Healthcare-Associated Infections and the Use of Antibiotics in German Hospitals

BACKGROUND

A national point prevalence survey (PPS) of healthcare-associated infections (HAI) and antibiotic use (AU) was carried out in Germany in 2022 in the framework of the European PPS conducted by the European Centre for Disease Prevention and Control (ECDC). The objective was to determine the prevalence of HAI and AU in German hospitals and to compare the obtained values with those of the most recent previous PPS, which was carried out in 2016.

METHODS

The German National Reference Center for the Surveillance of Nosocomial Infections was entrusted with the organization of the PPS of 2022. As recommended by the ECDC, each hospital in a representative sample of 50 hospitals was invited to participate, and all other interested hospitals in Germany were also able to participate if desired. The data were collected by specially trained hospital staff in May, June, and July 2022. The definitions and methods put forth by the ECDC were used.

RESULTS

Data from 66 586 patients in 252 hospitals were included. The prevalence of HAI in all participating hospitals was 4.9%, and that of AU was 26.9%. The HAI and AU prevalences were essentially unchanged in comparison to 2016. The most common types of HAI were surgical site infection (23.5%), lower respiratory tract infection (21.6%), and urinary tract infection (19.0%).

CONCLUSION

HAI were just as frequent in 2022 as in 2016, affecting approximately one in twenty hospitalized patients on any given day.

Cefazolin Might Be Adequate for Perioperative Antibiotic Prophylaxis in Intra-Abdominal Infections without Sepsis: A Quality Improvement Study

Background: The adequate choice of perioperative antibiotic prophylaxis (PAP) could influence the risk of surgical site infections (SSIs) in general surgery. A new local PAP guideline was implemented in May 2017 and set the first-generation cefazolin (CFZ) instead the second-generation cefuroxime (CXM) as the new standard prophylactic antibiotic. The aim of this study was to compare the risk of SSIs after this implementation in intra-abdominal infections (IAIs) without sepsis. Methods: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Germany analyzing patients after emergency surgery during 2016 to 2019 (n = 985), of which patients receiving CXM or CFZ were selected (n = 587). Propensity score matching was performed to ensure a comparable risk of SSIs in both groups. None-inferiority margin for SSIs was defined as 8% vs. 4%. Results: Two matched cohorts with respectively 196 patients were compared. The rate of SSIs was higher in the CFZ group (7.1% vs. 3.6%, p = 0.117) below the non-inferiority margin. The rate of other postoperative infections was significantly higher in the CFZ group (2.0% vs. 8.7%, p = 0.004). No other differences including postoperative morbidity, mortality or length-of-stay were observed. Conclusion: Perioperative antibiotic prophylaxis might be safely maintained by CFZ even in the treatment of intra-abdominal infections.

Antimicrobial Usage and Resistance in Makkah Region Hospitals: A Regional Point Prevalence Survey of Public Hospitals

(1) Background: Inappropriate use of antimicrobials and subsequently rise of antimicrobial resistance (AMR) remains a major public health priority. Over-prescribing of broad-spectrum antibiotics is one of the main contributing factors for the emergence of AMR. We sought to describe antimicrobial prescribing trends among patients in public hospitals in Makkah hospitals. (2) Method: We undertook a point prevalence survey (PPS) in six hospitals in Makkah, Saudi Arabia, from January 2019 to July 2019. The survey included all the inpatients receiving antimicrobials on the day of PPS. Data was collected using the Global point prevalence survey (PPS) tool developed by the University of Antwerp, Belgium. (3) Results: Of 710 hospitalized patients, 447 patients (61.9%) were treated with one or more antimicrobials during the study period. The average bed occupancy among six hospitals was 74.4%. The majority of patients received antimicrobials parenterally (90.3%). Of the total prescribed antimicrobials, 415 (53.7%) antimicrobials were used in medical departments, 183 (23.7%) in surgical departments, and 175 (22.6%) in ICUs. Pneumonia (17.3%), skin and soft tissue infections (10.9%), and sepsis (6.6.%) were three common clinical indications. Ceftriaxones were the most commonly used antibiotics that were prescribed in 116 (15%) of patients, followed by piperacillin, with an enzyme inhibitor in 84 (10.9%). (4) Conclusion: There was a high prevalence of antibiotic use in the hospitals of Makkah, which could be a potential risk factor for the incidence of resistant strains, particularly MRSA infection. Public health decision-makers should take these findings into consideration to update national policies for antibiotic use in order to reduce the risks of further increases of AMR.

