A prospective cluster trial to increase antibiotic prescription quality in seven non-ICU wards

Aim

To evaluate general shortcomings and faculty-specific pitfalls as well as to improve antibiotic prescription quality (ABQ) in non-ICU wards, we performed a prospective cluster trial.

Methods

An infectious-disease (ID) consulting service performed a prospective investigation consisting of three 12-week phases with point prevalence evaluation conducted once per week (=36 evaluations in total) at seven non-ICU wards, followed by assessment of sustainability (weeks 37-48). Baseline evaluation (phase 1) defined multifaceted interventions by identifying the main shortcomings. Then, to distinguish intervention from time effects, the interventions were performed in four wards, and the 3 remaining wards served as controls; after assessing effects (phase 2), the same interventions were performed in the remaining wards to test the generalizability of the interventions (phase 3). The prolonged responses after all interventions were then analyzed in phase 4. ABQ was evaluated by at least two ID specialists who assessed the indication for therapy, the adherence to the hospital guidelines for empirical therapy, and the overall antibiotic prescription quality.

Results

In phase 1, 406 of 659 (62%) patients cases were adequately treated with antibiotics; the main reason for inappropriate prescription was the lack of an indication (107/253; 42%). The antibiotic prescription quality (ABQ) significantly increased, reaching 86% in all wards after the focused interventions (502/584; nDf=3, ddf=1,697, F=6.9, p=0.0001). In phase 2 the effect was only seen in wards that already participated in interventions (248/347; 71%). No improvement was seen in wards that received interventions only after phase 2 (189/295; 64%). A given indication significantly increased from about 80% to more than 90% (p<.0001). No carryover effects were observed.

Discussion

ABQ can be improved significantly by intervention bundles with apparent sustainable effects.

Psychiatric rehabilitation: general issues

Rehabilitation aims at avoiding unfavourable consequences of a disorder and its care and at training and improving impaired and compensatory skills. The needs of the main diagnostic groups with resulting cognitive or social impairments, namely mental retardation, infantile autism, chronic depression, severe psychoneurosis, substance abuse, schizophrenia, and dementia in old age, have specific aspects. An increased need for rehabilitation was prompted by the worldwide movement of deinstitutionalisation, which hit above all the socially most vulnerable schizophrenics. The instruments and methods of rehabilitation for the socially disabled mentally ill go far beyond the sphere of psychiatry. Individualised rehabilitation must be in mutual interaction with the social and occupational environment. The socially disabled individual is, for example, dependent upon awareness and acceptance in the community, upon financial and social support or upon the availability of a job. In the case of persisting deficits, supportive measures at different levels are needed to compensate or to minimize severe consequences of impairments. Their approach is by the social environment with the objective to grant the optimum quality of life combined with a minimum loss of independence. The great variety of measures often required at the same time must be based on a network of services and their purposeful coordination. Psychiatric rehabilitation requires a functioning social system and, in times of scarce resources, political priorities.

Epidemiology of schizophrenia. The disease model of schizophrenia in the light of current epidemiological knowledge

Attempting an update of the epidemiology of schizophrenia, it is pointed out that schizophrenia seems to occur with the same core symptoms and almost at the same frequency in all countries and cultures studied. Methodologically sound studies have failed to produce evidence for a secular trend of the morbid risk. The genotype of schizophrenia is expressed as psychosis, personality disorders and non-specific disorders or it goes without manifest psychopathology. Minor brain anomalies are present in most cases. The British Child Development Study showed that behavioural, cognitive, emotional and neuromotor antecedents occur in 50% of cases, thus pointing to disordered brain development, very likely not specific to schizophrenia, since found in many other mental disorders as well. A look into the hidden early course of schizophrenia revealed a significant sex difference in age of onset and a prodromal phase of some 3 to 4 years throughout the cases. A case-control study showed that it is mainly during this early course before first admission that social disadvantage in schizophrenia arises. In the prephase a disease-related lack of social ascent plays a greater role than steps of social decline. The early social course differs between the sexes mainly due to an earlier onset of the disorder in males. The actual disease variables, that is, core symptoms and type of course, do not show any essential differences between males and females. These results indicate that schizophrenia is one of the rare uniform patterns of response of the brain, capable of being triggered by a large number of causes or favoured by non-specific risk factors. In this context the protective effect of estrogens will be discussed.

