HPS Weekly Report

Correspondence to:The Editor, HPS Weekly ReportHPS, Clifton House, Clifton Place Glasgow, G3 7LNScotland

T 0141-300 1100 F 0141-300 1172

E wreditor@hps.scot.nhs.uk http://www.ewr.hps.scot.nhs.uk/

Printed in the UKHPS is a division of the NHS National Services Scotland Registered as a newspaper at the Post Office © HPS 2008

8 October 2008Volume 42 No. 2008/41ISSN 1753-4224 (Online)

Contents

CURRENT NOTES

• Handhygieneauditreport–andInternationalInfectionPreventionWeek

• Clostridiumdifficileassociateddisease(CDAD)–quarterlyreport

• Staphylococcusaureusbacteraemias(SAB)–quarterlyreport

• Meningitiscampaigntoraisestudentawareness

• Protectionagainstblood-borneinfectionsintheworkplace:HIVandhepatitis

• Influenzasurveillance2008-2009–andthe2007-2008annualreport

• InfluenzaTable• Erratum

pages 346 - 347

SURVEILLANCE REPORTS

• QuarterlyreportontheSurveillanceofClostridium difficileAssociatedDisease(CDAD)inScotland,April2008-June2008

• TheStaphylococcus aureusbacteraemiaquarterlyreportofcumulativedatafromallNHSboardsinScotland

pages 348 - 358

NOTIFIABLE TABLES

to 26/9/2008

pages 359 - 360

CURRENT NOTES

Hand hygiene audit report – and International Infection Prevention Week

42/4101 Health Protection Scotland will publish the latest Compliance with Hand Hygiene - Audit Report as part of the National NHS Hand Hygiene Campaign on Wednesday 8 October 2008. This will be available for download from http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx.

On Wednesday 1 October 2008, NHS board chief executives were sent an embargoed and confidential copy of the report along with the ‘your questions answered’ paper. These were also be forwarded to infection control managers and local health board co-ordinators (LHBCs).

This is the fourth report to present hand hygiene compliance at a country level by HPS (the first report was published on 27 December 2007, the second was published on 17 April 2008 and the third was published on 3 July 2008) and continues to aid understanding of compliance throughout NHSScotland.

All operational NHS boards as well as a special NHS board in Scotland have taken part in monitoring staff compliance with hand hygiene, utilising an audit tool and a complementary protocol produced to support a standardised approach in Scotland.

At this time HPS are also actively working on messages to go out to NHS Scotland reiterating the importance of hand hygiene at the point of care in particular and the solutions to be used when performing hand hygiene, including the appropriate use of alcohol hand rubs and liquid soap and warm water. This message will reiterate the appropriate solutions to be used when performing hand hygiene. The distribution of credit card size flyers containing this message were sent to LHBCs in each board in order to coincide with International Infection Prevention Week (IIPW2008), which commences on 20 October. The message is:

Hand rubs containing alcohol are the recommended products for ensuring effective hand hygiene in all patient care situations except when:

• hands are visibly soiled• the patient is experiencing vomiting and/or diarrhoea• there is direct hand contact with any body fluids i.e. if gloves have been forgotten to be

worn• there is an outbreak of norovirus, Clostridium difficile or other diarrhoeal illness.

In these instances hands should always be cleaned with liquid soap and warm water.

Collaborative work with those leading on the Scottish Patient Safety Programme is also in progress in order to promote hand hygiene.

For further information on IIPW 2008, see the APIC website at http://www.apic.org/AM/Template.cfm?Section=2008_International_Infection_Prevention_Week&Template=/CM/HTMLDisplay.cfm&ContentID=10250.

Clostridium difficile associated disease (CDAD) – quarterly report42/4102 A total of 1732 cases of CDAD were identified in the period April-June 2008. This is a 7% reduction on the previous quarter (January – March 2008) and, when hospital activity is taken into account, a 6% reduction in the overall rate for Scotland.

There has been a 9.5% reduction compared to the same period in 2007. It is too early to draw conclusions about trends in CDAD in those aged 65 and over as the surveillance programme has been running for less than 2 years.

Ribotype 106 remains the most common type reported in Scotland. HPS takes the view that all cases of CDAD should be treated as though they are caused by hypervirulent strains given that there is a delay between diagnosis and typing results and good infection control measures are an essential means of controlling transmission.

For further details, see this week’s surveillance report.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

347

Staphylococcus aureus bacteraemias (SAB) – quarterly report

42/4103 The number and rate of MRSA bacteraemia reported in the period 1 April 2008-30 June 2008 was the lowest reported since 2003 and the rate per 1000 AOBDs has shown a statistically significant decrease overall.

The rate and number of SAB is the second lowest reported and is lower than the same quarter in any previous year of surveillance.

The specialties where both MRSA and MSSA bacteraemia are found most commonly are medical, renal and surgical. Infection prevention interventions focussed on these specialties are likely to have the greatest benefit in reducing SAB and HPS are working with the NHS boards in order to address this.

For further details, see this week’s surveillance report.

Meningitis campaign to raise student awareness

42/4104 The ‘Meningitis: Know the Signs’ Campaign begins its latest phase this week, with a special focus on students who have recently returned to college or university. The campaign, which aims to raise awareness about the symptoms of meningitis, encourages the public to seek out information on meningitis before illness occurs. It follows on from a successful campaign last year which saw student awareness levels of the risk of meningitis rise from 40% to 72%.

Students are being encouraged to learn the signs and symptoms and to look after each other during this busy time. The campaign consists of radio advertisements, posters and quick-guide symptoms cards which are being distributed across Scottish colleges and universities, and online message banners. The National Union of Students (NUS) Scotland also distributed ‘bags for life’ at Freshers Fayres which encouraged students to seek out more information.

The campaign has been developed in partnership between NHS Health Scotland, Health Protection Scotland, the Scottish Government and NHS 24 along with three leading charities, Meningitis Association Scotland, Meningitis Research Foundation and the Meningitis Trust and the National Union of Students (NUS) Scotland.

Protection against blood-borne infections in the workplace: HIV and hepatitis

42/4105 The Advisory Committee on Dangerous Pathogens (ACDP) guidance document Protection against blood-borne infections in the workplace: HIV and hepatitis was last published in 1996. An updated, draft version of the guidance is now available (at http://www.hse.gov.uk/biosafety/diseases/blood-borne-virus.htm) for consultation and the ACDP would value stakeholders’ comments.

The updated guidance is intended to cover workplace situations where exposure to blood-borne viruses (BBV) is possible. Aspects of virology, legal issues, controls and recommended actions post-exposure, are presented. A key aim of the guidance is to provide links to existing, specialist guidance where it exists, rather than reproducing information unnecessarily. The guidance has been split into several sections with appendices, as it is appreciated that not everyone will wish to read all sections, but comment on all areas will be welcomed.

The consultation ends on 17 November 2008.

Influenza surveillance 2008-2009 – and the 2007-2008 annual report

42/4106 October sees the start of influenza surveillance at HPS (see Influenza Table below). The annual surveillance runs throughout the winter months from October 2008 until May 2009 (week 40 till week 20) and provides information on which flu viruses are circulating in the community. Interpretation of the data from the various surveillance streams also helps to determine the intensity and the impact of the seasonal outbreak on the Scottish population and is useful information for service providers and the public alike.

Reports on influenza activity based on the surveillance indicators and further information on the various surveillance streams are available on the HPS website at: http://www.hps.scot.nhs.uk/resp/influenzaseason.aspx?subjectid=00.

In particular, the annual report for the 2007-2008 influenza season (published in September 2008) can be accessed at http://www.hps.scot.nhs.uk/resp/publicationsdetail.aspx?id=38980.

