Nosocomial infection and antibiotic use: a second national prevalence study in Germany

What Is the Ideal Duration for Surgical Antibiotic Prophylaxis?

Background: Surgical antibiotic prophylaxis practice became common in the 1970s and has since become almost universal. The earliest articles used three doses over 12 hours with the first being administered before the start of the operation. Conclusions: The duration of prophylaxis has varied widely in practice over time, but an increasing body of evidence has supported shorter durations, most recently with recommendations in influential guidelines to avoid administration after the incision is closed.

[Current hygiene regulations in the operating theatre with special focus on constructional and functional measures]

The article provides an overview of the most important innovations in hygiene recommendations that were published in 2018 by the Committee for Hospital Hygiene and Infection Prevention (KRINKO) on the prevention of postoperative wound infections. This summarizes several older recommendations and supplements, updates and extends them. The article focusses on technical and constructional hygiene regulations for operating theaters and includes the position of the German Statutory Accident Insurance (DGUV).

Isolation and Characterization of Lytic Bacteriophages Active against Clinical Strains of E. coli and Development of a Phage Antimicrobial Cocktail

Pathogenic E. coli cause urinary tract, soft tissue and central nervous system infections, sepsis, etc. Lytic bacteriophages can be used to combat such infections. We investigated six lytic E. coli bacteriophages isolated from wastewater. Transmission electron microscopy and whole genome sequencing showed that the isolated bacteriophages are tailed phages of the Caudoviricetes class. One-step growth curves revealed that their latent period of reproduction is 20-30 min, and the average value of the burst size is 117-155. During co-cultivation with various E. coli strains, the phages completely suppressed bacterial host culture growth within the first 4 h at MOIs 10^-7 to 10^-3. The host range lysed by each bacteriophage varied from six to two bacterial strains out of nine used in the study. The cocktail formed from the isolated bacteriophages possessed the ability to completely suppress the growth of all the E. coli strains used in the study within 6 h and maintain its lytic activity for 8 months of storage. All the isolated bacteriophages may be useful in fighting pathogenic E. coli strains and in the development of phage cocktails with a long storage period and high efficiency in the treatment of bacterial infections.

Healthcare-associated infections over an eight year period in a large university hospital in Sicily (Italy, 2011-2018)

Background

Up to 7% of hospitalised patients acquire at least one healthcare-associated infection (HAI). The aim of the present study was to quantify the burden of HAIs in an Italian hospital, identifying involved risk factors.

Methods

Prevalence point study carried out from 2011 to 2018. For each recruited patient, a data entry form was compiled including information on demographics, hospital admission, risk factors, antimicrobial treatment, and infection if present.

Results

A total of 2844 patients were included and 218 (7.03%) reported an infection. HAI prevalence rates showed a significant increase (average annual per cent change (AAPC) +33.9%; p=0.018) from 2011 to 2014 whereas from 2014 to 2018 a gradual decline was observed (AAPC -6.15%; p=0.35). Urinary tract infection was the most common HAI (25.2%) and a total of 166 (76.1%) pathogens were isolated from 218 infections. Enterococcus and Klebsiella species were the most prevalent pathogens, causing 15.1% and 14.5% of HAIs, respectively. A significant higher risk of HAIs was found in patients exposed to central catheter (adjusted odds ratio (adj-OR)=5.40), peripheral catheter (adj-OR=1.89), urinary catheter (adj-OR=1.46), National Healthcare Safety Network surgical intervention (adj-OR=1.48), ultimately fatal disease (adj-OR=2.19) or rapidly fatal disease (adj-OR=2.09) and in patients with longer hospital stay (adj-OR=1.01).

Conclusion

Intervention programmes based on guidelines dissemination and personnel training can contribute to reduce the impact of HAI. Moreover, McCabe score can be a very powerful and efficient predictor of risk for HAI. Finally, an unexpected very high burden of disease due to Enterobacteriaceae and Gram positive cocci that could be related to the frequent use of carbapenems and third generation cephalosporins in this hospital was found.

Evidence of the medical and economic benefits of implementing hygiene measures by a prevention link physician in trauma surgery: Study protocol for a biphasic multicenter prospective interventional pre-post cohort study using a structured intervention bundle development and tools of behavior change management

Introduction

The German Commission for Hospital Hygiene and Infection Prevention recommends nominating one authorized medical specialist in every medical department as an infection prevention link physician (PLP). It has been roughly described that a PLP serves as a link between the infection prevention team and the respective clinical departments. No detailed evidence about the contribution made by PLPs to the decrease of infection rates is available in Germany. The “HygArzt” project aims to demonstrate the medical and economic benefits of the implementation of hygiene measures by PLP in trauma surgery/orthopedics.

Methods

A multicenter interventional pre/post cohort study design was chosen. The study will run for a three-year period, including a pre-, post-, and an intervention phase, in four different hospitals, one of which will serve as pilot. A complex intervention containing evidence-based infection control measures will be developed and implemented by a PLP to proof efficacy. After the successful implementation of the preventive measures in the pilot hospital, the concept will be transposed to the three remaining trauma and orthopedic departments to confirm the transferability and generalizability. To enable the PLPs of the non-pilot departments, a subject-specific training program will be developed based on the study results of the pilot hospital and offered to the PLPs.

Discussion

Data are intended to provide evidence that and, if so, to which extent the implementation of specific preventive measures by a medical department-specific PLP is possible and results in a reduction of nosocomial infections in orthopedic surgery and traumatology.

Contribution to the literature

The present study describes a novel complex study design to prove the effectiveness of intervention measures for infection prevention. The study design and newly developed methodological approach could serve as a model for similar studies on infection prevention in the future. For the first time, the presented research project “HygArzt” focuses on the implementation of hygiene measures by an infection prevention link physician (PLP) and investigates whether nosocomial infections, especially surgical site infections, can be reduced by the measures implemented.

Trial registration

German clinical Trials register DRKS-ID:00013,296. Registered on March 5, 2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013296.

Challenges in interpretation of WGS and epidemiological data to investigate nosocomial transmission of vancomycin-resistant Enterococcus faecium in an endemic region: incorporation of patient movement network and admission screening

OBJECTIVES

VRE are listed, by the WHO, among the leading resistant pathogens causing greatest public concern; hence the spread and transmission of VRE, especially in hospitalized patients, need to be monitored. Despite the advancements in typing methods since the implementation of WGS for outbreak investigations, data interpretation, especially for vancomycin-resistant Enterococcus faecium (VREfm) in an endemic setting, remains challenging. In this study we explored the potential added benefit of incorporating patient movement data and admission screening to accurately estimate the magnitude of an outbreak.

METHODS

We sequenced 73 VREfm isolates from patients with bacteraemia (n = 43) and rectal colonization (n = 30/32). Genetic relatedness was determined by SNP distance (≤10) between isolates. Patient movements were visualized in a movement network, along with contact intensity and rectal colonization status prior to infection onset.

RESULTS

ST117, ST80 and ST203 were the predominant STs in our study population. Forty-four percent (18/41) of VREfm bacteraemia cases were of endogenous origin. SNP analysis of infection and colonization isolates revealed nine clonal groups. Eighty-six percent (37/43) of the patients were visualized in a transmission network due to spatiotemporal overlap. Nineteen out of 43 (44%) belonged to five transmission clusters. Incorporation of prior colonization status revealed that transmission was very likely in only 63% (12/19) of patients in these transmission clusters.

