or are injecting drugs; staff immunity to hepatitis B, and the type of injury.

The handling of sharps should be kept to a minimum and sheaths should never be reused. A special container should be used for sharp disposal, which should be kept at the point of use, away from the public. All staff members should also be aware of the appropriate safety procedure in case of a needlestick injury.

Following an injury, source patients should be asked if they are willing to provide a blood sample to test for blood-borne viruses. If there is a high risk of HIV transmission, post-exposure prophylaxis is recommended.

The typical recommended safety procedure includes:

  • Encourage bleeding – do not suck the wound
  • Wash under running water – do not scrub l Report to the manager and occupational health department, or A&E
  • Fill in an accident form and assess the risk

If the injury was from an unused needle, further action is not required. If it was from a used needle, a microbiologist or consultant for communicable disease control must carry out a risk assessment.

Unwanted medicines disposal is an essential service under the pharmacy contract in England and Wales. A waste disposal procedure should include cytotoxic, pharmaceutical and clinical waste. Clinical waste can be stored in the pharmacy until collected for safe disposal. Collection by the local authority is preferred for sharps. However, they can be collected as part of a needle exchange scheme or disposed of by the pharmacy. All staff should be trained on how to handle waste and respond to spillages.

MRSA decolonisation

Strict screening requirements are in place for patients admitted to hospital with MRSA as their risk of developing an MRSA-related infection is greater. One of the most serious is a bloodstream infection called MRSA bacteraemia.

Identifying patients who are colonised, but not infected, with MRSA can reduce the level of bacteria carriage, which lowers the risk of healthcare-associated infections. Patients who are colonised with, or have been previously positive for, MRSA should be isolated. MRSA decolonisation is usually given to patients prior to surgery. Eradication therapy varies between organisations, but usually involves topical or nasal antibacterial ointments and washes, and shampoos. Certain sites are more likely to act as MRSA carriage sites. If a patient is colonised or infected at one site, remaining sites should be swabbed to assess carriage. Sites more likely to be colonised or infected include:

  • Nose
  • Groin
  • Broken skin
  • Pressure sores
  • Wounds
  • Stoma sites
  • Entry tubes of invasive devices
  • Intubation tubes

When MRSA carriage eradication is unlikely to be successful (e.g. in patients with chronic wounds), the aim may be short-term carriage reduction.

Patients treated in the community, who are found to be colonised with MRSA, do not usually require eradication. However, this may vary depending on local policy. Pharmacists should be aware that patients with MRSA, or who have a history of MRSA, will probably require different antibacterials for prophylaxis and treatment than those recommended in guidelines.

Dressings can help protect against and eradicate MRSA. Patients with infected or colonised ulcers or wounds can use MRSA-active dressings (e.g. Iodoflex). If a patient is colonised at another site and has a MRSAnegative open wound, a protective dressing may be effective (e.g. Allevyn).

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