Erratum: Surveillance of known hepatitis C antibody positive cases in Scotland: Results to 30 June 2008: Table 4 in the surveillance report published on 24 September has been updated to reflect a newly adopted breakdown of the total figures. All electronic versions of this table have been updated on the website.

INFLUENZA TABLE: Reports from GP spotter practices of consultations for flu-like illness, rates per 100,000

WEEK No. WEEK ENDING AA BR DG FF FV GG GR HG LN LO OR TY WI SCOTLAND

40 3/10/08 15 16 67 0 3 8 N/R 0 3 4 N/R 0 71 8

N/R no return

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

348

Surveillance Reports

Quarterly report on the Surveillance of Clostridium difficile Associated Disease (CDAD) in Scotland, April 2008 - June 2008

Prepared by: The HPS C. difficile Working Group

Executive Summary

• This report covers the second quarter of 2008 for data collected under the mandatory CDAD surveillance programme. Data from April 2008-June 2008 in 15 NHS boards (previous reports have not included data from Golden Jubilee National Hospital) are presented and compared to previous quarters, including comparison with annual rates.

• A total of 1732 cases, in persons aged 65 and over, were identified during this period, which corresponds to a 7% decrease in comparison with the previous quarter (January 2008-March 2008) where 1861 cases were reported. When hospital activity is taken into account, this corresponds to a decrease of 6% in the overall rate for Scotland (from 1.41 to 1.33 per 1000 OCBD).

• In comparison with the second quarter of 2007 the overall rate for Scotland has decreased 9.5% in this quarter (April-June 2008) from 1.47 to 1.33 per 1000 OCBDs.

• A new addition to this report is the introduction of funnel plots to identify incidence rate outliers. For this quarter, all 15 NHS Boards were within the 95% confidence limits of the funnel plot. Thus no NHS Board in Scotland has a rate above the expected level.

• Ribotype 106 remains the most common type reported in Scotland followed by ribotype 001. All ribotypes isolated were sensitive to metronidazole and vancomycin.

• The National Surveillance Programme is retrospective (i.e. three months in arrears) and does not replace the need for local monitoring of cases of CDAD.

1. Introduction

The surveillance programme monitors the occurrence of CDAD in all patients aged 65 and over, presenting with diarrhoea, and who have been in contact with the healthcare system, including acute and non-acute hospitals and primary care.

This report covers the second quarter of 2008’s data collection under the mandatory CDAD surveillance programme. Data from April 2008-June 2008 in 15 NHS boards are presented and compared to the previous quarters of data and to annual rates.

2. Methods

2.1 Laboratory testing

Diarrhoeal stools from patients, aged 65 and older, were tested for toxin A and B using either an immunoassay or a cytotoxicity assay. A diarrhoeal stool is defined as a specimen that takes the shape of its container. A case of CDAD is someone in whose stool C. difficile toxin has been identified at the same time as they have diarrhoea not attributable to any other cause, or from patients from whose stool C. difficile has been cultured at the same time as they have been diagnosed with pseudomembranous colitis (PMC).

Isolates of C. difficile were typed using PCR ribotyping according the method described by O’Neill et al. (1996). Variable-length intragenic spacer regions of the rRNA complex were amplified by PCR, and ribotype patterns were compared directly with those of reference strains obtained from the UK national reference laboratory for C. difficile in Cardiff. The isolates were further susceptibility tested against 9 antibiotics using Etest (AB Biodisk, Solna, Sweden). Breakpoints were derived from the Clinical and Laboratory Standards Institute

(CLSI) criteria and aligned with those used in England and Wales: cefotaxime, (CEFO), (64μg/ml), clindamycin, (CLIN), (≥8μg/ml), erythromycin, (ERYT), (≥8μg/ml), levofloxacin, (LEVO), (≥8μg/ml), meropenem, (MERO), (≥16μg/ml), metronidazole, (METR) (≥32μg/ml), moxifloxacin, (MOXI), (≥8μg/ml), piperacillin-tazobactam (PIP/T), (≥128μg/ml), and vancomycin (VANC), (≥16μg/ml).

2.2 Reporting

Rates of CDAD are presented by NHS board. Each case is allocated to an NHS board based on the location of the diagnostic laboratory where the specimen was tested. The surveillance does not distinguish between cases from acute, non-acute hospitals, and the community. It is currently assumed that all cases have been in contact with the healthcare system within 12 weeks of acquiring CDAD and therefore can be classified healthcare associated cases. Duplicates have been removed. If a case is diagnosed twice within a 28-day period the second toxin positive test will be considered a duplicate.

Previous reports have not included case data from Golden Jubilee National Hospital. In this report, data is included from Golden Jubilee for the funnel plot analysis but have not been incorporated into the results for total cases and rates across Scotland.

In this quarter 65% of the laboratory data were received by HPS via the electronic reporting system ECOSS. Where available, de-duplicated ECOSS data are used for calculating the total number of cases for the national dataset. For those laboratories that still submit weekly paper-based reports to HPS, de-duplicated data from the HPS laboratory-reporting database are used.

Please note CDI rates in this report have been updated due to a subsequent revision of the national figures of hospital activity. Please go to http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=50174 for the newest revised data.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

349

The exact date of onset of illness is not reported; instead the date of collecting specimen from the patient is taken as a proxy for the onset of illness for the ECOSS reports. When this date is not available the date of receiving the specimen or date of reporting is used. Before entering the data into the dataset each diagnostic laboratory has the opportunity to review the data originating from themselves.

The new NHS boards for Scotland were used for generating the national dataset in this report. Cases from the previous Argyll & Clyde NHS board laboratories, including Vale of Leven, Inverclyde and Paisley, are now counted under the new Greater Glasgow & Clyde NHS board, while cases from Oban are counted under the Highland NHS board.

2.3 Data analysis

Calculation of rates

The incidence of CDAD per NHS board area was calculated as follows:

The number of total occupied bed days (total OCBDs) includes patients in acute hospitals and patients in non-acute geriatric medicine and geriatric long-term stay wards except for psychiatry and obstetrics. In contrast to previous reports, this and future reports will not contain rates for acute beds, as these rates were found unsuitable for monitoring CDAD in Scotland.

The bed day data used here were from the period April 2007-June 2007. In addition to the rates per occupied bed days, the rate of disease was also calculated per 100,000 inhabitants ≥ 65 years old for each NHS board.

Denominators for the new NHS board, Greater Glasgow & Clyde, were calculated as the sum of the two former boards, Greater Glasgow and Argyll & Clyde.

Identification of outliers

A funnel plot was produced for the incidence of CDAD in 15 NHS Boards in the period April-June 2008. The statistical analysis was based on an over-dispersed Poisson regression model with the logarithm of the total occupied bed days as an offset. In the funnel plots the incidence rates of CDAD per 1000 occupied bed days are plotted against the number of occupied bed days in 100,000s along with 95% confidence limits. Incidence rates outside of the 95% confidence limits are considered outliers.

3. Results

3.1 Surveillance data

During the period April 2008 to June 2008, HPS received case reports from 25 diagnostic laboratories in 15 NHS boards. In total, 100% of cases in this report were confirmed by the laboratories that reported them.

Note that the following data for cases and rates (apart from the funnel plot analysis) do not include Golden Jubilee figures.

The total number of cases identified in this period was 1732, which corresponds to a 7% decrease relative to the previous quarter (January-March 2008) where 1861 cases were recorded. The total number of cases and rates by NHS board are listed in Table 1. Two cases from Golden Jubilee National Hospital were reported this quarter.

The average rate of CDAD per 1000 total occupied bed days (OCBDs) ≥ 65 years old for the 14 NHS boards was 1.26 with a range of 0.19-1.94 and a standard deviation of 0.48 (Figure 1).