DISCUSSION

Although interpretation of WGS data is challenging, incorporation of patient movement data and colonization status by admission screening of high-risk patients may provide additional resolution when interpreting the magnitude of an outbreak in an endemic setting.

Preoperative Octenidine Application in Breast Reconstruction Surgery

BACKGROUND/AIM

Postoperative infection in implant-based reconstructive breast surgery is a common problem. The preoperative application of a disinfecting washing agent may reduce postoperative infection rates. This retrospective analysis aimed to evaluate whether preoperative Octenisan^® application yields a reduction in postoperative complications or infection rates in breast reconstructive surgery.

PATIENTS AND METHODS

Between 2016 and 2019, 127 women received implant-based breast reconstruction at the municipal hospital of Cologne, Holweide, Germany. A total of 197 treatments were performed. After giving consent, patients were asked to use Octenisan^® wash lotion for five days before breast reconstructive surgery. All patients were asked by a simple questionnaire whether they performed showering and washing according to the proposed protocol. In 96 cases patients did adhere to the protocol. In 101 cases they did not. Patient cohorts were then divided into patients who had applied Octenisan^® wash lotion and patients who had not. Endpoints were defined as minor complications with no implant loss and major complications with consecutive implant loss.

RESULTS

Patient adherence to the application regimen was 48.7%. Overall minor complications occurred in 34.4% with preoperative Octenidine usage and 36.6% without preoperative Octenidine usage. Major complications happened in 7% with preoperative Octenidine and 5% without Octenidine. Overall, there was no significant difference concerning minor or major complication rates.

CONCLUSION

Preoperative washing protocols involving the Octenisan^® wash lotion is relatively cheap and easy to follow. There is evidence that washing protocols result in a reduction of S. aureus infections leading to a better perioperative outcome. Octenisan^® is safe to use in implant-based breast reconstructive surgery and is not associated with higher risks for patients. Our study did not yield any significant reduction in perioperative and postoperative complication and infection rates. This is attributed to a relatively low study population. Wash lotion compliance was only 48.7%. Proper patient education is crucial. With those preliminary data, it is now possible to design a larger analysis since patient adherence to washing protocol with Octenisan^® wash lotion has been established.

Successful surgical closure of infected abdominal wounds following preconditioning with negative pressure wound therapy

PURPOSE

Traditionally, previous wound infection was considered a contraindication to secondary skin closure; however, several case reports describe successful secondary wound closure of wounds "preconditioned" with negative pressure wound therapy (NPWT). Although this has been increasingly applied in daily practice, a systematic analysis of its feasibility has not been published thus far. The aim of this study was to evaluate secondary skin closure in previously infected abdominal wounds following treatment with NPWT.

METHODS

Single-center retrospective analysis of patients with infected abdominal wounds treated with NPWT followed by either secondary skin closure referenced to a group receiving open wound therapy. Endpoints were wound closure rate, wound complications (such as recurrent infection or hernia), and perioperative data (such as duration of NPWT or hospitalization parameters).

RESULTS

One hundred ninety-eight patients during 2013-2016 received a secondary skin closure after NPWT and were analyzed and referenced to 67 patients in the same period with open wound treatment after NPWT. No significant difference in BMI, chronic immunosuppressive medication, or tobacco use was found between both groups. The mean duration of hospital stay was 30 days with a comparable duration in both patient groups (29 versus 33 days, p = 0.35). Interestingly, only 7.7% of patients after secondary skin closure developed recurrent surgical site infection and in over 80% of patients were discharged with closed wounds requiring only minimal outpatient wound care.

CONCLUSION

Surgical skin closure following NPWT of infected abdominal wounds is a good and safe alternative to open wound treatment. It prevents lengthy outpatient wound therapy and is expected to result in a higher quality of life for patients and reduce health care costs.

Analysis of Continuous Prevalence Survey of Healthcare-Associated Infections Based on the Real-Time Monitoring System in 2018 in Shandong in China

Background

Healthcare-associated infection (HAI) is a serious threat to the safety of patients worldwide. The prevalence survey is widely used to explore and study the characteristics of HAI. However, the annual continuous prevalence survey of hospital-acquired infections has not been reported so far.

Aim

This study is aimed at examining the occurrence and development trend of HAIs dynamically and accurately.

Methods

An annual continuous HAI prevalence survey based on the real-time monitoring system was conducted in representative hospitals from different regions in Shandong in China. Findings. A total of 64 hospitals participated in the survey, and 2,741,433 patients were monitored in 2018. The highest prevalence of HAIs in Shandong was 3.83% (February 15), the lowest was 1.85% (February 28), and the average was 2.45%. The percentile distribution of prevalence of HAIs in this study was as follows: P10, 2.23%; P25, 2.31%; P50, 2.41%; P75, 2.55%; and P90, 2.73%.

Conclusion

This study dynamically and accurately showed the occurrence and development trend of HAIs in Shandong in 2018. The results of this study can be used as a reference for the HAI prevalence survey in various medical institutions in Shandong and provide the basis for the regional HAI prevention and control strategy.

Rapid Detection of Pathogens in Wound Exudate via Nucleic Acid Lateral Flow Immunoassay

The rapid detection of pathogens in infected wounds can significantly improve the clinical outcome. Wound exudate, which can be collected in a non-invasive way, offers an attractive sample material for the detection of pathogens at the point-of-care (POC). Here, we report the development of a nucleic acid lateral flow immunoassay for direct detection of isothermally amplified DNA combined with fast sample preparation. The streamlined protocol was evaluated using human wound exudate spiked with the opportunistic pathogen Pseudomonas aeruginosa that cause severe health issues upon wound colonization. A detection limit of 2.1 × 10⁵ CFU per mL of wound fluid was achieved, and no cross-reaction with other pathogens was observed. Furthermore, we integrated an internal amplification control that excludes false negative results and, in combination with the flow control, ensures the validity of the test result. The paper-based approach with only three simple hands-on steps has a turn-around time of less than 30 min and covers the complete analytical process chain from sample to answer. This newly developed workflow for wound fluid diagnostics has tremendous potential for reliable pathogen POC testing and subsequent target-oriented therapy.

The Influence of Perioperative Antibiotic Prophylaxis on Wound Infection and on the Colonization of Wound Drains in Patients After Correction of Craniosynostosis

Objective: Evidence for the duration of perioperative antibiotic prophylaxis (PAP) after the correction of craniosynostosis in children is scarce. We evaluated the necessary duration of PAP to ensure a minimal rate of postoperative wound infections. Methods: In this monocentric, retrospective, and prospective pilot study, two PAP protocols were compared. From August 2017 to May 2018, treatment group 1 (TG 1) was treated using the standard PAP protocol with at least three doses of antibiotics. Between May 2018 and March 2019, a shortened PAP with a single-shot administration was given to treatment group 2 (TG 2a and b). Endpoints of this study were wound infection rate, colonization rate of wound drains, and the course of treatment reflected by clinical and laboratory data. Results: A cohort of 187 children underwent craniosynostosis correction: 167 were treated according to protocols--95 patients with at least three doses (TG 1) and 72 patients with a single-shot of cefuroxime (TG 2a). Baseline characteristics were similar for both groups. We could not detect significant differences, neither for wound infection rates (TG 1: 1.1%, TG 2a: 0.0%, p = 0.38) nor for colonization rates of wound drains (TG 1: 4.8%, TG 2a: 10.5%, p = 0.27). Conclusions: Single-shot PAP had no adverse effects on the wound infection rate or the colonization rate of the wound drains compared with prolonged perioperative antibiotic prophylaxis. As a result, single-shot preoperative PAP is now applied to the majority craniosynostosis patients undergoing surgical correction in our unit.

