BROUGHT TO YOU BY Role of the nurse in diagnosing infection: The right sample, every time The module has been written by Shanika Anne-Marie Crusz and Amelia Joseph Authors affiliation: Department of Clinical Microbiology Nottingham University Hospitals NHS Trust This learning module is intended for UK healthcare professionals only. PP-GEP-GBR-0948 Date of prep: March 2018
Introduction
AGENDA 1: Microorganisms and Infection 2: Antibiotics and Antimicrobial Resistance the role of a nurse 4: Diagnosing infection practical hints
Module Aims This module, primarily aimed at nurses, provides an explanation of the importance of infection and the impact of antimicrobial resistance. It aims to improve knowledge and understanding about the need for appropriate clinical specimens to enable effective laboratory diagnosis of infection to take place. This ensures that patients receive correct and timely antimicrobial therapy.
Learning objectives By the end of this module, you will be able to Describe why infection and appropriate antimicrobial use are significant concerns for modern healthcare Appreciate your role in obtaining appropriate, well-taken, timely specimens from different clinical/body sites to support the laboratory diagnosis of infection Understand how this important process contributes to our ability to use antibiotics appropriately to effectively treat infection in our patients now and in the future.
Microorganisms and Infection 1
Microorganisms Microorganisms (bacteria, fungi, parasites and viruses) cannot be seen with the naked eye but are all around us: in our environment, on and within our bodies Bacteria are single-celled microorganisms that are numerous and diverse Bacteria can be classified according to their basic shape Round known as cocci Rod-like known as bacilli the staining of their cell wall Purple known as Gram-positive Pink known as Gram-negative
Bacterial classification Cocci (Round) Coccus Staphylococci eg MRSA Streptococci eg Group A streptococci and Streptococcus pneumoniae
Bacterial classification Bacilli (Rods) bacillus Eg E. coli Eg C. difficile
Normal flora The human body is not sterile There are numerous microorganisms, mainly bacteria, that live on the skin and within certain areas of the body known as the normal flora The normal flora can protect against more harmful bacteria establishing themselves at these body sites Oropharynx Streptococci, Candida Skin e.g. Coagulase-negative Staphylococci Gastro-intestinal E. coli, Enterococci, Anaerobes, Candida Genito-urinary tract Lactobacillus
Colonisation and Infection Colonisation When bacteria grow on parts of the body exposed to the environment e.g. skin These may include bacteria forming part of the person s normal flora, as well as other bacteria that have been acquired This is a normal and inevitable process. The presence of colonising bacteria does not warrant antibiotic treatment. Infection When microorganisms cause damage to body tissues Infection can result in harm and often needs treatment, which can include antibiotics
Antibiotics and Antimicrobial Resistance 2
Antibiotics Antimicrobials are medicines that can be used to treat infections caused by microorganisms and include antibiotics, antivirals and antifungal agents. Antibiotics are antimicrobials that have specific activity against bacteria. Many antibiotics have been derived from chemicals made by bacteria to protect themselves from other bacteria. Some are synthetic or man-made. One of the first antibiotics, penicillin, was discovered in 1928 by Sir Alexander Fleming.
Why is infection management important? Antibiotics are used for the treatment of proven or suspected bacterial infection. In 2015, data from England showed that: 1 in 3 patients in hospitals in England are on an antibiotic at any one time Antibiotic use risen by 6.5 % over the past 4 years Source: https://www.gov.uk/government/publications/health-matters-antimicrobial-resistance/health-matters-antimicrobial-resistance
Why is infection management important? Antibiotics are unlike any other drug, as the more we use them the less effective they become against their target bacteria. Antibiotic resistance: the ability of bacteria to resist the effects of an antibiotic to which they were once sensitive. Antibiotic resistance is rising to concerning levels. There are very few new antibiotics available effective against antibiotic resistant bacteria.
