A quality management project in 8 selected hospitals to reduce nosocomial infections: a prospective, controlled study

Changing epidemiology of meticillin-resistant Staphylococcus aureus in 42 hospitals in the Dutch-German border region, 2012 to 2016: results of the search-and-follow-policy

IntroductionMeticillin-resistant Staphylococcus aureus (MRSA) is a major cause of healthcare-associated infections.AimWe describe MRSA colonisation/infection and bacteraemia rate trends in Dutch-German border region hospitals (NL-DE-BRH) in 2012-16.MethodsAll 42 NL-DE BRH (8 NL-BRH, 34 DE-BRH) within the cross-border network EurSafety Health-net provided surveillance data (on average ca 620,000 annual hospital admissions, of these 68.0% in Germany). Guidelines defining risk for MRSA colonisation/infection were reviewed. MRSA-related parameters and healthcare utilisation indicators were derived. Medians over the study period were compared between NL- and DE-BRH.ResultsMeasures for MRSA cases were similar in both countries, however defining patients at risk for MRSA differed. The rate of nasopharyngeal MRSA screening swabs was 14 times higher in DE-BRH than in NL-BRH (42.3 vs 3.0/100 inpatients; p < 0.0001). The MRSA incidence was over seven times higher in DE-BRH than in NL-BRH (1.04 vs 0.14/100 inpatients; p < 0.0001). The nosocomial MRSA incidence-density was higher in DE-BRH than in NL-BRH (0.09 vs 0.03/1,000 patient days; p = 0.0002) and decreased significantly in DE-BRH (p = 0.0184) during the study. The rate of MRSA isolates from blood per 100,000 patient days was almost six times higher in DE-BRH than in NL-BRH (1.55 vs 0.26; p = 0.0041). The patients had longer hospital stays in DE-BRH than in NL-BRH (6.8 vs 4.9; p < 0.0001). DE-BRH catchment area inhabitants appeared to be more frequently hospitalised than their Dutch counterparts.ConclusionsOngoing IPC efforts allowed MRSA reduction in DE-BRH. Besides IPC, other local factors, including healthcare systems, could influence MRSA epidemiology.

Concordance between the old and new diagnostic criteria for periprosthetic joint infection

PURPOSE

There is no uniform definition for periprosthetic joint infection (PJI). New diagnostic criteria were formulated in an international consensus meeting in 2013 and adopted by Centers for Disease Control (CDC) in 2016. The purpose of this study is to compare the new diagnostic criteria with the old CDC criteria from the year 1992.

METHODS

Patients, who had been treated for PJI of hip or knee from 2002 to 2014, in a tertiary care hospital, were identified. Patient records were reviewed by a physician to identify PJI cases fulfilling the old or new CDC criteria and to record data concerning the diagnostic criteria. PJI frequencies were calculated for the two diagnostic criteria sets. Cross tables were formed to compare the concordance between the two sets of criteria in the whole material and in different clinical subgroups.

RESULTS

Overall 405 cases fulfilling either or both sets of criteria for PJI were identified. 73 (18%) of the patients fulfilled only the old criteria, whereas only one (0.2%) fulfilled only the new criteria. Of the patients who did not fulfil the new criteria, in 39 (53%) the diagnosis was based solely on the clinician's opinion.

CONCLUSIONS

The number of PJIs is notably lower when using the new, more objective, diagnostic criteria. A large portion of the cases diagnosed as infection by the treating clinician, did not fulfil the new diagnostic criteria.

Surgical site infection after hand surgery outside the operating theatre: a systematic review

We carried out a systematic review to determine the incidence of infection for hand surgery done in settings other than the operating theatre. Databases were searched and a PRISMA chart created by three independent reviewers. From 1200 studies identified, 46 full text articles were reviewed and six were included (two Level 3 studies and four Level 4). In three studies there were no infections after surgery in an office, procedure room or emergency department. Two studies with a combined number of 1962 procedures reviewed carpal tunnel decompressions and reported identical infection rates of 0.4%. Although the current evidence is of poor quality, it suggests that some types of hand surgery may be done outside the operating theatre without increasing the risk of infection.

LEVEL OF EVIDENCE

IV.

Periprosthetic Infection following Primary Hip and Knee Arthroplasty: The Impact of Limiting the Postoperative Surveillance Period

BACKGROUND

Hip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated.

OBJECTIVES

To report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period.

METHODS

Prospective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions.

RESULTS

Overall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%–16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%–4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus.

CONCLUSIONS

PJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden.