Trends of Healthcare-associated Infections in a Tuinisian University Hospital and Impact of COVID-19 Pandemic

BACKGROUND

Although efforts to manage coronavirus disease 2019 (COVID-19) pandemic have understandably taken immediate priority, the impacts on traditional healthcare-associated infection (HAI) surveillance and prevention efforts remain concerning.

AIM

To describe trends in HAIs in a Tunisian university hospital through repeated point prevalence surveys over 9 years, assess the impact of measures implemented for COVID-19 pandemic, and to identify associated factors of HAI.

METHODS

The current study focused on data collected from annual point prevalence surveys conducted from 2012 to 2020. All types of HAIs as defined by the Centers for Disease Control and Prevention (CDC) were included. Data collection was carried out using NosoTun plug. Univariate and multivariate logistic analysis were used to identify HAI risk factors.

RESULTS

Overall, 2729 patients were observed in the 9 surveys; the mean age was 48.3 ± 23.3 years and 57.5% were male. We identified 267 infected patients (9.8%) and 296 HAIs (10.8%). Pneumonia/lower respiratory tract infections were the most frequent HAI (24%), followed by urinary tract infection (20.9%).The prevalence of infected patients increased from 10.6% in 2012 to 14.9% in 2020. However, this increase was not statistically significant. The prevalence of HAIs increased significantly from 12.3% to 15.5% (P =.003). The only decrease involved is bloodstream infections (from 2% to 1%). Independent risk factors significantly associated with HAI were undergoing surgical intervention (aOR = 1.7), the use of antibiotic treatment in previous 6 months (aOR = 1.8), peripheral line (aOR=2), parenteral nutrition (aOR=2.4), urinary tract within 7 days (aOR=2.4), central line (aOR = 6.3), and prosthesis (aOR = 12.8), length of stay (aOR = 3), and the year of the survey. Young age was found as protective factor (aOR = .98).

CONCLUSION

Contrary to what was expected, we noticed an increase in the HAIs rates despite the preventive measures put in place to control the COVID-19 pandemic. This was partly explained by the vulnerability of hospitalized patients during this period.

The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis

Background

Surgical site infection (SSI) describes an infectious complication of surgical wounds. Although SSI is thought to be preventable, it still represents a major cause of morbidity and substantial economic burden on the health system. Wound irrigation (WI) might reduce the level of bacterial contamination, but current data on its role in reducing or preventing SSI is conflicting. Our aim was to investigate the effectiveness of WI with normal saline prior to wound closure for the reduction of SSI in patients undergoing abdominal surgery.

Methods

We conducted a systematic literature search in MEDLINE, EMBASE, and CENTRAL from inception to present, and cross-checked the reference lists of all included primary studies and relevant systematic reviews. (Quasi-) randomized controlled trials (RCTs) investigating the rate of SSI when using normal saline vs. no irrigation prior to wound closure following abdominal surgery were included. Primary outcome was the rate of SSI, secondary outcome the mean length of hospital stay (LOS).

Results

Four RCTs including a total of 1194 patients were included for analysis. All studies compared wound irrigation with normal saline with no wound irrigation prior to wound closure. Their risk of bias was moderate. The relative risk of developing a SSI was lower when wound irrigation with normal saline was performed prior to wound closure although the effect was not statistically significant (risk ratio 0.73, 95%-confidence level: 0.37 to 1.43). Similarly, there was no difference in the LOS amongst both intervention arms.

Conclusion

This systematic review could not identify an advantage for routine irrigation of abdominal wounds with normal saline over no irrigation prior to wound closure in preventing or reducing the rate of SSI.

Systematic review registration

PROSPERO registry number CRD42018082287.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-020-00274-2.

Streptomyces sp SM01 isolated from Indian soil produces a novel antibiotic picolinamycin effective against multi drug resistant bacterial strains

A Kashmir Himalayan (India) soil isolate, Streptomyces sp. SM01 was subjected to small scale fermentation for the production of novel antimicrobials, picolinamycin (SM1). The production has been optimized which found to be maximum while incubated in AIA medium (pH 7) for 7 days at 30 °C. Seven days grew crude cell-free culture media (50 µL) showed a larger zone of inhibition against Staphylococcus aureus compared to streptomycin (5 µg) and ampicillin (5 µg). Extraction, purification, and chemical analysis of the antimicrobial component has been proved to be a new class of antibiotic with 1013 dalton molecular weight. We have named this new antibiotic as picolinamycin for consisting picolinamide moiety in the center of the molecule and produced by a Streptomyces sp. In general, the antimicrobial potency of this newly characterized antibiotic found to be higher against Gram-positive organisms than the tested Gram-negative organisms. The MIC of this antimicrobial compound was found to be 0.01 µg/ml for tested Gram-positive organisms and 0.02 to 5.12 µg/ml for Gram-negative organisms. Furthermore, it showed strong growth impairments of several multidrug resistance (MDR) strains, including methicillin-resistant strains of Staphylococci and Enterococci with the MIC value of 0.04 to 5.12 µg/ml and MDR (but methicillin-sensitive) strains of S. aureus with the MIC value of 0.084 µg/ml. It also showed anti-mycobacterial potential in higher concentrations (MIC is 10.24 µg/ml). Picolinamycin however did not show toxicity against tested A549 human cell line indicating that the spectrum of its activity limited within bacteria only.

Outbreak investigation of Serratia marcescens neurosurgical site infections associated with a contaminated shaving razors

Background

Surgical site infection (SSI) is the most common healthcare-associated infection. We report an outbreak of neurosurgical site infections caused by Serratia marcescens after craniotomy in a tertiary care hospital.

Methods

Between August 6 and 21, 2018, five cases of early-onset SSI caused by S. marcescens after craniotomy were recorded in a 1786-bed tertiary care hospital. Cultures were collected from potential environmental sources and healthcare workers. Whole-genome sequencing (WGS) was used to investigate the genetic relationships among S. marcescens isolates.

Results

The outbreak involved five patients; S. marcescens was isolated from the cerebrospinal fluid, pus, tissue, and blood samples from these patients. S. marcescens was also isolated from shaving razors and brushes. All S. marcescens isolates from the infected patients and razors showed the same resistance patterns on antibiotic-susceptibility tests. WGS revealed close clustering among four of five isolates from the patients and among three of four isolates from the razors. No additional patient developed S. marcescens infection after we stopped using the razors for scalp shaving.

Conclusions

We report an outbreak of neurosurgical site infections after craniotomy, which was associated with shaving razors contaminated by S. marcescens. Shaving scalps with razors should be avoided to prevent SSI.

Linezolid use in German acute care hospitals: results from two consecutive national point prevalence surveys

Background

Linezolid belongs to a reserve group of antibiotics. In recent years, reports on linezolid resistance in gram-positive cocci have become more frequent. Overuse of linezolid is a relevant factor for resistance development. The objective of this study was to describe current prescription practices of linezolid in German hospitals and identify targets for antimicrobial stewardship interventions.

