- Email: [email protected]
P29.17 Reduction in C. difficile cases at a district hospital following interventions based on a care bundle approach
Abstracts, 7th International Conference of the Hospital Infection Society, 10–13 October 2010, Liverpool, UK / Journal of Hospital Infection 76S1 (2010) S1–S90
(Brandt et al, 2008) unexpectedly showed significant higher SSI rates using unidirectional airflow in the OT for hip prosthesis and no differences for knee prosthesis. It is therefore essential to evaluate the usefulness of this ventilation system for cost-effectiveness. Methods: The study designed by GISIO adopts a multiple surveillance approach consisting of active surveillance of infection, antibiotic prophylaxis, and air microbial contamination in order to evaluate the role of microbial air contamination on the risk of SSI in hip and knee arthroprosthesis controlling for adherence to guidelines for antimicrobial prophylaxis. The project has been funded by the Italian CCM (Centro Controllo Malattie, Ministry of Health). SSI surveillance will be carried out according to the HELICS protocol, air microbial contamination will be performed by using passive and/or active sampling. Electronic data forms have been designed for web-based data collection, using SPSS Data Entry Enterprise Server (SPSS Inc.) at the LAPOSS (Laboratory for Planning, Experimentation and Analysis of Public Policies and Service for People), University of Catania. After surveillance staff will entered surveillance data and will completed online forms, each case will be sent to the Central Web Server, where it will be automatically routed to the appropriate centralized database available for data cleaning and data analysis in real time. The study will provide the opportunity to build benchmark data and indicators for better understanding of factors influencing risk of SSI in in hip and knee arthroprosthesis. P29.15 Surveillance of nosocomial bloodstream infections and pneumonia in patients with hematopoetic cell transplantation (‘ONKO-KISS’) M. Dettenkofer1 , M. Martin1 , D. Luft1 , R. Babikir1 , H. Bertz1 , A.F. Widmer2 , W.V. Kern1 , P. Gastmeier3 . 1 Universtiy Medical Center Freiburg, Germany; 2 University Hospital Basel, Switzerland; 3 Charit´e Berlin, Germany Background/Objective: For surveillance of nosocomial bloodstream infections (BSI) and pneumonia during neutropenia in adult patients undergoing hematopoetic cell transplantation (HCT), an ongoing multicenter surveillance project was initiated by the German National Reference Centre for Surveillance of Nosocomial Infections in 2000 (ONKO-KISS). Methods: Nosocomial Infections are identified using CDC definitions for laboratory-confirmed BSI and modified criteria for pneumonia in neutropenic patients [for detailed information see: CID 2005;40:926–31, or in German language: http:// www.nrz-hygiene.de/surveillance/onko.htm]. Results: Over the 60-month period from July 2004 up to June 2009 23 centres participated. Altogether 5,853 patients with 86,340 neutropenic days were investigated. Of these, 3,391 (58%) had undergone allogeneic and 2,462 (42%) autologous HCT. The mean length of neutropenia was 14.8 days (9.0 d after autologous and 18.9 d after allogeneic transplantation). In total, 904 bloodstream infections and 490 cases of pneumonia were identified. Incidence densities for allogeneic transplantation were 8.7 BSI/1,000 neutropenic days (ND) and for pneumonia 5.9/1,000 NDs (for autologous transpl.: 15.5/5.1). Following allogeneic transplantation, 16.6 BSI/100 patients and 11.1 cases of pneumonia/100 patients occurred whereas following autologous transplantation 13.9 cases of BSI/100 patients and 4.6 cases of pneumonia/100 patients were observed. The main pathogens associated with BSI were coagulasenegative staphylococci (46%). Conclusions: The ongoing ONKO-KISS project adds to the improvement of quality of care in HCT-patients by providing sound reference data on the occurrence of BSI and pneumonia during neutropenia. Since 2006, surveillance is extended to neutropenic patients with acute leukemia to allow participation for centres not performing HCT.
