Rebecca Guy

Trends in sources of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia: data from the national mandatory surveillance of MRSA bacteraemia in England, 2006–2009

The national mandatory surveillance system for reporting meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia in England has captured data on the source of reported bacteraemias since 2006. This study analysed episodes of MRSA bacteraemia (N=4404) where a probable source of infection was reported between 2006 and 2009. In 2009, this information was available for one-third of reported episodes of MRSA bacteraemia. Of these, 20% were attributed to intravascular devices and 28% were attributed to skin and soft tissue infection. Sixty-four percent of the patients were male, and urinary tract infection was a significantly more common source of MRSA bacteraemia in males compared with females (12% vs 3%). Detection of bacteraemia within two days of hospital admission does not reliably discriminate between community- and hospital-associated MRSA bacteraemia as community cases are frequently associated with an invasive procedure/device. Between 2006 and 2009, there was a significant decline in the proportion of episodes of MRSA bacteraemia associated with central vascular catheters [incidence rate ratio (IRR) 0.42, 95% confidence interval (CI) 0.29-0.61; P<0.001], peripheral vascular catheters (IRR 0.69, 95% CI 0.48-0.99; P=0.042) and surgical site infection (IRR 0.42, 95% CI 0.25-0.72; P=0.001), and a significant increase in the proportion of episodes of MRSA bacteraemia associated with skin and soft tissue infection (IRR 1.33, 95% CI 1.05-1.69; P=0.017) and attributed to contamination of the specimen (IRR 1.96, 95% CI 1.25-3.06; P=0.003). Since data were not available for all cases, the generalizability of these trends depends on the assumption that records with source data reflect a reasonably random sample of cases in each year. These changes have occurred in the context of a general decline in the rate of MRSA bacteraemia in England since 2006.

UK Renal Registry 16th Annual Report: Chapter 15 Epidemiology of Reported Infections amongst Patients Receiving Dialysis for Established Renal Failure in England from May 2011 to April 2012: a Joint Report from Public Health England and the UK Renal Registry

INTRODUCTION Infection remains one of the leading causes of mortality in established renal failure patients receiving renal replacement therapy (RRT). METHODS Data were submitted to Public Health England (PHE) by NHS acute Trusts via Health Care Associated Infection Data Capture System (HCAI-DCS) including whether the patients were receiving dialysis. Individual renal units then confirmed the record either directly via the database or after being contacted. Data were collected for the period 1st May 2012 to the 30th April 2013. RESULTS There were 31 episodes of MRSA bacteraemia, an overall rate of 0.13 per 100 dialysis patient years, representing a further year-on-year fall in MRSA rate. There were a higher number of MSSA episodes, 372 in total,with an overall rate of 1.59 per 100 dialysis patient years. The number of episodes of E. coli and C. difficile were 308 (1.32 per 100 dialysis patient years) and 123 (0.55 per 100 dialysis patient years) respectively. The presence of a central venous catheter was associated with an elevated risk of MRSA and MSSA bacteraemia. CONCLUSIONS We present data relating to infections in renal dialysis patients reported to PHE in one year. The rate of MRSA bacteraemia episodes in England continues to fall. There is a higher rate of MSSA infections.We also report the results of the second year of E. coli and C. difficile data collection. Future cycles will give further ideas of the trend in incidences of these infections. Further work to refine the definitions and data collection is necessary to ensure consistency of reporting across centres.