Methods

We analyzed all linezolid prescriptions from the datasets of the consecutive national point prevalence surveys performed in German hospitals in 2011 and 2016. In both surveys, data on healthcare-associated infections and antimicrobial use were collected following the methodology of the European Centre for Disease Prevention and Control.

Results

Overall, the percentage of linezolid among all documented antimicrobials increased significantly from 2011 to 2016 (p < 0.01). In 2011, 0.3% (119 of 41,539) patients received linezolid, in 2016 this proportion was significantly higher (0.4%; 255 of 64,412 patients; p < 0.01). In 2016, intensive care units (ICUs) were the wards most frequently prescribing linezolid. The largest proportion of patients receiving linezolid were non-ICU patients. Roughly 38% of linezolid prescriptions were for treatment of skin/soft tissue and respiratory tract infections. In 2016, linezolid was administered parenterally in 70% (n = 179) of cases. Multivariable analysis showed that the ward specialty ICU posed an independent risk factor, while Northern and Southwestern regions in Germany were independent protective factors for a high rate of linezolid prescriptions.

Conclusions

In conclusion, we detected potentials for improving linezolid prescription practices in German hospitals. Given the emergence of linezolid resistance, optimization of linezolid use must be a target of future antimicrobial stewardship activities.

The rise in vancomycin-resistant Enterococcus faecium in Germany: data from the German Antimicrobial Resistance Surveillance (ARS)

Background

Due to limited therapeutic options, vancomycin-resistant Enterococcus faecium (VREF) is of great clinical significance. Recently, rising proportions of vancomycin resistance in enterococcal infections have been reported worldwide. This study aims to describe current epidemiological trends of VREF in German hospitals and to identify factors that are associated with an increased likelihood of vancomycin resistance in clinical E. faecium isolates.

Methods

2012 to 2017 data from routine vancomycin susceptibility testing of 35,906 clinical E. faecium isolates from 148 hospitals were analysed using data from the German Antimicrobial Resistance Surveillance System. Descriptive statistical analyses and uni- and multivariable regression analyses were performed to investigate the impact of variables, such as year of sampling, age and region, on vancomycin resistance in clinical E. faecium isolates.

Results

From 2014 onwards the proportions of clinical E. faecium isolates exhibiting resistance to vancomycin increased from 11.2% (95% confidence interval [CI] 9.4-13.3%) to 26.1% (95% CI 23.1-29.4%) in 2017. The rise of VREF proportions is primarily observed in the southern regions of Germany, whereas northern regions do not show a major increase. In the Southwest and Southeast, VREF proportions increased from 10.8% (95% CI 6.9-16.5%) and 3.8% (95% CI 3.0-11.5%) in 2014 to 36.7% (95% CI 32.9-40.8%) and 36.8% (95% CI 29.2-44.7%) in 2017, respectively. VREF proportions were considerably higher in isolates from patients aged 40-59 years compared to younger patients. Further regression analyses show that in relation to secondary care hospitals, E. faecium samples collected in specialist care hospitals and prevention and rehabilitation care centres are more likely to be vancomycin-resistant (odds ratios: 2.4 [95% CI 1.2-4.6] and 2.4 [95% CI 1.9-3.0], respectively). No differences in VREF proportions were found between female and male patients as well as between different clinical specimens.

Conclusion

The proportion of VREF is increasing in German hospitals, particularly in southern regions in Germany. Increased efforts in infection control and antibiotic stewardship activities accounting for local resistance patterns are necessary to combat the spread of VREF in Germany.

Point prevalence surveys of health-care-associated infections: a systematic review

Health-care-associated infections (HAIs) are considered a serious public health issues that contribute substantially to the global burden of mortality and morbidity with respect to infectious diseases. The aim is to assess the burden of health-care-associated infections by collation of available data from published point prevalence surveys (PPS) on HAIs to give future guidance. Study protocol and methodology were designed according to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Published research papers that conducted a point prevalence survey of HAIs in hospital settings by following the structured survey methodology employed by European Centre of Disease Prevention and Control (ECDC) were included. Of 1212 articles, 67 studies were included in the final analysis conducted across different countries. Overall, 35 studies were conducted in Europe, 21 in Asia, 9 in America, and 2 in Africa. The highest prevalence of HAIs was recorded in a study conducted in adult ICU settings of 75 regions of Europe (51.3%). The majority of the studies included HAI data on urinary tract infections, respiratory tract infections, and bloodstream infections. Klebsiella pneumonia, Pseudomonas aeruginosa and E. coli were the most frequent pathogens responsible for HAIs. PPS is an useful tool to quantify HAIs and provides a robust baseline data for policymakers. However, a standardize surveillance method is required. In order to minimize the burden of HAIs, infection prevention and control programs and antibiotic stewardship may be effective strategies to minimize the risk of HAIs.

Hygiene in medical education - Increasing patient safety through the implementation of practical training in infection prevention

Objective: Insufficient hygiene knowledge increases the risk of hospital-acquired infections through insufficient compliance and therefore poses a potential risk to patient safety. Therefore in 2015 the teaching project "OT Training" was introduced at the Faculty of Medicine (MF) Leipzig and a restructuring of the series of lectures and practical training on the topic of "Hygiene" was developed and integrated in the medical study curriculum. Methodology: The "OT Training" in the pre-clinical component and the didactic restructuring of the hygiene workshops in the hospital semester were comprehensively developed by means of the currently applicable learning objective catalogues and have already been tested in existing teaching (per year N=320 students; 2015-17: N= 960). The "OT Training" and the series of lectures and practical training are evaluated externally by the Faculty of Medicine. In addition a self-developed questionnaire (for "OT Training") and an internal evaluation (for practical stations as part of the practical training series) were used. Results: Overall the "OT Training" was evaluated as "very good" (N=492; RR=51%). Alongside the high importance of hygiene in the hospital and operating area (Overall_hospital=97% and Overall_{Operative area}=98%) the salient feature of hygiene for self-protection and in particular for patient safety was also recognised at an early stage. Through the series of lectures and practical training which were also evaluated positively, the self-reported level of knowledge and the importance of hygiene for the students improved significantly (level of knowledge M_before=2.8 vs. M_after=3.9; p>0.000; importance M_before=3.3 vs. M_after=4.2; p>0.000; 5 point Likert scale; t-Test). Conclusion: Hygiene errors constitute a potential risk to patients. Consequently the early and continuous focus on hygiene in student education makes a contribution to increasing patient safety in the healthcare sector.

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.

[Hospital-acquired pneumonia]

Hospital-acquired pneumonia (HAP) is a frequent complication of hospitalisation. Due to rising multidrug resistant bacteria an appropriate, empiric and targeted therapy is essential and requires an accurate assessment of risk for multidrug resistant bacteria. A targeted, temporal therapy is indispensable and should begin after a focussed diagnosis. Re-evaluation of therapy is important, as clinical course, microbiological and laboratory results might lead to de-escalation of therapy. In this review article the current German guidelines on the diagnosis and therapy of hospital-acquired pneumonia are summarized. Special focus is put on targeted, risk-adapted therapy.

[Enterococci and surgical site infections : Causal agent or harmless commensals?]

BACKGROUND

The role of enterococci in the context of peritonitis and surgical site infections (SSI) has not yet been definitively clarified but enterococci are being detected more frequently. Numerous resistances reduce the available antibiotic options.

