Sepsis: Updated definitions and optimized management. / Sepsis: Diagnostik und Therapie im Wandel Aktuelle Strategien gegen eine lebensbedrohliche Erkrankung.

Sepsis is newly defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction will be determined by an increase in the Sepsis-related Organ Failure Assessment (SOFA) score. The updated definition should facilitate earlier recognition and more timely management of patients with sepsis. Sepsis should be treated as quickly and efficiently as possible as soon as it has been identified. This implies rapid administration of antibiotics and fluids.

Bacterial contamination of nonsterile gloves versus hands after hand hygiene.

BACKGROUND: Nonsterile gloves (NSG) are often overused, while the emphasis should lie in hand hygiene (HH). Furthermore, improper HH leads to contamination of NSG in glove boxes. The aim of this study was to compare microbial loads on hands from health-care workers (HCW) after HH to NSG and to study the influence of position and filling level of glove boxes on contamination rates. METHODS: Fingerprints on agar plates were made from randomly chosen HCWs directly after HH. Plates were incubated and colony-forming units counted. NSG taken from glove boxes were also sampled. Filling level and position (horizontal vs vertical) of the glove boxes were recorded. RESULTS: Median colony-forming units count was similar for hands after HH (N = 107, median 1, IQR 5) and NSG (N = 185, median 1, IQR 2, P-value .33). Only few samples in both groups showed growth of pathogenic bacteria. Neither the filling level (P-value .76), nor the position of the glove box (P-value .68) had an influence on NSG contamination. CONCLUSION: Microbial loads of hands after HH are comparable to NSG. Filling level or position of the glove box did not influence glove contamination. Whether similar microbial counts translate into comparable nosocomial infection rates warrants further research.

Low endotoxin release from Escherichia coli and Bacteroides fragilis during exposure to moxifloxacin.

BACKGROUND: Bacterial endotoxin is known to act as a potent trigger of disseminated coagulation and septic shock. During clinical antibiotic treatment, endotoxin may be released from Gram-negative bacteria. It is known that antibiotic classes differ in their ability to induce endotoxin release. AIM: It was the aim of this study to test the endotoxin-liberating potential of different antibiotics with activity against Escherichia coli and Bacteroides fragilis. METHODS: In vitro test models were used to evaluate the endotoxin-liberating potential of moxifloxacin, a 4th-generation quinolone with antianaerobic activity. Bacteria were exposed to moxifloxacin at 2×, 10× and 50× the minimal inhibitory concentration. Endotoxin release was measured by enzyme-linked immunosorbent and Limulus amoebocyte lysate assays. Comparator drugs were ceftazidime and imipenem, i.e. antibiotics with known high and low endotoxin-liberating potential, respectively. As a parameter for biological responses to endotoxin, the release of proinflammatory cytokines (tumor necrosis factor-α, interleukin-1ß) from monocytes/macrophages was quantified with bioassays. RESULTS: In all test systems, release of endotoxin during exposure of bacteria to moxifloxacin was minimal or low and comparable with that of imipenem. CONCLUSIONS: Moxifloxacin has a low potential to cause endotoxin-mediated detrimental clinical effects. Concerning its endotoxin-releasing properties, moxifloxacin appears to be a choice equivalent to the carbapenems.

Chemical disinfection in healthcare settings: critical aspects for the development of global strategies.

Chemical disinfection is an indispensable means of preventing infection. This holds true for healthcare settings, but also for all other settings where transmission of pathogens poses a potential health risk to humans and/or animals. Research on how to ensure effectiveness of disinfectants and the process of disinfection, as well as on when, how and where to implement disinfection precautions is an ongoing challenge requiring an interdisciplinary team effort. The valuable resources of active substances used for disinfection must be used wisely and their interaction with the target organisms and the environment should be evaluated and monitored closely, if we are to reliable reap the benefits of disinfection in future generations. In view of the global threat of communicable diseases and emerging and re-emerging pathogens and multidrug-resistant pathogens, the relevance of chemical disinfection is continually increasing. Although this consensus paper pinpoints crucial aspects for strategies of chemical disinfection in terms of the properties of disinfectant agents and disinfection practices in a particularly vulnerable group and setting, i.e., patients in healthcare settings, it takes a comprehensive, holistic approach to do justice to the complexity of the topic of disinfection.

[General screening on ICUs - the key for an effective MRSA prevention?]. / Krankenhaushygiene - Generalscreening auf Intensivstationen - der Schlüssel zur effektiven MRSA-Prävention?

The recommendations of the German Robert Koch Institute, concerning microbiological screening of newly admitted hospital patients for MRSA colonization, referred to specific risk groups such as patients admitted from long-term care facilities. New literature data indicate that a general MRSA screening policy of all incoming patients may be a cost-effective measure in intensive care units of large tertiary care hospitals.

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

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

Common RAPD pattern of Pseudomonas aeruginosa from patients and tap water in a medical intensive care unit.

