[Surveillance of antibiotic consumption in hospitals: tasks of the Public Health Service]. / Surveillance des Antibiotikaverbrauchs in Krankenhäusern : Aufgaben des öffentlichen Gesundheitsdienstes.

According to the German Protection Against Infection Act (IfSG; section 23 paragraph 4, July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring of antibiotic consumption in their institute. The introduction of the surveillance of antibiotic consumption aims to contribute to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The local public health authority is entitled to supervise the implementation of legal requirements in the hospital setting. The main aim of this article is to support local public health authorities in coping with this task by providing background information on the surveillance of antibiotic consumption and its role as a key component of antibiotic stewardship programs. Furthermore, criteria suitable for assessing the implementation of a functioning surveillance system are proposed. The possibilities and limitations of the activities of public health authorities in this context are addressed.

[Tuberculosis infection control - recommendations of the DZK]. / Infektionsprävention bei Tuberkulose - Empfehlungen des DZK.

The epidemiological situation of tuberculosis (TB) in Germany has improved considerably during the past few years. However, those in unprotected contact with infectious tuberculosis patients frequently and/or over longer periods of time and/or intensively continue to have a higher risk for TB infection. Rapid diagnosis, prompt initiation of effective treatment, and adequate infection control measures are of particular importance to prevent infection. The present recommendations depict the essentials of infection control as well as specific measures in the hospital (isolation, criteria for its duration and technical requirements, types of respiratory protection, disinfection measures, waste disposal). The specific requirements for outpatients (medical practice), at home, for ambulance services, and in congregate settings, including prisons, are also addressed. Compared with the previous recommendations the pattern of respiratory protection measures has been simplified. As a rule, hospital staff and those visiting infectious tuberculosis patients are advised to wear respiratory protection that satisfies the criteria of FFP2-masks (DIN EN 149), while patients should wear mouth-nose protectors (surgical masks) in the presence of others and outside the isolation room. A detailed depiction of criteria for isolation and its duration in smear positive and only culturally confirmed pulmonary tuberculosis has been added.

[Tuberculosis infection control--recommendations of the DZK]. / Infektionsprävention bei Tuberkulose--Empfehlungen des DZK.

The epidemiological situation of tuberculosis (TB) in Germany has improved considerably during the past few years. However, those in unprotected contact with infectious tuberculosis patients frequently and/or over longer periods of time and/or intensively continue to have a higher risk for TB infection. Rapid diagnosis, prompt initiation of effective treatment, and adequate infection control measures are of particular importance to prevent infection. The present recommendations depict the essentials of infection control as well as specific measures in the hospital (isolation, criteria for its duration and technical requirements, types of respiratory protection, disinfection measures, waste disposal). The specific requirements for outpatients (medical practice), at home, for ambulance services, and in congregate settings, including prisons, are also addressed. Compared with the previous recommendations the pattern of respiratory protection measures has been simplified. As a rule, hospital staff and those visiting infectious tuberculosis patients are advised to wear respiratory protection that satisfies the criteria of FFP2-masks (DIN EN 149), while patients should wear mouth-nose protectors (surgical masks) in the presence of others and outside the isolation room. A detailed depiction of criteria for isolation and its duration in smear positive and only culturally confirmed pulmonary tuberculosis has been added.

[Legionella in drinking water : outcomes of an exchange of ideas on the prevention of waterborne legionellosis]. / Legionellen im Trinkwasserbereich : Ergebnisse eines Fachgespräches zur Prävention trinkwasserbedingter Legionellosen.