OBJECTIVE

This article gives an overview of the pathogenic importance of enterococci and of current recommendations for therapy and prophylaxis. On the basis of our own data we discuss the relevance of enterococci for SSI.

MATERIAL AND METHODS

All colorectal resections carried out between January 2008 and September 2016 were retrospectively documented. Revision surgery, SSI and intra-abdominally or subcutaneously detected pathogens were recorded.

RESULTS

A total of 2713 interventions were evaluated with 28.3% having primary peritonitis. In 587 patients (21.6%) SSI followed, and pathogen determination was possible in 431 cases (73.4%). Enterococci were frequently found in re-operations (58.4%) and SSI (46.1%), with E. faecalis and E. faecium in approximately equal proportions. If intra-abdominal enterococci were detectable in patients with primary peritonitis, it was more common to develop SSI and enterococci were more frequently detected subcutaneously. Enterococci in SSI were found to be significantly more frequent in left hemicolectomies as well as in pre-existing renal insufficiency.

CONCLUSION

It can be inferred that enterococci are not adequately covered by commonly used perioperative antibiotic therapy or preoperative prophylaxis, which increases the risk for SSI by enterococci. This could be favored by selection of these pathogens due to the use of antibiotics without enterococcal efficacy (e. g. cephalosporins). The consideration in the choice of perioperative antibiotic prophylaxis by the additional administration of ampicillin or vancomycin could be advantageous.

Prevalence of nosocomial infections in Iran: A systematic review and meta-analysis

Background: Nosocomial infections represent a serious public health concern worldwide, and, especially, in developing countries where, due to financial constraints, it is difficult to control infections. This study aimed to review and assess the prevalence of nosocomial infections in Iran.

Methods: Different databases were searched between January 2000 and December 2017. To determine the pooled prevalence, the stochastic DerSimonian-Laird model was used, computing the effect size with its 95% confidence interval. To examine the heterogeneity among studies, the I2 test were conducted. The reporting of observational studies in epidemiology (STROBE) checklist was used to assess the methodological quality of observational studies. To further investigate the source of heterogeneity, meta-regression analyses stratified by publication year, sample size and duration of hospitalization in the hospital were carried out.

Results: 52 studies were included. Based on the random-effects model, the overall prevalence of nosocomial infection in Iran was 4.5% [95% CI: 3.5 to 5.7] with a high, statistically significant heterogeneity (I2=99.82%). A sensitivity analysis was performed to ensure the stability results. After removing each study, results did not change. A cumulative meta-analysis of the included studies was performed based on year of publication and the results did not change. In the present study, a high rate of infections caused by Klebsiella pneumoniae (urinary tract, respiratory tract, and bloodstream infections) was found.

Conclusion: Preventing and reducing hospital infections can significantly impact on reducing mortality and health-related costs. Implementing ad hoc programs, such as training healthcare staff on admission to the hospital, may play an important role in reducing infections spreading.

Prolonged antibiotic prophylaxis after thoracoabdominal esophagectomy does not reduce the risk of pneumonia in the first 30 days: a retrospective before-and-after analysis

PURPOSE

Thoracoabdominal esophageal resection for malignant disease is frequently associated with pulmonary infection. Whether prolonged antibiotic prophylaxis beyond a single perioperative dose is advantageous in preventing pulmonary infection after thoracoabdominal esophagectomy remains unclear.

METHODS

In this retrospective before-and-after analysis, 173 patients between January 2009 and December 2014 from a prospectively maintained database were included. We evaluated the effect of a 5-day postoperative course of moxifloxacin, which is a frequently used antimicrobial agent for pneumonia, on the incidence of pulmonary infection and mortality after thoracoabdominal esophagectomy.

RESULTS

104 patients received only perioperative antimicrobial prophylaxis (control group) and 69 additionally received a 5-day postoperative antibiotic therapy with moxifloxacin (prolonged-course). 22 (12.7%) of all patients developed pneumonia within the first 30 days after surgery. No statistically significant differences were seen between the prolonged group and control group in terms of pneumonia after 7 (p = 0.169) or 30 days (p = 0.133), detected bacterial species (all p > 0.291) and 30-day mortality (5.8 vs 10.6%, p = 0.274).

CONCLUSION

A preemptive 5-day postoperative course of moxifloxacin does not reduce the incidence of pulmonary infection and does not improve mortality after thoracoabdominal esophagectomy.

Promoting Hand Hygiene Compliance: PSYGIENE—a Cluster-Randomized Controlled Trial of Tailored Interventions

BACKGROUND

The German "Clean Hands Campaign" (an adaptation of the WHO "Clean Care is Safer Care" programme) to promote hand hygiene among hospital personnel at Hannover Medical School (MHH, Medizinische Hochschule Hannover), known as Aktion Saubere Hände (ASH), met with initial success. By 2013, however, compliance rates with hygienic hand disinfection in the hospital's ten intensive care units (ICUs) and two hematopoietic stem cell transplantation units (HSCTUs) had relapsed to their initial levels (physicians: 48%; nurses: 56%). The cluster- randomized controlled trial PSYGIENE was conducted to investigate whether interventions tai - lored in ways suggested by research in behavioral psychology might bring about more sustainable improvements than the ASH.

METHODS

The "Health Action Process Approach" (HAPA) compliance model specifies key psychological determinants of compliance. These determinants were assessed among health care workers in the ICUs and HSCTUs of the MHH by questionnaire (response rates: physicians: 71%; nurses: 63%) and by interviews of the responsible ward physicians and head nurses (100%). In 2013, 29 tailored behavior change techniques were implemented in educational training sessions and feedback discussions in the six wards that constituted the intervention arm of the trial, while ASH training sessions were provided in the control arm. The compliance rates for 2014 and 2015 (the primary outcomes of the trial) were determined by nonparticipating observation of hygienic hand disinfection, in accordance with the World Health Organization's gold standard.

RESULTS

The two groups did not differ in their baseline compliance rates in 2013 (intervention: 54%, control: 55%, p = 0.581). The tailored interventions led to increased compliance in each of the two follow-up years (2014: 64%, p<0.001; 2015: 70%, p = 0.001), while the compliance in the control arm increased to 68% in 2014 (p<0.001) but fell back to 64% in 2015 (p = 0.007). The compliance increases from 2013-2015 and the compliance rate in 2015 were higher in the intervention arm (p<0.005). This was mainly attributable to the nurses' behavior, as the corresponding parameters for physicians did not differ significantly between the two study arms in stratified analysis.

CONCLUSION

Tailored interventions based on behavioral psychology principles led to more sustainable increases in compliance with hand hygiene guidelines than ASH training sessions did. This was true among nurses, and thus also for hospital ward personnel as a whole (i.e., nurses and physicians combined). Further studies are needed to identify more target group-specific interventions that may improve compliance among physicians.

Antibiotic resistance: What is so special about multidrug-resistant Gram-negative bacteria?

In the past years infections caused by multidrug-resistant Gram-negative bacteria have dramatically increased in all parts of the world. This consensus paper is based on presentations, subsequent discussions and an appraisal of current literature by a panel of international experts invited by the Rudolf Schülke Stiftung, Hamburg. It deals with the epidemiology and the inherent properties of Gram-negative bacteria, elucidating the patterns of the spread of antibiotic resistance, highlighting reservoirs as well as transmission pathways and risk factors for infection, mortality, treatment and prevention options as well as the consequences of their prevalence in livestock. Following a global, One Health approach and based on the evaluation of the existing knowledge about these pathogens, this paper gives recommendations for prevention and infection control measures as well as proposals for various target groups to tackle the threats posed by Gram-negative bacteria and prevent the spread and emergence of new antibiotic resistances.

