Introduction

This guideline partially updates and replaces 'Infection control: prevention of healthcare-associated infection in primary and community care' (NICE clinical guideline 2). The recommendations are labelled according to when they were originally published (see About this guideline for details).

Clinical context

A wide variety of healthcare is delivered in primary and community care settings. Healthcare-associated infections arise across a wide range of clinical conditions and can affect patients of all ages. Healthcare workers, family members and carers are also at risk of acquiring infections when caring for patients.

Healthcare-associated infections can occur in otherwise healthy individuals, especially if invasive procedures or devices are used. For example, indwelling urinary catheters are the most common cause of urinary tract infections, and bloodstream infections are associated with vascular access devices.

Healthcare-associated infections are caused by a wide range of microorganisms. These are often carried by the patients themselves, and have taken advantage of a route into the body provided by an invasive device or procedure. Healthcare-associated infections can exacerbate existing or underlying conditions, delay recovery and adversely affect quality of life.

Patient safety has become a cornerstone of care, and preventing healthcare-associated infections remains a priority. It is estimated that 300,000 patients a year in England acquire a healthcare-associated infection as a result of care within the NHS. In 2007, meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridium difficile infections were recorded as the underlying cause of, or a contributory factor in, approximately 9000 deaths in hospital and primary care in England.

Healthcare-associated infections are estimated to cost the NHS approximately £1 billion a year, and £56 million of this is estimated to be incurred after patients are discharged from hospital. In addition to increased costs, each one of these infections means additional use of NHS resources, greater patient discomfort and a decrease in patient safety. A no-tolerance attitude is now prevalent in relation to avoidable healthcare-associated infections.

Rationale for the update

Since the publication of the NICE clinical guideline on the prevention of healthcare-associated infection in primary and community care in 2003, many changes have occurred within the NHS that place the patient firmly at the centre of all activities. First, the NHS Constitution for England defines the rights and pledges that every patient can expect regarding their care. To support this, the Care Quality Commission (CQC), the independent regulator of all health and adult social care in England, ensures that health and social care is safe, and monitors how providers comply with established standards. In addition, the legal framework that underpins the guidance has changed since 2003.

New guidance is needed to reflect the fact that, as a result of the rapid turnover of patients in acute care settings, complex care is increasingly being delivered in the community. New standards for the care of patients and the management of devices to prevent related healthcare-associated infections are needed that will also reinforce the principles of asepsis.

This guideline assumes that all providers of healthcare in primary and community care settings are compliant with current code of practice on preventing and controlling infections[1]. The guideline aims to help build on advice given in the code and elsewhere to improve the quality of care and practice in these areas over and above current standards.

The Guideline Development Group (GDG) recognises the important contribution that surveillance makes to monitoring infection, but it is not within the scope of this guideline to make specific recommendations about this subject.

This clinical guideline is a partial update of 'Infection control: prevention of healthcare-associated infection in primary and community care' (NICE clinical guideline 2; 2003), and addresses areas in which clinical practice for preventing healthcare-associated infections in primary and community care has changed, where the risk of healthcare-associated infections is greatest or where the evidence has changed. Where high-quality evidence is lacking, the GDG has highlighted areas for further research.

Audience

The population covered in this guideline is all adults and children receiving healthcare for which standard infection-control precautions apply in primary care and community care. This guideline is commissioned by the NHS, but people providing healthcare in other settings, such as private settings, may also find the guidance relevant.

This guideline applies to all healthcare workers employed in primary and community care settings, including ambulance services, and should ensure safe practice if applied consistently. Much care is also delivered by informal carers and family members, and this guideline is equally applicable to them.

Healthcare settings covered by this guideline are:

  • Primary care settings, such as general practices, dental clinics, health centres and polyclinics. This also includes care delivered by the ambulance service.

  • Community care settings, such as residential homes, nursing homes, the patient's own home, schools and prisons, where NHS healthcare is provided or commissioned.

Medical Device Regulations

The Medical Device Regulations implement the EC Medical Devices Directives into UK law. They place obligations on manufacturers to ensure that their devices (including medical gloves, needles and other devices discussed in this guideline) are safe and fit for their intended purpose before they are CE marked and placed on the market in any EC member state. Guidance on the MHRA's adverse incident reporting system is available for reporting adverse incidents involving medical devices.

Use of 'must' in recommendations

The GDG recognised that there is a legal duty to implement some of the recommendations in this guideline in order to comply with legislation. The word 'must' is used in these recommendations and details of the relevant legislation are given in footnotes to the recommendations.

The GDG was also aware that the consequences of not implementing some other recommendations on patient safety would be very serious – that is, there would be a greatly increased risk of adverse events, including death. The GDG therefore concluded that the use of the word 'must' in these recommendations is justified, in line with the guidance in chapter 9 of 'The guidelines manual (2009)'.

Drug recommendations

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. Where recommendations have been made for the use of drugs outside their licensed indications ('off label use'), these drugs are marked with a footnote in the recommendations.

  • National Institute for Health and Care Excellence (NICE)