Antibiotic stewardship and horizontal infection control are more effective than screening, isolation and eradication.

PURPOSE: The global rise of multidrug resistant organisms (MDROs) is of major concern since infections by these pathogens are difficult, and in some cases, even impossible to treat. This review will discuss the effectiveness of a pathogen-independent alternative approach consisting of the implementation of antibiotic stewardship (ABS) programs, improvement of hand hygiene compliance, and daily antiseptic body washings instead of "screening, isolation and eradication" as recommended by many infection control guidelines today. METHODS: A review of the literature. RESULTS: The classical approach composed of screening, isolation and eradication has many limitations, including lack of standardization of the screening methods, risk of medical errors for patients in isolation and failure to eradicate resistant bacteria. Notably, concrete evidence that this current infection control approach actually prevents transmission is still lacking. We found that a novel approach with the training of infectious diseases specialists can reduce the usage of antimicrobials, thereby significantly decreasing the emergence of new MDROs. Moreover, increased hand hygiene compliance not only reduces transmission of MDROs, but also that of sensitive organisms causing the majority of nosocomial infections. Further, instruments, such as continuing education, bed-side observation, and the use of new tools, e.g. electronic wearables and Wi-Fi-equipped dispensers, are all options that can also improve the current low hand hygiene compliance levels. In addition, daily antiseptic body washes were observed to reduce the transmission of MDROs, especially those deriving from the body surface-like MRSA and VRE in specific settings. Finally, antiseptic body washes were seen to have similar effects on reducing transmission rates as screening and isolation measures. CONCLUSIONS: In summary, this review describes a novel evidence-based approach to counteract the growing medical challenge of increasing numbers of MDROs.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases.

INTRODUCTION: In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. MATERIALS AND METHODS: A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. CONCLUSION: The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Differences between prolonged weaning patients from medical and surgical intensive care units.

BACKGROUND: It is not clear whether patients entering a specialized, interdisciplinary weaning unit from surgical or medical intensive care units (ICU) distinguish substantially. The purpose of the present study was to assess differences in patients with prolonged weaning being referred from surgical and medical ICU. METHODS: Data collected from April 2013 to April 2014 was conducted for retrospective analysis. Mortality rates, demographic data, clinical, and microbial differences in 150 patients with prolonged weaning were assessed (80 surgical and 70 medical). RESULTS: Surgical ICU referrals tended to be older (70.7 ± 11.3 vs. 67.3 ± 12.3, P = 0.051) and had fewer underlying pulmonary diseases (45% vs. 60%, P = 0.067). Sodium values at the time of referral to the weaning unit were significantly higher in surgical (147.1 ± 9.6) vs. medical (141.3 ± 6.7 mmol/l) patients (P < 0.001). Each 10-unit increase in sodium at the time of referral to the weaning unit was associated with a 2.5-day (95% CI -0.4, 5.4; P = 0.09) prolongation of stay in the weaning unit. Although significant differences in microbiological agents from tracheal aspiration were seen, the infection rate on the weaning unit was similar in both groups. There was no difference in weaning unit mortality between surgical and medical ICU patients (18% vs. 23%; P = 0.41). CONCLUSION: Few differences were found between patients being referred to a specialized weaning unit from surgical vs. medical ICUs. Besides differences in microbiological characteristics of tracheal secretions, there were also differences in sodium levels, which appear to influence on treatment duration.

[Prevention of transmission of multidrug-resistant bacteria]. / Prävention der Transmission von multiresistenten Erregern.

BACKGROUND: The increase in multidrug-resistant bacteria (MDR) is a worldwide problem. Depending on the type of pathogen there are only a few and less effective treatment options available; therefore, effective infection prevention is of major importance. OBJECTIVE: Which infection prevention and control measures are effective and feasible for the prevention of MDR transmission? MATERIAL AND METHODS: Discussion and critical appraisal of current recommendations and the available literature. RESULTS: Studies evaluating infection control measures for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and multidrug-resistant Gram-negative bacteria differ with respect to the prevalence of MDR, screening methods, number of available personnel and compliance with hand hygiene measures. Many databases result from outbreak investigations and are not comparable with the endemic setting. In addition, the bundle approach makes it impossible to evaluate a single measure alone. CONCLUSION: The guidelines and recommendations for dealing with colonized and infected patients are of low evidential value and often difficult to implement in the clinical practice. The single most important measure to avoid transmission is still disinfection of the hands. Single room isolation and contact precautions are often recommended but the relevance is unclear; however, the disadvantages of patients being isolated are well studied and of major concern. Screening measures have to be adapted to the local situation. Full body washing of all patients in at-risk areas with chlorhexidine appears to be an attractive and effective alternative to screening and isolation.