Although much is known about Legionella and the illness they cause, the relationship between their concentration in water and the risk of infection remains unclear. A comprehensive body of experience shows that the growth of Legionella in heated water distribution systems can be effectively controlled by following the preventive measures described in the generally acknowledged codes of practice. As orientation to trigger action, a technical action level of 100 colony-forming units in 100 ml water has found wide acceptance as the maximally tolerable concentration of Legionella in drinking water hygiene. However, this value as well as the concept for controlling the growth of Legionella in installations has developed historically. In part, the focus differs between drinking water hygiene and hospital hygiene. Also, there is no harmonized European approach for controlling Legionella. In spite of such differences, there are important international parallels in the assessment of the occurrence of Legionella, in experience with controlling them, and in recommendations for prevention. There is a need particularly for adequate studies to clarify the risk of infection as well as for the publication of existing data and experience showing the efficacy of measures for prevention, disinfection and system upgrading. Such data are necessary to support evidence-based prevention of Legionella infections and to create a better epidemiological data base in Germany. One chance for reaching this target would be to improve practices in diagnosis, reporting and central data evaluation-not only of illness, but including also data on Legionella occurrence. More frequent Legionella testing of pneumonia patients is a prerequisite for this, but particularly also for the rapid identification and removal of the source of infection. Further requirements include better training of planers, plumbers, and operators of drinking water installations about the approach to preventing Legionella contamination of drinking water installations described in standards and guidelines. The further development of practicable concepts for effective Legionella prevention requires good collaboration between public authorities responsible for drinking water and hospital hygiene on the federal and state levels and experts for the prevention of infection, hygiene, and sanitary installations.

[Healthcare-associated infections in long-term care facilities. German results of the European prevalence study HALT]. / Healthcare-associated infections in long-term care facilities (HALT). Ergebnisse aus Deutschland im Rahmen einer europäischen Prävalenzstudie.

The development of infections in elderly people living in long-term care facilities may have manifold causes. Infections are often treated with an antibiotic which can trigger the selection of multirestistant microorganisms and, therefore, represents an additional risk factor. In Germany as well as in other European countries, only a few prevalence studies on healthcare-associated infections (HCAI) in long-term care facilities have been performed and there is no continuous surveillance established for HCAI and antibiotic treatment. Therefore, the European prevalence study HALT (healthcare-associated infections in long-term care) was initiated to collect data of HCAI, antibiotic use, and the antibiotic resistance of microorganisms in long-term care facilities. From Germany, 73 institutions participated in the HALT project. The overall prevalence for an optional HCAI (at least one symptom) was 1.6 (CI 1.09-2.03) and for HCAI identified by the modified McGeer criteria 0.79 (CI 0.62-1.04). The overall prevalence for antibiotic use was 1.15 (CI 0.73-1.57). In the present paper, the German results of the HALT project are presented.

Prevalence and risk factors for nosocomial lower respiratory tract infections in German hospitals.

The prevalence and risk factors for nosocomial lower respiratory tract infections (LRTI) in Germany were determined as part of a national survey on nosocomial infections. The study included 14,966 patients in 72 representatively selected hospitals with departments of general medicine, surgery, obstetrics, gynecology, and intensive care units (ICU). Surveillance was carried out by four previously validated medical doctors who strictly applied the CDC-criteria for diagnosis of nosocomial infections. The overall prevalence of hospital-acquired LRTI was 0.72% with the highest rate in hospitals with more than 600 beds (1.08%) and among the patients on intensive care units (9.00%). Ventilator-associated pneumonia rates were highest in patients on ICUs (13.27). Polytrauma, impaired consciousness, chronic airway disease, prior surgery, and cardiovascular disease were significantly related to the occurrence of nosocomial LRTI. P. aeruginosa was the predominant organism causing nosocomial LRTI. Nosocomial LRTI remain a problem mainly on ICUs. Patients at risk should be monitored with extra care.

Importance of the surveillance method: national prevalence studies on nosocomial infections and the limits of comparison.