[Bernhard von Gudden's psychiatric assessment and the deposition of King Ludwig II of Bavaria in 1886 : Comments on the article by R. Steinberg in Der Nervenarzt 01/2019]

King Ludwig II of Bavaria drowned himself in Lake Starnberg on 13 June 1886 after subduing and drowning Bernhard von Gudden, a Munich-based psychiatrist who had tried to hold him back. Commissioned by Prince Luitpold, Ludwig's successor to the throne, von Gudden had provided a psychiatric assessment on the king. Finding him to be suffering from a progressive mental illness and paranoia (madness), he declared Ludwig incapable of ruling. On the basis of this report Ludwig was unlawfully declared incapacitated, deposed, arrested and locked up in the Berg Castle under von Gudden's medical supervision. We conducted a 5-year psychiatric historical study of King Ludwig II, the most thorough of its kind ever undertaken. The main results were: the private, official and political letters the king wrote until his very last day were reasonable, well-argued and impeccable in style. Until his final days Ludwig had invariably fulfilled his administrative tasks in a prompt and proper way. His handling of political affairs was also wise and reasonable. Due to social phobia afflicting him since his youth he neglected his representative duties as a monarch. Von Gudden's report is marred by severe flaws. In his article published in Der Nervenarzt (01/2019) R. Steinberg adopts von Gudden's psychiatric diagnosis and misjudgement. Steinberg writes that the king's illness developed "in a clear crescendo". In fact, it was the behavioral anomalies associated with the king's homosexual relationships that grew increasingly prevalent at the court, whereas Ludwig's mental efficiency improved over time. Given the historical misjudgment and numerous other errors that Steinberg adopts from von Gudden, I considered it necessary to compare and contrast his conclusions with results from our own research.

Squamous Cell Carcinoma Antigen for Monitoring Cervical Cancer

The tumour-associated antigen was determined in the plasma of patients with squamous cell carcinoma (SCC) of the uterine cervix by radioimmunoassay. Setting a limit of 2 ng/ml, levels were abnormal in 13.4% of healthy controls, in 14% of patients with carcinoma in situ and in 62% of patients with invasive cervical SCC. The incidence of elevated SCC antigen levels and the absolute antigen plasma concentration were dependent upon the tumour load, increasing significantly with advanced stage disease. Abnormal SCC antigen values in operable cervical cancer declined to normal within one week after radical hysterectomy with pelvic lymphadenectomy. In cases of radiotherapy antigen values took 4-6 weeks after the start of treatment to return to normal. The success of both treatment modalities was announced by an early rise in the SCC antigen in the initial phase of therapy, followed by normalisation. After successful primary treatment and a complete remission during further follow-up SCC antigen in plasma was only increased in 3.8% of the cases. Retrospective evaluations in ten patients with progressive disease showed the reappearance of abnormal SCC titers and further increase preceeding the clinically detectable relapse or progression, with a median interval of 8 weeks. The present study indicates that SCC antigen determination is not useful for the early diagnosis of cervical cancer, but it is a potential means for monitoring the efficacy of individual anticancer therapy of SCC of the uterine cervix and for detecting recurrent disease.

Früherkennung des Psychoserisikos mit dem Early Recognition Inventory (ERIraos)

Die Frühintervention bei schizophrenen Psychosen kann entweder im initialen Prodrom oder in der beginnenden ersten Episode stattfinden. Dies setzt eine zuverlässige Früherkennung von Risikopersonen voraus. Wir berichten über den Aufbau des zweistufigen Früherkennungsinventars ERIraos, bestehend aus einer Checkliste als Screeninginstrument und einer umfassenden Symptomliste und weiteren modularen Komponenten. Es werden erste Ergebnisse zur Reliabilität der Checkliste und zu ihrer Übereinstimmungsvalidität mit den interventionsrelevanten Einschlusskriterien berichtet.

Differential Effect of Newly Isolated Phages Belonging to PB1-Like, phiKZ-Like and LUZ24-Like Viruses against Multi-Drug Resistant Pseudomonas aeruginosa under Varying Growth Conditions

In this study, we characterize three phages (SL1 SL2, and SL4), isolated from hospital sewage with lytic activity against clinical isolates of multi-drug resistant Pseudomonas aeruginosa (MDR-PA). The host spectrum ranged from 41% to 54%, with all three phages together covering 79% of all tested clinical isolates. Genome analysis revealed that SL1 (65,849 bp, 91 open reading frames ORFs) belongs to PB1-like viruses, SL2 (279,696 bp, 354 ORFs) to phiKZ-like viruses and SL4 (44,194 bp, 65 ORFs) to LUZ24-like viruses. Planktonic cells of four of five selected MDR-PA strains were suppressed by at least one phage with multiplicities of infection (MOIs) ranging from 1 to 10⁻⁶ for 16 h without apparent regrowth of bacterial populations. While SL2 was most potent in suppressing planktonic cultures the strongest anti-biofilm activity was observed with SL4. Phages were able to rescue bacteria-infected wax moth larvae (Galleria melonella) for 24 h, whereby highest survival rates (90%) were observed with SL1. Except for the biofilm experiments, the effect of a cocktail with all three phages was comparable to the action of the best phage alone; hence, there are no synergistic but also no antagonistic effects among phages. The use of a cocktail with these phages is therefore expedient for increasing host range and minimizing the development of phage resistance.