The role of interspecies recombination in the evolution of antibiotic-resistant pneumococci

Multidrug-resistant Streptococcus pneumoniae emerge through the modification of core genome loci by interspecies homologous recombinations, and acquisition of gene cassettes. Both occurred in the otherwise contrasting histories of the antibiotic-resistant S. pneumoniae lineages PMEN3 and PMEN9. A single PMEN3 clade spread globally, evading vaccine-induced immunity through frequent serotype switching, whereas locally circulating PMEN9 clades independently gained resistance. Both lineages repeatedly integrated Tn916-type and Tn1207.1-type elements, conferring tetracycline and macrolide resistance, respectively, through homologous recombination importing sequences originating in other species. A species-wide dataset found over 100 instances of such interspecific acquisitions of resistance cassettes and flanking homologous arms. Phylodynamic analysis of the most commonly sampled Tn1207.1-type insertion in PMEN9, originating from a commensal and disrupting a competence gene, suggested its expansion across Germany was driven by a high ratio of macrolide-to-β-lactam consumption. Hence, selection from antibiotic consumption was sufficient for these atypically large recombinations to overcome species boundaries across the pneumococcal chromosome.

Prevalence and antibiotic susceptibility trends of periodontal pathogens in the subgingival microbiota of German periodontitis patients: A retrospective surveillance study

OBJECTIVE

This retrospective surveillance study aimed to follow periodontitis-associated bacterial profiles and to identify time-dependent changes in antibiotic susceptibility patterns.

MATERIALS AND METHODS

From 2008 to 2015, bacterial specimen from deep periodontal pockets were collected from a total of 7804 German adults diagnosed with periodontitis. Presence of selected bacteria was confirmed by anaerobic culture and nucleic acid amplification. Antimicrobial susceptibility of clinical isolates was tested by disc diffusion with antibiotics used for the treatment of periodontitis and oral infections. The prevalences of periodontal pathogens were calculated and temporal evolution of antimicrobial susceptibility towards amoxicillin, amoxicillin/clavulanic acid, metronidazole, doxycycline, clindamycin, azithromycin, ciprofloxacin and ampicillin was analysed with logistic regression.

RESULTS

The prevalence of patients harbouring bacteria was 95.9% Fusobacterium nucleatum, 88.0% Tannerella forsythia, 76.4% Treponema denticola, 76.5%, Campylobacter rectus, 76.0% Eikenella corrodens, 75.0% Capnocytophaga spp., 68.2% Porphyromonas gingivalis, 57.7% Peptostreptococcus micros, 43.1% Prevotella intermedia, 30.4% Eubacterium nodatum and 21.5% Aggregatibacter actinomycetemcomitans. In 63.5% of patients, one or more isolates were not susceptible to at least one of the antibiotics tested. The data further revealed a trend towards decreasing susceptibility profiles (p < 0.05) with antibiotic non-susceptibilities in 37% of patients in 2008 and in 70% in 2015.

CONCLUSIONS

The present study confirmed a high prevalence of periodontal pathogens in the subgingival microbiota of German periodontitis patients. The data revealed an incremental increase in isolates displaying resistance to some antibiotics but no relevant change in susceptibility to amoxicillin and metronidazole.

[Antibiotic stewardship : Structure and implementation]

Antibiotic resistance is a part of bacterial evolution and therefore unavoidable. Scarcity of novel treatment options requires prudent use of available antibiotics in order to decelerate the spread of resistance. This is the aim of antibiotic stewardship (ABS) programmes. The implementation of strategies that optimize antibiotic prescription and therapy necessitates the deployment of personnel as well as of structural resources. Necessary requirements for staff and strategies based on their evidence are described in the updated German S3 ABS Guideline. In the future, patients with infectious diseases will benefit from accelerated microbiological diagnostics as early adequate treatment not only reduces antibiotic consumption but also improves patient outcome. In addition, training of infectious disease specialists will substantially contribute to enhanced quality of care of patients with infectious disease.

Identifying opportunities for antimicrobial stewardship through a point prevalence survey in an Indian tertiary-care teaching hospital

OBJECTIVES

Unregulated and inappropriate use of antimicrobial agents has been a major driver of antimicrobial resistance with a dangerous impact on health issues in developing nations. We report an audit of antimicrobial use patterns in a tertiary-care teaching hospital in order to identify opportunities for antimicrobial stewardship.