Are chlorhexidine-containing dressings safe for use with ventricular drainages?

The purpose of this report was to assess the safety and application of chlorhexidine (CHG)-containing dressings--shown to reduce central line infection rates markedly--for external ventricular drainages (EVDs) and lumbar drainages (LDs). Cerebrospinal fluid samples of patients receiving standard dressings and CHG-containing dressing (ten each) were analyzed by high-performance liquid chromatography for the presence of CHG. The application was evaluated. CHG was not detectable in all samples. The dressings' application for EVDs and LDs worked without problems. Thus, the use of CHG-containing dressings for EVDs and LDs seems to be safe. Further studies addressing their infection reduction potential are warranted.

Reduction of central venous line-associated bloodstream infection rates by using a chlorhexidine-containing dressing.

PURPOSE: The reduction of central venous line (CVL)-associated bloodstream infections (CLABSIs) is generally advocated. However, despite implementing infection prevention recommendations, CLABSI rates remain high at some institutions. Therefore, a chlorhexidine-containing dressing should be assessed for its potential for infection reduction, adverse events (AEs) and practicability. METHODS: The number of CVLs, CVL days, CLABSIs and CLABSI rates with regard to the kind of dressing (standard vs. chlorhexidine-containing) were documented from November 2010 to may 2012 (1,298 patients with 12,220 CVL days) at two intensive care units (ICUs) and compared to historical controls. The practicability and safety of the chlorhexidine-containing dressing and reasons for not using this dressing were assessed. RESULTS: Forty CLABSIs occurred in 34 patients, resulting in a significantly lower overall CLABSI rate in patients with the chlorhexidine-containing dressing [1.51/1,000 CVL days; confidence interval (CI): 0.75-2.70] compared to patients with the standard dressing (5.87/1,000 CVL days; CI: 3.93-8.43; p < 0.0001). The CLABSI rate in historical controls receiving the standard dressing was 6.2/1,000 CVL days. The main reason for not using chlorhexidine-containing dressing was bleeding at the insertion site. AEs occurred in five patients and represented self-healing skin macerations (3 cases) and superficial skin necrosis (2 cases). CONCLUSIONS: In case of high CLABSI rates despite the implementation of standard recommendations, our findings suggest that a chlorhexidine-containing dressing safely decreases CLABSI rates.

Long-term sustainability of hand hygiene improvements in the hemodialysis setting.

PURPOSE: In a previous observational intervention study, we achieved a more than 100 % increase in overall hand hygiene (HH) compliance in the hemodialysis setting by increasing the number of hand rubs (HR) performed and concomitantly optimizing HH standard operating procedures (SOPs). SOPs were mainly aimed at reducing the number of avoidable opportunities due to a less than perfect workflow. However, the long-term sustainability of this successful intervention was not evaluated. The present study was carried out to evaluate the long-term effects of our previous successful intervention. METHODS: We conducted a follow-up observational study 1 year after the first intervention study in the same hemodialysis unit to assess the sustainability. No HH-related interventions were performed in the 1 year between studies. The main outcome was HH compliance, and the secondary outcome was opportunities per hemodialysis procedure. RESULTS: A total of 1,574 opportunities for HH and 871 hand rubs (HR) were observed during the follow-up observational study. Overall, compliance was 55 %, which was significantly than that at the end of the first study (62 %; p < 0.0001), but significantly higher than that at the start and mid-term phases of the first study (37 and 49 %, p < 0.0001). Both the decrease in HH opportunities and the increase in HR were sustained over the course of this observational study. The number of avoidable opportunities in the present study was similar to that at the end of the previous study. Thus, in 320 opportunities (20 %), gloves were worn instead of HR performed, representing 46 % of all missed HR. CONCLUSIONS: Despite a decrease in HH compliance compared to the last postintervention period, a multifaceted intervention focusing on standardization and workflow optimization resulted in a sustained improvement in HH. We therefore propose that standardization of the hemodialysis workflow aimed at improving HH is a promising avenue for improving the quality of patient care and outcome.