The overall rate for Scotland for this quarter was 1.33 per 1000 OCBDs, which corresponds to a decrease of 6% compared to the last quarter (1.41 per 1000 OCBDs). This quarter’s overall rate is 5% above the annual overall rate for 2007, which was 1.26 per 1000 OCBDs (see Table 1 for individual NHS boards in the Appendix).

In comparison with the overall rate for the second quarter of 2007, this quarter’s rate is down 9.5% (from 1.47 to 1.33 per 1000 OCBDs).

Note that Orkney does not provide a non-acute (overnight) specialty in elderly care.

The rates per total OCBDs decreased in seven NHS boards, increased in six and stayed the same in one NHS board, relative to the last quarter. Notably, NHS Lanarkshire reported a 35% decrease per 1000 total OCBD for this quarter (from 2.14 to 1.39). NHS Highland, which experienced greater than 50% reduction in the previous quarter, still has a rate well below the average rate for Scotland.

Rates of CDAD were also calculated using the population ≥ 65 years old per NHS board area as the denominator. The average rate for the 14 NHS boards was 176 cases per 100,000 persons ≥ 65 years old with a range of 30-281 and a standard deviation of 71 (Figure 2).

The average rate per 100,000 persons ≥ 65 years old has decreased by 2% compared to the previous quarter (from 180 to 176 per 100,000 persons ≥ 65 years old).

Rate per 1000 =

number of CDAD cases * 1000occupied bed days occupied bed days ≥ 65 y.o. in board area

FIGURE 1. Rates of CDAD per 1000 total occupied bed days in acute and non-acute hospitals in 14 NHS boards in Scotland

(*NHS Dumfries and Galloway occupied bed days data was incomplete during this period thereby giving an overstated CDAD rate when expressed per 1000 total OCBD).

Please note CDI rates in this report have been updated due to a subsequent revision of the national figures of hospital activity. Please go to http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=50174 for the newest revised data.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

350

3.2 Identification of outliers

The funnel plot of the incidence rates of CDAD per 1000 OCBDs shows that the rates in all NHS Boards were within the 95% confidence limits (see Figure 3).

Please note that the precision of these analyses are higher for the NHS Boards with large numbers of occupied bed days than for those with smaller number of OCBDs.

3.3 Typing and susceptibility data

Ribotype data

Isolates have been submitted by 23 hospitals (representing 14 NHS boards). Of the 294 specimens received in the period November 2007-June 2008, most were ribotype 106 (36.4 %), 001 (24.8 %), 027 (10.5 %), 078 (4.1 %), 002 (3.8 %) and 023 (3.1 %) (see Figure 4). These are cumulative data including the 79 ribotypes already reported for the 1st quarter of 2008.

Thirty-one isolates of the hypervirulent ribotype 027, corresponding to 10.5 % of the isolates, were reported in the period November 2007-June 2008 (see text below for details on reported 027 outbreaks).

Four isolates are awaiting results and a further two have been sent to Leeds for confirmation. In total, 21 different ribotypes were reported.

Antibiotic susceptibility

The susceptibilities of the 294 isolates were investigated by determining the minimum inhibitory concentration (MIC) for the nine antibiotics previously listed. Figure 5 shows the resistance profiles for the nine antibiotics. All isolates were sensitive to metronidazole (MIC range 0.032-1.5 µg/ml) and vancomycin (MIC range 0.25-2.0 µg/ml). Furthermore, all the isolates were sensitive to piperacillin-tazobactam (MIC range 0.5-20 µg/ml) and meropenem (MIC range 0.38-3.0 µg/ml).

Cefotaxime resistance was reported in 200 isolates (68.0%) (MIC range 1.5 to ≥256 µg/ml) and moxifloxacin resistance in 213 isolates (72.4%) (MIC range 0.75 to ≥32 µg/ml). The highest resistance rates reported were for levofloxacin (73.8%, MIC range 0.75 to ≥32 µg/ml), erythromycin (75.5%, MIC range 0.094 to ≥256 µg/ml), and clindamycin (86.4%, MIC range 1.0 to ≥256 µg/ ml).

Antibiotic susceptibility in ribotypes 106, 001 and 027

For the period November 2007-June 2008, cefotaxime resistance was observed in 91% (97/107) of ribotype 106, 89% (65/73) of ribotype 001 and 61% (19/31) of ribotype 027. Almost all isolates were resistant to erythromycin, levofloxacin and moxifloxacin (range 97-100%), with ribotype 027 being 100% resistant to all three antibiotics (31/31). Clindamycin resistance was observed in 90% (96/107) of ribotype 106, 86% (63/73) of ribotype 001 and 94% (23/31) of ribotype 027.

Ribotype 027 surveillance

From October 2006 to 1st August 2008, 65 cases of ribotype 027 have been reported in Scotland. It should be noted that

FIGURE 2. Rates of CDAD per 100,000 inhabitants ≥ 65 years old in 14 NHS boards in Scotland.

FIGURE 3. Funnel plot of rates of CDAD for all NHS Boards in Scotland against total occupied bed days (x1000) for the period April 2008-June 2008. Concave lines represent 95% confidence limits and the horizontal line the mean rate of CDAD.

FIGURE 4. C. difficile PCR ribotypes in Scotland. Specimens were submitted in the period November 2007-June 2008.

FIGURE 5. Resistance profiles among Scottish isolates for nine antibiotics (November 2007-June 2008).

Please note CDI rates in this report have been updated due to a subsequent revision of the national figures of hospital activity. Please go to http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=50174 for the newest revised data.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

351

this time period extends beyond the 3 month period of the quarterly report. Therefore, there are more isolates and antibiotic susceptibility data given here than for the 31 cases already mentioned (see section 3.3 Typing and susceptibility data – Ribotype data). Of the 65 cases in total, five were typed by the ARL in Cardiff, a further two isolates were identified by retrospective typing of samples as part of a research study, and antibiotic susceptibility data is available for the remaining 58 isolates. Figure 6 shows the resistance profiles for these 58 isolates. All the isolates were susceptible to metronidazole and vancomycin, with 100% resistance observed for erythromycin, levofloxacin and moxifloxacin. Clindamycin resistance was reported in 56 of 58 isolates (96.6%), whereas cefotaxime resistance was observed in 40 of 58 isolates (69 %).

Ribotype 027 outbreaks

No further outbreaks of 027 have been observed since the previous report. Sporadic cases of 027 continue to be identified by the Scottish C. difficile reference service. The service has seen a significant rise in the number of sample requests.

An additional 14 cases of 027 were confirmed as part of the investigation into the outbreak at the Vale of Leven Hospital, bringing the total number of 027 cases to 18. Antibiotic susceptibilities for these isolates are included in the cumulative data in Figure 6 above.

4. Discussion

This report covers CDAD surveillance data in persons, aged 65 and over, collected from April 2008-June 2008. Accumulated typing data is provided covering the period from November 2007-June 2008. In addition, there is some follow-up to the outbreaks reported in the last quarter.

A total of 1732 cases, in persons aged 65 and over, were identified during this period, which corresponds to a decrease of 7% in comparison with the total number from the previous quarter (January 2008-March 2008) where 1861 cases were reported.

When hospital activity is taken into account, this corresponds to a decrease of 6% in the overall rate for Scotland (from 1.41 to 1.33 per 1000 OCBDs).

During the same quarter last year (April 2007-June 2007), there were 1588 cases with an overall rate per 1000 OCBDs of 1.47 (this is the revised rate: see http://www.hps.scot.nhs.

uk/ewr/redirect.aspx?id=36578 for details). The rate for this quarter was 1.33 per 1000 OCBDs, which corresponds to a decrease of 9.5% in the rate for this year.

