Reducing urinary catheter use in geriatric patients - results of a single-center champion-led intervention.

BACKGROUND: Indwelling urinary tract catheters (UTC) are a well-known risk factor for urinary tract infections (UTI). Because geriatric patients are at high risk of infection, an intervention with a focus on appropriate and minimal UTC use was introduced in 4 acute care geriatric wards. METHODS: Between 11/2018 and 1/2020, unit-based data on UTC use and nosocomial UTI was collected in accordance with the methods of the German national surveillance system KISS. From 6/2019 to 1/2020, a champion-led intervention was implemented which focused on: (i) feedback of surveillance data, (ii) education and training in aseptic UTC insertion and maintenance, (iii) HCW's daily assessment of UTC necessity based on a checklist and (iv) timely removal of unnecessary UTCs. UTC use, incidence, and incidence densities for catheter-associated UTI (CAUTI) were calculated before and during the intervention. In addition, we analyzed adherence to a scheduled daily assessment of UTC necessity. Rate ratios (RR) with 95% confidence intervals (95%CI) were calculated. Differences based on the quality of checklist completion were evaluated using the Kruskal Wallis test. RESULTS: We analyzed the data of 3,564 patients with a total 53,954 patient days, 9,208 UTC days, and 61 CAUTI. Surveillance data showed a significant decrease in the pooled UTC utilization rate from 19.1/100 patient days to 15.2/100 patient days (RR = 0.80, 95%CI 0.77-0.83, p < 0.001). CAUTI per 100 patients dropped from 2.07 to 1.40 (RR = 0.68, 95%CI 0.41-1.12, p = 0.1279). Overall, 373 patients received a UTC during the intervention. Of those patients 351 patients had an UTC ≥ 2 days. The analysis of these patients showed that 186 patients (53%) received a checklist as part of their chart for daily evaluation of UTC necessity. 43 (23.1%) of the completed checklists were of good quality; 143 (76.9%) were of poor quality. Patients in the group whose checklists were of good quality had fewer UTC days (median 7 UTC days IQR (3-11)) than patients whose checklists were of poor quality (11 UTC days IQR (6-16), p = 0.001). CONCLUSION: We conclude that a champion-led, surveillance-based intervention reduces the use of UTC among geriatric patients. Further research is needed to determine to what extent the use of checklists in daily medical UTC assessment affects the prevention of CAUTI. The fact that patients whose checklists were completed well had fewer UTC days should encourage a conscientious and thorough daily review of the need for UTC.

Recommendations for treatment of critically ill patients with COVID-19 : Version 3 S1 guideline.

Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for clinicians and hospitals as well as the strain on many healthcare systems has been unprecedented.The majority of patients present with mild symptoms of coronavirus disease 2019 (COVID-19); however, 5-8% become critically ill and require intensive care treatment. Acute hypoxemic respiratory failure with severe dyspnea and an increased respiratory rate (>30/min) usually leads to intensive care unit (ICU) admission. At this point bilateral pulmonary infiltrates are typically seen. Patients often develop a severe acute respiratory distress syndrome (ARDS).So far, remdesivir and dexamethasone have shown clinical effectiveness in severe COVID-19 in hospitalized patients. The main goal of supportive treatment is to ascertain adequate oxygenation. Invasive mechanical ventilation and repeated prone positioning are key elements in treating severely hypoxemic COVID-19 patients.Strict adherence to basic infection control measures (including hand hygiene) and correct use of personal protection equipment (PPE) are essential in the care of patients. Procedures that lead to formation of aerosols should be carried out with utmost precaution and preparation.

[S2k Guideline - Recommendations for Inpatient Therapy of Patients with COVID-19]. / S2k-Leitlinie ­ Empfehlungen zur stationären Therapie von Patienten mit COVID-19.

Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.

[Perspectives for anesthesiologists in hospital hygiene]. / Perspektiven für Anästhesisten in der Krankenhaushygiene.