METHODS

A point prevalence survey was conducted to study the use of ten selected antibiotics in various adult inpatient facilities. Patient characteristics as well as indications and patterns of antibiotic prescription were recorded.

RESULTS

A total of 188 patients received any one of the survey antibiotics, accounting for 43% of patients admitted under the study specialties. Of the 188 patients, 59% were admitted in non-intensive care unit settings. The median (interquartile range) duration of hospitalisation during the survey was 8 (4.75) days. Intra-abdominal infections (75; 40%) and respiratory infections (41; 22%) were the most common reasons for admission. Empirical antibiotic use was observed in 66% of patients. Antimicrobial use without any microbiological test was evidenced in 32 patients (17%). Significant differences were noted between medical and surgical specialties in choice of antibiotic, dosage and utilisation of microbiological tests.

CONCLUSIONS

High empirical antibiotic use, poor transition from empirical to rational use, and underutilisation of microbiological tests were noted. The choice of antibiotics differed among specialties. Inappropriate dosing was greater in surgical specialties, especially with aminoglycosides. Adherence to local antibiotic policy, optimal dosing and audit of reserved antibiotic use can be useful approaches to strengthen antimicrobial stewardship programmes.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

Audit of pre-operative antibiotic prophylaxis usage in elective surgical procedures in two teaching hospitals, Islamabad, Pakistan: An observational cross-sectional study

An audit of the antibiotic prophylaxis in surgical procedures is the basic area of antimicrobial stewardship programme. The current research aimed to evaluate the adherence-proportion of the pre-operative antibiotic prophylaxis (PAP) practices in common elective surgical procedures. It was an eight-month (January 2017 to August 2017) observational cross-sectional patients’ treatment record-based study conducted at two tertiary care teaching hospitals of Islamabad, Pakistan. We investigated the three most commonly performed elective general surgical procedures at the hospitals in adults aged > 18 years with no previous infection or surgery. The required data were extracted from the medical charts. Current prescribing practices were compared with the standard prescribing guidelines. A total of 660 (Government Hospital (GH), n = 330 and Private Hospital (PH), n = 330) procedures were observed. The most commonly performed elective general surgical procedures were laparoscopic cholecystectomy 307/660 (46.5%), followed by direct inguinal hernia 197/660 (29.8%) and total thyroidectomy 156/660 (23.6%). Non-use of PAP was observed in 64/660 (9.7%) cases. PAP was given to 90.3% (n = 596/660) cases (300/330 (90.9%) patients in GH and 296/330 (89.7%) in PH; P = 0.599). Based on the existing guidelines, the choice of antibiotics was correct in only 4.2% (25/596) patients (10/300; 3.3% cases at GH and 15/296; 5% at PH). The appropriate use of antibiotics was significantly greater in direct inguinal hernia (n = 19/193; 9.8%) cases compared with that in total thyroidectomy (n = 4/152; 2.6%) and laparoscopic cholecystectomy (n = 2/251; 0.8%) cases; P = 0.001. Compliance to the timing was only 51% (n = 304/596) of the total patients received PAP which was significantly lower in GH 97/300 (32.3%) as compared with that in PH 207/296 (69.9%); P = 0.001. Administration timing of antibiotics was observed to be more appropriate in total thyroidectomy (n = 79/152; 51.9%) cases than in laparoscopic cholecystectomy (n = 130/251; 51.8%) and direct inguinal hernia (n = 95/193; 49.2%) cases; P = 0.001. The route and dose were appropriate in accordance with the guidelines in all cases (100%). Most of the patients received ceftriaxone, a third-generation cephalosporin that is no longer recommended by the latest international guidelines. The current analysis revealed an alarmingly poor adherence rate with the guidelines in the three elective surgical procedures at both hospitals. To improve the situation, training and awareness programs about the antimicrobial stewardship interventions on the institutional level may be valuable.

Antimicrobial usage in German acute care hospitals: results of the third national point prevalence survey and comparison with previous national point prevalence surveys

Objectives

Previous point prevalence surveys (PPSs) revealed the potential for improving antimicrobial usage (AU) in German acute care hospitals. Data from the 2016 German national PPS on healthcare-associated infections and AU were used to evaluate efforts in antimicrobial stewardship (AMS).

