Episode Transcript
Infection Control Explained (ICE) Podcast 4
This Podcast is brought to you by the GOSH Learning Academy.
[00:00:06] Kate H: Welcome back to the ICE Podcast. ICE stands for Infection Control Explained, and today we will be explaining a little bit more about resistant bug, that's called carbapenemase Producing Enterobacterales, otherwise known as CPE. So my name is Kate Harkus. I'm the lead practice educator for Infection Prevention and Control.
And I have with me today Kate Rennie, and she is one of the infection prevention nurses at GOSH, and she's gonna be speaking as our expert. So welcome Kate, how are you doing?
[00:00:39] Kate R: Thank you. I'm good, thank you. How are you?
[00:00:41] Kate H: Yes, all good. So let's dive straight in and can you tell me a little bit about CPE and what it is?
[00:00:48] Kate R: Sure. So CPE stands for carbapenemase producing Enterobacterales. Enterobacterales are a type of bacteria that normally live harmlessly in our gut, and CPE produce an enzyme called carbapenemase that destroys antibiotics called carbapenems, which are usually used to treat severe infections. We also refer to CPE at gosh as highly resistant bugs because of their level of antibiotic resistance.
[00:01:16] Kate H: Got you, so that sounds a little bit concerning to me I think hearing that. So how concerned are we about CPE?
[00:01:24] Kate R: CPE is a public health concern, but in normal life, like at home or at school, there aren't usually any additional precautions required.
[00:01:33] Kate H: Okay, I get you. But then. So say for example, when you talk about a severe infection and then maybe not enough antibiotics to treat them, what sort of scenario might that be?
[00:01:45] Kate R: Because both colonised and infected patients can spread bacteria to other patients, at GOSH and in other healthcare settings, we have to take additional precautions to reduce this risk.
So this can include things like staff wearing aprons or gowns, or a child or young person being cared for in a cubicle rather than a shared bay.
Children known to be colonised with CPE do have an infection alert on their computer record, which indicates that these additional precautions need to be taken.
[00:02:12] Kate H: Got you. So maybe could we go through some scenarios of when a patient might be admitted to the hospital?
[00:02:19] Kate R: Yeah, of course.
[00:02:20] Kate H: So say for example then a patient needed to come into an inpatient ward.
Where might that patient be admitted into?
[00:02:28] Kate R: So usually for our inpatient wards, any patient known to be colonised with CPE is admitted into a side room rather than a shared bay. Obviously, we do have patients admitted where we don't know their colonisation status, and this is why all patients are required to have a stool sample sent within the first 72 hours of admission.
So if a patient is being cared for in a bay and they have a stool sample on admission that comes back positive for CPE, we'll then ask for that patient to be moved into a side room.
[00:03:02] Kate H: I got you. So my next thoughts were then what tests needed. But you've already told me that they obviously need a stool sample.
Generally speaking, do we get good stool samples from everybody or is that something that we don't get enough of.
[00:03:18] Kate R: Our compliance with stool screening is better than it used to be. So we are actually doing a quality improvement project to improve compliance with stool screening in an attempt to identify knowingly colonised patients which will in turn reduce the risk of transmission to other patients.
So we started off in June last year with 25% compliance for the trust, and now as of June this year we are set 43% compliance. So it is a lot better but there is still room for improvement.
[00:03:45] Kate H: So would I know, so if I had a child that was coming into Great Ormond Street, would I know that they've got any symptoms or was there anything to tell me that they needed to be tested for this?
[00:03:55] Kate R: No. So CPE like any kind of bacteria that lives in the gut tends to live harmlessly there. So it's difficult to know when people are colonised because they don't display any symptoms. So there's no way of telling just by looking at someone which is why we ask for a stool sample as it's the most reliable way of diagnosing CPE.
[00:04:17] Kate H: Okay, just to clarify then, if we, obviously it lives in the community from what I'm understanding, and then we're not super concerned because it doesn't give us any symptoms. Then what is the concern in a hospital setting?
[00:04:31] Kate R: Sure. So within a hospital setting, obviously our patients are undergoing treatment.
They have indwelling devices which breach the skin barriers. They have treatments that can result in conditions that causes things like leaky guts. So where bacteria can transfer from the gut into the bloodstream. So the concern is that carbapenems are often used as a last resort antibiotic to treat severe infections.
And because CPEs destroy these antibiotics, if a patient develops an infection with CPE, it can be difficult and sometimes impossible to treat. So one of the aims of getting the stool sample from the patient on admission is that not all CPEs are resistant to the same antibiotics. So getting a stool sample on admission gives us an idea of what we would use as a first line antibiotic for that patient if they were to become unwell. Because things take a while to grow in the laboratory,it's important that we know what the patient is colonized with, what antibiotics to use, because it takes a couple of days to get those answers from a clinical sample.
[00:05:32] Kate H: I get you. That makes way more sense to me. Okay. So in my inpatient setting then, what if I'm a staff member, what sort of PPE do I need to wear?
Do I need to wear anything?
[00:05:44] Kate R: Yeah. So for staff members we would advise that they wear long sleeved gowns, but only if they're having direct close contact with the patients. For any part of their uniform that wouldn't normally be covered by an apron. A long sleeve gown is what they should be wearing for things like popping into a room to collect a meal tray or if they're going in to switch off a pump or just to have a conversation.