OBJECTIVE: To demonstrate the limits of comparison of national prevalence rates of nosocomial infections. DESIGN AND SETTING: Critical analysis of prevalence rates and methods of the Nosocomial Infections in Germany (NIDEP) study and other prevalence surveys with particular attention to the selection of patients, the qualification and training of the investigators, and the methods of identifying nosocomial infections. RESULTS: The lowest prevalence rate was found in Germany (3.5%), the highest in Belgium (9.3%). These differences may not be accurate, because variations in methods allow for differing explanations. CONCLUSIONS: Because of numerous methodological factors, comparison of infection rates between countries should be avoided. In contrast to other prevalence studies, the methodology of the German-NIDEP study permits registration of only certain infections, which is the main reason for the low rate.

Prevalence of nosocomial infections in representative German hospitals.

The nosocomial infection (NI) rate in German hospitals was studied in order to create reference data for comparison in hospitals where ongoing surveillance is impossible. The study was designed as a one-day prevalence study. Patients in 72 selected hospitals (inclusion criteria: acute care hospitals with departments for general medicine, surgery, obstetrics/gynaecology) were examined by four external investigators (physicians trained and validated in the diagnosis of NI). A total of 14,996 patients were studied. The overall prevalence rate was 3.5% (CI 3.1-3.9) with a variation of 0-8.9% between hospitals. The commonest NI were: urinary tract infection (42.1%), lower respiratory tract infection (20.6%), surgical site infections (15.8%) and primary sepsis (8.3%). The highest prevalence rate (15.3%) was found in intensive care ward patients, followed by surgery (3.8%), general medicine (3.0%) and gynaecology/obstetrics (1.4%). The infection rate varied significantly with hospital size. A microbiology laboratory report was only available for 56.5% of patients thought to have an NI, and there were remarkable differences between hospitals with and without an on-site microbiology laboratory. Because of this and other methodological reasons the NI prevalence rates reported here may represent the absolute minimum of nosocomially infected patients in Germany.

Analysis of risk factors for nosocomial infections--results from the first national prevalence survey in Germany (NIDEP Study, Part 1).

An analysis of risk factors for nosocomial infections (NI) was carried out using data from the first national prevalence survey on NI in Germany. Fourteen thousand, nine hundred and sixty-six patients, with a total of 543 NI, were included. Urinary tract infections (UTI), lower respiratory tract infections (LRTI), surgical site infections (SSI) and primary septicaemia (PS) were analysed. UTI were significantly associated with unconsciousness, age, prior operation, hospital size and female sex (P < 0.1). LRTI were significantly associated with chronic airway disease, intensive care units, unconsciousness, polytrauma, prior operation, cardiovascular disease, malignancy and absence of infection on admission. The department, age, diabetes mellitus, male sex and hospital size were risk factors for SSI. The department, prior operation and unconsciousness were significantly associated with PS. An investigator effect was observed for LRTI and PS. Although no final conclusions from a risk factor analysis based on prevalence data can be drawn the results support stratification of NI for routine surveillance.

Repeated prevalence investigations on nosocomial infections for continuous surveillance.

In order to obtain an overview for the planning of further infection control activities, nine repeated prevalence studies were performed at monthly intervals. These occurred in the surgical units of eight medium-sized German hospitals. A total of 4984 surgical patients were investigated, the number of patients observed in each hospital varied from 365 to 913 patients, an average of 69.2 patients per prevalence study per hospital. A total of 212 nosocomial infections were found, the majority being surgical site (43.9%) and urinary tract infection (33.0%). The overall prevalence rate was 4.0%. More than four repeated investigations had only a minor influence on the 95% confidence intervals, and a follow-up of late microbiological reports increased the prevalence rate by only 7.5%. However, it was very useful to record the presence of urinary catheters on the prevalence day and also the preceding days; for instance, a device-associated prevalence of 7.8 urinary tract infections per 100 patients with urinary catheters was found on the day of investigation. In order to evaluate the situation in one's own surgical department by prevalence studies and for reasons of cost-effectiveness, the workload can be limited to four repeated studies in most hospitals. A further follow-up of later microbiological reports is not recommended, and it seems useful to concentrate on patients with indwelling devices.