[Prevention of wound infections: basic measures]. / Prävention von Wundinfektionen: Basismaßnahmen.

Individual patient risk factors for wound infections, such as alcohol abuse, smoking or obesity can usually only be modified to a small extent. Studies have shown a reduction of surgical site infections due to the implementation of a benchmarking surveillance system. In order to prevent surgical site infections a variety of interventions are available, such as glucose control, correction of anemia and malnutrition and antibiotic therapy of infections before elective surgery. Reduction of the microbial skin flora by whole body washing procedures, avoidance of sharp razor shaving, application of antibiotic prophylaxis and correct surgical hand disinfection are additional measures. Intraoperative hypothermia should be avoided and strict compliance with asepsis is mandatory. Postoperative preventive measures include appropriate wound care and rapid removal of wound drainage.

[The current pathogen spectrum--what are we fighting against?]. / Das Keimspektrum von heute--gegen wen kämpfen wir?

Surgical site infections are mainly caused by bacteria from the patients' skin or gut flora representing endogenous infections. In orthopedic and trauma surgery the skin commensals dominate and as a consequence Gram-positive bacteria are the main pathogens, particularly S. aureus. Additionally and especially in the case of foreign body infections, less virulent pathogens, e.g. coagulase-negative staphylococci play an important role. Due to newer microbiological techniques in detecting pathogens the spectrum of causative organisms is steadily increasing. As known for other nosocomial infections the relevance of multidrug resistant bacteria in surgical site infections is growing and the key player is methicillin-resistant S. aureus (MRSA); however vancomycin-resistant enterococci (VRE), extended spectrum betalactamases and/or carbapenemases producing enterobacteria and recently even panresistant Acinetobacter baumannii isolates have to be considered.

[Treatment algorithm for periprosthetic infections of the knee joint]. / Behandlungsalgorithmus der periprothetischen Infektionen am Kniegelenk.

Periprosthetic knee joint infection is a rare complication. However, patients as well as surgeons have to deal with severe problems. The past years have brought new knowledge on periprosthetic knee joint infections which have resulted in new classifications. The present manuscript evaluates the current literature on this topic and presents a new therapeutic algorithm.

[Therapy of chronic osteomyelitis: soft tissues as "key to success"]. / Therapie der chronischen Osteomyelitis: Die Weichteile als "Schlüssel zum Erfolg"

Chronic osteomyelitis is a severe complication characterized by soft tissue and bone pathogenic infection resulting in osseous destruction. Surgical management is demanding and poses a challenge in achieving the goals of treatment, which are control of infection, bone healing as well as satisfactory functional outcome. Therapeutic strategies are based on a combined application of radical surgery and systemic antibiotic therapy. The bony defects which remain after extensive debridement have to be reconstructed with bone grafting after soft tissue coverage and the healing process is decisive for a successful outcome.

[Osteomyelitis in adults. Diagnostic principles and therapeutic strategies]. / Osteomyelitis im Erwachsenenalter. Diagnostische Prinzipien und therapeutische Strategien.

This review focuses on the presentation of the diagnostic and therapeutic principles for treatment of chronic osteomyelitis of long bones in adults. Early detection of the offending bacteria is a crucial step which has to be performed with tissue and fluids from the depth of the wound. Superficial samples and swaps from fistulas should be avoided and are not considered to be representative. Chronic osteomyelitis is characterized by necrotic and nonvascularized bony tissue which represents one of the most relevant sources for recurrence infection. Appropriate therapy includes radical excision of the diseased bone and infected scar tissue, closure of the wound with well-vascularized (muscle) flaps, stabilization, and administration of adequate antibiotics.

[Infection control in the operating room: preventive measures and isolation precautions in cases of multidrug resistant pathogens]. / Infektionskontrolle im OP: Präventions- und Isolierungsmaßnahmen bei multiresistenten Erregern.