Methods

A national PPS in Germany was organized by the German National Reference Centre for Surveillance of Nosocomial Infections in 2016 as part of the European PPS initiated by the ECDC. The data were collected in May and June 2016. Results were compared with data from the PPS 2011.

Results

A total of 218 hospitals with 64 412 observed patients participated in the PPS 2016. The prevalence of patients with AU was 25.9% (95% CI 25.6%-26.3%). No significant increase or decrease in AU prevalence was revealed in the group of all participating hospitals. Prolonged surgical prophylaxis was found to be common (56.1% of all surgical prophylaxes on the prevalence day), but significantly less prevalent than in 2011 (P < 0.01). The most frequently administered antimicrobial groups were penicillins plus β-lactamase inhibitors (BLIs) (23.2%), second-generation cephalosporins (12.9%) and fluoroquinolones (11.3%). Significantly more penicillins plus BLIs and fewer second-generation cephalosporins and fluoroquinolones were used in 2016. Overall, an increase in the consumption of broad-spectrum antimicrobials was noted. For 68.7% of all administered antimicrobials, the indication was documented in the patient notes.

Conclusions

The current data reaffirm the points of improvement that previous data identified and reveal that recent efforts in AMS in German hospitals require further intensification.

The Prevalence of Nosocomial Infection and Antibiotic Use in German Hospitals

BACKGROUND

In 2011 and again in 2016, the European Centre for Disease Prevention and Control (ECDC) asked all European countries to carry out nationwide studies on the prevalence of nosocomial infection (NI) and antibiotic use (AU). Data on NI and AU constitute an essential basis for the development of measures to prevent infection and lessen antibiotic resistance.

METHODS

The German prevalence study of 2016 was carried out according to the ECDC protocol. Alongside a sample of 49 acute-care hospitals requested by the ECDC that was representative in terms of size (number of beds), further hospitals were invited to participate as well. Analyses were made of the overall group (218 hospitals, 64 412 patients), the representative group (49 hospitals), and the core group (46 hospitals). The core group consisted of the hospitals that had participated in the study of 2011.

RESULTS

The prevalence of patients with NI was 4.6% in the overall group in 2016; it had been 5.1% in 2011 (p <0.01). In the representative group, the prevalence was 3.6% (compared to 5.1% in 2011, p <0.01). In the core group, the prevalence of NI was the same in 2016 as it had been in 2011. The prevalence of patients with ABU in the overall group remained the same, but a fall was seen in the representative group (21.5% versus 23.3%; p <0.01) and a rise in the core group (27.3% versus 26.2%; p = 0.02). The staff-patient ratio among the infection prevention and control professionals improved in all three groups.

CONCLUSION

A decrease in NI and AU prevalence was seen in the representative group, while mixed results were seen in the other analyzed groups. Further efforts to reduce NI and ABA are clearly necessary.

Point prevalence survey of antibiotic use and resistance at a referral hospital in Kenya: findings and implications

BACKGROUND AND AIMS

A substantial amount of antibiotic use in hospitals may be inappropriate, potentially leading to the development and spread of antibiotic resistance, adverse effects, mortality and increased hospital costs. The objective was to assess current patterns of antibiotic use in a leading referral hospital in Western Kenya. This would lead to the identification of opportunities for quality improvement in this hospital and others across Kenya.

METHODOLOGY

A point prevalence survey was carried out with data abstracted principally from patient medical records supplemented by interviews from physicians when needed. The pattern of antibiotic use was analyzed by descriptive methods. Differences in antibiotic use and indications between the selected wards were compared using the Chi-square test or Fisher's exact tests.

RESULTS

Among the patients surveyed, 67.7% were on antibiotics. The most common classes of antibiotics prescribed were third generation cephalosporins (55%), imidazole derivatives like metronidazole (41.8%) and broad spectrum penicillins (41.8%). The most common indication for antibiotic use was medical prophylaxis (29%), with local guidelines advocating antibiotic prophylaxis in mothers after delivery of their child as well as in neonates with birth asphyxia and low weight at birth. Dosing of antibiotics was seen as generally optimal when assessed against current recommendations.

CONCLUSION

Whilst the dosing of antibiotics seemed adequate, there was high use of antibiotics in this hospital. This needs to be urgently reviewed with currently appreciable empiric antibiotic use. Programmes are being instigated to address these concerns. This includes developing antibiotic guidelines and formularies especially for empiric use as well as implementing antimicrobial stewardship activities.

Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study

PURPOSE

Surgical antibiotic prophylaxis (SAP) is a common area of antimicrobial misuse. The aim of this study was to explore the social dynamics that influence the use of SAP.

METHODS

20 surgeons and anaesthetists from a tertiary referral hospital in Australia participated in semi-structured interviews focusing on experiences and perspectives on SAP prescribing. Interview data were analysed using the framework approach.

RESULTS

Systematic analysis of the participants' account of the social factors influencing SAP revealed four themes. First, antibiotic prophylaxis is treated as a low priority with the competing demands of the operating theatre environment. Second, whilst guidelines have increased in prominence in recent years, there exists a lack of confidence in their ability to protect the surgeon from responsibility for infectious complications (thus driving SAP over-prescribing). Third, non-concordance prolonged duration of SAP is perceived to be driven by benevolence for the individual patient. Finally, improvisation with novel SAP strategies is reported as ubiquitous, and acknowledged to confer a sense of reassurance to the surgeon despite potential non-concordance with guidelines or clinical efficacy.

CONCLUSIONS

Surgical-specific concerns have thus far not been meaningfully integrated into antimicrobial stewardship (AMS) programmes, including important dynamics of confidence, trust and mitigating fear of adverse infective events. Surgeons require specific forms of AMS support to enact optimisation, including support for strong collaborative ownership of the surgical risk of infection, and intra-specialty (within surgical specialties) and inter-specialty (between surgery, anaesthetics and infectious diseases) intervention strategies to establish endorsement of and address barriers to guideline implementation.

Is There an Association Between Use of Amoxicillin-Clavulanate and Resistance to Third-Generation Cephalosporins in Klebsiella pneumoniae and Escherichia coli at the Hospital Level?

AIMS

Amoxicillin-clavulanate is extensively used in European hospitals. Whether the hospital use of amoxicillin-clavulanate is associated with nonsusceptibility to third-generation cephalosporins (3GC) in Klebsiella pneumoniae is unknown. Our aim was to assess the relationship between the hospital use of amoxicillin-clavulanate and 3GC nonsusceptibility in K. pneumoniae and Escherichia coli.

METHODS

Yearly data of antibiotic use and 3GC nonsusceptibility in K. pneumoniae and E. coli were obtained from 33 French hospitals between 2011 and 2016. Decreased susceptibility to 3GC and Extended-Spectrum Beta-Lactamase (ESBL) production were modelled from antibiotic use with linear mixed models on years 2011 to 2015, and validated on year 2016.

RESULTS

Nonsusceptibility to 3GC increased in K. pneumoniae and E. coli. In a multivariable model that included year and use of 3GC and fluoroquinolones as explanatory variables, amoxicillin-clavulanate use was protective against 3GC nonsusceptibility in K. pneumoniae (incidence rate ratio [IRR], 0.992 [0.988-0.997]), and with ESBL production in K. pneumoniae (IRR, 0.989 [0.985-0.992]). The correlation coefficient between observed and predicted numbers of 3GC-nonsusceptible K. pneumoniae in 2016 was 0.95 (95% confidence interval, 0.89-0.98). There was no significant association between amoxicillin-clavulanate use and 3GC nonsusceptibility in E. coli.

CONCLUSION

Amoxicillin-clavulanate hospital use was protective against nonsusceptibility to 3GC in K. pneumoniae. Conversely, it was not associated with susceptibility to 3GC in E. coli. To decrease the hospital use of 3GC and fluoroquinolones, and 3GC nonsusceptibility in K. pneumoniae, it may be acceptable to increase the hospital use of amoxicillin-clavulanate. Interventional studies are necessary to confirm this hypothesis.

Prevalence of Healthcare-Associated Infections and Antimicrobial Use Among Adult Inpatients in Singapore Acute-Care Hospitals: Results From the First National Point Prevalence Survey

Background

We conducted a national point prevalence survey (PPS) to determine the prevalence of healthcare-associated infections (HAIs) and antimicrobial use (AMU) in Singapore acute-care hospitals.

Methods

Trained personnel collected HAI, AMU, and baseline hospital- and patient-level data of adult inpatients from 13 private and public acute-care hospitals between July 2015 and February 2016, using the PPS methodology developed by the European Centre for Disease Prevention and Control. Factors independently associated with HAIs were determined using multivariable regression.