For the first time, funnel plots were used to identify any case rate outliers. All NHS boards were within the 95% confidence limits.

A number of important caveats associated with the data in this report must be highlighted: (a) regional differences in healthcare provision and the age distribution of the population are factors likely to affect the number of persons acquiring CDAD in each NHS board area; (b) full compliance with the national surveillance protocol has been achieved gradually at different times in various NHS boards and comparison with previous data could therefore be associated with error; (c) previous validation studies (not mentioned in this report) showed that 9-35% of reported cases had no documented symptoms – some of these cases may have been reported as false-positive cases; and (d) case review studies reported in last quarter’s report showed that community-associated CDAD varies between NHS boards from 0-26%. For these reasons the data reported in this report should be interpreted with caution.

Typing of selected isolates from suspected outbreaks and cases of severe disease showed that ribotype 106 and 001 remain the two most prevalent strains in Scotland. There has been little change in the frequency of ribotype 106 and 001 since the previous quarterly report: 38% to 36.4% and 24.1% to 24.8%, respectively.

Since not all hospitals in Scotland have used the C. difficile ribotyping service yet, the distribution of ribotypes reported here may be not be fully representative of all NHS board areas. Furthermore selection bias favouring certain ribotypes (and antibiotic resistance patterns) could occur due to the sampling criteria provided in the surveillance protocol. A snapshot programme to ascertain the distribution of ribotypes in Scotland is therefore currently being developed by the C. difficile reference laboratory in collaboration with HPS.

The frequency of ribotype 027 has increased from 3.8% in the previous quarterly report to 10.5% in this report. This change is in part due to cases found in the recent Vale of Leven investigation, although the numbers are subject to bias as a large number of patients were investigated retrospectively. It remains to be seen whether levels will continue to rise.

In general there has been a large increase in submission of isolates across Scotland following heightened awareness of CDAD.

Of the Scottish 027 isolates that have been MIC-tested, 100% were resistant to fluoroquinolones, 96.6% to clindamycin and almost 70% resistant to cephalosporins, compared to 100%, 90% and 53%, respectively last quarter. Thus, the use of fluoroquinolones, cephalosporins and clindamycin may play an important role in the spread and persistence of ribotype 027 in Scotland.

More isolates of ribotype 078 have been reported in Scotland, although frequency has not changed markedly (4.1% compared to 3.8% in the previous quarterly report). Ribotype 078 is a new emerging type with similar mechanisms for hyper production of toxins as ribotype 027 and is commonly found in pigs. Ribotype 078 is increasingly being reported in Belgium, The Netherlands, and Northern Ireland.

FIGURE 6. Resistance of ribotype 027 to nine antibiotics (October 2006- 1 August 2008).

Please note CDI rates in this report have been updated due to a subsequent revision of the national figures of hospital activity. Please go to http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=50174 for the newest revised data.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

352

Previous reports have not included case data from Golden Jubilee National Hospital. In this report, data is included from Golden Jubilee for the funnel plot analysis but have not been incorporated into the results for total cases and rates across Scotland. As most procedures and healthcare given in the Golden Jubilee Hospital are planned and short-term in nature, rates of HAI are probably not comparable with other healthcare settings in Scotland.

It is important that the service is aware and remains vigilant to the possibility of outbreaks of C. difficile of any ribotype.

Appendix TABLE 1. Total number of cases this quarter, and quarterly vs. annual rates of CDAD in 14 NHS boards in Scotland.

Total number of cases Rates per 1000 total OCBD (elderly)Apr 2008-Jun 2008 Apr 2008-Jun 2008 Annual (2007)*

Ayrshire & Arran 160 1.62 1.37’

Borders 25 0.78 0.46

Dumfries & Galloway 41 1.16 1.75†

Fife 98 1.34 1.04

Forth Valley 126 1.71 1.19

Grampian 226 1.88 1.01

Greater Glasgow & Clyde 402 1.10 1.25

Highland 47 0.81 1.09

Lanarkshire 189 1.39 1.64

Lothian 261 1.35 1.31

Orkney 5 1.94 0.87

Shetland 1 0.19 0.77

Tayside 145 1.43 1.46

Western Isles 6 0.95 0.82

Scotland (overall) 1732 1.33 1.26*Note that annual rates (2007) are based on data collected from October 2006-September 2007.‘The annual rate per 1000 total OCBD for NHS Ayrshire and Arran has been revised retrospectively.† NHS Dumfries and Galloway occupied bed days data was incomplete during this period thereby giving an overstated CDAD rate when expressed per 1000 total OCBD.

Acknowledgement

We would like to thank all the microbiologists and biomedical scientists who have provided and reviewed data for the CDAD surveillance programme and the Scottish C. difficile reference service for providing ribotyping data. Information Services Division of the NHS in Scotland is thanked for providing the hospital activity denominator data for this report.

The last Clostridium difficile Associated Disease (CDAD) in Scotland Surveillance Report was in Issue 08/27The next Clostridium difficile Associated Disease (CDAD) Surveillance Report will be in Issue 09/02

Please note CDI rates in this report have been updated due to a subsequent revision of the national figures of hospital activity. Please go to http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=50174 for the newest revised data.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

353

The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS boards in Scotland

Prepared by: Scottish Surveillance of HAI Programme

Introduction

The S. aureus bacteraemia report will be presented as follows:

• National data on S. aureus bacteraemia, both meticillin resistant S. aureus (MRSA) and meticillin sensitive S. aureus (MSSA).

• Data on S. aureus bacteraemia, both MRSA and MSSA at an NHS board level in Appendix I. I (see full report at http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248).

• National and board level data on S. aureus antimicrobial resistance provided by the Scottish MRSA Reference Laboratory (SMRSARL) using isolates submitted to the European Antimicrobial Resistance Surveillance System (EARSS). Infections recorded as being associated with a device will also be reported at a national and board level.

S. aureus is a gram positive bacterium that colonises the anterior nares of about 30% of the healthy population. Although mainly a harmless coloniser, S. aureus can be a major cause of serious infection and both meticillin sensitive and meticillin resistant S. aureus (MSSA and MRSA) remain endemic in many UK hospitals. In addition, new and more virulent clones are arising in the community.

The EARSS programme, funded by the European Centre for Disease Prevention and Control (ECDC), is an international network of national surveillance systems which collects comparable and validated antimicrobial susceptibility data for public health action.

EARSS performs on-going surveillance of antimicrobial susceptibility for S. aureus causing invasive infections and monitors variations of antimicrobial resistance over time and place. Over 800 microbiological laboratories serving more than 1300 hospitals from 31 countries provide S. aureus susceptibility data1. According to EARSS (2006) the United Kingdom MRSA bacteraemia prevalence, as a proportion of all S. aureus bacteraemia, is one of the highest in Europe1.

MRSA is the most important cause of antibiotic-resistant healthcare associated infection worldwide2. Within 2 years of the introduction of meticillin for clinical use, the first meticillin resistant S. aureus was detected in the United Kingdom in 1961. Since then, the emergence and spread of MRSA has been documented on every continent 3-5. The use of specific antimicrobial drugs (fluoroquinolones, macrolides and cephalosporins) are associated with nosocomial MRSA 6-7, and a dose dependent association has been observed between exposure to antimicrobial drugs and nosocomial MRSA (patient and hospital level)8. Glycopeptide standard therapy has been associated with clinical failures (particularly with Glycopeptide Intermediate S. aureus (GISA) and/or isolates with ≥ 1.5 mg/l MIC)9-10 and resistance to new effective therapies (linezolid, daptomycin, tigecycline) has also been reported11.