BACKGROUND: Providing surgical treatment for patients colonised or infected with multidrug resistant organisms (MDROs) is daily routine in German hospitals. However, there is uncertainty about the application of adequate infection control measures in the OR. One of the reasons is that specific guidelines are not available. MATERIAL AND METHODS: We evaluated current practice in surgical departments of selected German university medical centres using a questionnaire. In addition, centres were asked to provide in-house standard operating procedures (SOP), if available. RESULTS: Nineteen questionnaires from 19 departments within 4 centres and 5 in-house SOPs were ana-lysed. The results showed a broad spectrum of applied infection control measures. Wide variations existed both within centres and within departments of the same centre regardless of existing in-house standards. CONCLUSIONS: Guidelines addressing perioperative infection control measures for patients harbouring MDROs should be developed with a focus on practicability to reduce both transmission of MDROs and unreasonable measures. Implementation of existing SOPs can be a target for optimisation.

Suspicion of viral gastroenteritis does improve compliance with hand hygiene.

PURPOSE: Viral gastroenteritis is common on pediatric wards, increasing the need for adherence with hand hygiene recommendations in order to prevent cross-transmission. Therefore, we investigated hand hygiene reflecting complete work-day activities on pediatric wards and focused on the influence of viral gastroenteritis. There are, so far, no studies representing complete working days on pediatric wards or addressing the influence of viral gastroenteritis. METHODS: This was a prospective, observational study (144 h in each group) on hand hygiene behavior in the care for children with and without suspected or proven viral gastroenteritis. RESULTS: We documented 40 and 30 hand hygiene opportunities per patient-day for ward-associated healthcare workers for children with and without viral gastroenteritis, respectively (P = 0.316). Healthcare workers' compliance with hand hygiene recommendations was significantly higher in children with viral gastroenteritis compared to those without, i.e., 72 versus 67% (P = 0.033), especially among physicians, being 92 versus 50% (P = 0.032). Compliance tended to be higher after patient contact than before, especially in the children with gastroenteritis (78 vs. 62%; P = 0.083). CONCLUSIONS: We conclude that viral gastroenteritis seemed to increase the number of daily opportunities for hand hygiene and did significantly increase compliance. In particular, this effect was seen after patient contact. Further research might address the awareness of undiagnosed transmissible diseases in order to prevent cross-transmissions.

[Hand hygiene: basic, but not trivial]. / Händehygiene--einfach, aber nicht trivial.

Hand hygiene is considered as the pillar of infection control and prevention. Healthcare-associated infections have a great impact on morbidity, length of hospital stay, and treatment costs. Hand disinfection is considered to be the single most effective tool to prevent healthcare-associated infections and cross-transmission of multi-drug resistant bacteria. The WHO defined "5 moments" for hand hygiene and highlighted the need for new strategies to improve everyday hand hygiene practices on the basis of the current low compliance. Reasons for non-compliance are multifaceted and behavioural, religious, and sociocultural aspects have to be considered when designing intervention programs. Despite all these barriers it is worth the effort to aim at quality of care improvement.

Impact of herpes simplex virus detection in respiratory specimens of patients with suspected viral pneumonia.

BACKGROUND: Respiratory infection and failure is a commonly encountered problem in intensive care unit (ICU) patients. However, despite the accumulating body of evidence to suggest that herpes simplex virus type 1 (HSV-1) is associated with pneumonia, the exact role played by this virus in this process is still not fully understood. Therefore, to identify patients at risk, we have conducted a case-control study to characterize patients with HSV-1-positive pneumonia. PATIENTS AND METHODS: Between 2007 and 2009, all patients with suspected viral pneumonia were tested for the presence of herpes viruses using a PCR assay approach with respiratory specimens. To identify possible associations, risk factors, and impact of HSV, HSV-1-positive ICU patients (n = 51) were compared to age-, gender-, and department- and season-matched HSV-negative patients (n = 52). RESULTS: HSV-positive patients differed significantly from the HSV-negative ones only in terms of time of mechanical ventilation (13 vs. 6 days, respectively; p = 0.002). Subgroup analysis in the patients aged >60 years and in those without bacterial detection revealed a similar trend (p = 0.01 and p = 0.004, respectively). Mortality did not differ between the groups or between the HSV-1-positive patients treated with aciclovir and those who were not. A viral load >10E+05 geq/ml was associated with mechanical ventilation (20/21 vs. 17/29; p = 0.004), acute respiratory distress syndrome (ARDS; 19/21 vs. 18/29; p = 0.005), sepsis (18/21 vs. 14/29; p = 0.008), detection of a bacterial pathogen in the same specimen (10/21 vs. 4/29; p = 0.01) and longer ICU stay (25 vs. 30 days; p = 0.04). CONCLUSION: Despite several associations with high viral load, the clinical outcome of HSV-1-positive ICU patients did not differ significantly from the clinical outcome of HSV-negative patients. This finding indicates that HSV-1 viral loads in respiratory specimens are a symptom of a clinically poor condition rather than a cause of it. Longitudinal and therapy studies are therefore needed to distinguish between HSV-1 as a causative pathogen and HSV-1 as a bystander of pneumonia/ARDS.