BACKGROUND: It is mandatory for hospitals in Germany to employ infection control physicians and have an external consultation. The recommended coverage has substantially increased in the last years. Typically, infection control physicians are specialists for hygiene and environmental medicine and/or for microbiology. As there is already a shortage of these specialists, a curricular educational program in infection control was developed by the German Medical Association in 2011. This program addresses specialists of different clinical disciplines. It covers a period of 24 months and includes 200 h of courses, divided into 6 modules. In addition, 7 weeks of internships must be absolved in hospital hygiene, in a microbiological laboratory and in the public health service. During the program, the trainee must be accompanied by a qualified supervisor, who is a specialist in hygiene. The aim of this article is to describe the current status of this program. METHODS: A total of 91 infection control physicians, organized in different networks, were invited by email to take part in a survey with the online tool Survey Monkey (San Mateo, USA). The questions in the survey aimed at the characteristics of the participants as well as the conditions of the program. Further information about the various general regulations and conditions of the course was gathered through internet research, and from telephone and email contact with the State Medical Associations. RESULTS: Approximately 250 physicians completed the program between 2011 and 2017. The graduates were mostly anesthesiologists (45%) and 81% had a leading position (consultant or higher) before beginning the program. Most of them also had further education in antibiotic stewardship and/or infectious diseases. The requirements regarding training hours, examination and certification varied between the State Medical Associations. The supervision, a mandatory part of the program, is also implemented differently from state to state. Of the participants 49% felt well-qualified for the challenges ahead after finishing this program. DISCUSSION: The program was able to increase the number of infection control physicians in a relatively short period of time; however, to guarantee a comparable quality of education it is necessary to standardize the requirements on a national level. The supervision also needs to be further specified. A new program is currently being developed by the German Medical Association, which will hopefully lead to an improvement of the educational program. Special strengths of the new infection control physicians are the broad clinical experience as well as the additional qualifications in antibiotic stewardship and/or infectious diseases. The weaknesses are the lack of practical experience and knowledge of technical hygiene. A mandatory inclusion of antibiotic stewardship and infectious diseases in the program would increase its impact. Anesthesiologists are well-suited for training as infection control physicians. For them, a new, exciting field of activity has opened up with the chance to be the head of their own department.

[Epidemiology, Diagnosis and Treatment of Adult Patients with Nosocomial Pneumonia - Update 2017 - S3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy, the German Radiological Society and the Society for Virology]. / Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie ­ Update 2017.

Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However, infections on general wards are increasing. A central issue are infections with multidrug resistant (MDR) pathogens which are difficult to treat in the empirical setting potentially leading to inappropriate use of antimicrobial therapy.This guideline update was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and treatment of HAP on the basis of quality of evidence and benefit/risk ratio.This guideline has two parts. First an update on epidemiology, spectrum of pathogens and antimicrobials is provided. In the second part recommendations for the management of diagnosis and treatment are given. New recommendations with respect to imaging, diagnosis of nosocomial viral pneumonia and prolonged infusion of antibacterial drugs have been added. The statements to risk factors for infections with MDR pathogens and recommendations for monotherapy vs combination therapy have been actualised. The importance of structured deescalation concepts and limitation of treatment duration is emphasized.

In vitro susceptibility to 19 agents other than ß-lactams among third-generation cephalosporin-resistant Enterobacteriaceae recovered on hospital admission.

Objectives: As part of the multicentre Antibiotic Therapy Optimisation Study, MIC values of 19 non-ß-lactam agents were determined for third-generation cephalosporin-resistant Escherichia coli , Klebsiella species and Enterobacter species (3GCREB) isolates collected in German hospitals. Methods: A total of 328 E. coli , 35 Klebsiella spp. (1 Klebsiella oxytoca and 34 Klebsiella pneumoniae ) and 16 Enterobacter spp. (1 Enterobacter aerogenes and 15 Enterobacter cloacae ) isolates were submitted to broth microdilution antimicrobial susceptibility testing with the MICRONAUT system. MICs of fluoroquinolones (levofloxacin and moxifloxacin), aminoglycosides (gentamicin, tobramycin, amikacin, streptomycin, neomycin and paromomycin), tetracyclines (tetracycline, minocycline and tigecycline), macrolides (erythromycin, clarithromycin and azithromycin) and miscellaneous agents [trimethoprim/sulfamethoxazole, chloramphenicol, nitrofurantoin, colistin and fosfomycin intravenous (iv)] were determined and reviewed against 2016 EUCAST breakpoints. Results: The MIC of levofloxacin was >2 mg/L for 128 of 328 E. coli and 8 of 35 Klebsiella spp., but only 1 of 16 Enterobacter spp. Rates of resistance to trimethoprim/sulfamethoxazole were high (>70%), except for Enterobacter spp. Rates of resistance to colistin and fosfomycin iv were still low. About 20% of the tested isolates were resistant to chloramphenicol. Only 1 (of 328) E. coli isolate had an MIC of amikacin >16 mg/L and only 33 of 328 E. coli and 1 of 35 Klebsiella spp. had an MIC of tobramycin >4 mg/L, whereas average gentamicin MICs were in general more elevated. A tigecycline MIC >2 mg/L was only found for 1 of 16 Enterobacter spp., but in none of the E. coli or Klebsiella spp. isolates. Conclusions: Our study gives insight into previously unreported non-ß-lactam MIC distributions of 3GCREB isolates.

