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Microlife: GP

From your local Clinical Microbiology Team


O c t o b e r 2 0 1 2

Welcome
In this edition we provide an update on how to diagnose Pertussis and advice on MRSA decolonisation treatment in the community. We hope you find this newsletter useful. Please send any comments to:
Savita.gossain@heartofengland .nhs.uk

Pertussis on the increase


hooping cough (pertussis) is a notifiable, highly contagious, acute bacterial infection of the respiratory tract caused by Bordetella pertussis.1 It affects people of all ages and can result in substantial morbidity and mortality. In the first 33 weeks of 2012 there have been 5,657 cases, an eight-fold increase from this time last year with eight reported deaths. These deaths have all been in young unimmunised infants.2 The highest numbers of confirmed cases continue to be reported in the South East and South West Regions but activity is high across all parts of the country.

infected person. Patients are infectious up to four days before the cough develops, and for about 21 days following the onset of symptoms. What are the symptoms of pertussis? Incubation period typically 7 - 10 days. Patients initially develop a common cold-like illness. Outbursts of coughing (paroxysms) within one to two weeks. An inspiratory whoop. Coughing bouts may be followed by vomiting or apnoeic episodes. Sufferers may produce thick, sticky, clear sputum, that is often very difficult to expectorate. This gradually worsens and lasts over a period of 2-6 weeks.

Clinical enquiries:
Heartlands Hospital: Microbiology Consultant 0121 424 3244

Why are rates increasing? Several factors may account for the apparent rise in pertussis cases, including Suspect pertussis in anyone with a increased awareness, new diagnostic chronic paroxysmal cough, a whoop Good Hope Hospital: methods and reduced potency of the is not always present. Microbiology Consultant acellular pertussis vaccine compared to 07917 648323 the earlier whole cell vaccine. Previous Who is most at risk? infection or vaccination does not The highest incidence has been Heartlands Hospital: confer lifelong immunity to pertussis. Virology enquiries: observed in infants under 3 months. Infections with whooping cough in These infants are too young to be Switchboard, bleep 2821 vaccinated or previously infected patients protected by immunisation, are at greater Out of Office Hours: are likely to be milder. risk of developing the disease and are Switchboard also at much greater risk of developing 0121 424 2000 How infectious is pertussis? complications, hospitalisation and death. Up to 90% of non-immune household The DH recently introduced a temporary Laboratory results: contacts are likely to develop the disease. programme to vaccinate pregnant women It is spread by close contact with an against pertussis to protect their infants.3 For all results enquiries, contact: 0121 424 3256 How to diagnose pertussis For diagnostic purposes, the disease is divided into early (<2 weeks from start of symptoms) and late (>2 weeks). Infants (if not requiring hospitalization) Children over 12 months and adults: Early disease Late disease send culture swab (see overleaf) send culture swab (see overleaf) send sample for serology (red top

Laboratory Opening Hours: Mon - Fri: 7am - 7pm Sat, Sun & Bank Holidays: 8am - 4pm

tube) NB: serology result only valid if not


vaccinated in the previous year

Pertussis increase ctd...


regional HPU immediately on How to take a pernasal swab through other nostril. A pernasal swab must be taken 3. Insert the swab into the me- 0844 225 3560. correctly to ensure an accurate dia tube. DO NOT wait for a laboratory diagnosis of pertussis can be 4. Ensure the swab is labelled diagnosis and confirmation. made. Swabs can be ordered accurately along with the comfrom Pathology Stores in the How to treat pertussis usual way. For suspected, epidemiologically linked or confirmed cases, recommended antibiotic regimens according to the age of the patient are available on the HPA website (Ref.1). Erythromycin, clarythromycin, 1. Remove cap from media tube Sagittal section of the nasal airway, azithromycin and co-trimoxazole by twisting. reproduced from Medical Microbiology are all recommended but differ Testing in Primary Care, Manson 2. Gently insert the fine, flexible Publishing. according to the age of the papernasal (turquoise top) swab tient. along the floor of the nasal cavity pleted request form. Send to lab Antibiotics should be adminisASAP. until it touches the posterior nasotered as soon as possible after onset of illness in order to eradipharynx & rotate 2-3 times before Notification of pertussis withdrawing. If obstruction is en- In all patients that you suspect cate the organism and limit ongoing transmission. countered, withdraw and re-insert have whooping cough notify your
References 1.HPAGuidelines.http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1287142671506; 2. Health Protection Agency. Pertussis notifications and deaths. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317133571994; 3. https://www.cas.dh.gov.uk/ ViewandAcknowledgment/ViewAlert.aspx?AlertID=101844

MRSA and Decolonisation


t is routine at the Heart of England NHS Foundation Trust to take a nose swab for MRSA (Methicillin Resistant Staphylococcus aureus) from all patients admitted to our hospitals If the patient is positive they are treated with an antiseptic body wash and nasal cream (decolonisation treatment) whilst in hospital. In some cases screening results may not be available until after the patient is discharged and therefore your patient will not have had any treatment. In these cases, we inform the patient and GP by automatic letter of a positive result so the need for treatment can be assessed. Most patients will not require any decolonisation treatment and can be reassured that MRSA that was detected will go naturally. However, patients with long standing illnesses, catheters, wounds and iv lines are at higher risk of developing an infection and we would recommend they are prescribed decolonisation treatment. On completion of the 5 day course of decolonisation, repeat swabbing is not usually required, unless clinically indicated. There is an information leaflet advising patients on how to use decolonisation treatment, and following feedback from GPs, these will, in future, be sent with

the letter to the practice. If you have any queries, comments or require further advice please contact a member of the Infection Prevention and Control Team (0121 424 1137) or Duty Microbiologist (see page 1). MRSA Decolonisation treatment Five days of anti-septic body wash Chlorhexidine Gluconate 4% Solution OD and a nasal cream Bactroban Nasal Ointment (Mupirocin 2% Nasal Ointment) TDS used as follows: The body wash should be used as a liquid soap and applied directly on to the skin (not diluted). The patient should preferably shower or bathe daily and wash their hair twice in the 5 day period with Chlorhexidine. A small amount of the nasal cream should be applied to the inner surface of each nostril TDS for the 5 day period. N.B. For patients allergic to Chlorhexidine, Octenisan Wash Lotion can be used as an alternative in same way as above.