The role of nurses in managing infection As Healthcare Professionals, we strive to place the patient at the centre of all that we do in our roles All Professionals involved in Infection Management, and Nurses specifically, are at the front-line of delivering quality care, which includes administering antibiotics In addition to this, there are specific actions that nurses can perform as part of their daily roles to improve the management of infection. These can reduce the demand for antibiotics and enhance the effectiveness of prescribed antimicrobials (RCN position statement AMR 2014)
Reducing the demand for antibiotics: what can you do? Influence patient knowledge and expectations Reduce development of hospital-acquired infection and use of invasive devices Implement and participate in immunisation programmes eg patient and staff flu vaccination Obtain specimens only when clinical need clearly indicated (right patient, right site) Support the timely transport to laboratory to maintain specimen quality and accurate results (right container, labelling and request card details)
Knowledge summary check Infectious diseases are important global, national and local health problems. Resistance to existing antibiotics is rising, rendering them less effective There are few new antibiotics being developed. It is important that existing antibiotics are used appropriately to treat bacterial infection to improve health and save lives now as well as in the future Nurses play a central role in reducing the demand for unnecessary antibiotic use
Diagnosing infection 3
Diagnosing Infection Clinical suspicion of infection Patient Patient care improved Obtain Specimen for laboratory: Right specimen Right container Right labelling Right time Results available: Results reviewed Right interpretation Clinical decision e.g. Start, stop or change antibiotics Infection control precautions Timely transport Laboratory Results reported
Diagnosing Infection First step: The patient Patient Before thinking about sending any specimens to the laboratory, it is essential to consider the patient s symptoms and the clinical findings Only if there is a clinical suspicion of infection: Next step: The specimen Specimen Obtain the right specimen to send to the laboratory Understand why you are taking the specimen Remember, there s no such thing as a routine microbiology sample
Specimen Mid Stream Urine Advise or assist patients with obtaining a good quality specimen: Wash genital area with water Women hold labia apart Men retract foreskin Start passing urine, then obtain sample in the middle of the urine flow Transport to laboratory as soon as possible Boric acid urine containers Boric acid urine containers Must Must be filled be to filled the to line Powder in tube is a preservative the fill line Powder in tube is a preservative Sterile universal containers Sterile universal containers Must be be transported immediately, or refrigerated if there is a delay transported immediately, or refrigerated if there is a delay
Specimen Catheter Specimen Urine How to obtain a high-quality specimen: Do not sample urine from drainage port of the catheter bag Using an aseptic non-touch technique, obtain sample directly from the sampling port of the catheter This prevents bacteria being introduced during sampling For more references: https://www.nursingtimes.net/journals/2013/04/10/l/i/k/060509obtaining-a-catheter-specimen-of-urine.pdf Last visited Jan 2018
Specimen Swabs If an abscess or collection is present, obtaining pus in a sterile universal container is much better than a swab Many organisms do not survive well on swabs, and laboratories cannot perform some tests on swabs Use a charcoal swab for suspected bacterial infection Charcoal helps bacteria to survive on the swab Surface swabs of chronic wounds e.g. ulcers, will often grow colonising bacteria which may not helpful in diagnosing deeper infection (deep surgical samples may be required)
Specimen Drain fluid Drains, such as intra-abdominal drains, are very often colonised with microorganisms Drain exit sites also become colonised, similar to other chronic skin breaks If infection is suspected, do not send fluid from the drain bag or bottle as this will be heavily contaminated Using an aseptic non-touch technique, aspirate fresh fluid directly from the sampling port, or the tubing before it is connected to the bag or bottle
Specimen Faeces Use a specimen container with a spoon provided in the lid Obtain a liquid sample (Bristol types 5 to 7) As a guide, the faeces should take the form of the container it is in Fill the container to the bottom of the spoon (approximately 5ml) Clinical details e.g. travel history or recent antibiotics, will help the laboratory to select the appropriate tests. Fill to here
Specimen Respiratory Sputum specimens should be mucous or purulent salivary specimens will only contain mouth organisms and may be rejected by the laboratory Respiratory physiotherapists can assist with obtaining adequate sputum specimens For Viral investigations (e.g. influenza), a sputum specimen or viral throat swab should be obtained
Specimen For every sample, every time: Check it is from the right patient Specimen container and request card labels filled in completely, with test requests clearly written. If you are unsure why the sample is being sent, check with a clinician before sending to the laboratory. Timely transport to the lab is essential This allows a rapid result which can positively influence the patient s care Serious consequences can occur, for example: A sample is sent with the wrong patient label on, and antibiotic therapy is subsequently stopped incorrectly.