Disinfection of gloves: feasible, but pay attention to the disinfectant/glove combination

BACKGROUND

Compliance with hand hygiene is complicated by indications for hand disinfection in rapid succession during the care of one patient. In such situations, disinfection of gloves could facilitate better workflow and optimize compliance rates.

AIM

We analysed the efficacy of disinfecting gloves by comparing an individual effect of five different hand disinfectant solutions in combination with three different glove types.

METHODS

The investigation was performed in accordance with DIN EN 1500:2013. For all combinations, ten analyses were performed, including (1) right/left-hand examination disinfection efficacy after the first and fifth contamination with E. coli K12 NCTC 10538, (2) recovery rates after contamination, (3) reduction efficacy, (4) fingertip immersion culture, and (5) check for tightness. Disinfection of the ungloved hands was taken as an additional benchmark.

FINDINGS

The disinfection efficacy for all disinfectant/glove combinations was better with rather than without gloves. For eight combinations, the disinfection efficacy was always >5.0 log₁₀. There were significant differences within the gloves (P=0.0021) and within the disinfectant product (P=0.0023), respectively. In detail, Nitril Blue Eco-Plus performed significantly better than Vasco Braun (P=0.0017) and Latex Med Comfort (P=0.0493). Descoderm showed a significantly worse performance than Promanum pure (P=0.043). In the check for tightness, only the Vasco Braun gloves showed no leaks in all samples. There were relevant qualitative differences pertaining to the comfort of disinfecting gloves.

CONCLUSION

The disinfection efficacy for the different disinfectant/glove combinations was greater than for the ungloved hands. However, various disinfectant/glove combinations produce relevant differences as regards disinfection efficacy.

Preliminary survey of local bacteriophages with lytic activity against multi-drug resistant bacteria

Bacteriophages (phages) represent a potential alternative for combating multi-drug resistant bacteria. Because of their narrow host range and the ever emergence of novel pathogen variants the continued search for phages is a prerequisite for optimal treatment of bacterial infections. Here we performed an ad hoc survey in the surroundings of a University hospital for the presence of phages with therapeutic potential. To this end, 16 aquatic samples of different origins and locations were tested simultaneously for the presence of phages with lytic activity against five current, but distinct strains each from the ESKAPE-group (i.e., Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter cloacae). Phages could be isolated for 70% of strains, covering all bacterial species except S. aureus. Apart from samples from two lakes, freshwater samples were largely devoid of phages. By contrast, one liter of hospital effluent collected at a single time point already contained phages active against two-thirds of tested strains. In conclusion, phages with lytic activity against nosocomial pathogens are unevenly distributed across environments with the prime source being the immediate hospital vicinity.

Evaluation of hydrogen peroxide vapor for the inactivation of nosocomial pathogens on porous and nonporous surfaces

BACKGROUND

Clostridium difficile spores and multidrug-resistant (MDR) organisms, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and MDR Acinetobacter baumannii, are important nosocomial pathogens that are difficult to eliminate from the hospital environment. We evaluated the efficacy of hydrogen peroxide vapor (HPV), a no-touch automated room decontamination system, for the inactivation of a range of pathogens dried onto hard nonporous and porous surfaces in an operating room (OR).

METHODS

Stainless steel and cotton carriers containing >4 log10 viable MRSA, VRE, or MDR A baumannii were placed at 4 locations in the OR along with 7 pouched 6 log10Geobacillus stearothermophilus spore biologic indicators (BIs). HPV was then used to decontaminate the OR. The experiment was repeated 3 times.

RESULTS

HPV inactivated all spore BIs (>6 log10 reduction), and no MRSA, VRE, or MDR A baumannii were recovered from the stainless steel and cotton carriers (>4-5 log10 reduction, depending on the starting inoculum). HPV was equally effective at all carrier locations. We did not identify any difference in efficacy for microbes dried onto stainless steel or cotton surfaces, indicating that HPV may have a role in the decontamination of both porous and nonporous surfaces.

CONCLUSION

HPV is an effective way to decontaminate clinical areas where contamination with bacterial spores and MDR organisms is suspected.

Influence of signal colored hand disinfectant dispensers on hand hygiene compliance at a medical intensive care unit

To assess the influence of signal colors on hand disinfectant dispenser activities, health care workers (HCWs) at a medical intensive care unit were analyzed for a total of 20 weeks with 8 weeks before and 12 weeks after exchange to signal color. No significant increase in hand rubs (HRs) per patient day (PD) was observed (about 40 HRs/PD); however, HCW-adjusted compliance showed a 6% increase with signal colored devices. Therefore, colored devices may help to improve hand hygiene compliance.

[Schizophrenia - a disorder in its own right?: results from 25 years of the ABC study]

BACKGROUND

The ABC schizophrenia study conducted by the same team over 25 years initially aimed at illuminating the onset, prodromal stage and sex differences in age at first hospitalization in schizophrenia. New hypotheses were systematically generated from the results achieved.