Antimicrobial resistance (AMR) threatens the effectiveness of successful treatment of infections and is a public health issue

with local, national, and global dimensions. Antimicrobial resistance can result in increased morbidity, disease burden, and mortality.

It is therefore important that surveillance of meticillin sensitive and meticillin resistant S. aureus should be undertaken in a systematic way, results fed back routinely to healthcare staff and the inappropriate or unnecessary use of antimicrobials avoided12.

This is the second report in which we present AMR data. In time we propose identifying trends in resistance and looking at associated strain types to assist stakeholders in developing a better understanding of the evolving epidemiology of this organism.

This report also includes information on device associated S. aureus bacteraemia. This information is obtained from the EARSS form submitted to the SMRSARL by diagnostic laboratories with each S. aureus blood isolate. One of the recommendations of the NHS Scotland National HAI Prevalence Survey was that there should be targeted incidence surveillance for vascular catheter infections and S. aureus bacteraemia13. The insertion of vascular catheters has been well documented as being a risk factor for bacteraemia14-16.

National data on S. aureus bacteraemia

Data reporting periods

Additional data in this report

All S. aureus bacteraemia reported to HPS from 1 April 2008 to 30 June 2008.

Antimicrobial resistance data from 1 April 2008 to 30 June 2008.

Device associated infections from 1 April 2008 to 30 June 2008.

Data sourcesAll 14 NHS boards in Scotland report the first isolate of MSSA and the first isolate of MRSA from a blood culture within a two week period to HPS from routine laboratory data.

All 14 NHS boards in Scotland submit the first S. aureus blood isolated from a patient to the SMRSARL for typing

TABLE 1: Reporting periods for S. aureus

S. aureus bacteraemia Data available from 1 April 2005 to 30 June 2008

MSSA bacteraemia Data available from 1 April 2005 to 30 June 2008

MRSA bacteraemia Data available from 1 January 2003 to 30 June 2008

Antimicrobial resistance

Data available from 1 April 2008 to 30 June 2008

Device associated infections

Data available from 1 April 2008 to 30 June 2008

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

354

and antimicrobial susceptibility testing as part of the EARSS programme.

Episodes of S. aureus bacteraemia are included in this report if we receive a report from either of the above surveillance systems.

(On occasion an NHS board will not submit a S. aureus blood isolate to the SMRSARL and therefore typing and antimicrobial susceptibility will not be performed. As a result the total numbers in the two surveillance systems will not always be equal. Health Protection Scotland will continue to monitor submission of isolates to the SMRSARL in order to ensure compliance with HDL(2006) 3817).

DefinitionsIn the United Kingdom an episode of S. aureus bacteraemia (MRSA and MSSA) is defined as a person from whose blood MRSA or MSSA has been isolated and reported by an accredited diagnostic microbiology laboratory in the absence of a positive blood culture in the previous two weeks18.

This definition has been applied to the EARSS isolates in order that the two datasets are aligned. This enables consistency in reporting.

One acute occupied bed day (AOBD) is an acute bed occupied for one night. An acute bed is any bed other than a Care of the Elderly Long Stay or Psychiatric bed18.

HEAT TargetThere is a national HEAT target for NHS boards in Scotland to achieve an overall 30% reduction of S. aureus bacteraemia by 2010 against a validated base line data period of April 2005 to March 2006. Each NHS Board has an individual target ranging from a reduction of 25% to 40%.

MethodsAll S. aureus bacteraemia data sent to HPS are defined in terms of episodes and validated. Methods are detailed in the S. aureus bacteraemia protocol18.

AOBDs come from the Information Services Division (ISD) of National Services Scotland (NSS) (www.isd.org).

Antimicrobial resistance data is supplied by the SMRSARL as part of the EARSS programme.

Statistical methodsQuarterly S. aureus bacteraemia rates were analysed through negative binomial regression and rates predicted to the end of the HEAT target period (31 March 2010). Analysis was performed in Intercooled Stata for Windows 9.1.

Analysis of S. aureus bacteraemia rate and numerator dataS. aureus bacteraemia data are expressed as rates using acute occupied bed days (AOBDs) as the denominator and, where appropriate, by numerator alone, e.g. within the Pareto charts where the number of episodes is more informative.

S. aureus bacteraemia trend analysis is presented as predicted estimates of future S. aureus bacteraemia rates with 95% prediction intervals and by overlaying HEAT trajectory figures.

MRSA bacteraemia analysis is by Statistical Process Control (SPC) Chart19. MSSA data (and therefore data on all S. aureus bacteraemia) are not presented as an SPC chart because there are insufficient data points.

The number of MRSA and MSSA bacteraemia are shown by specialty in separate Pareto charts. This method shows the frequency of events in descending order along with the cumulative proportion and is often used to identify areas for improvement.

The numbers of S. aureus bacteraemia (MRSA and MSSA) are presented in a run chart showing the quarterly number against time.

S. aureus antimicrobial susceptibility data are provided at a National level in tabular form along with information on numbers of device associated infections.

Data presentation and interpretationDetails of the data, figure types and interpretation are provided with each graphic within the main report.

Antimicrobial resistance and device associated data for Scotland as a whole is shown in table form for all isolates submitted to SMRSARL during the period 1 April 2008 to 30th June 2008.

Local use of this reportTo achieve the HEAT target of 30% reduction in S. aureus bacteraemia by 2010 NHS Boards will have to ensure they undertake significant and sustained system changes targeted at the primary infections that cause S. aureus bacteraemia. Anything less than this is unlikely to result in a successful achievement of the HEAT target. To optimise progress towards achieving the S. aureus bacteraemia HEAT target, NHS Boards should:

• Be aware of the locations in which most S. aureus bacteraemia occur in their NHS Board

• Be aware of the primary infections causing S. aureus bacteraemia in these areas

• Deploy the HPS care bundles designed to reduce specific primary infections in the areas with the greatest incidence of S. aureus bacteraemia.

HPS have produced tools to further assist infection control teams to direct their activities where they are likely to yield the greatest benefits in reducing S. aureus bacteraemia. These tools include a device days reduction estimate tool, and the use of SBAR (Situation, Background, Assessment, Recommendation)20 templates to optimise effective communication within individual NHS Boards.

National policy documents related to this work

This S. aureus bacteraemia report is produced in compliance with:

HDL(2006) 38. A revised framework for national surveillance of healthcare associated infection in Scotland, SGHD17.

HDL(2001) 57. A framework for national surveillance of hospital acquired infection in Scotland, SEHD21.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

355

Results

Table 2 represents the quarterly number of validated episodes of MRSA bacteraemia from 1 January 2003 to 30th June 2008, the validated number of MSSA bacteraemia from 1 April 2005 to 30th June 2008 and the total number of S. aureus bacteraemia from 1 April 2005 to 30th June 2008 along with rates per 1000 AOBDs for all NHS boards in Scotland.

The most recent quarter, 1 April 2008 to 30th June 2008, has the lowest number and rate of MRSA bacteraemia of any quarter reported to this surveillance programme since the quarter October to December 2003 and is lower than the same quarter in any previous year.

The rate and number of S. aureus bacteraemia is the second lowest reported since MSSA bacteraemias were included in this surveillance programme and is lower than the same quarter of any year of the surveillance.

Figure 1 shows the quarterly number of S. aureus bacteraemia in Scotland from 1 April 2005 to 30th June 2008 as a run chart with the HEAT trajectory line from 1 April 2005 to HEAT target end of 31 March 2010.

The annual number of S. aureus bacteraemia reported in Scotland has fallen by 5.2% per year (95% CI 1.3% to 8.9%) since the HEAT baseline of 1 April 2005 to 31 March 2006. As the confidence interval contains the HEAT target of a 7% per year decrease there is no evidence that target will not be achieved.