Infect Control Hosp Epidemiol 2017;38:147–153

Infectious Complications after Major Abdominal Cancer Surgery: In Search of Improvable Risk Factors

BACKGROUND

Major resections for esophageal, gastric, hepatic, pancreatic, and colorectal cancer continue to be associated with a high peri-operative morbidity of up to 30%-40%. To a large extent, this morbidity is caused by infectious complications that add up to a considerable burden to patients and hospital costs. The objective of this large retrospective cross-sectional study was to determine independent patient and operation-related risk factors for infectious complications after major abdominal cancer operations to elucidate how infection rates can be reduced and improve health-care quality.

PATIENTS AND METHODS

In 1,389 cancer patients who underwent a major resection procedure between 2009 and 2013, infectious complications and their independent determinants were analyzed by multivariable logistic regression (p < 0.05).

RESULTS

Male gender was a risk factor for infections in general, whereas patients ≥65 y (odds ratio [OR] 1.75; p = 0.008), urinary tract infection (OR 0.51; p = 0.004), American Society of Anesthesiologists score (OR 1.55; p = 0.004), overall (OR 1.70; p = 0.037), vascular (OR 1.59; p = 0.020), and neurologic comorbidity (OR 2.22; p = 0.001) were associated significantly with pneumonia. Intra-abdominal drainage (OR 1.41; p = 0.024) and a duration of surgery of ≥180 min (OR 1.85; p = 0.001) were risk factors for surgical site infections. Total parenteral nutrition was significantly associated with intravascular catheter-induced infections (OR 18.09; p < 0.001) and sepsis (OR 6.69; p < 0.001).

CONCLUSIONS

In this study, several independent risk factors for infectious complications in major abdominal cancer operations were identified, providing opportunities for further reducing peri-operative infections. General awareness and focus on preventing infectious complications may have a significant impact on health-care outcomes and costs.

Nosokomiale Pneumonie – Antibiotikatherapie und hygienische Interventionsstrategien

Die Pneumonie ist auch in unserer Zeit eine schwere Infektionskrankheit. Sie ist eine der häufigsten infektiösen Todesursachen der westlichen Industrieländer und steht an 3. Stelle unter den Infektionskrankheiten. Jede 4. ärztlich diagnostizierte Pneumonie ist nosokomial erworben. Nosokomiale Pneumonien führen neben einer verlängerten Morbidität und erhöhten Letalität zu einer Verlängerung der Krankenhausverweildauer und zu erheblichen Kosten.

Review of indicators for cross-sectoral optimization of nosocomial infection prophylaxis - a perspective from structurally- and process-oriented hygiene

In the care of patients, the prevention of nosocomial infections is crucial. For it to be successful, cross-sectoral, interface-oriented hygiene quality management is necessary. The goal is to apply the HACCP (Hazard Assessment and Critical Control Points) concept to hospital hygiene, in order to create a multi-dimensional hygiene control system based on hygiene indicators that will overcome the limitations of a procedurally non-integrated and non-cross-sectoral view of hygiene.

Three critical risk dimensions can be identified for the implementation of three-dimensional quality control of hygiene in clinical routine: the constitution of the person concerned, the surrounding physical structures and technical equipment, and the medical procedures. In these dimensions, the establishment of indicators and threshold values enables a comprehensive assessment of hygiene quality. Thus, the cross-sectoral evaluation of the quality of structure, processes and results is decisive for the success of integrated infection prophylaxis.

This study lays the foundation for hygiene indicator requirements and develops initial concepts for evaluating quality management in hygiene.

Disease burden of prosthetic joint infections after hip and knee joint replacement in Finland during 1999-2004: capture-recapture estimation

We evaluated the Finnish Hospital Infection Program (SIRO) conducting incidence surveillance for prosthetic joint infection (PJI) from 1999 to 2004. We estimated its sensitivity using capture-recapture methods and assessed the disease burden of PJIs after hip (THA) and knee (TKA) arthroplasties (N = 13 482). The following three data sources were used: SIRO, the Finnish Arthroplasty Register (FAR), and the Finnish Patient Insurance Center (FPIC), which were cross-matched, and 129 individual PJIs were identified. After adjusting for the positive predictive value of SIRO (91%) a log-linear model including an interaction term between FAR and FPIC provided an estimated PJI rate of 1.6% [95% confidence interval (CI): 1.2-2.4] for THA and 1.3% (1.1-1.6) for TKA. Sensitivity for SIRO varied from 36% to 57%. The annual disease burden was 2.1 PJIs per 100 000 population after THA and 1.5 after TKA. The true disease burden of PJIs may be heavier than the rates from national sentinel surveillance systems usually suggest.