METHODS

A population-based sample of 276 first admission cases (232 first episodes, age 12-59 years), including a subsample of 130 first admissions (115 first episodes), were assessed to study prodromal stage, first illness episode, medium and long-term course and symptom dimensions in schizophrenia. The samples were compared with age and sex-matched healthy controls and with patients first admitted for unipolar depression. A total of 1,109 consecutive first admissions for schizophrenia spectrum disorders independent from the other study samples were assessed to study changes in symptomatology across the age range.

RESULTS

Before the onset of psychotic symptoms the prodromal stages of schizophrenia and severe and moderately severe depression are difficult to distinguish. The most frequent symptom in the course of schizophrenia, depressed mood, also represents the most frequent initial symptom in both disorders. Prodromal depression is a predictor of more depressive and positive symptoms in the first episode but not in the further course of the illness. Psychosis incidence for men, diagnosed according to ICD 9 (295, 297, 298.3/4), shows a pronounced peak at age 15-24 years, for women a lower peak at age 15-29 years and a second, still lower peak at the menopausal age of 45-49 years. The explanation, confirmed in animal experiments, lies in a protective effect of estrogen due to reduced D2 receptor sensitivity. The effect is antagonized by an elevated genetic risk. Functional and social impairment emerge even at the prodromal stage and the severity depends on sex and social status. Young men with schizophrenia show a less favorable social course because of the earlier age of onset and socially adverse illness behavior. Late onset is associated with a milder, primarily paranoid symptomatology and less severe social impairment. Schizophrenia is a disorder of all ages showing roughly equal life time incidence rates for men and women but considerable difference in certain periods of age. The symptom dimensions show a plateau-like course 2-5 years after the first episode. Hidden behind this picture are irregular symptom exacerbations which vary in duration. Schizophrenia conveys the picture of recurrent vulnerability to crisis and not of a stable residual state of disordered brain development or of a progressive neurodegenerative process.

Simultaneous placement of multiple central lines increases central line-associated bloodstream infection rates

BACKGROUND

Surveillance for central line (CL)-associated bloodstream infections (CLABSIs) is generally advocated. However, the standard definition of this surveillance does not take into account the number of CLs in place and thus the possibility of increased infection risk with multiple CLs in place simultaneously. In this study, we tested the hypothesis that simultaneous placement of more than 1 CL is associated with an increased CLABSI rate.

METHODS

The number of CLs, CL-days, and CLABSIs and CLABSI rates with regard to the number of CLs in place simultaneously was documented in 2 intensive care units between 2001 and 2011. Standard CLABSI rates, as well as the rates for 1 CL and multiple CLs in place, were calculated.

RESULTS

The average CLABSI rate was significantly lower in patients with 1 CL in place compared with those with more than 1 CL in place (3.69 per 1,000 CL-days vs 13.09/1,000 CL-days; incidence rate ratio [IRR], 3.63; 95% confidence interval [CI], 2.61-5.05). Importantly, all differences from the standard rate (5.94/1,000 CL-days) were significant (1 CL vs standard: IRR, 0.61; 95% CI, 0.51-0.74; more than 1 CL vs standard: IRR, 2.23; 95% CI, 1.87-2.65; both P < .0001).

CONCLUSIONS

Our data show that the number of CLs in place had a strong influence on CLABSI rates. Thus, we advocate stratifying patients by the number of CLs in place to take this increased risk of infection into account during surveillance.

Preventing progression to first-episode psychosis in early initial prodromal states

BACKGROUND

Young people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred.

AIMS

To investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive-behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS.

METHOD

A randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up.

RESULTS

A total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019).

CONCLUSIONS

Integrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.

Prospective surveillance of drain associated meningitis/ventriculitis in a neurosurgery and neurological intensive care unit

OBJECTIVES

There are currently no data available on drain associated infection occurrence related to the number of drainage days (DD), and thus drain associated infection rates. Therefore, a prospective surveillance study was conducted to determine drain associated infection rates and DD of hospital acquired external ventricular drain (EVD) and lumbar drain (LD) associated meningitis/ventriculitis in a neurosurgery and a neurological intensive care unit.

METHODS

All patients admitted in 2005 and 2006 were documented. Data on age, admitting diagnosis, type and duration of drain, duration of hospital stay and occurrence of meningitis were recorded and analysed statistically.

RESULTS

A total of 1333 patients were included, amounting to 3023 DD. After exclusion of 15 contaminations, a total of 26 cases of meningitis were reported accounting for an overall device associated meningitis rate of 8.6 infections/1000 DD. Infections associated with LD seemed to occur more frequently (19.9/1000 DD) compared with EVD (6.3/1000 DD). The presence of intraventricular blood and previous trauma were significant risk factors for infection (p = 0.003; p = 0.04). Finally, length of stay was significantly longer in meningitis patients (p = 0.0003). Coagulase negative staphylococci were the main pathogen (56%) causing meningitis, followed by Staphylococcus aureus (25%).