TABLE 2: Quarterly No. of S. aureus bacteraemia (MRSA and MSSA) in Scotland,

Quarter

No.

of M

RSA

ba

cter

aem

ia

No.

of M

SSA

bact

erae

mia

No.

of S

. au

reus

ba

cter

aem

ia

Acu

te

Occ

upie

d B

ed D

ays

(AO

BD

s)

MR

SA

bact

erae

mia

pe

r 100

0 A

OB

Ds

MSS

A ba

cter

aem

ia

per 1

000

AO

BD

s

S. a

ureu

s ba

cter

aem

iape

r 100

0 A

OB

Ds

Jan 03-Mar 03 255 1306371 0.195

Apr 03-Jun 03 227 1269416 0.179

Jul 03-Sep 03 176 1261838 0.139

Oct 03-Dec 03 217 1277360 0.170

Jan 04-Mar 04 267 1303814 0.205

Apr 04-Jun 04 259 1241546 0.209

Jul 04-Sep 04 201 1245799 0.161

Oct 04-Dec 04 247 1259193 0.196

Jan 05-Mar 05 253 1299434 0.195

Apr 05-Jun 05* 221 375 596 1247816 0.177 0.301 0.478

Jul 05-Sep 05 247 511 758 1247136 0.198 0.410 0.608

Oct 05-Dec 05 264 422 686 1259126 0.210 0.335 0.545

Jan 06-Mar 06 274 460 734 1297157 0.211 0.355 0.566

Apr 06-Jun 06 252 358 610 1282329 0.197 0.279 0.476

Jul 06-Sep 06 212 389 601 1243355 0.171 0.313 0.483

Oct 06-Dec 06 227 280 507 1252014 0.181 0.224 0.405

Jan 07-Mar 07 249 359 608 1294344 0.192 0.277 0.470

Apr 07-Jun 07 215 415 630 1248276 0.172 0.332 0.505

Jul 07-Sep 07 210 459 669 1234589 0.170 0.372 0.542

Oct 07-Dec 07 207 417 624 1235570 0.168 0.337 0.505

Jan 08-Mar 08 197 390 587 1236015 0.156 0.316 0.475

Apr 08-Jun 08 185 392 577 1247905 0.148 0.314 0.462

* Mandatory reporting of MSSA bacteraemia was introduced in July 2006 and MSSA data was validated back to 1 April 2005.

FIGURE 1: Run chart of quarterly number of S. aureus bacteraemia in Scotland, 1 April 2005 to 30 June 2008 with HEAT target trajectory to 31 March 2010.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

356

Figure 2 shows the quarterly S. aureus bacteraemia rate per 1000 AOBDs from 1 April 2005 to 30th June 2008 with a trend line of a ‘Model Prediction’ taking account of seasonal variations.

The confidence limits of the predicted model represent the range of values where we are 95% confident the true value will lie. This figure therefore presents a more accurate indication of the progress towards the HEAT target, because it takes account of seasonal variation in S. aureus bacteraemia. Note that the prediction intervals get wider the further into the future projected. As more data become available these confidence intervals will narrow.

Figure 2 indicates that if current trends are at least maintained, Scotland is unlikely to achieve the level required in the HEAT target by early 2010. Local interventions at NHS Board level are required to ensure this target is achieved.

Figure 3 represents the MRSA bacteraemia rate per 1000 AOBDs for Scotland as a Statistical Process Control (p) chart. This chart has control limits set at 3 standard deviations (sd) from the mean, warning limits set at 2 sd from the mean and highlight limits set at 1 sd from the mean. The centre line is the mean of all results to date.

In Figure 3 the latest quarterly MRSA bacteraemia rate is below the lower control limit indicating that a change has occurred and suggesting that a reduction in the MRSA bacteraemia rate for Scotland has been achieved.

Figure 4 shows a Pareto chart of the number of MRSA bacteraemia by specialty with the number of MRSA bacteraemia for each specialty represented by a bar and the cumulative proportion of MRSA bacteraemia represented by a line.

The highest number of MRSA bacteraemia were detected in General Medicine (Figure 4). Over 70% of all MRSA bacteraemia were found in General Medicine, General Surgery, Renal, HDU/ICU and Care of the Elderly. Targeting these areas in infection prevention initiatives is likely to have the biggest impact in reducing SAB.

Figure 5 shows a Pareto chart of the number of MSSA bacteraemia by specialty with the number of MSSA bacteraemia for each specialty represented by a bar and the cumulative proportion of MSSA bacteraemia represented by a line.

The highest number of MSSA bacteraemia were detected in General Medicine, approximately 70% of all MSSA bacteraemia were found in General Medicine, unspecified specialties, Renal, Accident and Emergency and General Surgery (Figure 5).

Figures 4 and 5 indicate that the specialties General Medicine, Renal and General Surgery are the specialties where both MRSA and MSSA bacteraemia are most often detected in NHS Scotland and are therefore the areas where the largest impact could be achieved.

FIGURE 3: SPC chart of quarterly MRSA bacteraemia per 1000 AOBDs in Scotland, 1 January 2003 to 30 June 2008.

FIGURE 2: S. aureus bacteraemia per 1000 AOBDs in Scotland showing HEAT target and predicted rates with prediction limits.

FIGURE 4: Pareto chart of the number of MRSA bacteraemia by specialty, 1 January 2003 to 30 June 2008.

FIGURE 5: Pareto chart of the number of MSSA bacteraemia by specialty, 1 April 2005 to 30 June 2008.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

357

Cases detected in Accident and Emergency may, in some instances, be community acquired cases, although the number of true community acquired S. aureus bacteraemia is considered to be low23,24.

A community acquired S. aureus bacteraemia is defined by a positive blood culture for patients hospitalised for less than 48

Antibiotic

MSSA n = 291 MRSA n = 140 Total n = 431

Number of isolates that were: Number of isolates that were:

S I R N

Res

ista

nce

rate

(%

)

S I R N

Res

ista

nce

rate

(%

)

Tota

l num

ber o

f no

n-su

scep

tible

st

rain

s

Tota

l Res

ista

nce

rate

(%)

Chloramphenicol 291 0 0 0 0.0 139 1 0 0 0.7 1 0.2

Ciprofloxacin 266 2 23 0 8.6 4 0 136 0 97.1 161 37.4

Clindamycin 289 0 2 0 0.7 101 0 39 0 27.9 41 9.5

Erythromycin 258 8 25 0 11.3 34 3 103 0 75.7 139 32.3

FusidicAcid 261 8 22 0 10.3 134 3 3 0 4.3 36 8.4

Gentamicin 287 0 4 0 1.4 126 4 10 0 10.0 18 4.2

Kanamycin 284 0 7 0 2.4 116 0 24 0 17.1 31 7.2

Levofloxacin 286 2 3 0 1.7 134 3 3 0 4.3 11 2.6

Linezolid 289 0 0 2 0.0 140 0 0 0 0.0 0 0.0

Mupirocin 291 0 0 0 0.0 130 1 9 0 7.1 10 2.3

Oxacillin 291 0 0 0 0.0 0 0 140 0 100.0 140 32.5

Rifampicin 290 0 1 0 0.3 136 0 4 0 2.9 5 1.2

Streptomycin 291 0 0 0 0.0 139 0 1 0 0.7 1 0.2

Synercid 291 0 0 0 0.0 139 0 1 0 0.7 1 0.2

Teicoplanin 285 0 0 0 0.0 140 0 0 0 0.0 0 0.0

Tetracycline 271 0 20 0 6.9 126 1 13 0 10.0 34 7.9

Tobramycin 284 0 7 0 2.4 116 0 24 0 17.1 31 7.2

Trimethoprim 242 0 49 0 16.8 103 0 37 0 26.4 86 20.0

Vancomycin 291 0 0 0 0.0 140 0 0 0 0.0 0 0.0

Key: S - sensitive; I - intermediate; R - resistant; N - not tested

TABLE 3: Antibiotic susceptibility of S. aureus isolates (MSSA and MRSA) from Scotland, 1 April 2008 to 30 June 2008.