Chapter 12 Epidemiology of Staphylococcus Aureus Bacteraemia Amongst Patients Receiving Dialysis for Established Renal Failure in England in 2009 to 2011: A Joint Report from the Health Protection Agency and the UK Renal Registry

Introduction: Infection remains one of the leading causes of death in patients with end-stage renal failure (ESRF) receiving dialysis. Since April 2007, all centres providing renal replacement therapy in England have been required to provide additional data on patients with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. From January 2011 this has also been required for patients with Methicillin Sensitive Staphylococcus Aureus (MSSA). MRSA data for 2009–2011 and the first 6 months of MSSA data are reported. Methods: Potential bacteraemia were identified by the Health Protection Agency based on clinical details provided and the clinical setting. The records were ‘shared’ with the parent renal centre who then complete the additional data on the HCAI-DCS website. Centres were also contacted by phone and email as a further validation step. Results: From April 2009–2010 there were 77 confirmed episodes of MRSA bacteraemia at a median rate of 0.25 per 100 prevalent dialysis patients. This number decreased to 61 episodes between April 2010–2011 at a median rate of 0 per 100 prevalent dialysis patients. Overall there has been an 82% reduction in absolute episodes since the first year of mandatory reporting in 2007. The incidence of bacteraemia in patients with a central venous catheter was approximately six fold higher than in those with an AV fistula. From 1st January to 30th June 2011 there were 160 episodes of MSSA bacteraemia with a rate of 1.06 episodes per 100 dialysis patients, again the risk was six fold higher in patients with a CVC. Conclusions: Overall rates of MRSA bacteraemia in dialysis patients continued to fall although there remained variation between renal centres. Initial data from the early days of MSSA reporting suggested high rates of infection and an even greater variation between renal centres. This requires confirmation from future data collection.

Appendix E Methodology for Estimating Catchment Populations of Renal Centres in England for Dialysis Patients

Providing accurate centre-level incidence and prevalence rates for patients receiving renal replacement therapy (RRT) in the UK has been limited in the past by the difficulty in estimating the catchment population from which the RRT population was derived. One reason for this is that the geographical boundaries separating renal centres are relatively arbitrary and dependent upon a number of factors including referral practice, patient choice and patient movement. Previously, incidence and prevalence rates have been calculated at Local Authority/Primary Care Trust/Health Board level where denominator data were available, but not at renal centre level. Previous UK Renal Registry (UKRR) Annual Reports have suggested an estimate of the size of the catchment populations. These were extrapolated figures originally derived from data in the 1992 National Renal Survey undertaken by Paul Roderick. The purpose of this appendix is to present an estimate of the dialysis catchment population for all renal centres in England. The document also contains a methodological description and discussion of the limitations of this estimate. These catchment population estimates have been used in this report (chapter 1: UK RRT Incidence in 2009: national and centre-specific analyses) to calculate RRT incidence rates by renal centre, rather than only by Primary Care Trust/HB.

Contents Vol. 26, 2013

N. Ahmad, Madison, Wisc. P. Altmeyer, Bochum C. Antoniou, Athens H. Bachelez, Paris J.M. Baron, Aachen E. Benfeldt, Roskilde E. Berardesca, Rome D.R. Bickers, New York, N.Y. I. Bogdan Allemann, Zürich K. De Paepe, Brussels P. Elsner, Jena A. Farkas, Szeged A. Giannetti, Modena M.W. Greaves, London R.H. Guy, Bath J. Hadgraft , London E.M. Jackson, Bonney Lake, Wash. J. Kresken, Viersen J. Krutmann, Düsseldorf R. Neubert, Halle D.R. Roop, Aurora, Colo. T. Ruzicka, Munich M. Schäfer-Korting, Berlin S. Seidenari, Modena J. Wohlrab, Halle Journal of Pharmacological and Biophysical Research

UK Renal Registry 15th Annual Report: Appendix D Methodology used for Analyses of PCT/HB Incidence and Prevalence Rates and of Standardised Ratios

The areas used were the 146 English primary care trusts (PCTs), the five English care trusts, the seven Welsh Local Health Boards, the fourteen Scottish Health Boards and the five Health and Social Care Trusts in Northern Ireland – these different types of area are collectively called PCT/HBs here. These areas in England are likely to undergo significant reorganisation in the next few years with the introduction of clinical commissioning groups. There will be more of these areas each containing smaller population groups, although the boundaries have yet to be finalised.