Colonization with third-generation cephalosporin-resistant Enterobacteriaceae on hospital admission: prevalence and risk factors.

OBJECTIVES: The objectives of this study were to prospectively assess the rectal carriage rate of third-generation cephalosporin-resistant Enterobacteriaceae (3GCREB) in non-ICU patients on hospital admission and to investigate resistance mechanisms and risk factors for carriage. METHODS: Adult patients were screened for 3GCREB carriage at six German tertiary care hospitals in 2014 using rectal swabs or stool samples. 3GCREB isolates were characterized by phenotypic and molecular methods. Each patient answered a questionnaire about potential risk factors for colonization with MDR organisms (MDROs). Univariable and multivariable risk factor analyses were performed to identify factors associated with 3GCREB carriage. RESULTS: Of 4376 patients, 416 (9.5%) were 3GCREB carriers. Escherichia coli was the predominant species (79.1%). ESBLs of the CTX-M-1 group (67.3%) and the CTX-M-9 group (16.8%) were the most frequent ß-lactamases. Five patients (0.11%) were colonized with carbapenemase-producing Enterobacteriaceae. The following risk factors were significantly associated with 3GCREB colonization in the multivariable analysis (P < 0.05): centre; previous MDRO colonization (OR = 2.12); antibiotic use within the previous 6 months (OR = 2.09); travel outside Europe (OR = 2.24); stay in a long-term care facility (OR = 1.33); and treatment of gastroesophageal reflux disease (GERD) (OR = 1.22). CONCLUSIONS: To our knowledge, this is the largest admission prevalence study of 3GCREB in Europe. The observed prevalence of 9.5% 3GCREB carriage was higher than previously reported and differed significantly among centres. In addition to previously identified risk factors, the treatment of GERD proved to be an independent risk factor for 3GCREB colonization.

Epidemiology of healthcare associated infections in Germany: Nearly 20 years of surveillance.

OBJECTIVE: To describe the epidemiology of healthcare-associated infections (HAI) in hospitals participating in the German national nosocomial infections surveillance system (KISS). METHOD: The epidemiology of HAI was described for the surveillance components for intensive care units (ITS-KISS), non-ICUs (STATIONS-KISS), very low birth weight infants (NEO-KISS) and surgical site infections (OP-KISS) in the period from 2006 to 2013. In addition, risk factor analyses were performed for the most important infections of ICU-KISS, NEO-KISS and OP-KISS. RESULTS: Data from a total of 3,454,778 ICU patients from 913 ICUs, 618,816 non-ICU patients from 142 non-ICU wards, 53,676 VLBW from 241 neonatal intensive care units (NICU) and 1,005,064 surgical patients from operative departments from 550 hospitals were used for analysis. Compared with baseline data, a significant reduction of primary bloodstream infections (PBSI) and lower respiratory tract infections (LRTI) was observed in ICUs with the maximum effect in year 5 (or longer participation) (incidence rate ratio 0.60 (CI95 0.50-0.72) and 0.61 (CI95 0.52-0.71) respectively). A significant reduction of PBSI and LRTI was also observed in NEO-KISS when comparing the baseline situation with the 5th year of participation (hazard ratio 0.70 (CI95 0.64-0.76) and 0.43 (CI95 0.35-0.52)). The effect was smaller in operative departments after the introduction of OP-KISS (OR 0.80; CI95 0.64-1.02 in year 5 or later for all procedure types combined). Due to the large database, it has not only been possible to confirm well-known risk factors for HAI, but also to identify some new interesting risk factors like seasonal and volume effects. CONCLUSIONS: Participating in a national surveillance system and using surveillance data for internal quality management leads to substantial reduction of HAI. In addition, a surveillance system can identify otherwise not recognized risk factors which should - if possible - be considered for infection control management and for risk adjustment in the benchmarking process.

Prevalence of carbapenem-resistant organisms and other Gram-negative MDRO in German ICUs: first results from the national nosocomial infection surveillance system (KISS).