hours and for whom infection was not incubating at the time of admission22. Table 3 indicates that the proportion of S. aureus isolates which were meticillin resistant during the period 1 April 2008 to 30 June 2008 was 32% (140 of 431 isolates). Thirty one isolates were recorded on the EARSS form as being device associated however on 332 occasions this information was not available.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

358

The last bacteraemias and MRSA Surveillance Report was in Issue 08/29The next bacteraemias and MRSA Surveillance Report will be in Issue 09/02

Key Summary Points

• The data within this report includes data on episodes of MRSA bacteraemia during the period 1 January 2003 to 30th June 2008, episodes of MSSA bacteraemia during the period 1 April 2005 to 30th June 2008 and antimicrobial resistance data during the period 1 April 2008 to 30 June 2008.

• The number and rate of MRSA bacteraemia reported in the period 1 April 2008 to 30th June 2008 was the lowest yet reported since the third quarter of 2003.

• The MRSA bacteraemia rate per 1000 AOBDs in Scotland has shown a decrease in this quarter compared to the period 1 January 2003 to 31 March 2008.

• The annual number of S. aureus bacteraemia has fallen by 5.2% per year (1.3%, 8.9%). As the confidence interval contains the HEAT target of a 7% reduction, there is no evidence that this is not on target.

• The rate and number of S. aureus bacteraemia is the second lowest reported since MSSA bacteraemias were included in this surveillance programme and is lower than the same quarter of any year of the surveillance.

• The specialties where both MRSA and MSSA bacteraemia are found most often within the national dataset are General Medicine, Renal and General Surgery. Infection prevention interventions focussed on these specialties are likely to have the greatest benefit in reducing SABs.

• The proportion of S. aureus isolates submitted to the SMRSARL which were meticillin resistant during the period 1 April 2008 to 30th June 2008 was 32%.

• There were 431 isolates submitted to the SMRSARL during the period 1 April 2008 to 30 June 2008. Thirty one of these were recorded as being device associated however on 332 occasions this information was not available. HPS will work with NHS Boards to enhance compliance with reporting of these data.

For information on the data included in this report contact the SSHAIP team at SSHAIP@hps.scot.nhs.uk.

For information on infection prevention and control please contact the Infection Control Team at HPSInfectionControl@hps.scot.nhs.uk.

For information on the antimicrobial resistance data included in this report please contact the AMR team at AMR@hps.scot.nhs.uk

References1. EARSS Annual Report 2006. Found at http://www.rivm.nl/earss/Images/EARSS%202006

%20Def_tcm61-44176.pdf

2. Karchmer, A.W., Nosocomial bloodstream infections: organisms, risk factors, and implica-tions. Clin Infect Dis, 2000. 31 Suppl 4: p. S139-43.

3. Boyce, J.M., Cookson, B. Christiansen, K. Hori, S. Vuopio-Varkila, J. Kocagoz, S. et al, Meticillin-resistant Staphylococcus aureus. Lancet Infect Dis, 2005. 5(10): p. 653-63.

4. Zinn, C.S., Westh, H. and Rosdahl, V.T.An international multicenter study of antimicrobial resistance and typing of hospital Staphylococcus aureus isolates from 21 laboratories in 19 countries or states. Microb Drug Resist, 2004. 10(2): p. 160-8.

5. Kesah, C., Ben Redjeb, S. Odugbemi, T.O. Boye, C.S. Dosso, M. Ndinya Achola, J.O. et al, Prevalence of methicillin-resistant Staphylococcus aureus in eight African hospitals and Malta. Clin Microbiol Infect, 2003. 9(2): p. 153-6.

6. Graffunder, E.M. and Venezia, R.A. Risk factors associated with nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection including previous use of antimicrobials. J Antimicrob Chemother, 2002. 49(6): p. 999-1005.

7. Weber, S.G..Gold, H.S. Hooper, D.C. Karchmer A.W. and Carmeli, Y. Fluoroquinolones and the risk for methicillin-resistant Staphylococcus aureus in hospitalized patients. Emerg Infect Dis, 2003. 9(11): p. 1415-22.

8. Monnet, D.L., Methicillin-resistant Staphylococcus aureus and its relationship to antimicrobial use: possible implications for control. Infect Control Hosp Epidemiol, 1998. 19(8): p. 552-9.

9. Sakoulas, G., Rose, W. Rybak, M.J. Pillai, S. Alder, J. Moellering, R.C. Jr. et al, Evaluation of endocarditis caused by methicillin-susceptible Staphylococcus aureus developing nonsusceptibility to daptomycin. J Clin Microbiol, 2008. 46(1): p. 220-4.

10. Soriano, A., Marco, F. Martinez, J.A. Pisos, E. Almela, M. Dimova, V.P. et al, Influence of vancomycin minimum inhibitory concentration on the treatment of methicillin-resistant Staphylococcus aureus bacteraemia. Clin Infect Dis, 2008. 46(2): p. 193-200.

11. Moreillon, P., New and emerging treatment of Staphylococcus aureus infections in the hospital setting. Clin Microbiol Infect, 2008. 14 Suppl 3: p. 32-41.

12. Coia, J.E., Duckworth, G.J. Edwards, D.I Farrington, M. Fry, C. Humphreys, H. et al Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. J Hosp Infect, 2006. 63 Suppl 1: p. S1-44.

13. Reilly, J., Stewart, S. Allardice, G.A. Noone, A. Robertson, C. Walker A. et al, Results from the Scottish National HAI Prevalence Survey. J Hosp Infect, 2008. 69(1): p. 62-8.

14. Edgeworth, JD., Yadegarfar, G., Pathak, S., Batra, R., Cockfield, J.D., Wyncoll, D., et al. An outbreak in an intensive care unit of a strain of methicillin-resistant Staphylococcus aureus sequence type 239 associated with an increased rate of vascular access device-related bacteraemia. Clin Infec Dis, 2007. 44:493-501.

15. Hawkins, C., Huang, J., Jun, N., Noskin, G.A., Zembower, T.R., Bolon, M., Persistent Staphylococcus aureus bacteraemia: an analysis of risk factors and outcomes. Arch Intern Med, 2007. 167(17):1861-7.

16. Heo, S.T., Peck, K.R., Ryu, S.Y., Kwon, K.T., Ko, K.S., Oh, W.S. et al. Analysis of methicillin resistance among Staphylococcus aureus blood isolates in an emergency department. J Korean Med Sci, 2007. 22(4):682-6.

17. HDL(2006) 38. A revised framework for national surveillance of healthcare associated infection in Scotland, SGHD.

18. Protocol for the Scottish mandatory surveillance programme for Staphylococcus aureus bacteraemia found at http://www.documents.hps.scot.nhs.uk/hai/sshaip/guidelines/MRSA/MRSA-bacteramia-protocol-v3-2007-09.pdf

19. Benneyan J.C., Statistical quality control methods in infection control and hospital epidemiology, Part I: Introduction and basic theory. Infect Control Hosp Epidemiol 1998; 19:194-214.

20. Leonard, M., Graham, S., Bonacum, D., The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004; 13 (Suppl 1): i85-i90.