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P29.16 Methicillin-resistant Staphylococcus aureus in hospitals and the community: can screening interrupt the feedback loop? S.R. Deeny1 , B.S. Cooper2 , B.D. Cookson1 , J.V. Robotham1 . 1 Health Protection Agency, United Kingdom; 2 Mahidol-Oxford Tropical Medicine Research Unit, Thailand Methicillin-resistant Staphylococcus aureus (MRSA) represents a threat to the health of hospitalised patients. Patients can remain asymptomatically colonised with MRSA for at least a year and if re-admitted during that time, those patients may re-introduce MRSA into the hospital. Thus, the movement of patients in and out of hospital plays an important role in nosocomial transmission dynamics. Previous modelling studies have shown that control measures which are effective in the short term can fail in the long term, due to readmissions from the community reservoir of MRSA. We developed a stochastic, individual-based model simulating the transmission of MRSA within hospitals, incorporating patient movement. We consider patient movement patterns throughout the patient journey and allow for the possibility that different patient groups may have different readmission rates. We use this model to examine the effectiveness of various screening strategies e.g. (i) universal screening, (ii) screening targeted groups of high risk patients, particularly the impact of screening ‘core groups’ of frequently readmitted patients, and (iii) screening on discharge. Once MRSA positive patients are detected, de-colonisation or isolation strategies are applied. The results of the model identify optimal screening policies, including who should be screened and when in their patient journey. We show that the proportion of hospital admissions who are re-admitted, and the prevalence within the re-admitted population, can have a direct influence on the effectiveness of screening and thus control. In particular, we find that targeting screening to frequently re-admitted (and typically high prevalence) patient groups can increase the effectiveness of a screening program. We demonstrate that models such as this, that consider the feedback loop between the hospital and community, can inform the development of effective MRSA screening and control. P29.17 Reduction in C. difficile cases at a district hospital following interventions based on a care bundle approach D. Enoch, A. Jack, D. Mlangeni, A. Sismey. Peterborough & Stamford Hospitals NHS Foundation Trust, United Kingdom Background: Clostridium difficile is the commonest cause of diarrhoea in hospitalised patients and is associated with significant morbidity and mortality. The Department of Health introduced guidelines to reduce cases using a bundle approach. Aim: We present our experience of controlling C. difficile for 2 years before and after implementing a C. difficile care bundle using ORION criteria. Methods: Peterborough & Stamford Hospitals NHS FT is a district hospital with 600 beds. We performed a prospective descriptive study of all patients with C. difficile toxin positive results occurring in adults ≥18 y from Jan 2006 to Dec 2009. The infection control team (ICT) initially consisted of 0 consultant microbiologists (rising to 1 in Mar 2006 and 2 in Jan 2008), 2.2 whole time equivalent (WTE) infection control nurses (4.2 WTE in Nov 2009) and 1 antibiotic pharmacist. Interventions included daily ICT ward rounds, a deep clean programme, increased education, rapid isolation, root cause analysis (RCA) of all cases (Jan-Mar 2008) and restriction of cephalosporin usage (Apr 2008) along with antibiotic audits. A new isolation ward was opened in Jul 2008. RCA data were obtained prospectively for all cases after Jan 2008. Hospital onset was defined as that ≥48 h after admission.
