Title SCOTTISH MRSA REFERENCE LABORATORY LABORATORY PROCEDURE NUMBER / VERSION User Manual DATE OF ISSUE 20/01/2017 REVIEW INTERVAL AUTHORISED BY AUTHOR 1 Year Dr. B. Jones Dr E. Dickson COPY 1 of 1 Master file in Q-Pulse LOCATION OF COPY GG&C website www.nhsggc.org.uk/smrl DOCUMENT REVIEW HISTORY All review / revision details are available in Q-Pulse Date Amendment Initials MRSA User Manual Controlled document Page 1 of 11
Scottish M.R.S.A. Reference Laboratory User Manual 2017 We aim to select our test repertoire for the benefit of our users and their patients. If you have any suggestions for improving our service please contact us. CONFIDENTIALITY POLICY NHSGG&C Standing Financial Instructions and Fraud Policy ensure that users confidential information is protected and that this department cannot undertake activity that would diminish confidence in its impartiality. Users confidential information is also governed by our procedure RL_MP_010 Management of data & information and by NHSGG&C I.T. Policy. Activity that would diminish confidence in impartiality or integrity is also prohibited by the Health & Care Professions Council code of conduct. Complaints procedure:- We will:- 1. Take all complaints seriously. 2. Deal with the client in a courteous manner. 3. Try to resolve the issue immediately at a local level. 4. Inform the client about the progress of the complaint. 5. Make corrective action as soon as possible. 6. Investigate root cause analysis to prevent recurrence. If you have a complaint, contact the laboratory manager (see page 5). MRSA User Manual Controlled document Page 2 of 11
Section One: Section Two: The Scottish M.R.S.A. Reference Laboratory Introduction 4 Laboratory hours 4 Contact details 5 Services provided by the SMRSARL Submission of samples 6 Transportation of specimens 7 Specimen acceptance & rejection criteria 7 Confirmation of MRSA status 8 Antibiotic susceptibility monitoring 8 spa sequencing types 8 Epidemiological typing 8 Toxin typing 8 Control of infection advice 9 Staphylococci other than MRSA 9 Vancomycin resistant enterococci 9 Request turnaround times 10 Reporting of results 10 Section Three: Interpretation of SMRSARL Results 10 Teaching commitment 11 Areas of special interest 11 Problems, complaints, service improvements 11 MRSA User Manual Controlled document Page 3 of 11
SECTION ONE: HISTORY & INTRODUCTION The Scottish MRSA Reference Laboratory (SMRSAL) was established in April 1997 in response to a rapid increase in the number of MRSA infections in Scottish hospitals. Between 1991 and 1995 about 500 MRSA infections were reported annually to the Scottish Centre for Infection and Environmental Health (SCIEH). In 1996 this rose markedly to 1500. Since the SMRSARL was established, the number of isolates referred continued an upward trend with over 7500 reports in 2009. Numbers then began to decline in 2010 to 6000, until 2015 when 4155 reports were issued. This decrease likely reflects the falling numbers of MRSA infections. The SMRSARL is commissioned by Health Protection Scotland (HPS) which is part of the NHS National Services Scotland, and is based on Level 5 of the New Lister Building, Glasgow Royal Infirmary. The laboratory provides a National MRSA Reference Service and accepts isolates from laboratories throughout Scotland. The service includes confirmation of MRSA status, sequence typing, antibiotic sensitivity monitoring, detection of toxin genes and epidemiological typing of strains. In addition SMRSARL provides advice on infection control issues, teaching and training of medical and technical staff and has an ongoing research and development program. SMRSARL collaborates with HPS to provide data on the national trends in MRSA epidemiology in Scotland. LABORATORY HOURS: Monday to Friday: Saturday morning: Public holidays: Emergency situations: Availability of advice: 08:45 am to 5pm Specimen reception only. Specimen reception only. As required after discussion with Director or Medical Director. 08:45 am to 5pm, Monday to Friday Out of hours Under exceptional circumstances tests will be performed outside the normal laboratory hours. MRSA User Manual Controlled document Page 4 of 11
CONTACT DETAILS Scottish M.R.S.A. Reference Laboratory (SMRSARL) Level 5, New Lister Building 10-16 Alexandra Parade Glasgow Royal Infirmary GLASGOW G31 2ER Telephone:- 0141 201-8671 Director: Prof. J. Coia 0141 201 8633 John.Coia@ggc.scot.nhs.uk Laboratory Manager: Mr Henry Mather 0141 201 8669 Henry.Mather@ggc.scot.nhs.uk Clinical Scientist: Dr Elizabeth Dickson 0141 201 8662 Elizabeth.Dickson2@ggc.scot.nhs.uk Enquires: Contact Dr Elizabeth Dickson on 0141 201 8662 in the first instance, but in the event of difficulty any of the contacts on this page. MRSA User Manual Controlled document Page 5 of 11