16S pan-bacterial PCR can accurately identify patients with ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) remains a challenge to intensive care units, with secure diagnosis relying on microbiological cultures that take up to 72 hours to provide a result. We sought to derive and validate a novel, real-time 16S rRNA gene PCR for rapid exclusion of VAP. Bronchoalveolar lavage (BAL) was obtained from two independent cohorts of patients with suspected VAP. Patients were recruited in a 2-centre derivation cohort and a 12-centre confirmation cohort. Confirmed VAP was defined as growth of >10⁴ colony forming units/ml on semiquantitative culture and compared with a 16S PCR assay. Samples were tested from 67 patients in the derivation cohort, 10 (15%) of whom had confirmed VAP. Using cycles to cross threshold (C_t) values as the result of the 16S PCR test, the area under the receiver operating characteristic (ROC) curve (AUROC) was 0.94 (95% CI 0.86 to 1.0, p<0.0001). Samples from 92 patients were available from the confirmation cohort, 26 (28%) of whom had confirmed VAP. The AUROC for C_t in this cohort was 0.89 (95% CI 0.83 to 0.95, p<0.0001). This study has derived and assessed the diagnostic accuracy of a novel application for 16S PCR. This suggests that 16S PCR in BAL could be used as a rapid test in suspected VAP and may allow better stewardship of antibiotics.

The Reduction in Antibiotic Use in Hospitals

BACKGROUND

Over 350 000 patients are treated in German hospitals for sepsis or pneumonia each year. The rate of antibiotic use in hospitals is high. The growing problem of drug resistance necessitates a reconsideration of antibiotic treatment strategies.

METHODS

Antibiotics were given liberally in the years 2010 and 2011 in a German 312-bed hospital. Special training, standardized algorithms to prevent unnecessary drug orders, and uniform recommendations were used in 2012 and 2013 to lessen antibiotic use. We retrospectively studied the hospital's mortality figures and microbiological findings to analyze how well these measures worked.

RESULTS

Antibiotic consumption fell from 67.1 to 51.0 defined daily doses (DDD) per 100 patient days (p <0.001) from the period 2010-2011 to the period 2012-2013. The mortality of patients with a main diagnosis of sepsis fell from 1% (95/305) to 19% (63/327; p = 0.001), while that of patients with a main diagnosis of pneumonia fell from 12% (22/178) to 6% (15/235; p = 0.038). The overall mortality fell from 3.0% (623/ 20 954) to 2.5% (576/22 719; p = 0.005). In patients with nosocomial urinary tract infections with Gram-negative pathogens (not necessarily exhibiting three- or fourfold drug resistance), the rate of resistance to three or four of the antibiotics tested fell from 11% to 5%.

CONCLUSION

Reducing in-hospital antibiotic use is an achievable goal and was associated in this study with lower mortality and less drug resistance. The findings of this single-center, retrospective study encourage a more limited and focused approach to the administration of antibiotics.

The Microbiology Effect: A Call for Education Research

In this letter from the Editor, Dr. Samantha Elliott calls for more research into the ways in which microbiology courses impact the behaviors of pre-nursing students.

Epidemiology of multidrug resistant bacterial organisms and Clostridium difficile in German hospitals in 2014: Results from a nationwide one-day point prevalence of 329 German hospitals

BACKGROUND

One important aspect in combatting resistance to antibiotics is to increase the awareness and knowledge by epidemiological studies. We therefore conducted a German-wide point-prevalence survey for multidrug resistant bacterial organisms (MDROs) and Clostridium difficile (CD) to assess the epidemiology and structure quality of infection control in German hospitals.

METHOD

1550 hospitals were asked to participate and to report surveillance data on the prevalence of Methicillin-resistant and Vancomycin resistant Staphylococcus aureus (MRSA, VRSA/GRSA), Vancomycin resistant Enterococcus faecalis/faecium (VRE), multiresistant strains of Escherichia coli (EC), Klebsiella spp. (KS), Enterobacter spp. (ES), Acinetobacter spp. (AB) and Pseudomonas spp. (PS). as well as CD infections.

RESULTS

Surveys from 73,983 patients from 329 hospitals were eligible for analysis. MRSA was the most often reported pathogen (prevalence: 1.64 % [CI95: 1.46-1.82]), followed by 3 multidrug resistant EC (3MRGN-EC) (0.75 % [CI95: 0.60-0.89]), CD (0.74 % [CI95: 0.60-0.88]), VRE (0.25 % [CI95: 0.13-0.37]) und 3MRGN-KS (0.22 % [CI95: [0.15-0.29]). The majority of hospitals met the German recommendations for staffing with infection control personnel.

CONCLUSION

The continuing increase in participating hospitals in this third survey in a row indicates a growing awareness to MDROs and our pragmatic approach. Our results confirm that MRSA, 3MRGN-EC, VRE and 3MRGN-KS remain the most prevalent MDROs in German hospitals.

Temporal trends of healthcare associated infections and antimicrobial use in 2011-2013, observed with annual point prevalence surveys in Ferrara University Hospital, Italy

INTRODUCTION

Healthcare associated infections (HAIs) and misuse of antimicrobials (AMs) represent a growing public health problem. The Point Prevalence Surveys (PPSs) find available information to be used for specific targeted interventions and evaluate their effects. The objective of this study was to estimate the prevalence of HAIs and AM use, to describe types of infections, causative pathogens and to compare data collected through three PPSs in Ferrara University Hospital (FUH), repeated in 3 different years (2011-2013). The population-based sample consists of all patients admitted to every acute care and rehabilitation Department in a single day.

METHODS

ECDC Protocol and Form for PPS of HAI and AM use, Version 4.2, July 2011. Risk factor analysis was performed using logistic regression.

RESULTS

1,239 patients were observed. Overall, HAI prevalence was 9.6%; prevalence was higher in Intensive Care Units; urinary tract infections were the most common HAIs in all 3 surveys; E.coli was the most common pathogen; AM use prevalence was 51.1%; AMs most frequently administered were fluoroquinolones, combinations of penicillins and third-generation cephalosporins. According to the regression model, urinary catheter (OR: 2.5) and invasive respiratory device (OR: 2.3) are significantly associated risk factors for HAIs (p < 0.05).

CONCLUSIONS

PPSs are a sensitive and effective method of analysis. Yearly repetition is a useful way to maintain focus on the topic of HAIs and AM use, highlighting how changes in practices impact on the outcome of care and providing useful information to implement intervention programs targeted on specific issues.

Multiple factors influencing OR ventilation system effectiveness

The issue of surgical site infections has become more critical during the last years. The number of airborne microbes depends on the number released by the staff in the room or supplied from neighbouring rooms. In order to minimize the risk of nosocomial infections during surgical procedures technical developments like ventilation systems were introduced in the operating room (OR). In this study several factors like clothing and types of ventilation systems have been investigated and their impact on the effectiveness for reducing microbial burden in the OR has been assessed. In case of OR-gowns we found a benefit for a disposable Swedish clothing concept regarding microbiological contamination in comparison with the German standard multiuse clothing. Moreover our study shows that there is comparable effectiveness of a fairly novel temperature controlled airflow ventilation system (TAF) compared to standard low turbulent uni-directional airflow (TAV).