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Abstracts, 7th International Conference of the Hospital Infection Society, 10–13 October 2010, Liverpool, UK / Journal of Hospital Infection 76S1 (2010) S1–S90
Results: 928 cases occurred in the 4 year period with 353 in 2006, 341 in 2007 (pre-intervention) and 139 (2008) and 95 in 2009 (post intervention, with RCA data). The mean age was 80; 40% were male. 70% were hospital onset. 90% received antibiotics in the preceding 30d. Cephalosporin use fell during 2008. Co-amoxiclav and piperacillin-tazobactam use rose. Audits showed improvements in prescribing habits. The deep clean led to a reduction in cases for 3 months. The crude (attributable) mortality at one month was 27% (4.2%). Discussion: We demonstrate a reduction in C. difficile cases from 353 in 2006 to 95 cases in 2009 following the introduction of a care bundle approach. P29.18 Universal screening for methicillin-resistant Staphylococcus aureus (MRSA) in an acute hospital E. Creamer1 , A. Dolan1 , O. Sherlock1 , D. Fitzgerald-Hughes1 , T. Thomas1 , J. Walsh1 , A.C. Shore2 , D.J. Sullivan2 , P.M. Kinnevey2 , A.S. Rossney3,4 , P. O’Lorcain4 , E.G. Smyth1 , R. Cunney4 , D.C. Coleman2 , H. Humphreys1 . 1 Beaumont Hospital, Ireland; 2 Dental Science and Dublin Dental Hospital, Ireland; 3 St. James’s Hospital, Ireland; 4 Health Protection Surveillance Centre, Ireland Background: Universal screening was conducted as a component of a four-year research study to examine the prevalence of MRSA in patients and to evaluate initiatives to reduce the prevalence of MRSA. Prior to 2010 patient consent was required for screening. Objective: To determine the prevalence of MRSA when universal screening was introduced without the need for consent (2010), and to compare with when consent was required (2007–09). Methods: Consenting patients on selected wards in a 700-bed acute hospital were screened during three point prevalence periods (PPPs) between 2007 and 2009. Universal screening, without the need for consent, was carried out during a further two PPPs in 2010. Specimens were cultured onto MRSA-selective chromogenic agar (MRSA-Select, Bio-rad). Results: Overall MRSA was isolated from 10% (77/798) of patients, 6% (11/172) screened <72 hours post admission (Group A) and 10% (60/626) screened >72 hours post admission (Group B). MRSA was detected in 11% (38/339) of patients screened during the first three PPPs, compared to 7% (33/459) during the latter two PPPs, p = 0.02. MRSA declined in Group A patients from 7% (8/111) during the first three PPPs compared to 5% (3/61) during the last two PPPs, and in Group B patients from 13% (30/228) to 8% (30/398). Universal screening of non-risk patients for MRSA, (i.e. not admitted from nursing homes, other hospitals, no previous history of MRSA or chronic wounds) indicated less MRSA, 3% (4/153) in Group A compared to 9% (46/490) in Group B, p = 0.006. Conclusions: Although MRSA isolation doubled in patients and screens when consent was not required, universal screening yielded low MRSA rates in admission patients, especially those with no risks for MRSA, but higher in patients screened >72 hours after admission. Universal admission screening may not be justified in our population, if there is compliance with targeted screening of MRSA risk patients. P29.19 MRSA bacteraemia in a district hospital with low levels of MRSA infection: lessons learnt and actions implemented as a result of root cause analysis D. Enoch1 , N. Carter1 , J. Cargill2 , C. Wilkinson1 . 1 Peterborough & Stamford Hospitals NHS Foundation Trust, United Kingdom; 2 Leeds General Infirmary, United Kingdom Background: MRSA bloodstream infection (BSI) is associated with increased mortality and morbidity. Root cause analysis (RCA) is a recognised way of learning lessons from adverse incidents.