SECTION TWO: SERVICES PROVIDED Submission of Samples Request forms Fill out the details on the request forms as completely as possible (request forms are available from SMRSARL directly or from the website. Forms can be photocopied). By Post Specimens should be sent to: Scottish MRSA Reference Laboratory Level 5 New Lister Building 10-16 Alexandra Parade Royal Infirmary GLASGOW G31 2ER Telephone 0141 201 8633 (Director) 0141 201 8661 (Section Manager) By DX Courier Address: DX 6490200 BISHOPBRIGGS 90GX Urgent specimens A "fast track" system is available for urgent specimens. Please telephone to request "fast tracking" of specimen and to notify when the specimen will arrive. Sample and request form information must be compatible. The minimum information that should be provided is as follows: ESSENTIAL Sample Patient s Full Name * Date of Birth and/ or Hospital Unit Number CHI number, etc. DESIRABLE Date and Time of sample collection MRSA User Manual Controlled document Page 6 of 11
Request Form Patients Full Name* Date of Birth and/or Hospital Unit Number, CHI number, etc Sending Hospital/Laboratory Name of requesting microbiologist. Clinical Information Date and Time of sample Collection Investigation (s) required * or Proper Coded Identifier Referring microbiologist s Contact Number These details are essential for sample processing, interpretation of test results and for enhanced epidemiological surveillance. On the request form please also indicate where reports should be sent. Transportation of specimens All submissions must comply with UN3373 postal regulations. Specimens Isolates for characterisation should be transported to the SMRSARL & must be sent as pure cultures on agar slopes (preferably in bijoux bottles) or on swabs in transport medium. Specimen acceptance & rejection criteria. Improperly Labelled specimens/ Request Forms Sample or request forms received without the minimum essential identification will be referred back to requesting laboratory. Samples and forms that are mismatched The requesting microbiologist (or appropriate laboratory staff) will be contacted and determination of error decided. Specimen may be discarded if error not determined and repeat sample requested Samples that arrive with no form If a sample arrives with no form, a blank request form will be filled out with the details taken from the specimen, booked in and stored for future testing. MRSA User Manual Controlled document Page 7 of 11
Forms that arrive with no sample The form will be booked in & a report issued stating that no sample was received. Samples that are inappropriately labelled Samples that arrive with no details on them may still be processed, however the report will state No name on specimen but received in the same bag as request form. Under the direction of a senior member of staff further action might be: Processing the specimen and withholding results Storage of the specimen Requesting a fresh specimen and request form. Damaged/ Leaking Samples The action taken will often depend on the preciousness of the sample. Some may be difficult to repeat and it may be necessary to try to save and use what has been received. Tests performed on all isolates received Phenotypic confirmation of MRSA status is carried out on all isolates received. Antimicrobial susceptibilities are performed on all Staphylococcus aureus isolates. Genotyping is currently by spa typing and PFGE or MLST if required. Phenotypic characteristics of Scottish MRSA continue to be monitored. Confirmation of MRSA status All isolates are tested by PCR: to detect the species specific nuc gene and the meca gene for resistance to the methicillin group of antibiotics (isolates with borderline resistance to this group are tested by oxacillin and cefoxitin E-tests). Antibiotic susceptibility monitoring Isolates are tested for resistance to 18 antibiotics (using VITEK 2). The resulting antibiogram is part of the phenotyping pattern; it is also used to monitor changing resistance patterns. Susceptibility is also monitored using Etests and MICE gradient strips to certain antimicrobial agents (oxacillin, cefoxitin, linezolid, vancomycin, teicoplanin and daptomycin) Isolates with reduced susceptibility to mupirocin are further tested by PCR for the presence of the mupa gene to distinguish between high and low level mupirocin resistance. Epidemiological typing Epidemiological typing is predominantly carried out by spa typing, and the sequences of MRSA and MSSA are assigned a type by the universally accepted Ridom database. Pulsed field gel electrophoresis (PFGE) on MRSA is carried out where appropriate or requested upon discussion with laboratory and consultants. PFGE typing of MSSA and CNS is also performed if appropriate. PFGE is a more discriminatory technique and is particularly valuable in the investigation of localised outbreaks Sequenced based typing (MLST) is carried out on selected isolates. Toxin Testing All isolates received are tested by PCR for two exfoliative toxins (eta and etb) and MRSA User Manual Controlled document Page 8 of 11
