The Thuringian registry for bloodstream infections, antibiotic resistance and the practice of blood culture sampling--AlertsNet

Evidence-based blood culture (BC) testing is of utmost importance for intensive care unit (ICU) patients suspected for sepsis. Knowledge of the aetiological agent and its susceptibility to anti-infective agents enables the clinician to initiate appropriate antimicrobial therapy and guides diagnostic procedures. This has been shown to reduce mortality, ICU stay and antibiotic overuse. Whereas microbiological laboratory practice has been highly standardised, shortfalls in pre-analytic procedures in the ICU have a significant effect on the diagnostic yield. Currently, surveillance data on BC practice lack hospital-, patient- and laboratory-based denominator data. Supporting information on differences in the clinical practice of BC testing, differences in the characteristics of the institution and the case-mix on specific wards, as well as differences in the availability of microbiological laboratories is demanded on a population basis. A population-based survey on BC practice has been established for the German Federal State of Thuringia connecting both hospitals and microbiological laboratories within an electronic registry for immediate enrolment of BC findings (AlertsNet; http://www.alertsnet.de). The registry includes microbiological results and clinical data as well as institutional variables (e.g. case severity indices) from all patients with clinically relevant positive BCs at the participating centres. The main objectives are to sustain and expand a population-based surveillance and warning system for the assessment of diagnosis, risk factors, treatment and outcomes of hospitalised patients and to improve outcomes of patients with bloodstream infections.

Bloodstream infections, antibiotic resistance and the practice of blood culture sampling in Germany: study design of a Thuringia-wide prospective population-based study (AlertsNet)

INTRODUCTION

Bloodstream infections are a major cause of death worldwide; blood culture (BC) sampling remains the most important tool for their diagnosis. Current data suggest that BC rates in German hospitals are considerably lower than recommended; this points to shortfalls in the application of microbiological analyses. Since early and appropriate BC diagnostics are associated with reduced case fatality rates and a shorter duration of antimicrobial therapy, a multicomponent study for the improvement of BC diagnostics was developed.

METHODS AND ANALYSIS

An electronic BC registry established for the German Federal state of Thuringia is the structural basis of this study. The registry includes individual patient data (microbiological results and clinical data) and institutional information for all clinically relevant positive BCs at the participating centres. First, classic result quality indicators for bloodstream infections (eg, sepsis rates) will be studied using Poisson regression models (adjusted for institutional characteristics) in order to derive relative ranks for feedback to clinical institutions. Second, a target value will be established for the process indicator BC rate. On the basis of this target value, recommendations will be made for a given combination of institutional characteristics as a reference for future use in quality control. An interventional study aiming at the improvement of BC rates will be conducted thereafter. On the basis of the results of a survey in the participating institutions, a targeted educational intervention will be developed. The success of the educational intervention will be measured by changes in the process indicator and the result indicators over time using a pre-post design.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics committee of the University Hospital Jena and from the Ethics committee of the State Chamber of Physicians of Thuringia. Findings of AlertsNet will be disseminated through public media releases and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00004825.

Impact of hospitalization and antimicrobial drug administration on antimicrobial susceptibility patterns of commensalEscherichia coliisolated from the feces of horses

Objective-To evaluate antimicrobial susceptibility of commensal Escherichia coli strains isolated from the feces of horses and investigate relationships with hospitalization and antimicrobial drug (AMD) administration. Design-Observational study. Animals-68 hospitalized horses that had been treated with AMDs for at least 3 days (HOSP-AMD group), 63 hospitalized horses that had not received AMDs for at least 4 days (HOSP-NOAMD group), and 85 healthy horses that had not been hospitalized or treated with AMDs (community group). Procedures-Fecal samples were submitted for bacterial culture, and up to 3 E coli colonies were recovered from each sample. Antimicrobial susceptibility of 724 isolates was evaluated. Prevalence of resistance was compared among groups by use of log-linear modeling. Results-For 12 of the 15 AMDs evaluated, prevalence of antimicrobial resistance differed significantly among groups, with prevalence being highest among isolates from the HOSP-AMD group and lowest among isolates from the community group. Isolates recovered from the HOSP-AMD and HOSP-NOAMD groups were also significantly more likely to be resistant to multiple AMDs. Resistance to sulfamethoxazole and resistance to trimethoprim-sulfamethoxazole were most common, followed by resistance to gentamicin and resistance to tetracycline. Use of a potentiated sulfonamide, aminoglycosides, cephalosporins, or metronidazole was positively associated with resistance to 1 or more AMDs, but use of penicillins was not associated with increased risk of resistance to AMDs. Conclusion and Clinical Relevance-Results suggest that both hospitalization and AMD administration were associated with prevalence of antimicrobial resistance among E coli strains isolated from the feces of horses.