CONCLUSIONS

To the best of the authors' knowledge, this study represents the first to provide data on EVD as well as LD associated meningitis rates calculated per 1000 DD; a parameter that is well established for other invasive devices such as central venous and urinary tract catheters. However, further prospective studies are needed to investigate the possible risk factors for meningitis.

[Early diagnosis of schizophrenia]

Efforts to achieve early detection of and timely intervention in incipient psychotic conditions are characteristic of an extremely innovative area of schizophrenia research over the last ten years or more. Within the Competency Network on Schizophrenia, the Early Recognition Inventory, ERIraos was developed and tested with the aim of identifying persons at an elevated risk of developing a psychosis, and providing them with timely treatment. In this study, the early diagnostic work-up and intervention were performed at the early intervention centers located in Bonn, Düsseldorf, Cologne and Munich. The initial results regarding transition to a psychosis based on 1 year follow-up data are now available.The outcomes of these analyses form the basis for the revision of the Early Recognition Inventory, with the aim of bringing it into line with the requirements met with in practice.

Schizophrenie und Depression

BACKGROUND

Comparison of symptom-related and social role development between patients with schizophrenia, major depression and healthy controls provided insights into the untreated early course of the two disorders.

SAMPLES AND METHODS

Symptoms, functional impairment and social disability were assessed and compared using the IRAOS and several other cross-sectional instruments in three samples.

RESULTS

At the early illness stages there was considerable overlap in the symptom patterns and impairments presented by persons with schizophrenia and severe depression. The two disorders did not diverge until later in the early illness course with the onset of psychotic symptoms. Depressive symptoms showed a maximum in the first psychotic episode and relapse episodes and decreased with the remitting episode. Due to differences in cognitive appraisal depressed patients reported more functional impairment and social disability than patients with schizophrenia did.

CONCLUSION

The early course of symptoms and social impairment in schizophrenia and depression seems to offer an opportunity to distinguish these disorders from variants of normal development fairly early. However, early diagnostic distinction and prediction of psychosis versus depression risk at the pre-psychotic prodromal stage do not seem promising due to the broad overlap in symptoms and impairment.

[History of psychiatric care]

The lecture incorporates stages of the Ettelbruck jubilee-hospital into european psychiatric history of the two last centuries. Beginning with social exclusion in the sense of a Michel Foucauld ("Central Hospice"), then turning into a typical large psychiatric hospital the CHNP is nowadays a specialized clinic with national tasks within the network of mental health community care. Milestones of this evolution are: the isolation theory of the 19th and beginning of the 20th centuries; eugenics and euthanasia on patients in Nazi-Germany; the second psychiatric revolution after World War 2 and it's impact in Luxembourg.

Surveillance of nosocomial infections in a neurologic intensive care unit

OBJECTIVE

To assess data on the epidemiology of nosocomial infection (NI) among neurologic intensive care patients.

DESIGN

Prospective periodic surveillance study.

SETTING

An 8-bed neurologic intensive care unit (ICU).

PATIENTS

All those admitted for more than 24 hours during five 3-month periods between January 1999 and March 2003.

METHODS

Standardized surveillance within the German infection surveillance system.

RESULTS

Three hundred thirty-eight patients with a total of 2,867 patient-days and a mean length of stay of 8.5 days were enrolled during the 15-month study period. A total of 71 NIs were identified among 52 patients. Urinary tract infections (UTIs) were the most frequent NI (36.6%), followed by pneumonia (29.6%) and bloodstream infections (BSIs) (15.5%). The overall incidence and incidence density of NIs were 21.0 per 100 patients and 24.8 per 1,000 patient-days, respectively. Incidence densities were 9.8 UTIs per 1,000 urinary catheter-days (CI95, 6.4-14.4), 5.6 BSIs per 1,000 central venous catheter-days (CI9s, 2.8-10.0), and 12.8 cases of pneumonia per 1,000 ventilation-days (Cl95, 8.0-19.7). Device-associated UTI and pneumonia rates were in the upper range of national and international reference data for medical ICUs, despite the intensive infection control and prevention program in operation in the hospital.

CONCLUSION

Neurologic intensive care patients have relatively high rates of device-associated nosocomial pneumonia and UTI. For a valid comparison of surveillance data and implementation of targeted prevention strategies, we would strongly recommend provision of national benchmarks for the neurologic ICU setting.

Periodic Surveillance of Nosocomial Infections in a Neurosurgery Intensive Care Unit

BACKGROUND

We assessed data on the epidemiology of nosocomial infections (NIs) in a 14-bed neurosurgical intensive care unit (NSICU) and used surveillance data for the promotion of quality improvement activities.

