NHS GG&C Public Health Protection Unit (PHPU)/ Infection Control Policy. For investigation and management of PVL SA

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1 Page 1 of 16 NHS GG&C Public Health Protection Unit (PHPU)/ Infection Control Policy For investigation and management of PVL SA Document Control Summary Approved by and date Date of Publication Developed by NHS GG&C PHPU department Related Documents Distribution / Availability NHSGGC Infection Prevention and Control Policy Manual Implications of Race Equality and other diversity duties for this document Equality and Diversity Impact Assessment Completed Lead Manager Responsible Director and the Internet This policy must be implemented fairly and without prejudice whether on the grounds of race, gender, sexual orientation or religion. Health Protection Nurse Specialist Vincent McKeown Board Infection Control Manager

2 Page 2 of 16 Table of Contents Introduction and Aim Background Definitions Roles and Responsibilities Procedure Summary After Care Literature Page Appendices Appendix 1 : Risk Assessment and Management of Cases of PVL SA Infection Appendix 2 : Risk Assessment and Management of close contacts of PVL SA Infection Appendix 3 : Sample Questionnaire Appendix 4: Contacts of current case Appendix 5 : PVL Staphylococcus Aureus Information for Patients

3 Page 3 of 16 INTRODUCTION AND AIM Panton Valentine Leukocidin (PVL) is a toxin carried on some Staphylococcus aureus (SA) which causes skin infections and, rarely, necrotising pneumonia and other invasive infections. There is not a strong evidence base on which to base policy; this policy draws on national guidance and local agreements and aims to prevent and control PVL Staph aureus infections. BACKGROUND The PVL gene is found in approximately 2% of laboratory isolates associated with staphylococcal disease, although numbers of PVL associated isolates may be increasing (Cunnington et al, 2009). At present 60% of PVL SA isolates are meticillin sensitive (MSSA) and 40% meticillin resistant (MRSA). Transmission is directly via close personal contact or directly via contaminated environments. The epidemiology of PVL SA differs from that of other SA. Cases tend to be younger and, in the UK, associated with community settings rather than hospital. CDC guidance refers to risk factors for PVL related infection as 5 Cs: Contaminated items (e.g. towels) Close contact (contact sports) Crowding (e.g. closed communities) Cleanliness Cuts and other compromised skin integrity Outbreaks or clusters can occur in the community.

4 Page 4 of 16 DEFINITIONS Case : the isolation of a PVL positive S.aureus from a patient with a PVL like infection including: skin and soft tissue infection, necrotising pneumonia and septic shock. Close contact: contacts from a household type setting or sexual contacts within seven days before onset of acute infection High risk groups: healthcare workers, prisoners, military personnel, residential/care home staff, those involved in contact sport Outbreak: Two or more confirmed cases of the same strain of PVL SA outwith the same household or in a care home setting.

5 Page 5 of 16 ROLES AND RESPONSIBILITIES Clinicians (primary or secondary care): Are responsible for the clinical management of cases and, where appropriate, contacts, and should notify PHPU of clinical cases with a positive test for PVL SA in the following circumstances: A single case in a patient in a high risk group (healthcare worker, residential/care home staff, those involved in gyms or close contact sports, or belong to a closed community (prison, military camp, care home) There is a cluster or outbreak in the community or institutional setting The case has necrotising pneumonia. Infection Control Teams: should be notified of all cases of PVL SA by the Scottish MRSA Reference Lab. PHPU: should undertake the public health assessment and management of cases and contacts of PVL SA in high risk groups: closed communities and in situations where clusters or outbreaks are reported. PHPU should seek advice from microbiology with regard to specific treatment and or decontamination regimes as indicated. PHPU should liaise with the GP with regard to the management of cases and contact from a public health perspective. Microbiology/ICD: should advise on the treatment and management of cases and contact in healthcare settings, and liaise with PHPU with regard to the management of community cases and/or contacts as appropriate. Microbiologists should ensure that appropriate samples are referred to the Scottish MRSA reference lab. Scottish MRSA reference Lab: PHPU/ICTs should receive reports of confirmed PVL cases from the Scottish MRSA reference laboratory as appropriate.