The epidemiology of Pseudomonas aeruginosa infections and colonizations was studied prospectively on a 12-bed medical intensive care unit. Patients were monitored for P. aeruginosa colonization by performing throat swabs or tracheal aspirates on admission and weekly thereafter over a period of 6 months. Cultures of possibly infected sites were taken as clinically indicated. Water samples from all patient care-related tap water outlets were collected in 2-weekly intervals and examined for the presence of P. aeruginosa. Strains isolated from patients and water samples were analysed by serotyping and random amplified polymorphic DNA polymerase chain reaction (RAPD-PCR) typing. During the 6-month period, 60 of 143 (42%) water samples contained P. aeruginosa at various levels ranging from 1 to >100 colony-forming units per 100ml sample. Genotypically, water samples contained 8 different clonotypes. Nine patients had infections due to P. aeruginosa and 7 patients were colonized. Isolates from patients showed a similar distribution of genotypes as did tap water isolates, and strains of identical genotype as patient strains had been isolated previously from tap water outlets in 8 out of 16 (50%) infection or colonization episodes. However, patients also harboured strains not previously isolated from tap water. Thus, in addition to tap water, other environmental or unknown reservoirs appeared to play a role for the epidemiology of P. aeruginosa infections on this ward. However, because tap water played a significant role for strain transmissions, we conclude that intensified water site care is justified.

State-space analysis of joint angle kinematics in normal treadmill walking.

By restricting analysis to single averaged strides considered to be characteristic for the individual under investigation, current methods in gait analysis do not exploit the full dynamics of continuous locomotion. Therefore, a novel approach is presented that is based on long-term measurements of kinematic data during treadmill walking. The method consists of reconstructing the system attractor in the embedding space and then analyzing its geometric structure. Estimating the dimension of movement trajectories correlates well with the notion of controlling multiple degrees of freedom during performance of complex movement tasks such as walking. The influence of walking speed on the complexity of physiologic walking was investigated in 10 healthy subjects walking on a treadmill at seven fixed speeds. The results suggest that human walking becomes more complex at slower speeds. This may be associated with results from EMG studies demonstrating more irregular EMG patterns at very slow walking speeds. This study emphasizes that tools from non-linear dynamics are well suited for providing more insight into motor control in humans.

From diagnostics to therapy--conceptual basis for real-time movement feedback in rehabilitation medicine.

Recently, locomotion therapy on a treadmill has become part of rehabilitation programs for neurological gait disorders (spinal cord injury, hemiplegia). Instrumental gait analysis is an important tool for quantification of therapy progress in terms of functional changes in a patient's gait patterns. Whereas most of current applications focus on diagnostic assessment of gait, the current paper presents an extension of movement analysis offering enhanced therapeutic options. Specifically, the conceptual basis for application of real-time movement feedback in rehabilitation medicine is outlined and is put into context with recent developments in the field. A first technical realization of these concepts is presented and first results are reported. Furthermore, open questions towards a universal environment for movement feedback in rehabilitation medicine are discussed and future lines of research are identified.

Ecology of Pseudomonas aeruginosa in the intensive care unit and the evolving role of water outlets as a reservoir of the organism.

In spite of the significant changes in the spectrum of organisms causing intensive care unit (ICU)-associated infections, Pseudomonas aeruginosa has held a nearly unchanged position in the rank order of pathogens causing ICU-related infections during the last 4 decades. Horizontal transmissions between patients have long been considered the most frequent source of P aeruginosa colonizations/infections. The application of molecular typing methods made it possible, during the last approximately 7 years, to identify ICU tap water as a significant source of exogenous P aeruginosa isolates. A review of prospective studies published between 1998 and 2005 showed that between 9.7% and 68.1% of randomly taken tap water samples on different types of ICUs were positive for P aeruginosa , and between 14.2% and 50% of infection/colonization episodes in patients were due to genotypes found in ICU water. Faucets are easily accessible for preventive measures, and the installation of single-use filters on ICU water outlets appears to be an effective concept to reduce water-to-patient transmissions of this important nosocomial pathogen.

Lesser-known or hidden reservoirs of infection and implications for adequate prevention strategies: Where to look and what to look for.

In developing hygiene strategies, in recent years, the major focus has been on the hands as the key route of infection transmission. However, there is a multitude of lesser-known and underestimated reservoirs for microorganisms which are the triggering sources and vehicles for outbreaks or sporadic cases of infection. Among those are water reservoirs such as sink drains, fixtures, decorative water fountains and waste-water treatment plants, frequently touched textile surfaces such as private curtains in hospitals and laundry, but also transvaginal ultrasound probes, parenteral drug products, and disinfectant wipe dispensers. The review of outbreak reports also reveals Gram-negative and multiple-drug resistant microorganisms to have become an increasingly frequent and severe threat in medical settings. In some instances, the causative organisms are particularly difficult to identify because they are concealed in biofilms or in a state referred to as viable but nonculturable, which eludes conventional culture media-based detection methods. There is an enormous preventative potential in these insights, which has not been fully tapped. New and emerging pathogens, novel pathogen detection methods, and hidden reservoirs of infection should hence be given special consideration when designing the layout of buildings and medical devices, but also when defining the core competencies for medical staff, establishing programmes for patient empowerment and education of the general public, and when implementing protocols for the prevention and control of infections in medical, community and domestic settings.