PURPOSE: Standardized prevalence and incidence data on carbapenem-resistant organisms (CRO) and, as a relevant subgroup, carbapenem-resistant Enterobacteriaceae (CRE) are scarce. CRO-surveillance within the German nosocomial infection surveillance system (KISS) aims to provide epidemiological surveillance data on CRO colonizations and infections. METHODS: CRO-surveillance is part of a KISS-module for the surveillance of multidrug-resistant organisms (MDRO). MDRO-KISS methods require surveillance of all patients admitted to the ward and standardized documentation of imported and ICU-acquired cases. Data on all MDRO-carriers including colonization and infection with MDRO are collected. All presented data were routine data collected from January 1st 2013 until December 1st 2013 in accordance with the German Protection against Infection Act (IfSG). RESULTS: 341 ICUs submitted data on MDRO during the first year. In total, 5,171 cases of multidrug-resistant Gram-negative bacteria (MRGN) were identified. 848 were CRO (16%). 325 CRO-cases were acquired within the ICU (38%), and 373 CRO-patients had an infection (44%). CRO-prevalence was 0.29 per 100 patients. Acquisition rate of MRGN was 1.32 per 1,000 patient days. This rate is more than doubled the acquisition rates of other MDRO under surveillance within MDRO-KISS (0.57 MRSA, 0.49 VRE). CRO-acquisition rate was 0.3 per 1,000 patient days. Incidence density of MRGN infections bacteria was 0.58 per 1,000 patient days (CRO 0.15/1,000 patient days). CONCLUSIONS: To date, CRO are common in German ICUs and the relatively large proportions of ICU-acquired CRO and infections emphasize their potential to cause outbreaks. High MRGN infection rates and high ESBL prevalence data from clinical studies suggest a lack of MRGN identification in asymptomatic carriers.

Klebsiella spp. in endoscopy-associated infections: we may only be seeing the tip of the iceberg.

PURPOSE: Two endoscopy-associated nosocomial outbreaks caused by carbapenemase-producing Klebsiella pneumoniae (CPKP) were recently observed in two German hospitals. In this study, we performed a systematic search of the medical literature in order to elucidate the epidemiology of Klebsiella spp. in endoscopy-associated outbreaks. METHODS: Medline, the Outbreak Database ( http://www.outbreak-database.com ) and reference lists of articles extracted from these databases were screened for descriptions of endoscopy-associated nosocomial outbreaks. The data extracted and analysed were: (1) the type of medical department affected; (2) characterisation of pathogen to species and conspicuous resistance patterns (if applicable); (3) type of endoscope and the grade of its contamination; (4) number and the types of infections; (5) actual cause of the outbreak. RESULTS: A total of seven nosocomial outbreaks were identified, of which six were outbreaks of endoscopic retrograde cholangiopancreatography-related infections and caused by contaminated duodenoscopes. Including our own outbreaks in the analysis, we identified one extended-spectrum beta-lactamase-producing K. pneumoniae strain and six CPKP strains. Insufficient reprocessing after the use of the endoscope was the main reason for subsequent pathogen transmission. CONCLUSIONS: There were only two reports of nosocomial outbreaks due to Klebsiella spp. in the first three decades of endoscopic procedures, but seven additional outbreaks of this kind have been reported within the last 4 years. It is very likely that many of such outbreaks have been missed in the past because this pathogen belongs to the physiological gut flora. However, with the emergence of highly resistant (carbapenemase-producing) strains, strict adherence to infection control guidelines is more important than ever.

How many outbreaks of nosocomial infections occur in German neonatal intensive care units annually?

BACKGROUND: Outbreaks on neonatal intensive care units (NICUs) achieve huge media interest, but the real number of neonatal outbreaks within a country is unknown. METHOD: This calculation is based on the data of the component for nosocomial infections in very low birth weight (VLBW) infants of the German national nosocomial infection surveillance system (NEO-KISS) from 2006 to 2011. Almost all German NICUs caring for VLBW infants participated in this surveillance system. A cluster was defined and an outbreak was assumed when at least two cases of severe neonatal infection (bloodstream infection, pneumonia) occurred within a defined time interval in one center with the same pathogen species in different patients. Four different intervals were used for calculation: 14, 30, 60, and 90 days. Infections with coagulase-negative staphylococci (CoNS) were excluded. RESULTS: A total of 228 NICUs provided data in the six-year study period. A total of 37,038 VLBW infants and 1,361,950 patient days were used for the calculation. 7,405 severe neonatal infections occurred, and a microbiological detection of the pathogen was successful in 2,084 cases. Altogether, between 121 and 280 outbreaks were calculated according to the different time intervals used. Most outbreaks were due to Staphylococcus aureus, followed by Enterococcus spp. and Enterobacter spp. CONCLUSION: It can be assumed that at least between 26 and 61 neonatal outbreaks with at least two severe infections take place in German NICUs per year. The actual number seems to be higher because only laboratory-confirmed infections in a subgroup of patients were used for the analysis.