6 Page 6 of 16 PROCEDURE SUMMARY Single sporadic cases (and contacts) N.B. The decolonisation regime and infection control advice for PVL SA are the same as for MRSA and can be found at 20V4%20-% Assessment and management of single cases in the community should be undertaken by the GP with advice from microbiology as required. Cases in high risk groups or possible clusters/outbreaks should be reported to PHPU. The public health assessment and management of cases reported to PHPU should be undertaken as per the flowchart in Appendix 1. Decolonisation of the case should not be undertaken until the acute infection resolved The GP should undertake decolonisation of the case with advice from PHPU/ICT as appropriate. The GP should have access to an appropriate patient information leaflet on PVL SA. Repeat screening following decolonisation should be undertaken for cases in high risk groups only If still positive repeat decolonisation with no further screening post decolonisation The public health assessment and management of close contacts of cases reported to PHPU should be undertaken as per the flowchart in Appendix 2 The GP should undertake decolonisation of the contacts as per the advice from PHPU and a patient information leaflet on PVL SA should be provided. Decolonisation of contacts of cases of necrotising pneumonia caused by PVL SA should start immediately without screening. Advice should be sought from microbiology. (A five day decolonisation regime preferably, including a chlorhexidine gargle is recommended ) For cases with other PVL SA infections the assessment should include whether contacts have had past or current PVL SA infections. If so, current infections should be treated before decolonisation is attempted If a household contact is likely to be colonised because of a past history of PVL infection, all contacts in the household should undergo decolonisation at the same time as the index case without prior screening. If there is no past history among contacts, but one or more contacts are in high risk groups, then this contact(s) should be screened. If any contact in a high risk group screens positive then the entire family

7 Page 7 of 16 should be decolonised If a contact requiring decolonisation has a pre existing dermatological condition or is a neonate, this should be discussed with a dermatologist/obstetrician prior to starting the course of treatment All those screened positive should receive the PVL SA information leaflet and all those receiving decolonisation should receive the decolonisation leaflet. After decolonisation, further screening is not required unless a case or a close contact is particularly vulnerable to infection or poses a special risk to others. If this is the case repeat screening of the case and or contacts should be undertaken one week post decolonisation. Following the second round of decolonisation, no further screening should be undertaken. If the index case or contacts develop further acute infections these should be managed clinically as appropriate, and further specialist advice sought. Healthcare workers should not work if they have a proven acute PVL SA infection and should not return to work until the infection has resolved and 48 hours of a 5 day de colonisation regime has been completed (HPA). Occupational Health should be informed. Management of potential clusters/outbreaks The HPA Guidance on the diagnosis and management of PVL SA infections should be followed : An OCT should be established chaired by the CPHM if the community is the main focus or ICD if it is the hospital. The local outbreak control plan should also be used: 20-%20Outbreak%20Policy%20V2.pdf AFTER CARE There may be implications for actions in the future depending on the re occurrence or otherwise of acute infections If there is further acute infection after treatment, specialist advice should be sought.

8 Page 8 of 16 LITERATURE Health Protection Agency (2010) : Local and Regional Services, Management of PVL Staphylococcus aureus. Recommendations for Practice. Health Protection Agency (2008) Guidance on the diagnosis and management of PVL associated Staphylococcus aureus infections in England (2 nd edition Health Protection Agency : Frequently Asked Questions neleukocidinpvl/pvlfaq/ Cunnington et al, (2009), Severe Invasive Panton Valentine Leukocidin positive Staphylococcus aureus infections in children in London UK, Journal of Infection, Vol 59, pp