Aim: To evaluate the effectiveness of a RCA programme in reducing BSI further from low levels. Methods: A retrospective review of all MRSA BSI in a 600bed District Hospital was undertaken for 1st Apr 2008 – 31st Mar 2010. BSI occurring ≤48 h of admission is classified as either community (C) or healthcare-associated (HCAI) if from a patient previously hospitalised. BSI >48 h is considered hospitalacquired (H). RCA are performed by a multidisciplinary team including the infection control team and clinical ward staff, scrutinised by directors and actions implemented accordingly. Results: There were 21 episodes (19 patients). 63% were male (mean age 72 y). The onset was HCAI (9), H (7), transfer (2) and C (1). The source was wound (5), central venous catheter (CVC; 4), peripheral cannula (PVC; 3), recurrence (2), urinary catheter (2) and other (4). 11 were previously MRSA positive; 3 were not decolonised and 2 were positive at other hospitals. 12 had renal disease and 9 were diabetic. 15 had prosthetic material. Issues raised by RCA included: • Compliance with MRSA screening • Care of patients with prosthetic devices • Inadequate initial treatment of BSI. Changes implemented from RCA: • Increased screening of inpatients in high risk areas (e.g. ITU, oncology) • Decolonisation regimens in Critical Care • 7 day testing • Opening of new isolation ward • Introduction of care bundles with staff education concerning CVC, PVC, urinary catheters, antibiotics • Improved discharge planning • Improved communication between hospital and community. Discussion: RCA has led to reductions in CVC and PVC-related bacteraemias and compliance with screening has increased, leading to a reduction in the number of avoidable BSIs. P29.20 Epidemiology of methicillin resistant Staphylococcus aureus in Scotland J. Wilson1 , A. Eastaway1 , G. Edwards2 , B. Cosgrove2 . 1 Health Protection Scotland, United Kingdom; 2 Scottish MRSA Reference Laboratory, United Kingdom Background: Scotland has a mandatory reporting scheme whereby all first MRSA bacteraemia isolates are referred to the Scottish MRSA Reference Laboratory for typing and antibiotic susceptibility testing. Bacteraemia specimens are used as a proxy indicator of the level of MRSA infection in Scottish hospitals. Little is known about the characteristics of non-bacteraemia isolates at a national level. Aims: This study was designed to look at MRSA from all specimen types, to monitor trends in strains, emerging antimicrobial resistance and toxin genes. The changing epidemiology of MRSA is a matter of Public Health concern and this study aims to provide epidemiological information on circulating strains in Scotland. Methods: Scottish diagnostic laboratories send all new MRSA isolates collected over a period of one week, 4 times a year to the Scottish MRSA Reference Laboratory for typing and toxin testing. Epidemiological information was provided with each isolate. All isolates were phenotypically typed using biotype and antibiogram. Genotyping was performed using PCR-ribotyping and PFGE. Isolates were tested for resistance to 22 antibiotics. Toxin testing was performed: toxic shock syndrome toxin-1, two exfoliative toxins and the PVL gene was tested for. Sequenced based typing (spa typing) was performed on all isolates. Surveillance period: Oct 2008 – Mar 2010. Results: The total number of isolates analysed was 688. Five hundred and fifty nine of these were EMRSA-15 (spa type t032, t022), 70 were EMRSA-16 (t018), with the remaining isolates falling into the “other” category. The PVL toxin was found in 17 isolates
(Brandt et al, 2008) unexpectedly showed significant higher SSI rates using unidirectional airflow in the OT for hip prosthesis and no differences for knee prosthesis. It is therefore essential to evaluate the usefulness of this ventilation system for cost-effectiveness. Methods: The study designed by GISIO adopts a multiple surveillance approach consisting of active surveillance of infection, antibiotic prophylaxis, and air microbial contamination in order to evaluate the role of microbial air contamination on the risk of SSI in hip and knee arthroprosthesis controlling for adherence to guidelines for antimicrobial prophylaxis. The project has been funded by the Italian CCM (Centro Controllo Malattie, Ministry of Health). SSI surveillance will be carried out according to the HELICS protocol, air microbial contamination will be performed by using passive and/or active sampling. Electronic data forms have been designed for web-based data collection, using SPSS Data Entry Enterprise Server (SPSS Inc.) at the LAPOSS (Laboratory for Planning, Experimentation and Analysis of Public Policies and Service for People), University of Catania. After surveillance staff will entered surveillance data and will completed online forms, each case will be sent to the Central Web Server, where it will be automatically routed to the appropriate centralized database available for data cleaning and data analysis in real time. The study will provide the opportunity to build benchmark data and indicators for better understanding of factors influencing risk of SSI in in hip and knee arthroprosthesis. P29.15 Surveillance of nosocomial bloodstream infections and pneumonia in patients with hematopoetic cell transplantation (‘ONKO-KISS’) M. Dettenkofer1 , M. Martin1 , D. Luft1 , R. Babikir1 , H. Bertz1 , A.F. Widmer2 , W.V. Kern1 , P. Gastmeier3 . 