Antibiotic stewardship in Germany: a cross-sectional questionnaire survey of 355 intensive care units.

PURPOSE: Little information is available on antibiotic prescription management in German hospitals. The objective of this cross-sectional study was to determine the prevalence and components of antibiotic stewardship measures in German intensive care units (ICUs). METHODS: A questionnaire survey was sent to all ICUs participating in the German nosocomial infection surveillance system (n = 579) in October 2011. Data on antibiotic management structures were collected and analyzed by structural hospital and ICU factors. RESULTS: The questionnaire was completed by 355 German ICUs (response rate 61 %). Common measures used (>80 % of the ICUs) were personnel restrictions for antibiotic prescriptions, routine access to bacterial resistance data, and pharmacy reports on antibiotic costs and consumption. A small proportion of ICUs (14 %) employed physicians specialized in the prescription of antimicrobial medication. Hospitals with their own microbiological laboratory report participation in surveillance networks for antimicrobial use (34 %) and bacterial resistance (32 %) twice as often as hospitals with external laboratories (15 and 14 %, respectively, p < 0.001). Also, non-profit and public hospitals participate more often in surveillance networks for bacterial resistance than private hospitals (>23 % vs. 11 %, p < 0.05). CONCLUSIONS: While the majority of ICUs report to have some antibiotic policies established, the contents and composition of these policies vary. Organizational-level control strategies to improve antibiotic management are common in Germany. However, strategies widely considered effective, such as the systematic cross-institutional surveillance of antimicrobial use and bacterial resistance in a standardized manner or the employment of infectious disease specialists, are scarce. This study provides a benchmark for future antibiotic stewardship programs.

Costs and prolonged length of stay of central venous catheter-associated bloodstream infections (CVC BSI): a matched prospective cohort study.

PURPOSE: Central venous catheter-associated bloodstream infections (CVC BSI) are a common and serious complication among critically ill patients on intensive care units (ICUs), but also result in a financial burden for the health care system. Our aim was to determine the additional costs and length of stay (LOS) of patients with ICU-acquired CVC BSI. METHODS: We used the surveillance method of the German nosocomial infection surveillance system (Krankenhaus Infections Surveillance System, KISS) to find cases of CVC BSI. The associated costs of CVC BSI were estimated as true costs generated within our hospital. We used a matched cohort design, comparing patients with CVC BSI and patients without BSI. The study period was from January to December 2010. Patients were matched by age, sex, and Simplified Acute Physiology Score (SAPS). The LOS in the ICU of control patients needed to be at least as long as that of CVC BSI patients before the onset of CVC BSI. RESULTS: We matched 40 CVC BSI patients to 40 patients without BSI. The median hospital costs for CVC BSI patients were significantly higher than for patients without BSI (60,445 € vs. 35,730 €; p = 0.006) and the CVC BSI patients stayed longer in the hospital than patients without CVC BSI (44 days vs. 30 days; p = 0.110). The median attributable costs per CVC BSI was 29,909 € (p = 0.006) and the median attributable LOS was 7 days (p = 0.006). CONCLUSION: CVC BSI is associated with increased hospital costs and prolonged hospital stay. Hospital management should implement control measurements to keep the incidence of CVC BSI as low as possible.

Bloodstream infection due to extended-spectrum beta-lactamase (ESBL)-positive K. pneumoniae and E. coli: an analysis of the disease burden in a large cohort.