Surgical site infections: epidemiology, microbiology and prevention

Surgical site infections (SSIs) are defined as infections occurring up to 30 days after surgery (or up to one year after surgery in patients receiving implants) and affecting either the incision or deep tissue at the operation site. Despite improvements in prevention, SSIs remain a significant clinical problem as they are associated with substantial mortality and morbidity and impose severe demands on healthcare resources. The incidence of SSIs may be as high as 20%, depending on the surgical procedure, the surveillance criteria used, and the quality of data collection. In many SSIs, the responsible pathogens originate from the patient's endogenous flora. The causative pathogens depend on the type of surgery; the most commonly isolated organisms are Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp. and Escherichia coli. Numerous patient-related and procedure-related factors influence the risk of SSI, and hence prevention requires a 'bundle' approach, with systematic attention to multiple risk factors, in order to reduce the risk of bacterial contamination and improve the patient's defences. The Centers for Disease Control and Prevention guidelines for the prevention of SSIs emphasise the importance of good patient preparation, aseptic practice, and attention to surgical technique; antimicrobial prophylaxis is also indicated in specific circumstances. Emerging technologies, such as microbial sealants, offer the ability to seal and immobilise skin flora for the duration of a surgical procedure; a strong case therefore exists for evaluating such technologies and implementing them into routine clinical practice as appropriate.

[Prevention of nosocomial infections]

Nosocomial infections are still an important issue in surgical wards. About one patient in 15 is affected, most of them from surgical site or urinary tract infections, but pneumonia cases can also be observed frequently. Some of these infections are due to multiresistant pathogens. About one third of nosocomial infections can be regarded as avoidable. Routine surveillance of nosocomial infections and multiresistant pathogens, feedback of data to all personnel involved in patient care, and routine educational activities in this field are the crucial elements for achieving high compliance with the most important infection control measures.

Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury

BACKGROUND

Critical pathways for the management of patients with severe traumatic brain injury (STBI) may contribute to reducing the incidence of hospital complications, length of hospitalization stay, and cost of care. Such pathways have previously been developed for departments with significant resource availability. In Mexico, STBI is the most important cause of complications and length of stay in neurotrauma services at public hospitals. Although current treatment is designed basically in accordance with the Brain Trauma Foundation guidelines, shortfalls in the availability of local resources make it difficult to comply with these standards, and no critical pathway is available that accords with the resources of public hospitals. The purpose of the present study was to design and to validate a critical pathway for managing STBI patients that would be suitable for implementation in neurotrauma departments of middle-income level countries.

METHODS

The study comprised two phases: design (through literature review and design plan) and validation (content, construct, and appearance) of the critical pathway.

RESULTS

The validated critical pathway for managing STBI patients entails four sequential subprocesses summarizing the hospital's care procedures, and includes three components: (1) nodes and criteria (in some cases, indicators are also included); (2) health team members in charge of the patient; (3) maximum estimated time for compliance with recommendations.

CONCLUSIONS

This validated critical pathway is based on the current scientific evidence and accords with the availability of resources of middle-income countries.

Incidence of healthcare-associated infections in high-risk neonates: results from the German surveillance system for very-low-birthweight infants

Infants with birthweight <1500g (VLBW) are at high risk of healthcare-associated infection (HAI). We present surveillance data from the NEO-KISS surveillance system, collected between 2000 and 2005 by 52 neonatology departments in Germany. Infants were stratified into two birthweight categories (<1000 and 1000-1499 g), and rates of nosocomial bloodstream infection (BSI), nosocomial pneumonia and necrotising enterocolitis (NEC) were calculated. The data presented comprise 8677 VLBW and 339,972 patient-days. The incidence of bloodstream infection was 6.5 per 1000 patient-days (8.5 and 4.0 according to birthweight category). The incidence of central venous catheter (CVC)-associated BSI was 11.1 per 1000 CVC-days and the incidence of peripheral venous catheter (PVC)-associated BSI was 7.8 per 1000 PVC-days. The incidence of pneumonia was 0.9 per 1000 patient-days (1.3 and 0.4 according to birthweight category). The incidence of pneumonia among intubated patients was 2.7 per 1000 ventilator-days, while the incidence of pneumonia among patients receiving continuous nasel positive airway pressure (CPAP) was 1.0 per 1000 CPAP-days. The incidence of NEC was 0.9 per 1000 patient-days (1.1 and 0.6 according to birthweight category). HAI is frequent among VLBW and shows wide variation between neonatology departments. Preventive strategies to reduce infections in these infants should be prioritised.