1 Universtiy Medical Center Freiburg, Germany; 2 University Hospital Basel, Switzerland; 3 Charit´e Berlin, Germany Background/Objective: For surveillance of nosocomial bloodstream infections (BSI) and pneumonia during neutropenia in adult patients undergoing hematopoetic cell transplantation (HCT), an ongoing multicenter surveillance project was initiated by the German National Reference Centre for Surveillance of Nosocomial Infections in 2000 (ONKO-KISS). Methods: Nosocomial Infections are identified using CDC definitions for laboratory-confirmed BSI and modified criteria for pneumonia in neutropenic patients [for detailed information see: CID 2005;40:926–31, or in German language: http:// www.nrz-hygiene.de/surveillance/onko.htm]. Results: Over the 60-month period from July 2004 up to June 2009 23 centres participated. Altogether 5,853 patients with 86,340 neutropenic days were investigated. Of these, 3,391 (58%) had undergone allogeneic and 2,462 (42%) autologous HCT. The mean length of neutropenia was 14.8 days (9.0 d after autologous and 18.9 d after allogeneic transplantation). In total, 904 bloodstream infections and 490 cases of pneumonia were identified. Incidence densities for allogeneic transplantation were 8.7 BSI/1,000 neutropenic days (ND) and for pneumonia 5.9/1,000 NDs (for autologous transpl.: 15.5/5.1). Following allogeneic transplantation, 16.6 BSI/100 patients and 11.1 cases of pneumonia/100 patients occurred whereas following autologous transplantation 13.9 cases of BSI/100 patients and 4.6 cases of pneumonia/100 patients were observed. The main pathogens associated with BSI were coagulasenegative staphylococci (46%). Conclusions: The ongoing ONKO-KISS project adds to the improvement of quality of care in HCT-patients by providing sound reference data on the occurrence of BSI and pneumonia during neutropenia. Since 2006, surveillance is extended to neutropenic patients with acute leukemia to allow participation for centres not performing HCT.
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P29.16 Methicillin-resistant Staphylococcus aureus in hospitals and the community: can screening interrupt the feedback loop? S.R. Deeny1 , B.S. Cooper2 , B.D. Cookson1 , J.V. Robotham1 . 1 Health Protection Agency, United Kingdom; 2 Mahidol-Oxford Tropical Medicine Research Unit, Thailand Methicillin-resistant Staphylococcus aureus (MRSA) represents a threat to the health of hospitalised patients. Patients can remain asymptomatically colonised with MRSA for at least a year and if re-admitted during that time, those patients may re-introduce MRSA into the hospital. Thus, the movement of patients in and out of hospital plays an important role in nosocomial transmission dynamics. Previous modelling studies have shown that control measures which are effective in the short term can fail in the long term, due to readmissions from the community reservoir of MRSA. We developed a stochastic, individual-based model simulating the transmission of MRSA within hospitals, incorporating patient movement. We consider patient movement patterns throughout the patient journey and allow for the possibility that different patient groups may have different readmission rates. We use this model to examine the effectiveness of various screening strategies e.g. (i) universal screening, (ii) screening targeted groups of high risk patients, particularly the impact of screening ‘core groups’ of frequently readmitted patients, and (iii) screening on discharge. Once MRSA positive patients are detected, de-colonisation or isolation strategies are applied. The results of the model identify optimal screening policies, including who should be screened and when in their patient journey. We show that the proportion of hospital admissions who are re-admitted, and the prevalence within the re-admitted population, can have a direct influence on the effectiveness of screening and thus control. In particular, we find that targeting screening to frequently re-admitted (and typically high prevalence) patient groups can increase the effectiveness of a screening program. We demonstrate that models such as this, that consider the feedback loop between the hospital and community, can inform the development of effective MRSA screening and control. P29.17 Reduction in C. difficile cases at a district hospital following interventions based on a care bundle approach D. Enoch, A. Jack, D. Mlangeni, A. Sismey. Peterborough & Stamford Hospitals NHS Foundation Trust, United Kingdom Background: Clostridium difficile is the commonest cause of diarrhoea in hospitalised patients and is associated with significant morbidity and mortality. The Department of Health introduced guidelines to reduce cases using a bundle approach. Aim: We present our experience of controlling C. difficile for 2 years before and after implementing a C. difficile care bundle using ORION criteria. Methods: Peterborough & Stamford Hospitals NHS FT is a district hospital with 600 beds. We performed a prospective descriptive study of all patients with C. difficile toxin positive results occurring in adults ≥18 y from Jan 2006 to Dec 2009. The infection control team (ICT) initially consisted of 0 consultant microbiologists (rising to 1 in Mar 2006 and 2 in Jan 2008), 2.2 whole time equivalent (WTE) infection control nurses (4.2 WTE in Nov 2009) and 1 antibiotic pharmacist. Interventions included daily ICT ward rounds, a deep clean programme, increased education, rapid isolation, root cause analysis (RCA) of all cases (Jan-Mar 2008) and restriction of cephalosporin usage (Apr 2008) along with antibiotic audits. A new isolation ward was opened in Jul 2008. RCA data were obtained prospectively for all cases after Jan 2008. Hospital onset was defined as that ≥48 h after admission.