UK Renal Registry 15th Annual Report: Appendix H Coding: Ethnicity, EDTA Primary Renal Diagnoses, EDTA Causes of Death

Ethnicity data is recorded in the clinical information systems in the individual renal centres in the format of 9S. . . read codes. If extracted from local PAS systems in a different format, it is recoded to the 9S. . . format by the centre, before being sent to the UKRR. For report analyses, ethnic categories are condensed into five groups (White, Asian, Black, Chinese and other). For some analyses Chinese are grouped into other.

UK Renal Registry 15th Annual Report: Appendix I Acronyms and Abbreviations used in the Report

ACE (inhibitor) Angiotensin converting enzyme (inhibitor) ANZDATA Australia and New Zealand Dialysis and Transplant Registry APD Automated peritoneal dialysis ADPKD Autosomal dominant polycystic kidney disease APKD Adult polycystic kidney disease AV Arteriovenous AVF Arteriovenous fistula AVG Arteriovenous graft BAPN British Association of Paediatric Nephrology BCG Bromocresol green BCP Bromocresol purple BMI Body mass index BP Blood pressure BTS British Transplant Society CAB Clinical Affairs Board (Renal Association) CABG Coronary artery bypass grafting CAPD Continuous ambulatory peritoneal dialysis CCL Clinical Computing Limited CCPD Cycling peritoneal dialysis CHr Target reticulocyte Hb content CI Confidence interval CK Creatine kinase CKD Chronic kidney disease CK-MB Creatine kinase isoenzyme MB COPD Chronic obstructive pulmonary disease CRF Chronic renal failure CRP C-reactive protein CVVH Continuous veno-venous haemofiltration CXR Chest x-ray DBP Diastolic blood pressure DCCT Diabetes Control and Complications Trial DH Department of Health DM Diabetes mellitus DOPPS Dialysis Outcomes and Practice Patterns Study E&W England and Wales E, W & NI England, Wales and Northern Ireland EBPG European Best Practice Guidelines ECG Electrocardiogram EDTA European Dialysis and Transplant Association EF Error factor eGFR Estimated glomerular filtration rate

Appendix F Additional Data Tables for 2010 Incident and Prevalent Patients

Abrdn 76 24 L Rfree 74 11 15 Airdrie 88 13 L St.G 75 13 12 Antrim 95 5 LWest 89 2 8 B Heart 81 16 3 Leeds 72 19 9 B QEH 75 19 6 Leic 67 20 13 Bangor 81 19 Liv Ain 94 6 Basldn 94 6 Liv RI 57 30 13 Belfast 87 8 4 M Hope 55 31 14 Bradfd 83 14 3 M RI 65 21 14 Brightn 72 28 Middlbr 83 12 5 Bristol 79 11 11 Newc 65 17 18 Camb 63 11 26 Newry 90 10 Cardff 73 19 8 Norwch 74 26 Carlis 76 24 Nottm 66 27 6 Carsh 85 8 7 Oxford 65 21 14 Chelms 62 38 Plymth 69 27 4 Clwyd 92 8 Ports 65 26 9 Colchr 100 Prestn 83 14 3 Covnt 71 23 6 Redng 52 38 10 Table F.1.2. Number of patients per treatment modality at 90 days (incident cohort 1/10/2009 to 30/09/2010)

Appendix D: Methodology Used for Analyses of PCT/HB Incidence and Prevalence Rates and of Standardised Ratios

The areas used were the 147 English primary care trusts (PCTs), the 5 English care trusts, the 7 Welsh Local Health Boards, the 14 Scottish Health Boards and the 5 Health and Social Care Trusts in Northern Ireland – these different types of area are collectively called PCT/ HBs here. For Wales, Scotland and Northern Ireland this is the first report in which we have used these areas – previously local authorities/council areas/district council areas were used.