Validation of surgical site infection surveillance in orthopedic procedures

BACKGROUND

Valid data are essential for a national surveillance system of nosocomial infections.

METHODS

In 8 hospitals conducting surgical site infection (SSI) surveillance for orthopedic procedures, a validation team performed a blinded retrospective chart review (10 operations with reported infections, 40 without) and interviewed infection control nurses.

RESULTS

In total, 397 patient charts were reviewed. Positive and negative predictive values for routine surveillance were 94% (95% CI: 89%-99%) and 99% (95% CI: 99%-100%), respectively. When these results were applied to the aggregated surveillance data (403 infections, 10,068 noninfections), sensitivity was 75% (95% CI: 56%-93%) and specificity 100% (95% CI: 97%-100%). The following case finding methods were used: ward visits (in 7/8 hospitals), microbiology reports (5/8), ward notifications by link nurses (8/8), and other nursing (7/8) and medical (5/8) staff. The wound culture rate ranged from 9 to 67 per 1000 patient-days. All hospitals carried out postdischarge surveillance on readmission and all but 1 at follow-up visits and by an additional questionnaire.

CONCLUSION

Most SSIs reported by the hospitals were true infections, showing that, when an SSI was reported, the definitions were correctly implemented. Some SSIs were missed, which might be due to weaknesses in case finding. Variation in diagnostic practices may also affect SSI rates.

Results from a four-year study on the prevalence of nosocomial infections in Franche-Comté: attempt to rank the risk of nosocomial infection

The aim of this study was to rank the risk of nosocomial infection (NI) according to patient type by analysing the results of annual prevalence studies carried out in Franche-Comté from 2001 to 2004. Patients (N=14,905) were divided into four categories according to the number of endogenous risk factors (age, immunodepression, MacCabe score). The overall prevalence of infection was 6.1% and varied according to the category of patient from 1.93% (no risk factors) to 15.2% (three risk factors). The frequencies of NI related to an invasive procedure and to cross-contamination with multi-drug-resistant (MDR) bacteria were 30.9% and 12.3%, respectively; these percentages did not depend on the type of patient. The prevalence of NI decreased over time for patients with two or three risk factors, but was stable for patients with no risk factors. More than 40% of NIs were potentially avoidable (related to invasive procedures or involving cross-transmission of an MDR bacterium) regardless of the category of patient. This study suggests that at least 30% of NIs could be avoided.

Surgical site infection surveillance: analysis of adherence to recommendations for routine infection control practices

OBJECTIVE

To evaluate the application of surgical site infection control procedures in general surgery departments in hospitals in the Piemonte region of Italy.

DESIGN

The descriptive study entailed 1 week of observation in the general surgery departments and 1 week of observation in the operating rooms of 49 hospitals in Piemonte; the survey was conducted in 2003.

METHODS

Data collection forms were designed to record information about presurgical patient preparation (form 1) and infection control practices routinely used by surgical teams (form 2).

RESULTS

A total of 856 patients were observed; 88% of operations were surgical wound class I or II; 70.6% of patients had hair removed, 28.8% showered the day before the operation; antimicrobial prophylaxis was administered in 63.3% of cases (68.4% on induction of anesthesia and 26% on the day of the operation) and was continued into the postoperative period in 43% of cases. A total of 799 operations were observed; the mean number of healthcare personnel in the operating room was 6; doors were opened an average of 12 times during an operation; 88% of the surgical team members wore a cap/hood and mask correctly; 25% of surgeons and 41% of instrument nurses wore an eye shield; preoperative hand and forearm scrubbing technique was correct in 78% of cases (surgeons, 74.6%; instrument nurses, 86.6%; and anesthesiologists, 73%).

CONCLUSIONS

A comparison between the survey data and the international recommendations for SSI prevention highlighted practices that could be improved with corrective interventions. The study provided an opportunity for sharing feedback on appropriate data with healthcare personnel and was an effective instrument to audit infection control practices.

A Systematic Review of Quasi-Experimental Study Designs in the Fields of Infection Control and Antibiotic Resistance

We performed a systematic review of articles published during a 2-year period in 4 journals in the field of infectious diseases to determine the extent to which the quasi-experimental study design is used to evaluate infection control and antibiotic resistance. We evaluated studies on the basis of the following criteria: type of quasi-experimental study design used, justification of the use of the design, use of correct nomenclature to describe the design, and recognition of potential limitations of the design. A total of 73 articles featured a quasi-experimental study design. Twelve (16%) were associated with a quasi-experimental design involving a control group. Three (4%) provided justification for the use of the quasi-experimental study design. Sixteen (22%) used correct nomenclature to describe the study. Seventeen (23%) mentioned at least 1 of the potential limitations of the use of a quasi-experimental study design. The quasi-experimental study is used frequently in studies of infection control and antibiotic resistance. Efforts to improve the conduct and presentation of quasi-experimental studies are urgently needed to more rigorously evaluate interventions.