21. HDL(2001) 57. A framework for national surveillance of hospital acquired infection in Scotland, SEHD.

22. Garner, J.S., Jarvis, W.R., Emori, T.G., Horan, T.C., Hughes, J.M., CDC definitions for nosocomial infections. Am J Infect Control 1988; 16: 128-140.

23. Wyllie, D.H., Peto T.E.A., Crook D, MRSA bacteraemia in patients on arrival in hospital: a cohort study in Oxfordshire 1997-2003. BMJ 2005; 331: 992-5.

24. Duckworth, G. Improving surveillance of MRSA bacteraemia. BMJ 2005; 331: 976-977.

Acknowledgements

Health Protection Scotland is grateful to all the microbiologists throughout Scotland who provided the S. aureus bacteraemia data for this report and helped in its preparation, staff at the Scottish MRSA Reference Laboratory who provided the EARSS data and the Information Services Division of National Services Scotland who provided the hospital activity data.

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

359

Statutory Notification of Infectious Diseases (by age) Week ended 26 September 2008

A National Statistics release

Age Group

Infectious Disease All ages Under 1 1 - 4 5 - 14 15 - 24 25 - 34 35 - 44 45 - 64 65 & over Not known M F M F M F M F M F M F M F M F M F M FAnthrax - - - - - - - - - - - - - - - - - - - -Bacillary dysentery 3 3 - - - - - - 1 - 1 - - - 1 2 - - - 1Chickenpox 68 84 5 3 36 53 12 15 4 1 - 3 4 1 3 4 - - 4 4Cholera - - - - - - - - - - - - - - - - - - - -Diphtheria - - - - - - - - - - - - - - - - - - - -Erysipelas - - - - - - - - - - - - - - - - - - - -Food poisoning 88 114 1 1 9 8 6 9 11 13 10 15 9 17 27 37 15 14 - -Legionellosis 1 - - - - - - - - - - - - - 1 - - - - -Leptospirosis - - - - - - - - - - - - - - - - - - - -Lyme Disease 3 9 - - - - - - - - - - - 2 3 5 - 2 - -Malaria - - - - - - - - - - - - - - - - - - - -Measles - 1 - - - - - - - - - 1 - - - - - - - -Meningococcal infection 2 - 1 - - - - - 1 - - - - - - - - - - -Mumps 4 6 - - 1 - - 1 2 2 - 2 1 1 - - - - - -Paratyphoid fever - - - - - - - - - - - - - - - - - - - -Plague - - - - - - - - - - - - - - - - - - - -Poliomyelitis - - - - - - - - - - - - - - - - - - - -Puerperal fever - - - - - - - - - - - - - - - - - - - -Rabies - - - - - - - - - - - - - - - - - - - -Relapsing fever - - - - - - - - - - - - - - - - - - - -Rubella 1 1 1 - - - - - - - - 1 - - - - - - - -Scarlet fever 3 6 - 1 - - 2 4 1 1 - - - - - - - - - -Smallpox - - - - - - - - - - - - - - - - - - - -Tetanus - - - - - - - - - - - - - - - - - - - -Toxoplasmosis - - - - - - - - - - - - - - - - - - - -Tuberculosis: respiratory 1 1 - - - - - - - - - 1 1 - - - - - - -Tuberculosis: non-respiratory - 3 - - - - - - - - - - - 1 - - - 2 - -Typhoid fever - - - - - - - - - - - - - - - - - - - -Typhus fever - - - - - - - - - - - - - - - - - - - -Viral haemorrhagic fevers - - - - - - - - - - - - - - - - - - - -Viral hepatitis 7 3 - - - - - - 1 1 2 1 3 - 1 1 - - - -Whooping cough 3 2 1 - - - - - - 2 - - 1 - 1 - - - - -TOTAL 184 233 9 5 46 61 20 29 21 20 13 24 19 22 37 49 15 18 4 5

HP

S W

EE

KLY R

EP

OR

T Volum

e 42 No.2008/41

8 October 2008

360

Source: Health Protection Scotland, NHS National Services Scotland

NHS BOARD ABBREVIATIONSAA Ayrshire & Arran GG Greater Glasgow & Clyde LN Lanarkshire SH Shetland TY TaysideBR Borders FF Fife GR Grampian LO Lothian WI Western IslesDG Dumfries & Galloway FV Forth Valley HG Highland OR Orkney

Statutory Notification of Infectious Diseases (by NHS board) Week ended 26 September 2008

Amendments: add 1 Chickenpox (FF 1 x wk 20); 8 Food poisoning (FF 5 x wk 21, GG 1 x wk 38, GR 2 x wk 32); 2 Mumps (GG 2 x wk 37); 2 Viral hepatitis (FF 2 x wk 21) delete 2 Food poisoning (GR 1 x wk 23, GR 1 x wk 38); 1 Measles (LO 1 x wk 38)

NHS BOARD AREA Infectious Disease AA BR DG FF FV GR GG HG LN LO OR SH TY WI

Currentweek

Previousweek

Total from1st week of year

Currentweek

last year 2007 2008Anthrax - - - - - - - - - - - - - - - - - - -

Bacillary dysentery - - 1 - - - - 2 - 3 - - - - 6 2 5 121 77

Chickenpox 9 - 7 14 13 37 36 5 8 - - - 23 - 152 111 128 17711 9394

Cholera - - - - - - - - - - - - - - - - - 3 2

Continued fever - - - - - - - - - - - - - - - - - - -

Diphtheria - - - - - - - - - - - - - - - - - 1 -

Erysipelas - - - - - - - - - - - - - - - - - 17 18

Food poisoning 11 - 7 14 15 27 46 9 21 38 2 - 12 - 202 179 137 5295 5585

Legionellosis - - - - - - - - - - - - 1 - 1 - 1 33 17

Leptospirosis - - - - - - - - - - - - - - - - - 1 4

Lyme Disease - - - 1 - - - 11 - - - - - - 12 9 10 154 176

Malaria - - - - - - - - - - - - - - - - 2 11 14

Measles - - - - - - - 1 - - - - - - 1 4 2 131 177

Meningococcal infection 1 - - - - - 1 - - - - - - - 2 2 1 123 87

Mumps 1 - - - 1 2 3 - 2 1 - - - - 10 7 34 2372 610

Paratyphoid fever - - - - - - - - - - - - - - - 1 1 1 3

Plague - - - - - - - - - - - - - - - - - - -

Poliomyelitis - - - - - - - - - - - - - - - - - - -

Puerperal fever - - - - - - - - - - - - - - - - - 1 -

Rabies - - - - - - - - - - - - - - - - - - -

Relapsing fever - - - - - - - - - - - - - - - - - - -

Rubella - - - - - - 2 - - - - - - - 2 - 2 116 86

Scarlet fever - - - 2 - - 6 - - - - - 1 - 9 2 2 251 789

Smallpox - - - - - - - - - - - - - - - - - - -

Tetanus - - - - - - - - - - - - - - - - - - -

Toxoplasmosis - - - - - - - - - - - - - - - - - - 1

Tuberculosis : resp. - - - - - 2 - - - - - - - - 2 3 4 173 187

Tuberculosis : non-resp. - - - - - 2 - - 1 - - - - - 3 4 2 75 94

Typhoid fever - - - - - - - - - - - - - - - - - 1 1

Typhus fever - - - - - - - - - - - - - - - - - - -

Viral haemorrhagic fevers - - - - - - - - - - - - - - - - - - -

Viral hepatitis - - - 3 - 3 - - - - - - 4 - 10 23 15 1003 1225

Whooping cough - - - 1 - 2 - - 1 - - - 1 - 5 2 4 73 96

TOTAL 22 0 15 35 29 75 94 28 33 42 2 0 42 0 417 349 350 27667 18643