PATIENTS AND METHODS

Prospective periodic surveillance was performed over five 3-month periods between July 1998 and October 2002 on all patients admitted with a length of stay > 24 hours.

RESULTS

763 patients with a total of 4,512 patient days and a mean length of stay of 5.9 days were enrolled within the 15-month study period. A total of 93 NIs were identified in 82 patients. Urinary tract infections (24.7%), pneumonia (23.6%), and bloodstream infections (17.2%) were the most frequent NIs recorded. Device-associated incidence rates were 6.0 (3.8-9.0, CI(95%)) for urinary tract infection, 4.4 (2.4-7.4, CI(95%)) for bloodstream infection, and 10.3 (6.3-15.9, CI(95%)) for pneumonia per 1,000 days at risk. For improvement of infection control-related processes, evidence-based infection control guidelines were established and an NSICU nurse was designated to be responsible for infection control issues on the ward. In addition, several infection control problems arose during the observation periods and were rapidly responded to by introducing specific intervention strategies.

CONCLUSION

Periodic surveillance is a valuable tool for assessing the epidemiology of NIs in the NSICU setting as well as for promoting the initiation of quality improvement activities.

Fulminante Mycoplasma-pneumoniae-assoziierte Meningoenzephalitis des Erwachsenen

Mycoplasma pneumoniae (M. pn.) commonly causes respiratory tract infections in humans. In a certain percentage of cases it may also be associated with various peripheral and central nervous system manifestations. We report a case of a 38-year-old previously healthy man who presented with hemiplegia and somnolence after he had suffered from a febrile respiratory infection 10 days earlier. Clinical features and laboratory investigations supported the diagnosis of an acute M. pneumoniae-associated meningoencephalitis. He was treated by an aggressive antibiotic and immunomodulatory regimen over the course of several weeks in the neurocritical care unit. Decompressive hemicraniectomy was performed due to life-threatening raised intracranial pressure. However, the patient recovered almost completely and presented with a mild neurological deficit after 3 months. Based on this case we give a review of the literature and discuss potential pathomechanisms and diagnostic approaches.

Serum bactericidal activity of piperacillin/tazobactam against Staphylococcus aureus, piperacillin-susceptible and piperacillin-resistant Escherichia coli and Pseudomonas aeruginosa

BACKGROUND

The serum bactericidal test measures the highest level of an antibiotic-containing serum dilution at which 99.9% of bacteria are killed. In this study the serum bactericidal activity of piperacillin/tazobactam was determined for bacteria often involved in severe infections. In earlier studies titres >/=1:8 in the serum bactericidal tests correlated well with clinical success in the treatment of endocarditis and osteomyelitis as well as bacterial eradication.

METHODS

Blood samples of 6 healthy volunteers were taken before and 1 and 4 h after piperacillin/tazobactam (4.5 g) administration. Serum concentrations and serum bactericidal activity were determined for 10 strains each of Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli, both piperacillin-resistant and piperacillin-susceptible according to NCCLS guidelines.

RESULTS

100% of S. aureus and piperacillin-susceptible E. coli, 90% of piperacillin-resistant E. coli and 80% of P. aeruginosa were killed 1 h after drug administration. 4 h after drug administration serum bactericidal activity decreased to 60% for S. aureus, 90% for piperacillin-susceptible E. coli, 80% for piperacillin-resistant E. coli and 30% for P. aeruginosa.

CONCLUSIONS

Excellent serum bactericidal activity of piperacillin/tazobactam was recorded 1 h after drug administration for S. aureus, E. coli and P. aeruginosa. After 4 h limited killing rates for P. aeruginosa could be detected, which supports the idea of a combination therapy.

Distribution of multi-resistant Gram-negative versus Gram-positive bacteria in the hospital inanimate environment

We prospectively studied the difference in detection rates of multi-resistant Gram-positive and multi-resistant Gram-negative bacteria in the inanimate environment of patients harbouring these organisms. Up to 20 different locations around 190 patients were surveyed. Fifty-four patients were infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) and 136 with multi-resistant Gram-negative bacteria. The environmental detection rate for MRSA or VRE was 24.7% (174/705 samples) compared with 4.9% (89/1827 samples) for multi-resistant Gram-negative bacteria (P<0.001). Gram-positive bacteria were isolated more frequently than Gram-negatives from the hands of patients (P<0.001) and hospital personnel (P=0.1145). Environmental contamination did not differ between the intensive care units (ICUs) and the general wards (GWs), which is noteworthy because our ICUs are routinely disinfected twice a day, whereas GWs are cleaned just once a day with detergent. Current guidelines for the prevention of spread of multi-resistant bacteria in the hospital setting do not distinguish between Gram-positive and Gram-negative isolates. Our results suggest that the inanimate environment serves as a secondary source for MRSA and VRE, but less so for Gram-negative bacteria. Thus, strict contact isolation in a single room with complete barrier precautions is recommended for MRSA or VRE; however, for multi-resistant Gram-negative bacteria, contact isolation with barrier precautions for close contact but without a single room seems sufficient. This benefits not only the patients, but also the hospital by removing some of the strain placed on already over-stretched resources.