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Abstracts, 7th International Conference of the Hospital Infection Society, 10–13 October 2010, Liverpool, UK / Journal of Hospital Infection 76S1 (2010) S1–S90
Results: 928 cases occurred in the 4 year period with 353 in 2006, 341 in 2007 (pre-intervention) and 139 (2008) and 95 in 2009 (post intervention, with RCA data). The mean age was 80; 40% were male. 70% were hospital onset. 90% received antibiotics in the preceding 30d. Cephalosporin use fell during 2008. Co-amoxiclav and piperacillin-tazobactam use rose. Audits showed improvements in prescribing habits. The deep clean led to a reduction in cases for 3 months. The crude (attributable) mortality at one month was 27% (4.2%). Discussion: We demonstrate a reduction in C. difficile cases from 353 in 2006 to 95 cases in 2009 following the introduction of a care bundle approach. P29.18 Universal screening for methicillin-resistant Staphylococcus aureus (MRSA) in an acute hospital E. Creamer1 , A. Dolan1 , O. Sherlock1 , D. Fitzgerald-Hughes1 , T. Thomas1 , J. Walsh1 , A.C. Shore2 , D.J. Sullivan2 , P.M. Kinnevey2 , A.S. Rossney3,4 , P. O’Lorcain4 , E.G. Smyth1 , R. Cunney4 , D.C. Coleman2 , H. Humphreys1 . 1 Beaumont Hospital, Ireland; 2 Dental Science and Dublin Dental Hospital, Ireland; 3 St. James’s Hospital, Ireland; 4 Health Protection Surveillance Centre, Ireland Background: Universal screening was conducted as a component of a four-year research study to examine the prevalence of MRSA in patients and to evaluate initiatives to reduce the prevalence of MRSA. Prior to 2010 patient consent was required for screening. Objective: To determine the prevalence of MRSA when universal screening was introduced without the need for consent (2010), and to compare with when consent was required (2007–09). Methods: Consenting patients on selected wards in a 700-bed acute hospital were screened during three point prevalence periods (PPPs) between 2007 and 2009. Universal screening, without the need for consent, was carried out during a further two PPPs in 2010. Specimens were cultured onto MRSA-selective chromogenic agar (MRSA-Select, Bio-rad). Results: Overall MRSA was isolated from 10% (77/798) of patients, 6% (11/172) screened <72 hours post admission (Group A) and 10% (60/626) screened >72 hours post admission (Group B). MRSA was detected in 11% (38/339) of patients screened during the first three PPPs, compared to 7% (33/459) during the latter two PPPs, p = 0.02. MRSA declined in Group A patients from 7% (8/111) during the first three PPPs compared to 5% (3/61) during the last two PPPs, and in Group B patients from 13% (30/228) to 8% (30/398). Universal screening of non-risk patients for MRSA, (i.e. not admitted from nursing homes, other hospitals, no previous history of MRSA or chronic wounds) indicated less MRSA, 3% (4/153) in Group A compared to 9% (46/490) in Group B, p = 0.006. Conclusions: Although MRSA isolation doubled in patients and screens when consent was not required, universal screening yielded low MRSA rates in admission patients, especially those with no risks for MRSA, but higher in patients screened >72 hours after admission. Universal admission screening may not be justified in our population, if there is compliance with targeted screening of MRSA risk patients. P29.19 MRSA bacteraemia in a district hospital with low levels of MRSA infection: lessons learnt and actions implemented as a result of root cause analysis D. Enoch1 , N. Carter1 , J. Cargill2 , C. Wilkinson1 . 1 Peterborough & Stamford Hospitals NHS Foundation Trust, United Kingdom; 2 Leeds General Infirmary, United Kingdom Background: MRSA bloodstream infection (BSI) is associated with increased mortality and morbidity. Root cause analysis (RCA) is a recognised way of learning lessons from adverse incidents.