PURPOSE: The burden of extended-spectrum beta-lactamase (ESBL)-positive Enterobacteriaceae (ESBL-E) is growing worldwide. We aimed to determine the financial disease burden attributable to ESBL-positive species in cases of bloodstream infection (BSI) due to K. pneumoniae and E. coli. METHODS: We conducted a cohort study on patients with BSI due to K. pneumoniae or E. coli between 2008 and 2011 in our institution. Data were collected on true hospital costs, length of stay (LOS), basic demographic parameters, underlying diseases as Charlson comorbidity index (CCI) and ESBL positivity of the pathogens. Multivariable regression analysis on hospital costs and length of stay was performed. RESULTS: Overall we found 1,851 consecutive cases of ESBL-E BSI, 352 (19.0%) cases of K. pneumoniae BSI and 1,499 (81.0%) cases of E. coli BSI. Sixty-six of E. coli BSI (18.8%) and 178 of K. pneumoniae BSI (11.9%) cases were due to ESBL-positive isolates, respectively (p = 0.001). 830 (44.8%) cases were hospital-onset, 215 (61.1%) of the K. pneumoniae and 615 (41.0%) of the E. coli cases (p < 0.001). In-hospital mortality was overall 19.8, 25.0% in K. pneumoniae cases and 18.5% in E. coli cases (p = 0.006). Increased hospital costs and length of stay were significantly associated to BSI with ESBL-positive K. pneumoniae. CONCLUSION: In contrast to BSI due to ESBL-positive E. coli, cases of ESBL-positive K. pneumoniae BSI were associated with significantly increased costs and length of stay. Infection prevention measures should differentiate between both pathogens.

Sink interventions in the ICU to reduce risk of infection or colonization with Gram-negative pathogens: a systematic review of the literature.

BACKGROUND: Healthcare-associated infections (HAIs) are a major problem in intensive care units (ICUs). The hospital water environment is a potential reservoir for Gram-negative bacteria (GNB), and it has been shown that contaminated sinks contribute to the spread of GNB in outbreak and non-outbreak settings. This study aimed to investigate which sink interventions may reduce GNB infection and colonization rates in the ICU. METHODS: A database search (MEDLINE via PubMed, EMBASE via Ovid and ClinicalTrials.gov) was undertaken without restrictions on language or date of publication. Studies of any design were included if they described an intervention on the water fixtures in patient rooms, and presented data about HAI or colonization rates in non-outbreak settings. Acquisition (infection and/or colonization) rates of GNB and Pseudomonas aeruginosa were analysed as outcomes. RESULTS: In total, 4404 records were identified. Eleven articles were included in the final analysis. No randomized controlled trials were included in the analysis, and all studies were reported to have moderate to serious risk of bias. Removing sinks and applying filters on taps had a significant impact on GNB acquisition, but there was high heterogeneity among reported outcomes and sample size among the studies. CONCLUSION: Few studies have investigated the association of sinks in patient rooms with healthcare-associated acquisition of GNB in non-outbreak settings. Heterogeneity in study design made it impossible to generalize the results. Prospective trials are needed to further investigate whether removing sinks from patient rooms can reduce the endemic rate of HAIs in the ICU.

National MRSA rates run along with fair play of national football teams: a cross-national data analysis of the European Football Championship, 2008.

BACKGROUND: We aimed to assess the relationship between national methicillin-resistant Staphylococcus aureus (MRSA) proportions and indicators for fair play in the European Football Championship, 2008. FINDING: We obtained methicillin resistance data for S. aureus from the European Antimicrobial Resistance Surveillance System (EARSS) project. All teams which qualified for the final tournament and had reported data to the EARSS were included in the analysis. Hosting countries were excluded. The number of yellow and red cards was calculated per 100 min as an indicator for fair play. Red cards were weighted like yellow cards. We calculated correlations between antibiotic resistance and use using two-tailed Spearman's coefficient (r) for non-parametric correlations. In 2008, 16 countries qualified for the European Football Championship. Five countries (Turkey, Switzerland, Croatia, Russia and Austria) did not report MRSA data to the EARSS and/or were hosting countries. The correlation of national MRSA proportions and the fair play indicator was highly significant (p = 0.038), with a correlation coefficient of 0.632. CONCLUSION: This study shows that national MRSA proportions increase with more unfair play of the national teams: Sweden and the Netherlands played the fairest and had the lowest MRSA proportions. However, it remains to be proven (e.g. in the European Football Championship, 2012) whether this fair play indicator, indeed, can serve as an indicator for adherence with MRSA guidelines or whether this correlation cannot be substantiated.

Nosocomial infections in very low birthweight infants in Germany: current data from the National Surveillance System NEO-KISS.