[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.

Implementation of the updated 2015 Commission for Hospital Hygiene and Infection Prevention (KRINKO) recommendations "Prevention and control of catheter-associated urinary tract infections" in the hospitals in Frankfurt/Main, Germany

Aim: The Commission for Hospital Hygiene and Infection Prevention (KRINKO) updated the recommendations for the prevention of catheter-associated urinary tract infections in 2015. This article will describe the implementation of these recommendations in Frankfurt’s hospitals in autumn, 2015.

Material and methods: In two non-ICU wards of each of Frankfurt’s 17 hospitals, inspections were performed using a checklist based on the new KRINKO recommendations. In one large hospital, a total of 5 wards were inspected. The inspections covered the structure and process quality (operating instructions, training, indication, the placement and maintenance of catheters) and the demonstration of the preparation for insertion of a catheter using an empty bed and an imaginary patient, or insertion in a model.

Results: Operating instructions were available in all hospital wards; approximately half of the wards regularly performed training sessions. The indications were largely in line with the recommendations of the KRINKO. Alternatives to urinary tract catheters were available and were used more often than the urinary tract catheters themselves (15.9% vs. 13.5%). In accordance with the recommendations, catheters were placed without antibiotic prophylaxis or the instillation of antiseptic or antimicrobial substances or catheter flushing solutions. The demonstration of catheter placement was conscientiously performed. Need for improvement was seen in the daily documentation and the regular verification of continuing indication for a urinary catheter, as well as the omission of regular catheter change.

Conclusion: Overall, the recommendations of the KRINKO on the prevention of catheter-associated urinary tract infections were adequately implemented. However, it cannot be ruled out that in situations with time pressure and staff shortage, the handling of urinary tract catheters may be of lower quality than that observed during the inspections, when catheter insertion was done by two nurses. Against this background, a sufficient number of qualified staff and regular ward rounds by the hygiene staff appear recommendable.

Kern W. Outpatient Antibiotic Prescription

BACKGROUND

In view of the rise in antibiotic resistance and Clostridium difficile superinfection, close monitoring of antibiotic prescribing practices is essential so that targeted quality assurance measures can be taken.

METHODS

We analyzed nationwide data from multiple statutory health insurance carriers on prescriptions of systemic antibiotics in the years 2008-2014, with special attention to cephalosporins and fluoroqinolones. Prescribing rates were characterized in terms of defined daily doses (DDD) per 1000 statutory insurees per year and were analyzed separately for each age group and each federal state in Germany. Trends were analyzed with joinpoint regression.

RESULTS

Antibiotic prescribing rates for persons aged 15 to 69 increased slightly overall during the period of observation. On the other hand, there was a significant decline in antibiotic prescribing rates for persons under age 15 in all of the German states, with a mean annual decrease of 6.8%. There was also a slight decline in antibiotic prescribing rates for persons aged 70 and above, mainly accounted for by fluoroquinolones. Cephalosporin prescribing rates rose significantly in all states, by an overall average of 7.6% per annum. Cephalo - sporin prescribing rates rose significantly in all age groups except persons under age 15, for whom there was a decline that did not reach statistical significance.

CONCLUSION

This study revealed an overall decline in outpatient antibiotic prescriptions for persons under age 15 as well as other major changes in prescribing practices for the types of antibiotics studied. The observed marked rise in cephalosporin prescribing rates in all German states demands special attention because of the associated danger of increased antibiotic resistance and C. difficile superinfection. Oral cephalosporins are not recommended as drugs of first choice in current guidelines.

[Hygiene measures in the intensive care station]

Medical personnel in intensive care units (ICU) deal with critically ill patients and a high work load. Patients face a higher risk of acquiring a nosocomial infection during their ICU stay. Especially, invasively ventilated patients are threatened. A catheter-related bloodstream infection might even lead to more severe complications. The number of multiresistant pathogens continues to rise; thus, comprehensive infection control measures are crucial to avoid pathogen transmission and infection. The most important measure is hand disinfection. With a proper personnel-patient ratio, educational programs, and infection control bundles, it is possible to reduce infection rates and enhance compliance among health care workers.

Improving hospital hygiene to reduce the impact of multidrug-resistant organisms in health care--a prospective controlled multicenter study

BACKGROUND

Nosocomial infections are the most common complication during inpatient hospital care. An increasing proportion of these infections are caused by multidrug-resistant organisms (MDROs). This report describes an intervention study which was designed to address the practical problems encountered in trying to avoid and treat infections caused by MDROs. The aim of the HARMONIC (Harmonized Approach to avert Multidrug-resistant Organisms and Nosocomial Infections) study is to provide comprehensive support to hospitals in a defined study area in north-east Germany, to meet statutory requirements. To this end, a multimodal system of hygiene management was implemented in the participating hospitals.

METHODS/DESIGN

HARMONIC is a controlled intervention study conducted in eight acute care hospitals in the 'Health Region Baltic Sea Coast' in Germany. The intervention measures include the provision of written recommendations on methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and multi-resistant Gram-negative bacteria (MRGN), supplemented by regional recommendations for antibiotic prescriptions. In addition, there is theoretical and practical training of health care workers (HCWs) in the prevention and handling of MDROs, as well as targeted and critically gauged applications of antibiotics. The main outcomes of the implementation and analysis of the HARMONIC study are: (i) screening rates for MRSA, VRE and MRGN in high-risk patients, (ii) the frequency of MRSA decolonization, (iii) the level of knowledge of HCWs concerning MDROs, and (iv) specific types and amounts of antibiotics used. The data are predominantly obtained by paper-based questionnaires and documentation sheets. A computer-assisted workflow-based documentation system was developed in order to provide support to the participating facilities. The investigation includes three nested studies on risk profiles of MDROs, health-related quality of life, and cost analysis. A six-month follow-up study investigates the quality of life after discharge, the long-term costs of the treatment of infections caused by MDROs, and the sustainability of MRSA eradication.

DISCUSSION

The aim of this study is to implement and evaluate an area-wide harmonized hygiene program to control the nosocomial spreading of MDROs. Comparability between the intervention and control group is ensured by matching the hospitals according to size (number of discharges per year/number of beds) and level of care (standard or maximum). The results of the study may provide important indications for the implementation of regional MDRO management programs.

[Prevention of catheter-associated urinary tract infections: established and new aspects for the clinical routine : Revised recommendations on "prevention and control of catheter-associated urinary tract infections" of the commission for hospital hygiene and infection prevention at the Robert Koch Institute]

Catheter-associated urinary tract infections (CAUTI) are one of the most common healthcare-associated infections (HAI) in Germany and are of particular relevance for intensive and standard care units. The revised guidelines of the commission for hospital hygiene and infection prevention (KRINKO) provide an update on prevention of CAUTI. The guidelines consider and evaluate the new literature published after the initial publication in 1999. The KRINKO recommendations should be implemented to protect patients from such infections, especially as CAUTIs are one of the most preventable types of HAI. In this respect tailor-made infection prevention bundles seem to be most effective and continuous infection surveillance procedures are of particular importance. Thus, a comparison with the reference data provided by the (German) National Reference Center for surveillance of nosocomial infections is possible. This article explains the recommendations for prevention measures included in the new KRINKO guidelines.