Antibiotic resistance--an alarming health care issue

Emerging highly infectious viral agents, resurgent diseases, and mutating bacteria have created a significant and costly health care crisis. Antibiotics that were proven to be definitive weapons against infectious disease now are losing their effectiveness. This article describes the etiology and impact of this global problem and offers perioperative nurses and other health care professionals guidelines about basic infection control and infectious disease prevention to help combat this crisis.

Development of penicillin resistance among Staphylococcus aureus isolated from bovine mastitis in Denmark and other countries

This review gathers the published information regarding penicillin resistance among Staphylococcus aureus isolated from bovine mastitis from 43 different countries worldwide. For selected countries, trends over time are shown. The occurrence of resistance in the different countries is discussed in relation to the potential value of penicillin for therapy.

Are clinical laboratories in California accurately reporting vancomycin-resistant enterococci?

In order to determine whether hospital-based clinical laboratories conducting active surveillance for vancomycin-resistant enterococci in three San Francisco Bay area counties (San Francisco, Alameda, and Contra Costa counties) were accurately reporting vancomycin resistance, five vancomycin-resistant enterococcal strains and one vancomycin-susceptible beta-lactamase-producing enterococcus were sent to 31 of 32 (97%) laboratories conducting surveillance. Each strain was tested by the laboratory's routine antimicrobial susceptibility testing method. An Enterococcus faecium strain with high-level resistance to vancomycin (MIC, 512 microg/ml) was correctly reported as resistant by 100% of laboratories; an E. faecium strain with moderate-level resistance (MIC, 64 microg/ml) was correctly reported as resistant by 91% of laboratories; two Enterococcus faecalis strains with low-level resistance (MICs, 32 microg/ml) were correctly reported as resistant by 97 and 56% of laboratories, respectively. An Enterococcus gallinarum strain with intrinsic low-level resistance (MIC, 8 microg/ml) was correctly reported as intermediate by 50% of laboratories. A beta-lactamase-producing E. faecalis isolate was correctly identified as susceptible to vancomycin by 100% of laboratories and as resistant to penicillin and ampicillin by 68 and 44% of laboratories, respectively; all 23 (74%) laboratories that tested for beta-lactamase recognized that it was a beta-lactamase producer. This survey indicated that for clinically significant enterococcal isolates, laboratories in the San Francisco Bay area have problems in detecting low- to moderate-level but not high-level vancomycin resistance. Increasing accuracy of detection and prompt reporting of these isolates and investigation of cases are the next steps in the battle for control of the spread of vancomycin resistance.

The pathogenesis of Staphylococcus aureus in the trauma patient and potential future therapies

BACKGROUND

Staphylococcus aureus is the most frequently isolated pathogen in the trauma patient and uses multiple virulent factors to cause infection. At the cellular level, infection begins with the prokaryotic bacterial cell manipulating the eukaryotic host cell through its virulent factors. Researching this cellular interaction by describing the mechanisms of actions of various virulent factors may lead to new preventive therapies which will make the trauma patient less susceptible to S aureus infections.

METHODS

Surgical, medical, and microbial literature was reviewed to provide an update on S aureus pathogenesis.

RESULTS

Novel future therapies, in addition to antibiotics, are being devised based on understanding the molecular nature of S aureus pathogenesis.

CONCLUSION

The impact of S aureus on trauma will increase as S aureus develops more antibiotic resistance and as the trauma population becomes older and includes an increasing proportion of immunocompromised patients. To meet the challenge of increased virulence, trauma surgeons should be directly involved in the research of microbial pathogenesis.