BACKGROUND: Infants with very low birthweight (< 1 500 g, VLBW) are at increased risk for nosocomial infections (NI). In 2 000, we implemented a surveillance system for VLBW infants in Germany: NEO-KISS. In 2005, a joint committee of healthcare providers and insurance companies required German neonatology departments to participate. As a result, NEO-KISS is now a nationwide surveillance system for NI in VLBW infants. PATIENTS AND METHODS: We present NEO-KISS data collected between 2007 and 2011 by 228 neonatology departments. Rates of sepsis, pneumonia and necrotising enterocolitis (NEC) were calculated. In order to evaluate the department-specific infection rate we introduced a new indicator: the Standardised Infection Rate (SIR). The SIR considers the department-specific patient distribution (based on the patients' birthweight) and describes the ratio of observed and expected infections (calculated from the reference data for this individual patient distribution). The data presented comprise 33 048 VLBW infants.The incidence density of CVC-associated sepsis 8.6 per 1 000 CVC-days. RESULTS AND CONCLUSION: The incidence of pneumonia among mechanically ventilated patients was 2.7/1 000 ventilator days. The incidence of NEC was 0.8. The SIR showed strong variation among the participating departments. It is an excellent tool for identifying outliers in nosocomial infection rates and for stimulating activities to decrease the risk of nosocomial infections.

No increase in primary nosocomial candidemia in 682 German intensive care units during 2006 to 2011.

We evaluated the epidemiology of and trends in primary nosocomial candidemia within a network of 682 German intensive care units (ICUs) during 2006 to 2011. Nosocomial laboratory-confirmed bloodstream infection (NLCBI) was diagnosed using standard definitions from the United States Centers for Disease Control and Prevention. Incidences were calculated by NLCBI per 1,000 patients and incidence densities per 1,000 patient-days and per 1,000 central-line days. In the 682 ICUs, there were 2,220,803 patients, 7,943,615 patient-days and 5,363,026 central-line days. A total of 381 of the 6,666 NLCBIs were associated with Candida albicans, 142 with non-albicans Candida. Non-albicans Candida made up 26% of all the Candida isolates. The mean incidence density of Candida central line-associated NLCBIs was 0.09 per 1,000 central-line days and remained unchanged between 2006 and 2011. Crude ICU mortality was 21.9% for C. albicans and 29.7% for non-albicans Candida. Candida was the fourth leading cause of primary NLCBIs, accounting for 6.5% of all bloodstream infections acquired in ICUs. Based on an incidence density of 0.07 per 1,000 patient-days, extrapolation of our data resulted in 465 primary nosocomial Candida NLCBIs in German ICUs per year. Our data show that there was no increase in primary Candida NLCBIs during 2006 to 2011.

Sinks in patient rooms in ICUs are associated with higher rates of hospital-acquired infection: a retrospective analysis of 552 ICUs.

BACKGROUND: Sinks in hospitals are a possible reservoir for healthcare-related pathogens. They have been identified as a source of nosocomial outbreaks in intensive care units (ICU); however, their role in non-outbreak settings remains unclear. AIM: To investigate whether sinks in ICU patient rooms are associated with a higher incidence of hospital-acquired infection (HAI). METHODS: This analysis used surveillance data from the ICU component of the German nosocomial infection surveillance system (KISS) from 2017 to 2020. Between September and October 2021, all participating ICUs were surveyed about the presence of sinks in their patient rooms. The ICUs were then divided into two groups: the no-sink group (NSG) and the sink group (SG). Primary and secondary outcomes were total HAIs and HAIs associated with Pseudomonas aeruginosa (HAI-PA). FINDINGS: In total, 552 ICUs (NSG N=80, SG N=472) provided data about sinks, total HAIs and HAI-PA. The incidence density per 1000 patient-days of total HAIs was higher in ICUs in the SG (3.97 vs 3.2). The incidence density of HAI-PA was also higher in the SG (0.43 vs 0.34). The risk of HAIs associated with all pathogens [incidence rate ratio (IRR)=1.24, 95% confidence interval (CI) 1.03-1.50] and the risk of lower respiratory tract infections associated with P. aeruginosa (IRR=1.44, 95% CI 1.10-1.90) were higher in ICUs with sinks in patient rooms. After adjusting for confounders, sinks were found to be an independent risk factor for HAI (adjusted IRR 1.21, 95% CI 1.01-1.45). CONCLUSIONS: Sinks in patient rooms are associated with a higher number of HAIs per patient-day in the ICU. This should be considered when planning new ICUs or renovating existing ones.