Gender-Specific Differences in Surgical Site Infections: An Analysis of 438,050 Surgical Procedures from the German National Nosocomial Infections Surveillance System

Background

Surgical site infections (SSI) are among the most frequent healthcare-associated infections. They impose a substantial burden with increased morbidity and exceeding healthcare costs. Risk factors such as age, diabetes, and smoking status are commonly accounted for in the literature, but few studies address gender differences.

Methods

Data from the German Nosocomial Infections Surveillance System (Krankenhaus-Infektions-Surveillance-System (KISS)) from 2005 to 2010 were analysed for cardiac, vascular, visceral, and orthopaedic surgery, with a total of 438,050 surgical procedures and 8,639 SSI. Rates of SSI and isolated pathogens were analysed for gender.

Results

Women had a lower rate of SSI (SSI/100 procedures) in abdominal surgery than men (2.92 vs. 4.37; p < 0.001). No gender-specific differences were found in orthopaedic and vascular surgery, while women had a higher risk for SSI in cardiac surgery (5.50 vs. 3.02; p < 0.001). Isolated pathogens showed differences for sensitive Staphylococcus aureus and Pseudomonas aeruginosa, which were more frequent in women (both p = 0.007), while coagulase-negative staphylococci occurred more often in men (18.8 vs. 14.0%; p < 0.001).

Conclusion

Gender differences in SSI exist and are procedure-specific. The underlying mechanisms need to be further elucidated so that targeted measures for the prevention of SSI can be developed.

Clostridium difficile infection: guideline-based diagnosis and treatment

BACKGROUND

Clostridium difficile (C. difficile) is the pathogen that most commonly causes nosocomial and antibiotic-associated diarrheal disease. Optimized algorithms for diagnosis, treatment, and hygiene can help lower the incidence, morbidity, and mortality of C. difficile infection (CDI).

METHODS

This review is based on pertinent articles that were retrieved by a selective search in PubMed for recommendations on diagnosis and treatment(up to March 2014), with particular attention to the current epidemiological situation in Germany.

RESULTS

The incidence of CDI in Germany is 5 to 20 cases per 100,000 persons per year. In recent years, a steady increase in severe, reportable cases of CDI has been observed, and the highly virulent epidemic strain Ribotype 027 has spread across nearly the entire country. For therapeutic and hygiene management, it is important that the diagnosis be made as early as possible with a sensitive screening test, followed by a confirmatory test for the toxigenic infection. Special disinfection measures are needed because of the formation of spores. The treatment of CDI is evidence-based; depending on the severity of the infection, it is treated orally with metronidazole, or else with vancomycin or fidaxomicin. Fulminant infections and recurrences call for specifically adapted treatment modalities. Treatment with fecal bacteria (stool transplantation) is performed in gastroenterological centers that have experience with this form of treatment after multiple failures of drug treatment for recurrent infection. For critically ill patients, treatment is administered by an interdisciplinary team and consists of early surgical intervention in combination with drug treatment. A therapeutic algorithm developed on the basis of current guidelines and recommendations enables risk-adapted, individualized treatment.

CONCLUSION

The growing clinical and epidemiological significance of CDI compels a robust implementation of multimodal diagnostic, therapeutic, and hygienic standards. In the years to come, anti-toxin antibodies, toxoid vaccines, and focused bacterial therapy will be developed as new treatment strategies for CDI.

Nosocomial Infections and Epidemiology of Antibiotic Resistance in Teaching Hospitals in South East of Iran

Aim:

Antibiotic resistance as one of the most serious health threats worldwide leading to a high rate of morbidity and mortality. The aim of present study was to examine the prevalence of nosocomial infections (NIs) and pattern of antibiotic resistance in teaching hospitals in Iran

Methods:

This cross-sectional descriptive study was conducted in a period of one year in three teaching hospitals and all patients with suspected NIs symptoms were chooses. Among these patients who showed antibiotic resistance were included in the study. The samples for clinical test in laboratory were obtained with using standard methods and aseptic technique by trained personnel. Antibiotic susceptibility testing was performed by Kirby-Bauer’s disk diffusion method on Muller-Hinton agar (Hi Media, Mumbai, India) in accordance with the standards of the Clinical Laboratory Standards Institute.

Results:

During one year study, 561 patients with nosocomial infections were recognized and among them 340 patients (60.6%) showed some level of antibiotic resistance. The most common cause of NIs in present study was Acinetobacter and the most type of infection was respiratory system infections (52.7%). The highest resistance rate was against Ciprofloxacin (61.8%) followed by Imipenem (50.3%).

Conclusion:

Rate of NIs and antibiotics resistance is high in Iranian hospital. So Iranian health ministry should provide guideline and suitable programs for prevention of NIs and antibiotic therapy in hospitals.

[Perioperative antibiotic prophylaxis]

In times of growing bacterial resistance against antimicrobiotic drugs the broad prescription of antibiotics in human medicine must be carefully considered. The perioperative antibiotic treatment is in the center of that conflict. On the one hand an efficient pathogen reduction for the preemptive treatment of infectious complications is desired but on the other hand it is suspected that this promotes the selection of multiresistant pathogens which could lead to an increase of more complicated nosocomial infections. The aim of this article is a critical appraisal of this subject on the basis of the 2012 guidelines of the German working group of Hygiene in Hospital and Practice (AWMF) and the 2010 recommendations of the Paul-Ehrlich-Gesellschaft.

Perioperative Antibiotic Prophylaxis and Antimicrobial Therapy of Intra-Abdominal Infections

Background

The increase of antimicrobial resistances to first- and second-line antibiotics, especially of Gram-negative bacteria, and the lack of novel antimicrobial substances are a challenge in the treatment of intra-abdominal infections.

Methods

Review article.

Results

The efficacy and safety of perioperative antibiotic prophylaxis in visceral surgery has been demonstrated by several meta-analyses. Perioperative antibiotic prophylaxis is defined as a single administration of antibiotics shortly before a surgical intervention. A so-called prolonged prophylaxis including the postoperative period (e.g. 1-3 days postoperatively) should be avoided as it does not reduce the number of wound infections and is associated with an increased risk of antimicrobial resistance and side effects. Antimicrobial management of severe intra-abdominal infections involves a delicate balance of optimizing empirical therapy which has been shown to improve outcomes while simultaneously reducing unnecessary use of antimicrobials.

Conclusion

Antimicrobial resistance poses a serious threat to human health and requires a rational use of antibiotics to curb further spreading. This applies for perioperative prophylaxis as well as for the treatment of intra-abdominal infections.

[Perioperative antibiotic prophylaxis for major urological interventions]

BACKGROUND

With the emergence of multidrug resistant bacteria reaching alarming levels and the year-long developmental void of new antimicrobial drugs, the rational and appropriate use of antibiotics is of paramount importance. The number of surgical interventions is still increasing so that surgical site infections represent the most frequent form of nosocomial infection.

METHOD

Fundamental hygiene measures as well as aseptic and tissue-preserving surgical techniques are supported by perioperative antibiotic prophylaxis to prevent surgical site infections. This is accomplished by a single short-term antibiotic administration at the beginning of or at the latest during the operative intervention. Due to its contribution to the total consumption of antibiotics and when misused to the development of multidrug resistance, an appropriate and controlled perioperative antibiotic prophylaxis is mandatory.

INDICATION

The indications for perioperative antibiotic prophylaxis depend on the type of surgical procedure, the classification of operative wounds as well as individual patient and operation-related risk factors.