Comparison of the bactericidal activity of moxifloxacin and levofloxacin against Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli and Klebsiella pneumoniae

In addition to MIC and MBC tests in this study the serum bactericidal activity of 3.1 microg/ml of moxifloxacin or 5.2 microg/ml of levofloxacin was determined against ten susceptible strains of S. aureus, S. epidermidis, E. coli and K. pneumoniae. Moxifloxacin achieved markedly better activity against S. aureus and S. epidermidis as compared to levofloxacin. Activity of moxifloxacin against E. coli and K. pneumoniae was excellent but not superior to levofloxacin. In conclusion both fluorquinolones are highly effective against E. coli and K. pneumoniae, moxifloxacin being superior with respect to gram-positives like S. aureus and S. epidermidis.

Prevention and early intervention in schizophrenia: facts and visions

There are large-scale preventive programmes to reduce the risk of death and disability caused by several frequent physical diseases. The primary and secondary prevention of schizophrenia, a disorder entailing many years of life in disability, is still being neglected. Prevention is aimed at reducing the incidence, severity or consequences of the disorder. To find ways of preventive intervention in schizophrenia, the aetiological risk factors must be identified, then eliminated or modified. As possible targets pre-, peri- and postnatal complications, urbanicity and early behavioural risk indicators are discussed. As examples of successful early prevention targeted at risk indicators attempts to prevent depression and violence are considered. The most promising approach at present is secondary prevention focused on early illness course. Based on a controlled retrospective assessment of 232 first illness episodes the course of prodromi, impairments and psychotic symptoms prior to the climax of the first episode is shown. Most of the social consequences occur before the first treatment contact, thus making plain the urgent need for preventive action. Tools sufficiently validated are not yet available for early diagnosis and prediction of psychosis onset at the prepsychotic stage. So intervention has to be based on high-risk inclusion criteria, which exclude large proportions of at-risk persons. Appropriate early intervention at the prepsychotic, prodromal and the early psychotic stage as well as relevant ethical considerations are discussed. The frequency of and distress associated with single psychotic symptoms in the general population are potent predictors of a psychosis. The vision of treating this early illness dimension with third-generation, side-effect-free antipsychotics or of preventing its onset by oestrogen-like substances is discussed.

Gender differences in schizophrenia

Sex differences in schizophrenia can be caused by the disease process itself, by genetic and hormonal differences, by differences in the maturation and morphology of the brain and in age- and gender-specific behavioural patterns. These hypotheses will be tested on the major results reported in the literature as well as on different levels (epidemiology, risk factors, animal experiments, a controlled clinical study) on data from the ABC Schizophrenia Study. Symptomatology, lifetime risk and symptom-related course of illness-the latter without consideration of age-show no gender differences. However, until menopause illness onset is delayed and severity of illness is reduced by oestrogen on the level of gene expression and transmitter functioning. Oestrogen has an antagonistic effect on the-familial or exogenous-predisposition to illness. As a result, the age distribution of onset and the severity of first-episode illness in young men and post-menopausal women differ from the normal. First intervention trials with oestrogen substitution of neuroleptic therapy have demonstrated antipsychotic effects. The poorer social course of schizophrenia in men than in premenopausal women is accounted for by men's lower level of social development at illness onset and the subsequent impediment of their further development. Men's socially adverse illness behaviour, too, is a contributing factor. Scarcity of the knowledge of differences in the development, morphology and functioning of the male and female brain does not yet allow any definitive conclusions about gender differences in schizophrenia.

MRSA-retrospective analysis of an outbreak in the burn centre Aachen

The growing interest in methicillin-resistant Staphylococcus aureus (MRSA) has been caused by its increased appearance in hospital and community populations. In our burn centre, an outbreak of MRSA was noticed during an 8-month period. We were able to isolate MRSA in eight patients. DNA analysis by pulsed-field gel electrophoresis (PFGE) demonstrated the development of five different strains during this period. Only two patients developed an infection caused by MRSA colonisation. The infections were proven by positive blood culture or catheter colonisation. One patient developed a clinical vancomycin-resistant sepsis which was treated successfully with the additional application of Quinupristin/Dalfopristin. THIS ANALYSIS SHOWS THAT: (1) the development of MRSA in a burn unit is often created in a single patient by long-term antibiotic therapy and not a result of cross-infection, (2) manifest MRSA infection seldom occurs even in colonised burn patients, and (3) a clinically vancomycin-resistant MRSA infection in burn patients can be treated sufficiently with Quinupristin/Dalfopristin.

