Use of quantitative microbiological analyses to trace origin of contamination of parenteral nutrition solutions

Good handling practice of parenterally administered medicines in neonatal intensive care units - position paper of an interdisciplinary working group

This position paper, developed by an interdisciplinary expert group of neonatologists, paediatric infectious disease physicians, clinical pharmacists and specialists for the prevention and control of nosocomial infections, describes the "Good handling practice of medicines parenterally administered to patients on NICUs". It takes equal account of patient safety and the specialties of neonatal intensive care regarding feasibility and proportionality. The overall concept is perceived as a "learning system", in which open communication within the health-care team relating to medication errors and critical incidents enables continuous development and improvement to ensure patient safety. In our opinion, pharmacists, who are responsible for the supply of ready-to-administer parenteral medicinal products for neonatal intensive care patients, as well as the hygiene staff responsible on site are integral parts of the interdisciplinary treatment team. Risks of the current clinical practice of parenteral treatment of NICU patients are discussed in detail and recommendations for safety-relevant procedures are given.

Media Stories on NICU Outbreaks Lead to an Increased Prescription Rate of Third-Line Antibiotics in the Community of Neonatal Care

BACKGROUND Between 2010 and 2012, 3 outbreaks of nosocomial infections in German neonatal intensive care units (NICUs) attracted considerable public interest. Headlines on national television channels and in newspapers had important consequences for the involved institutions and a negative impact on the relationship between families and staff in many German NICUs. OBJECTIVE To determine whether NICU outbreaks reported in the media influenced provider behavior in the community of neonatal care and led to more third-line antibiotic prescribing. DESIGN Observational cohort study. METHODS To investigate secular trends, we evaluated data for very-low-birth-weight infants (VLBWIs, birth weight <1,500 g) enrolled in the German Neonatal Network (GNN) between 2009 and 2014 (N=10,253). For outbreak effects, we specifically analyzed data for VLBWIs discharged 6 months before (n=2,428) and 6 months after outbreaks (n=2,508). RESULTS The exposure of all VLBWIs to third-line antibiotics increased after outbreaks (19.4% before vs 22.5% after; P=.007). This trend particularly affected male infants (4.6% increase; P=.005) and infants with a birth weight between 1,000 and 1,499 g (3.5% increase; P=.001) In a logistic regression analysis, month of discharge as linear variable of time was associated with increased exposure to third-line antibiotics (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.009-1.014; P<.001), and discharge within the 6-month period after outbreak reports independently contributed to this long-term trend (OR, 1.14; 95% CI, 1.017-1.270; P=.024). CONCLUSIONS Media reports directly affect medical practice, eg, overuse of third-line antibiotics. Future communication and management strategies must be based on objective dialogues between the scientific community and investigative journalists. Infect Control Hosp Epidemiol 2016;37:924-930.

Lesser-known or hidden reservoirs of infection and implications for adequate prevention strategies: Where to look and what to look for

In developing hygiene strategies, in recent years, the major focus has been on the hands as the key route of infection transmission. However, there is a multitude of lesser-known and underestimated reservoirs for microorganisms which are the triggering sources and vehicles for outbreaks or sporadic cases of infection. Among those are water reservoirs such as sink drains, fixtures, decorative water fountains and waste-water treatment plants, frequently touched textile surfaces such as private curtains in hospitals and laundry, but also transvaginal ultrasound probes, parenteral drug products, and disinfectant wipe dispensers. The review of outbreak reports also reveals Gram-negative and multiple-drug resistant microorganisms to have become an increasingly frequent and severe threat in medical settings. In some instances, the causative organisms are particularly difficult to identify because they are concealed in biofilms or in a state referred to as viable but nonculturable, which eludes conventional culture media-based detection methods. There is an enormous preventative potential in these insights, which has not been fully tapped. New and emerging pathogens, novel pathogen detection methods, and hidden reservoirs of infection should hence be given special consideration when designing the layout of buildings and medical devices, but also when defining the core competencies for medical staff, establishing programmes for patient empowerment and education of the general public, and when implementing protocols for the prevention and control of infections in medical, community and domestic settings.

[Historical development and current demands on medical training, further and advanced training in hygiene and infection prevention]

New risks in nosocomial infections and the dramatic increase in antibiotic-resistant pathogens in healthcare facilities have pointed to the urgent need for a good education of students and practitioners in the basics of hospital hygiene and infection prevention. On the other hand in the last 10 years a large number of institutes of hygiene in universities were closed with remarkable consequences concerning the decreased education in modern hygiene and public health. A broad historical overview over the last 200 years of teaching hygiene and public health at German universities is given which was integrated into the education of medical students. Nowadays many universities do not teach modern hygiene and public health. The demand of re-establishing new institutes of hygiene by the German Medical Council is discussed. The curriculum for the formation of hospital hygienists is presented.

How many outbreaks of nosocomial infections occur in German neonatal intensive care units annually?

BACKGROUND

Outbreaks on neonatal intensive care units (NICUs) achieve huge media interest, but the real number of neonatal outbreaks within a country is unknown.

METHOD

This calculation is based on the data of the component for nosocomial infections in very low birth weight (VLBW) infants of the German national nosocomial infection surveillance system (NEO-KISS) from 2006 to 2011. Almost all German NICUs caring for VLBW infants participated in this surveillance system. A cluster was defined and an outbreak was assumed when at least two cases of severe neonatal infection (bloodstream infection, pneumonia) occurred within a defined time interval in one center with the same pathogen species in different patients. Four different intervals were used for calculation: 14, 30, 60, and 90 days. Infections with coagulase-negative staphylococci (CoNS) were excluded.

RESULTS

A total of 228 NICUs provided data in the six-year study period. A total of 37,038 VLBW infants and 1,361,950 patient days were used for the calculation. 7,405 severe neonatal infections occurred, and a microbiological detection of the pathogen was successful in 2,084 cases. Altogether, between 121 and 280 outbreaks were calculated according to the different time intervals used. Most outbreaks were due to Staphylococcus aureus, followed by Enterococcus spp. and Enterobacter spp.

CONCLUSION

It can be assumed that at least between 26 and 61 neonatal outbreaks with at least two severe infections take place in German NICUs per year. The actual number seems to be higher because only laboratory-confirmed infections in a subgroup of patients were used for the analysis.

[Experiences with outbreaks of nosocomial infections]

Ten years after the publication of the recommendation: "Outbreak management and structural proceedings in case of cumulative occurrence of nosocomial infections" of the federal commission of hospital hygiene, these recommendations are now being re-evaluated. To date, the recommendations have proven valid and have maintained their significance for an effective management. However, besides new hygienic-microbiological methods and an increased sensitivity of the perception of nosocomial outbreaks by the public, by politicians and by the press, it is necessary to consider new issues in this field. Outbreaks are tragic events placing an extraordinary burden on all persons involved, which can have significant consequences. Therefore, it is necessary to ensure prompt outbreak management by experienced professionals who must combine a systematic on-site inspection, hygienic-microbiological investigation and typing methods used with epidemiological approaches. To assure these requirements, the support of independent reference centres such as universal hygiene institutes should be guaranteed. Politicians should be involved only after a scientific evaluation of the details of the outbreak has been made. A national documentation centre, e.g. at the Robert Koch Institute, should be established, thereby making experiences with outbreaks widely available.