Laboratory Laboratory processing Specimen registered electronically Laboratory processing 1. Identification of micro-organisms 2. Antibiotic sensitivities Report generated and communicated to clinical team
Part 5: Treating infection: Result interpretation Results Interpretation of Result Essential to interpret the laboratory result in the clinical context of the patient Is there clinical evidence of infection that requires antibiotic treatment? A positive Microbiology result (even if antibiotic sensitivities are given) does NOT always mean that antibiotics should be started eg if this is colonisation as there are no clinical signs of infection Pseudomonas aeruginosa from leg ulcer swab which is not cellulitic Asymptomatic bacteriuria and a positive urine dipstick
Part 5: Treating infection: Result interpretation Sepsis There are some severe infections such as sepsis that must be treated promptly with effective antibiotics When a patient is identified as at high-risk of death from sepsis, antibiotics must be prescribed and administered within 1 hour It is essential to send appropriate samples (including 2 sets of blood cultures) urgently to the laboratory to support: Laboratory diagnosis of infection by identifying the causative microorganism Ensure appropriate choice of antibiotic
Part 6 Summary and Clinical vignette Summary of key learning Nurses have a key role as the interface between the laboratory and the patient Reducing the inappropriate use of antibiotics is a key intervention to limit antibiotic resistance emerging. This will benefit current patients, as well as future patients, preserving the current antibiotics we have available. Sending the right specimen (well-taken & timely) when infection is suspected helps to achieve the right laboratory diagnosis of infection This allows the right targeted antibiotic choice to be made, which improves patient care, minimises the risk of side effects and reduces the risk of resistance emerging.
Part 6 Summary and Clinical vignette Case Study What does getting it right, every time mean for the patient? 84 year old lady was admitted with urinary tract infection, requiring IV antibiotics for 10 days She developed diarrhoea 2 days prior to discharge Stool specimen was obtained but not transported to the laboratory for 24 hours Specimen then tested positive for C. difficile toxin Infection control precautions had not been taken and a new patient was now in the bed space without the appropriate cleaning taking place Medical team had to contact patient s GP to review her diarrhoea and arrange appropriate therapy to be started Timely transport of the specimen would have prevented this situation and led to better care for the patient herself, and the other ward patients.
References and Resources Antimicrobial prescribing and stewardship competencies. 2013. Developed by ARHAI and PHE. Antimicrobial resistance: RCN position on the nursing contribution. 2014. Royal College of Nursing ESPAUR: report 2016 - Gov.uk Additional Resources: elearning for Healthcare, NHS HEE http://www.e-lfh.org.uk/programmes/
Questions 3
QUESTION 1 WHICH OF THE FOLLOWING BACTERIA DO NOT BELONG TO COCCI (choose all that apply): 1. Escherichia coli 2. Clostridium difficile 3. Streptococcus pneumoniae 4. Staphylococci
QUESTION 2 WHICH ONE OF THE FOLLOWING STATEMTENTS IS NOT CORRECT: 1. Lactobacillus can be present in genitourinary tract as a part of normal bacterial flora in this site. 2. The normal flora can protect against more harmful bacteria establishing themselves at the body sites. 3. Colonisation is when microorganisms cause damage to body tissues. 4. The presence of colonising bacteria does not warrant antibiotic treatment.
QUESTION 3 DATA FROM ENGLAND (2015) SHOW THAT ANTIBIOTIC USE INCREASED BY : 1. 2.5 % over the past 4 years 2. 4.5 % over the past 4 years 3. 6.5 % over the past 4 years 4. 8.5 % over the past 4 years 5. Antibiotic use significantly decreased over the last decade
QUESTION 4 WHICH ONE OF THE FOLLOWING IS NOT CORRECT ABOUT ANTIBIOTICS? 1. Antibiotics are unlike any other drug, as the more we use them the more effective they become against their target bacteria. 2. There are few antibiotics available that are effective against antibiotic resistant bacteria. 3. Antibiotics are used to treat bacterial infection. 4. Antibiotics are antimicrobials that have specific activity against bacteria.
QUESTION 5 WHAT CAN YOU DO TO REDUCE THE DEMAND FOR ANTIBIOTICS (choose all that apply): 1. Use antibiotics more now so that people need them less in the future. 2. Influence patient knowledge and expectations. 3. Reduce development of hospital-acquired infection and use of invasive devices. 4. Implement and participate in immunisation programmes e.g. patient and staff flu vaccination.
QUESTION 6 WHAT IS THE FIRST STEP IN LABORATORY PROCESSING WHEN DIAGNOSING AN INFECTION? 1. Identification of micro-organisms within the specimen. 2. Report generated and communicated to clinical team. 3. Register the specimen electronically. 4. Obtain a good quality specimen.
Certificate of completion Name:.. Completed training course: Role of the nurse in diagnosing infection: The right sample, every time
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