Aim: To evaluate the effectiveness of a RCA programme in reducing BSI further from low levels. Methods: A retrospective review of all MRSA BSI in a 600bed District Hospital was undertaken for 1st Apr 2008 – 31st Mar 2010. BSI occurring ≤48 h of admission is classified as either community (C) or healthcare-associated (HCAI) if from a patient previously hospitalised. BSI >48 h is considered hospitalacquired (H). RCA are performed by a multidisciplinary team including the infection control team and clinical ward staff, scrutinised by directors and actions implemented accordingly. Results: There were 21 episodes (19 patients). 63% were male (mean age 72 y). The onset was HCAI (9), H (7), transfer (2) and C (1). The source was wound (5), central venous catheter (CVC; 4), peripheral cannula (PVC; 3), recurrence (2), urinary catheter (2) and other (4). 11 were previously MRSA positive; 3 were not decolonised and 2 were positive at other hospitals. 12 had renal disease and 9 were diabetic. 15 had prosthetic material. Issues raised by RCA included: • Compliance with MRSA screening • Care of patients with prosthetic devices • Inadequate initial treatment of BSI. Changes implemented from RCA: • Increased screening of inpatients in high risk areas (e.g. ITU, oncology) • Decolonisation regimens in Critical Care • 7 day testing • Opening of new isolation ward • Introduction of care bundles with staff education concerning CVC, PVC, urinary catheters, antibiotics • Improved discharge planning • Improved communication between hospital and community. Discussion: RCA has led to reductions in CVC and PVC-related bacteraemias and compliance with screening has increased, leading to a reduction in the number of avoidable BSIs. P29.20 Epidemiology of methicillin resistant Staphylococcus aureus in Scotland J. Wilson1 , A. Eastaway1 , G. Edwards2 , B. Cosgrove2 . 1 Health Protection Scotland, United Kingdom; 2 Scottish MRSA Reference Laboratory, United Kingdom Background: Scotland has a mandatory reporting scheme whereby all first MRSA bacteraemia isolates are referred to the Scottish MRSA Reference Laboratory for typing and antibiotic susceptibility testing. Bacteraemia specimens are used as a proxy indicator of the level of MRSA infection in Scottish hospitals. Little is known about the characteristics of non-bacteraemia isolates at a national level. Aims: This study was designed to look at MRSA from all specimen types, to monitor trends in strains, emerging antimicrobial resistance and toxin genes. The changing epidemiology of MRSA is a matter of Public Health concern and this study aims to provide epidemiological information on circulating strains in Scotland. Methods: Scottish diagnostic laboratories send all new MRSA isolates collected over a period of one week, 4 times a year to the Scottish MRSA Reference Laboratory for typing and toxin testing. Epidemiological information was provided with each isolate. All isolates were phenotypically typed using biotype and antibiogram. Genotyping was performed using PCR-ribotyping and PFGE. Isolates were tested for resistance to 22 antibiotics. Toxin testing was performed: toxic shock syndrome toxin-1, two exfoliative toxins and the PVL gene was tested for. Sequenced based typing (spa typing) was performed on all isolates. Surveillance period: Oct 2008 – Mar 2010. Results: The total number of isolates analysed was 688. Five hundred and fifty nine of these were EMRSA-15 (spa type t032, t022), 70 were EMRSA-16 (t018), with the remaining isolates falling into the “other” category. The PVL toxin was found in 17 isolates