How many infections are caused by patient-to-patient transmission in intensive care units?

OBJECTIVE

The proportion of intensive care unit (ICU)-acquired infections that are a consequence of nosocomial cross-transmission between patients in tertiary ICUs is unknown. Such information would be useful for the implementation of appropriate infection control measures.

DESIGN

A prospective cohort study during 18 months.

SETTING

Five ICUs from two university hospitals.

PATIENTS

All patients admitted for >/=48 hrs.

MEASUREMENT

ICU-acquired infections were ascertained during daily bedside patient and chart reviews. Episodes of potential cross-transmission were identified by highly discriminating genetic typing of all clinical and surveillance isolates of the ten bacterial species most frequently associated with nosocomial infections in ICUs. Isolation of indistinguishable isolates in two or more patients defined potential transmission episodes.

MAIN RESULTS

During 28,498 patient days, 431 ICU-acquired infections and 141 episodes of nosocomial transmissions were identified. A total of 278 infections were caused by the ten species that were genotyped, and 41 of these (14.5%) could be associated with transmissions between patients.

CONCLUSION

Infections acquired during treatment in modern tertiary ICUs are common, but a causative role of direct patient-to-patient transmission can only be ascertained for a minority of these infections on the basis of routine microbiological investigations.

The preventable proportion of nosocomial infections: an overview of published reports

The proportion of nosocomial infections potentially preventable under routine working conditions remains unclear. We performed a systematic review to describe multi-modal intervention studies, as well as studies assessing exogenous cross-infection published during the last decade, in order to give a crude estimate of the proportion of potentially preventable nosocomial infections. The evaluation of 30 reports suggests that great potential exists to decrease nosocomial infection rates, from a minimum reduction effect of 10% to a maximum effect of 70%, depending on the setting, study design, baseline infection rates and type of infection. The most important reduction effect was identified for catheter-related bacteraemia, whereas a smaller, but still substantial potential for prevention seems to exist for other types of infections. Based on these estimates, we consider at least 20% of all nosocomial infections as probably preventable, and hope that this overview will stimulate further research on feasible and cost-effective prevention of nosocomial infections for daily practice.

Comparison of US and non-US central venous catheter infection rates: evaluation of processes and indicators in infection control study

OBJECTIVE

We sought to identify the presence or absence of international variation in central venous catheter-associated bloodstream infection (BSI) rates and to examine associated infection control practices that might underlie the differences.

DESIGN

The Evaluation of Processes and Indicators in Infection Control (EPIC) study was conducted as a prospective surveillance study.

SETTINGS

The study took place in intensive care units (ICUs) from 14 countries, which were from the Asian Pacific (3), Europe (7), Middle East (2), and South America (2), in addition to 41 US hospitals.

METHODS

We compared the National Nosocomial Infections Surveillance catheter-associated BSI rate between the non-US and US units. We also compared the following organization factors between the 2 groups: hospital factors (ownership, average daily census of patients); ICU type (medical vs surgical); number of beds; and infection control-related factors (number of staff, number of hours spent on study ICU surveillance, years of experience, number of inservice sessions on line infection, number of blood cultures drawn/1000 patients).

RESULTS

We found no significant difference in catheter-associated BSI rates between non-US and US hospitals (5.02 +/- 0.75 vs 3.82 +/- 0.42/1000 days, respectively; P =.27). Non-US hospitals were more likely to be government-owned (10/14 vs 7/41;P <.001) and to have larger daily patient census (795 +/- 84 vs 276 +/- 47 patients; P <.001). There was no difference in ICU type or number of beds. Infection control committees were present in all US and non-US hospitals. No significant differences were found in the number of staff involved in surveillance in the study ICU, years of experience, hours spent on surveillance, or the provision of inservices on line care. The use of barriers during line insertion also did not differ.

CONCLUSIONS

Catheter-associated BSIs in patients in the ICU were not significantly different between non-US and US hospitals. All hospitals had infection control committees, and there were no significant differences in time spent and numbers of persons involved in ICU surveillance activities. These findings suggest that many aspects of the standards of care do not differ between the 2 groups.