Results

Of the 5415 patients surveyed, there were 646 patients (11.9%; 95% confidence interval [CI], 11.1%-12.8%) with 727 distinct HAIs, of which 331 (45.5%) were culture positive. The most common HAIs were unspecified clinical sepsis (25.5%) and pneumonia (24.8%). Staphylococcus aureus (12.9%) and Pseudomonas aeruginosa (11.5%) were the most common pathogens implicated in HAIs. Carbapenem nonsusceptibility rates were highest in Acinetobacter species (71.9%) and P. aeruginosa (23.6%). Male sex, increasing age, surgery during current hospitalization, and presence of central venous or urinary catheters were independently associated with HAIs. A total of 2762 (51.0%; 95% CI, 49.7%-52.3%) patients were on 3611 systemic antimicrobial agents; 462 (12.8%) were prescribed for surgical prophylaxis and 2997 (83.0%) were prescribed for treatment. Amoxicillin/clavulanate was the most frequently prescribed (24.6%) antimicrobial agent.

Conclusions

This survey suggested a high prevalence of HAIs and AMU in Singapore's acute-care hospitals. While further research is necessary to understand the causes and costs of HAIs and AMU in Singapore, repeated PPSs over the next decade will be useful to gauge progress at controlling HAIs and AMU.

[What is the perception of the 10-point plan of the German Federal Ministry of Health against multidrug-resistant pathogens and measures of antibiotic stewardship? : An interdisciplinary analysis among German clinicians and development of a decision tool for urologists]

BACKGROUND

Due to increasing antibiotic resistances, relevant treatment problems are currently emerging in clinical practice. In March 2015, the German Federal Ministry of Health (BMG) published a 10-point plan designed to combat this development. Furthermore, the first German guideline on antibiotic stewardship (ABS) was implemented in 2013 and instructs physicians of different specialties about several treatment considerations. Evidence is scarce on how such concepts (10-point plan/BMG, ABS) are perceived among clinicians.

MATERIALS AND METHODS

Within the MR2 study (Multiinstitutional Reconnaissance of practice with MultiResistant bacteria - a survey focusing on German hospitals), a questionnaire including 4 + 35 items was sent to 18 German hospitals between August and October 2015, surveying internists, gynecologists, general surgeons, and urologists. Using multivariate logistic regression models (MLRM), the impact of medical specialty and further criteria on the endpoints (1) awareness of the 10-point plan/BMG and (2) knowledge of ABS measures were assessed. Fulfillment of endpoints was predefined when average or full knowledge was reported (reference: poor to no knowledge).

RESULTS

Overall response rate was 43% (456/1061) for fully evaluable questionnaires. Only 63.0 and 53.6% of urologists and nonurologists (internists, gynecologists, and general surgeons), respectively, attended training courses regarding multidrug-resistance or antibiotic prescribing in the 12 months prior to the study (P = 0.045). The endpoints average and full knowledge regarding 10-point plan/BMG and ABS measures were fulfilled in only 31.4 and 32.8%, respectively. In MLRM, clinicians with at least one previous training course (reference: no training course) were 2.5- and 3.8-fold more likely to meet respective endpoint criteria (all P < 0.001). Medical specialty (urologists vs. nonurologists) did not significantly impact the endpoints in both MLRM.

CONCLUSIONS

The 10-point plan/BMG and ABS programs should be implemented into clinical practice, but awareness and knowledge of both is insufficient. Thus, it stands to reason that the actual realization of such measures is inadequate and continuous training towards rational prescription of antibiotics is necessary, regardless of medical specialty.

[Antibiotic stewardship and Staphylococcus aureus Bacteremia]

Rates of antibiotic resistance are increasing worldwide and impact on the treatment of patients with bacterial infections. A broad and uncritical application in inpatient and outpatient settings as well as in agriculture has been recognized as the main driving force. Antibiotic stewardship (ABS) programs aim at countering this worrisome development using various direct interventions such as infectious disease counseling. Blood stream infections caused by Staphylococcus (S.) aureus are severe infections associated with high mortality rates. ABS interventions such as de-eskalation of the antibiotic regimen or application of narrow-spectrum beta-lactam antibiotics can significantly reduce mortality rates. In this review, we discuss the importance of ABS programs and infectious disease counseling for the treatment of S. aureus blood stream infection.