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11 Page 11 of 16 APPENDIX 3. SAMPLE QUESTIONNAIRE for PHPU Date & Time reported: Name of Person reporting: Designation: Taken by: 1. PATIENT DETAILS AND DEMOGRAPHICS Name: Country of birth / ethnicity: Address: Contact details: HPU: Date of Birth: Gender: Male / Female GP name and address: Home phone number: Occupation or setting (Please circle) Mobile number: 1 Hospital [e.g. patient or health care worker] 2 Nursing/residential [e.g. resident or care worker] 3 Nursery/childcare/school worker 4 Any institutional setting (e.g. sports centre/ armed forces/ prison) 5 Food handler 6 Other. Please specify Current clinical status (Please circle) Confirmed case: S. aureus has been confirmed as PVLpositive by SRU, HPA Colindale in a patient with skin or soft tissue infection (SSTI), or invasive disease such as necrotising pneumonia Suspected case: Patient has any of the infections above or there is clustering of SSTIs within a household or social group; or invasive infections in immunocompetent people, particularly community acquired necrotising/haemorrhagic pneumonia in the young Is the patient currently in hospital: Name of Hospital: Ward: Has the hospital infection control team been informed: Colonisation: The presence of PVL positive S. aureus without any symptoms/ signs of infection Yes / No Telephone No: Yes / No Is the patient currently in the community setting: Yes / No In own home: Yes / No If No where is patient currently : Has the relevant community infection control team been informed: Yes / No

12 Page 12 of RISK FACTORS FOR PVL Staphylococcus aureus (please tick as many as apply) Healthcare / Social Care Worker Care Home resident Personal or family history of skin or soft tissue infection(s) Visits a gymnasium Takes part in contact sports Military personnel Travel outside the UK in the last 12 months Attends any other institutional setting (e.g. prison, nursery) Please specify Has he/she had contact with a confirmed or suspected case? (Please circle) Yes / No / Not known If known, name of the confirmed or suspected case: Clinical status of other case: Infected Colonised Suspected Don t know Estimated period of contact: to Estimated duration of contact: Hours Days Months Type of contact: Household Social Work Health care setting Other (please specify) 3. CLINICAL DETAILS Main symptoms in the case: Comorbid illnesses: (please circle all that are applicable) Eczema / Psoriasis / Weeping skin lesions Immunosuppression due to Other systemic diseases None 4. LABORATORY DETAILS Date of test for PVL SA: Result of screen: Testing not complete SA isolated, PVL testing not complete PVL MSSA PVL MRSA Other S. aureus Negative for SA* If PVL SA was isolated: Date of first positive result : Date sent to SRU, HPA : PVL strain type: *Note: If screening swabs were obtained while receiving antibiotic treatment in preceding 48 hours, a negative result is not valid and the screen needs to be repeated. 5. TREATMENT DETAILS

13 Page 13 of 16 What was the indication for treatment? Decolonisation Treatment of infection Date treatment commenced: Treatment details Antibiotic used: Duration of course: Repeat treatment details: 6. OUTCOME OF TREATMENT If patient belongs to high risk group, was screening for clearance recommended post decolonisation? (High risk group: Hospital health care worker, nursing/ residential home care worker, Nursery / childcare/ school worker, works in sports centre/ gym/ prison/ correction facility, food handler) Yes / No / Not known Clearance screening results negative? Yes / No / Not known Date of most recent screen: Patient Status Still colonized Cleared PVL infection Deceased Not known If deceased, date of death: If deceased, was a) the death attributed to PVL b) PVL contributed to death c) PVL was incidental to death d) not known 7. OTHER RELEVANT INFORMATION

14 Page 14 of 16 APPENDIX 4 : CONTACTS OF CURRENT CASE ( FOR PHPU): Name & Relationship to index case Date of Birth GP Details Occupation Risk factors for PVL infection Symptoms/signs of PVL infection present? Exclusion required? Screening required? Decolonisation / treatment required?