If they're not anticipated to pick the child up or anything like that, then an apron is perfectly fine In terms of gloves there is often a misconception that gloves are required for patients colonised with CPE. But hand hygiene is a lot more effective than glove use, and we would only recommend gloves in line with standard precautions.
So that's if any exposure to blood or bodily fluids is anticipated.
[00:06:31] Kate H: Got you. And if I'm a parent, do I need to wear anything special?
[00:06:36] Kate R: No, so parents don't have to wear anything special. Obviously it's their child. They live with them. So they all share most of the time the same flora doesn't necessarily mean that the parent is colonised.
Sometimes with healthy adults, these bacteria can come and go. So they live transiently in the body. So it might be that they have once upon a time been colonised, but because they're generally fit and healthy it can just pass with time. The only thing we would ask from parents is that they, perform good hand hygiene, so using hand sanitizer when they're entering and leaving the bed space. And also if they're planning to take anything out of the room for example, meal trays or if they need to sterilize a a baby bottle or a dummy that they wipe it down with the Clinell wipe before removing it from the room.
'cause it can transfer on surfaces and contaminated equipment and items.
[00:07:30] Kate H: And then I can imagine if they're going to change a nappy or something, we are talking good soap and water hand hygiene afterwards. Absolutely. Yeah. Yeah, definitely. I should do,
[00:07:37] Kate R: definitely.
[00:07:38] Kate H: Okay. So is there anything special then, if it lives on surfaces and stuff, is there anything special that we need to consider from an environment sort of point of view?
[00:07:48] Kate R: Yeah, definitely. So CPE does like to live in the environment. It does like to live in sinks. So I think one of the key messages is that sinks are only used for the purpose of hand hygiene. So that's your hand washing sinks, in patient bed spaces in the bathroom, they're there to use as hand washing sink.
They're not to wash equipment in. We have dedicated equipment washing sinks in various rooms in the hospital. So staff areas like their drug room will have equipment washing sinks. The sluice will, sometimes some of our expressing rooms have equipment washing sinks as well. So things shouldn't be being poured down the sink or washed in sinks as that can encourage the growth of bacteria in sinks.
Then in terms of cleaning the environment. Day to day it would just be in line with kind of the usual cleans that we expect for every patient. So the domestic staff will go in and clean the patient's room, the nurses will make sure that the equipment utilised on the patient is clean, and then when patients are discharged, is when the kind of more enhanced cleans come into play.
So we have different levels of cleans at GOSH which mean different things. So we have what we call a level four clean, which will be a chlorine clean of the whole room. So floors, walls, equipment, ceiling. And then after that we, a machine that produces hydrogen peroxide vapor, and that's just to make sure that the environment is safe for the next patient.
[00:09:14] Kate H: Okay. Thank you for that. I think that's really made things a bit clearer for me. And so the, you are part of the Infection prevention control team. Is there anything that the team are doing to help prevent the spread of CPE?
[00:09:29] Kate R: Yeah, so we routinely screen, well, we advocate for routine screening of all patients.
That's within 72 hours of admission and every 30 days. We encourage the cleaning of hands before and after patient contact by providing our alcohol hand gel at the point of care. So that's for patients, parents and staff to use. And we work with our cleaning teams, obviously, to ensure and improve levels of cleanliness in wards and general areas.
[00:10:03] Kate H: Got you. Thank you. So thinking about then trying to de- alert a patient, so will a patient ever be clear of CPE and be able to have their alert removed?
[00:10:16] Kate R: So because CPE can live harmlessly in the gut for long periods, and it's often difficult to know when they no longer pose a risk or are no longer present, we don't routinely declare children free from CPE at GOSH.
And I think it's important to mention that this isn't just about the isolation of people, patients colonised with CPE. It's important that alert stays there as it is a flag for appropriate antimicrobial prescribing.
[00:10:44] Kate H: Okay. I understand. So to wrap up then, what are your three key take home messages about CPE?
[00:10:55] Kate R: So I would say number one, when a patient is admitted to, GOSH, we will ask for a stool sample, which will test for CPE. And it's important that we try to collect this within the first three days of admission. So if you are a parent or a patient and you are asked to provide a stool sample, it's really important that we get this as it really does help us to give you the best care possible if there were to become a unwell with an infection.
Number two, CPE isn't just person to person transmission. It can be transferred in the environment like we've discussed. So I think it's just important to think about what you're taking in and out of rooms. Making sure things are cleaned appropriately before they're leaving the room. And also thinking more about what type of equipment is used with that patient.
And that leads me onto number three, which is that some items can be difficult to clean. And we do see this a lot in infection control. This doesn't mean that these items can't be used for patients colonised with CPE but we do need to ensure that the equipment is managed safely. So if you're a staff member and you are unsure about a piece of equipment, for example, if it's got velcro straps, which are very difficult to clean if it's made of a material which obviously can't be wiped daily, it's important that you contact us
'cause we can really support you with a risk assessment to make sure that the patient's care isn't impacted negatively by not being able to use the piece of equipment. But that. That piece of equipment in future is safe for other patients to use.
[00:12:33] Kate H: Got you. I understand. Thank you so much for your time.
I hope that's been helpful for anybody listening and we'll see you next time for the next ICE podcast. Thanks, Kate.
[00:12:44] Kate R: Thank you. Bye.
[00:12:45] SA: Thank you for listening to this episode. If you want to find out more about the work of the GOSH Learning Academy, you can find us on social media on Twitter, Instagram, and LinkedIn.
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