Panton-Valentine Leukocidin (PVL) genes. Other PCR tests are available for detection of staphylococcal toxin genes: nine enterotoxin genes (sea, seb, sec, sed, see, seg, seh, sei and sej) and toxic shock syndrome toxin-1 (tst). Control of infection advice Advice on the various aspects of the control of MRSA infection is available. Staphylococci other than MRSA Many of the tests performed in the Reference Laboratory are useful in the investigation of other staphylococci. Epidemiological typing of MSSA and CNS by PFGE and species identification of CNS by phenotypic methods will be undertaken on request. Vancomycin resistant enterococci A pulsed field gel electrophoresis protocol is in place to enable the investigation of possible cross-transmission or outbreak events with nosocomial VRE. This service is available upon request and must be discussed with HPS as well as the laboratory prior to submission of isolates. Referral Policy Samples referred will be accepted from laboratories throughout Scotland. Advice and information will be provided to clinicians and agencies Scotland-wide. As a minimum, every laboratory should send specimens to the Reference Laboratory where confirmation that an isolate is an MRSA is necessary. At the discretion of the sending laboratory, the following should be sent to the Reference Laboratory: All outbreak/cross-infection isolates (MRSA and MSSA) All blood cultures (MRSA and MSSA) as part of the EARSS-Net surveillance programme Isolates with resistance to mupirocin, glycopeptides, daptomycin or linezolid Isolates with unusual characteristics or those whose characteristics have changed CNS requiring identification to the species level VRE isolates for investigation of infection control events. Currently all isolates are tested for the PVL, eta and etb genes. Tests for other toxins are also carried out when specifically requested by the user. MRSA User Manual Controlled document Page 9 of 11
Turnaround Times Notes Strain Typing 1 7-8 working days 2 PCR confirmation of MRSA status 5 working days Fast Track 1-3 working days 3 1. Includes phenotypic confirmation of MRSA status, antibiotic sensitivity and genotypic typing. 2. Time from receipt of pure culture until report has been posted. Working days do not include weekends. Time refers to 95% of referrals. 3. Urgent specimens will be "fast tracked". From receipt of pure culture PCR confirmation of MRSA status can be performed in 1 day and strain typing in 3 days. Reporting of results All results are reported through the Telepath System, with paper reports posted to the sending laboratories. All results are sent to HPS for epidemiology and audit purposes. SECTION THREE: INTERPRETATION OF SMRSARL OF RESULTS The issued report provides guidance to assist in the interpretation of SMRSARL results regarding the laboratory confirmation of staphylococcal isolates. Although all of our tests have been evaluated and validated, a small number of cases will require individual interpretation. Clinical information should be taken into account where necessary when interpreting SMRSARL results. Teaching, Research & Development The Reference Laboratory is committed to the teaching of medical and technical staff and has a continuing commitment to Research & Development activities relevant to the work of the laboratory. This includes collaborative work with Microbiologists, Infection Control Nurses, Scientists and Biomedical Scientists in referring hospitals. Areas of special interest: Community MRSA MRSA in animals Molecular characterisation of MRSA clones MRSA User Manual Controlled document Page 10 of 11
Staphylococcus aureus with borderline susceptibility to methicillin (BORSA s) Evaluation of media for MRSA screening Nosocomial vancomycin resistant enterococci epidemiology Problems, Complaints and Service Improvements If any problems are encountered with the service or any matter for complaint arises, please contact the Director, Prof. John Coia (0141 201 8633). In addition, suggestions for improvement of the service are always welcome. MRSA User Manual Controlled document Page 11 of 11