[Psychiatry as a profession]

With reference to Max Weber's timeless analysis of science and politics as a profession, the present paper describes the philosophical background and historical development of the tasks and tools, institutionalization, and socialization of psychiatry as a profession. In the mid twentieth century, psychiatrists' emergence from ideological confinement in asylums, where they were separated from urban culture and medicine in general, finally allowed them to benefit from accumulating knowledge and technological progress in the field of medicine. After its transition from a custodial to a therapeutic discipline, psychiatry has acquired a variety of new fields of action and duties that require a high degree of expertise on psychological and biological levels. At the same time, people have increasingly come to expect relief not only from disease, but also from manifold problems of everyday life. As a consequence, there has been an inflationary growth of professional psychiatric and psychotherapeutic and nonprofessional services. The professional requirements that psychiatrists should meet have also increased quantitatively and qualitatively in the wake of the historical change from a caring, paternalistic attitude towards the mentally ill to a therapeutic partnership. To a greater degree than physicians working in other medical fields, psychiatrists get personally involved with their patients. As a consequence, the mental burden of their profession is at times immense. For this reason, the ethics of a medical profession has special implications for psychiatrists. The fascinating advances in therapeutic methods, neurobiological knowledge, and the increasingly differentiated diagnostic tools, e.g., noninvasive investigation of the morphology and functioning of the brain, have turned psychiatry into one of the most interesting contemporary professions. Psychiatry is now facing an enormous challenge of meeting the standards of expertise.

Gender aspects in schizophrenia: bridging the border between social and biological psychiatry

OBJECTIVE

This paper tries to show that gender differences in mental diseases are a valuable paradigm for research into the interplay between biological and psychosocial factors--not only regarding pathogenetic mechanisms, but also concerning therapeutic approaches.

METHOD

Based on relevant literature, this topic is highlighted using schizophrenia as an example.

RESULTS

Schizophrenic disorders show a later age of onset in women and a slightly better course, especially in young women. As to pathogenesis, there is some evidence that the age difference might be due at least partly to the female sex hormone oestradiol being a protective factor. Differences in course might also have to do with this biological factor, but at the same time with the psychosocial advantages of a higher age of onset and other psychosocial factors. Concerning therapy, these gender differences have important implications for pharmacotherapy, but also psychotherapy and social measures.

CONCLUSION

A gender-sensitive approach in psychiatry improves our understanding of mental illness and our therapeutic strategies and at the same time illustrates that comprehensive psychiatry cannot be practised in artificially separated 'drawers' called 'biological psychiatry', on one hand, and 'social psychiatry' on the other.

Onset and early course as determinants of the further course of schizophrenia

OBJECTIVE

First treatment contact is preceded by a lengthy prodromal and psychotic prephase. We analysed the occurrence of symptoms and disabilities prior to first contact and their consequences for medium-term illness course.

METHOD

A population-based sample of 232 first episodes of schizophrenia was studied retrospectively using the IRAOS and compared with matched peers from the population of origin. Further illness course was studied prospectively at six cross-sections over 5 years from first admission onwards.

RESULTS

Three quarters showed a prodromal phase of 5 years (mean) and a 1-year accumulation of psychotic symptoms. First to appear were depressive and negative symptoms and early signs of cognitive and social impairment. Social disability emerged 4 to 2 years before first contact. Further illness course was determined by stage of social development at psychosis onset with the consequence of a significantly poorer course for men than women because of men's earlier illness onset. Symptomatology, type of onset, age and gender influenced social course via stage of social development and, additionally, via young men's socially adverse illness behaviour.

CONCLUSION

Social course is determined by individual stage of social development at illness onset and by early illness course. Therefore, early detection and intervention are needed.

[Schizophrenia and delusions in middle aged and elderly patients. Epidemiology and etiological hypothesis]

Knowledge of the similarities and differences between early- and late-onset schizophrenia and between late-onset schizophrenia and paranoid disorder of old age and very old age is fragmentary. We compared diagnosis, subtypes, syndromes and symptoms between first-episode schizophrenia (ICD-9: 295) and paranoid disorder (ICD-9: 297, 298.3/4.) over the life cycle in a population-based (N = 232) and a clinical first-admission sample (N = 1109). Apart from different age patterns of the sexes only two symptom groups were significantly different between early- and late-onset illness: paranoid and systematic delusions showed a linear increase, symptoms of disorganisation a linear decrease over the life cycle. Clearly different between early- and late-onset illness were the neurobiological and psychological risk factors, suggesting that both neurodevelopmental and neurodegenerative disorder causes psychopathology typical of schizophrenia. Late- (40 to 60) and very-late-onset (over 60) cases of both groups of illness showed the same symptom profiles, merely the number of symptoms being higher in the group diagnosed with schizophrenia. Age was the only factor significantly contributing to a clinico-diagnostic differentiation of schizophrenia from paranoid disorder beyond age 40.