15 Page 15 of 16 APPENDIX 5 : PVL STAPHYLOCOCCUS AUREUS INFORMATION FOR PATIENTS What is PVL Staphylococcus aureus? Staphylococcus aureus ('SA') is a bacterium (germ) that commonly lives on healthy skin. About one third of healthy people carry it quite harmlessly, usually on moist surfaces such as the nostrils, armpits and groin. This is known as colonization. Some types of Staphylococcus aureus produce a toxin called Panton Valentine Leukocidin (PVL) and they are known as PVL SAs. (Panton and Valentine were two doctors who first found this chemical which can kill white blood cells called leukocytes hence leukocidin ). What type of illness does it cause? All SAs, including PVL SAs, can cause harm if they get an opportunity to enter the body, for example through a cut or a graze. They can cause boils or skin abscesses and are occasionally associated with more serious infections of the lungs, blood, joints and bones. Some SAs such as PVL SA are more likely to cause infections than others. How do you catch PVL SA? Anyone can get a PVL SA infection. Infection can occur in fit, healthy people. PVL SA can be picked up by having: skin to skin contact with someone who is already infected, for example close family or during contact sports, or contact with an item or surface that has PVL SA on it from someone else, for example shared gym equipment, shared razors, shared towels. How is PVL SA treated? Boils and abscesses should be drained by incision by a doctor or nurse. Some infections may be treated with a course of antibiotics. In addition, the PVL SAs carried on your skin may be eliminated with a five day skin treatment (washes, creams and shampoos). This is done to reduce the chances of you getting repeated infections and reduce the chances of you spreading PVL SAs to others. In some patients this skin treatment may not be entirely successful, but the more carefully you follow the instructions, the more likely you are to clear the PVL SAs from your skin. Your GP may recommend checking members of your household and close contacts, e.g. partners/children, in case they are also carrying PVL SAs, and offering them skin treatments where necessary. How do I prevent passing PVL SAs to other people? You need to keep infected areas of your body covered with clean, dry dressings or plasters. Change these regularly and as soon as discharge seeps to the surface. It is important that fluid or pus from infected skin is contained, because it has large numbers of PVL SAs that can spread to others. Do not touch, poke or squeeze infected skin. This contaminates your hands and can push the PVL SAs deeper into the skin. Contact your GP surgery if you have a boil or abscess that needs draining.

16 Page 16 of 16 Cover your nose and mouth with a tissue when you cough or sneeze, particularly if you have a cold, because PVL SAs can live in your nose. Throw the tissue in the bin at once and then wash your hands. Wash your hands frequently with liquid soap and water, and especially after changing your plasters, dressings, and bandages or touching infected skin. Encourage others at home to wash their hands regularly with liquid soap. Use a separate towel and keep it separately, so others don't use it by mistake. Have it washed frequently in a hot wash. Regularly vacuum and dust (wiping with a damp cloth) your bedroom, bathroom, kitchen and other rooms, as well as personal items and shared items, such as keyboards. Household detergent is adequate for cleaning. Clean your sink, taps and bath after use with a disposable cloth and household detergent, then rinse clean and throw away the cloth. Can I go to work or school when I have a PVL SA infection? You should not work as a carer in a nursery, hospital, residential or care home or similar place until your skin has healed and you have permission to return to work from your local occupational health department, GP or manager. You should not work in the food industry, e.g. waitress, chef, food production, until your skin has healed and you have permission to return to work from your local occupational health department or GP. You may carry on with other types of work, provided you keep infected skin areas covered with clean, dry dressings. If you are not sure about working, contact your local occupational health department or your GP. Children can only go to school if they are old enough to understand the importance of good hand hygiene, and if their infected skin is covered with a clean dry dressing which will stay dry and in place until the end of the school day. Children should not take part in contact sports, or use communal gym equipment until their skin is healed. The GP s advice is essential, and school management should be informed. People who have eczema or a more generalised skin condition should remain off work or school until treatment has been completed for both the eczema or skin condition and the PVL SA infection. You need to continue treating your skin to keep it in good condition. In the long term this helps to reduce the risk of spread of PVL SA to others. Can I go to swimming pools, gyms or sports facilities when I have a PVL SA infection? You should not use communal facilities for example gym equipment, saunas, swimming pools, or have a massage, manicure or similar until your skin has healed.