[Antibiotic stewardship: Measures for optimization of antibacterial therapy]

Because the development of resistance is steadily increasing, especially among Gram-negative pathogens and new developments in antibiotics are lacking, a rational antibiotic therapy is necessary now more than ever. A continuing uncritical and non-guideline-conform use of antibiotics leads to selection of multidrug-resistant pathogens, which can colonize patients and as instigators of infections make treatment more difficult. A prerequisite for targeted antibiotic therapy is a critical testing of the suspected infection diagnosis based on a guideline-conform microbiological preanalytical procedure. To promote a guideline-conform antibiotic therapy in hospitals with respect to choice of substance, dosage and duration, in December 2013 so-called antibiotic stewardship (ABS) measures were summarized in a so-called S3-guideline from the Association of the Scientific Medical Societies in Germany (AWMF) under the auspices of the German Society for Infectious Diseases (DGI). With a strategy of targeted antibiotic therapy and infection prevention it is possible to achieve optimum treatment results and to minimize the development of resistance.

Quality of documentation on antibiotic therapy in medical records: evaluation of combined interventions in a teaching hospital by repeated point prevalence survey

This study aimed to improve the quality of documentation on antibiotic therapy in the computerized medical records of inpatients. A prospective, uncontrolled, interrupted time series (ITS) study was conducted by repeated point prevalence survey (PPS) to audit the quality of documentation on antibiotic therapy in the medical records before and after a combined intervention strategy (implementation of guidelines, distribution of educational materials, educational outreach visits, group educational interactive sessions) from the antimicrobial stewardship team (AST) in the academic teaching hospital (CHU) of Liège, Belgium. The primary outcome measure was the documentation rate on three quality indicators in the computerized medical records: (1) indication for treatment, (2) antibiotics prescribed, and (3) duration or review date. Segmented regression analysis was used to analyze the ITS. The medical records of 2306 patients receiving antibiotics for an infection (1177 in the pre-intervention period and 1129 in the post-intervention period) were analyzed. A significant increase in mean percentages in the post-intervention period was observed as compared with the pre-intervention period for the three quality indicators (indication documented 83.4 ± 10.4 % vs. 90.3 ± 6.6 %, p = 0.0013; antibiotics documented 87.9 ± 9.0 % vs. 95.6 ± 5.1 %, p < 0.0001; and duration or review date documented 31.9 ± 15.4 % vs. 67.7 ± 15.2 %, p < 0.0001). The study demonstrated the successful implementation of a combined intervention strategy from the AST. This strategy was associated with significant changes in the documentation rate in the computerized medical records for the three quality indicators.

Regional distribution of nosocomial infections due to ESBL-positive Enterobacteriaceae in Germany: data from the German National Reference Center for the Surveillance of Nosocomial Infections (KISS)

Surveillance systems for hospital infections are reporting increasing rates of extended-spectrum β-lactamase (ESBL)-positive Enterobacteriaceae in Europe. We aimed to perform a national survey on this trend and on the regional distribution of nosocomial infections due to ESBL-positive Enterobacteriaceae in German hospitals. Data from 2007 to 2012 from two components of the German national nosocomial infection surveillance system were used for this analysis. The data derive from intensive care units and surgical departments. Independent factors determining the proportion of ESBL-positive Enterobacteriaceae among nosocomial infections due to Enterobacteriaceae and changes in its regional distribution (broken down into German federal states) were calculated by regression analysis. From 2007 to 2012, the data showed a significantly increasing proportion of ESBL-positive Enterobacteriaceae in surgical site infections (from 11.46 to 15.38, 134%, p 0.003), urinary tract infections (9.36 to 16.56, 177%, p <0.001) and lower respiratory tract infections (11.91 to 14.70, 123%, p <0.001) due to Enterobacteriaceae. Factors independently associated with a growing proportion were: Thuringia (p 0.009; odds ratio (OR) 1.53), North Rhine-Westphalia (p <0.001; OR 1.41) and general surgery ward (p 0.002; OR 1.47). The proportion of ESBL-positive Enterobacteriaceae in nosocomial infections has significantly increased in Germany over the last 6 years. Hospitals in Central Germany and surgical departments in all of Germany are especially affected by this development.