External ventricular and lumbar drainage-associated meningoventriculitis: prospective analysis of time-dependent infection rates and risk factor analysis.

BACKGROUND: Data on time-dependency of external ventricular drainage (EVD)- and lumbar drainage (LD)-associated meningoventriculitis (MV) are scarce and discussions on the subject are controversial; no data exist for infection rates (IR) relative to drainage-days. For this reason, we conducted an observational study to determine time-dependent IRs and to perform a risk factor analysis. PATIENTS AND METHODS: All patients (n = 210) requiring an EVD or LD during an 18-month period in 2007 and 2008 were enrolled and characterized. Data on type and duration of drainage, ICP measurement, number of drainage manipulations, hospital stay and time point of MV were analysed statistically. RESULTS: A total of 34 MV cases were reported with 17 for each kind of drainage accounting for an IR of 7.5 and 24.7 MV/1000 EVD- and LD-days, respectively. Of these, 28/34 MV (82%) occurred within the first 12 days, and IRs were highest between days 4 and 9. Longer drainage duration (>5 and >9 days, respectively) was correlated with a significant lower risk of MV (p = 0.03; p < 0.001). In this study, significant risk factors for MV were LD [vs. EVD, OR: 2.3 (1.1-4.7); p = 0.01], a previous MV [OR: 7.0 (2.1-23.3); p = 0.002], and neoplasm [OR: 11.6 (3.4-39); p = 0.001]. Simultaneous drainage, ICP and a previous drainage showed no influence on infection. CONCLUSION: To the best of our knowledge, this study is the first to provide data on time dependency of EVD- and LD-associated MV-IR based on drainage-days. However, because of the limited scale of our study, it would be desirable to confirm these results in a more powerful larger study. In conclusion, we recommend that future efforts should be made to better identify preventable risk factors as well as to define time periods of higher risk for the difficult-to-diagnose MV infection as a first step in profiling high risk patients.

[Effectiveness and risks of isolation precautions in patients with MRSA and other multidrug-resistant bacteria]. / Patienten mit multiresistenten Erregern: Wirksamkeit und Risiko von Isolierungsmassnahmen bei "MRSA & Co."

The transmission of multidrug-resistant organisms (MRSA, VRE and ESBL producing bacteria) occurs predominantly if health-care workers are not compliant with hand hygiene procedures. The impact of single-room isolation in transmission prevention is often overestimated. As long as hand disinfection is not performed before and after patient contact and gloves are not removed, a single room will not prevent transmission by -itself. Understaffing is additionally worsening the situation. There is no consistent evidence sup-port-ing strict single-room isolation even though data show supportive tendencies. Social isolation is one of the risks that should be considered as well as the economic impact of using shared rooms as a single room. Up-to-date, evidence-based standard operating procedures and individual infection control recommendations should take these considerations into account. In general, contact precautions including isolation in a single room are performed in MRSA and VRE-positive patients. If a single room cannot be provided in a given case (a common problem in intensive care units), contact precautions can be performed in a shared room as an alternative. The problem of establishing an optimal compliance with standard precautions (especially hand hygiene) throughout all professional groups should be addressed. Additional precautions, including single-room isolation, should be implemented critically if indicated.

COVID-19-associated shortage of alcohol-based hand rubs, face masks, medical gloves, and gowns: proposal for a risk-adapted approach to ensure patient and healthcare worker safety.

The coronavirus disease 2019 (COVID-19) pandemic has caused a huge demand for alcohol-based hand rubs, medical gloves, face masks, and gowns in healthcare and from the public. More and more hospitals face a serious shortage of these articles. We propose a risk-adapted approach to ensure adequate patient and healthcare worker safety for as long as possible.