Toxicological assessment of trace β-diketone antibiotic mixtures on zebrafish (Danio rerio) by proteomic analysis

β-Diketone antibiotics (DKAs) can produce chronic toxicity in aquatic ecosystems due to their pseudo-persistent in the environment. In this study, after long-term DKA exposure to zebrafish (Danio rerio), 47 protein spots had greater than 2-fold differential expression as compared to the control; there were 26 positive proteins with 14 up-regulated and 12 down-regulated. The main functions of the differentially expressed proteins were related to signal transduction mechanisms and the cytoskeleton. Of the 26 target genes, 11 genes were consistent between their transcriptional and translational levels. Low dose DKA exposure (4.69 and 9.38 mg/L) stimulated spontaneous movement in zebrafish. Changes in both creatine kinase activity and creatine concentration showed a similar trend to zebrafish activity. There was no obvious change in SV-BA after DKA exposure, while a reduction of heart rate was concomitant with increasing DKA concentrations. DKAs also induced severe histopathological changes in zebrafish heart tissue, such as dissolution of cristae and vacuolation of mitochondria. These results demonstrated that trace-level DKA exposure affects a variety of cellular and biological processes in zebrafish.

Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center

BACKGROUND

Restricted use of third-generation cephalosporins and fluoroquinolones has been linked to a reduced incidence of hospital-acquired infections with multidrug-resistant bacteria. We implemented an intensified antibiotic stewardship (ABS) programme in the medical service of a university hospital center aiming at a reduction by at least 30% in the use of these two drug classes.

METHODS

The ABS programme was focused on the 300-bed medical service. Prescription of third-generation cephalosporins was discouraged, whereas the use of penicillins was encouraged. Monthly drug use density was measured in WHO-ATC defined and locally recommended daily doses (DDD and RDD) per 100 patient days, to evaluate trends before (01/2008 to 10/2011) and after starting the intervention (1/2012 to 3/2013). The effect was analysed using interrupted time-series analysis with six non-intervention departments as controls.

RESULTS

Following initiation of the ABS intervention, overall antibiotic use in the medical service declined (p < 0.001). There was a significant intervention-related decrease in the use of cephalosporins and fluoroquinolones (p < 0.001) outperforming the decreasing baseline trend. Trend changes observed in some of the control departments were smaller, and the difference between trend changes in the medical service and those in control departments were highly significant for overall use and cephalosporin use reductions (p < 0.001) as well as for the increasing use of penicillins (p < 0.001). Mean use density levels (in RDD per 100 patient days) dropped for cephalosporins from 16.3 to 10.3 (-37%) and for fluoroquinolones from 17.7 to 10.1 (-43%), respectively. During the same period, the use of penicillins increased (15.4 to 18.2; 18%). The changes in expenditures for antibiotics in the medical service compared to control services minus programme costs indicated initial net cost savings likely to be associated with the programme.

CONCLUSION

An intensified ABS programme targeting cephalosporin und fluoroquinolone use in the setting of a large academic hospital is feasible and effective. The intervention may serve as a model for other services and hospitals with a similar structure and baseline situation.

Dramatic increase in vancomycin-resistant enterococci in Germany

OBJECTIVES

Among European countries, Germany has one of the highest proportions of vancomycin-resistant Enterococcus faecium bloodstream infections. The aim of this study was to investigate the development of vancomycin-resistant enterococci (VRE) in German hospitals and to consider the regional distribution of VRE in Germany.

METHODS

Data from three components of the German national nosocomial surveillance system (KISS) from the period 2007-12 were used for analysis: ICU-KISS data on nosocomial primary bloodstream infections and urinary tract infections from intensive care units (ICUs); OP-KISS data on surgical site infections from surgical departments; and Pathogen-KISS data concentrating on VRE cases (infections and colonizations) in ICUs. Trends over time were calculated and a map according to German federal states was prepared.

RESULTS

Data from up to 645 ICUs and 681 surgical departments for 2 year periods from 2007 to 2012 were analysed. The proportion of VRE increased significantly for surgical site infections (526%; P < 0.01) and bloodstream infections (265%; P < 0.01) and non-significantly for urinary tract infections (278%; P = 0.07). A large subgroup of ICUs also reported VRE cases in the same period, with a significant increase of 282%. The mapping of federal states showed large variation in VRE proportions and incidence rates in a belt of states with significantly higher VRE proportions from west (North Rhine-Westphalia) to east (Saxony).

CONCLUSIONS

The high overall VRE proportion in Germany is mainly due to the situation in four states. There is an urgent need to analyse the epidemiology of VRE in detail to develop appropriate infection control strategies.