Can quality circles improve hospital-acquired infection control?

It is a fundamental principle of continuous quality improvement (CQI) that processes should be the objects of quality improvement. The objective of this study was to improve process quality concerning the prevention of hospital-acquired infections in surgical departments and intensive care units by a continuous quality improvement (CQI) approach based mainly on quality circles. This approach was evaluated in a prospective controlled intervention study in medium-size acute care hospitals (four intervention and four control hospitals). During two intervention periods (each 10 months) four external physicians with training in hospital epidemiology and infection control introduced and supervised quality circles in the intervention hospitals. Process quality was assessed by interviewing senior staff members before the first and after the second intervention period using standardized questionnaires. The gold standard process quality was defined on the basis of the CDC/HICPAC-guidelines for the prevention of hospital-acquired infections. Most of the evaluated aspects of process quality belonged to the HICPAC-categories IA and IB respectively, the CDC category I. Fifty quality circle sessions were performed in the four intervention hospitals of which 28 were dealing directly with key subjects in infection control. In the intervention hospitals, 19.8% of evaluated aspects of process quality which concerned the prevention of hospital-acquired infections were improved compared to only 6.9% in the control hospitals (P<0.05). Sixty-six point seven percent of positive changes in process quality were initiated by the results of the quality circles. Our study demonstrates that a CQI approach based on infection control quality circles can lead to a substantial improvement of process quality regarding the prevention of hospital-acquired infections.

Nosocomial wound infections: a prevalence study and analysis of risk factors.

This first German prevalence study surveilling nosocomial wound infections (NWI) was carried out in 72 representatively selected hospitals. NWI were recorded by 4 validated investigators. Seventy-nine NWI were recorded among 4983 operated patients (prevalence rate: 1.61%), most of them after amputation of limbs (6.1%) and operations on the colon or rectum (3.1%). The 3 risk factors from the NNIS (National Nosocomial Infection Surveillance) index for postoperative wound infections were for the first time applied in this prevalence study. Patients with contaminated wounds had significantly more wound infections (P=0.01, likelihood ratio test) whereas, in contrast to the NNIS index, patients with ASA score >3 (P= 0.07) or long lasting operations (>75th percentile) did not (P=0.1). Therefore, for the stratification of NWI rates wound contamination is the single most important factor.

[Nosocomial infections in Germany--assessment and prevention. NIDEP Study, 1: On prevalence in surgery]. / Nosokomiale Infektionen in Deutschland--Erfassung und Prävention. NIDEP-Studie, Teil 1: Zur Prävalenz in der Chirurgie.

One aim of the NIDEP study (nosocomial infections in Germany: surveillance and prevention) was to determine in part 1 (surveillance) the prevalence of nosocomial infections (NI) in patients in surgical departments of 72 representatively selected hospitals in Germany. The surveillance was carried out by four previously validated physicians who applied the CDC criteria for NI. The overall rate of NI was 3.8%. Urinary tract infections (1.45%) and surgical wound infections (1.34%) were the most common NI. The highest rate of wound infections was noted after amputations (7.2%), conventional appendectomies (4.1%) or operations on the colon or rectum (3.8%). The use of perioperative antibiotics varied widely depending on the kind of operation and was not in accordance with international guidelines in all hospitals.

Prevalence of primary bloodstream infections in representative German hospitals and their association with central and peripheral vascular catheters.

The prevalence of noncentral and central lines and the prevalence of nosocomial primary bloodstream infections was investigated in 72 representative German hospitals (NIDEP Study). Data from a total of 14,966 patients were documented. On the prevalence day, it amounted to 23.9% for noncentral and 5.1% for central lines. The total prevalence of nosocomial primary bloodstream infections was 0.3%, 8.3% of all nosocomial infections recorded were primary bloodstream infections. The device utilization rate of vascular catheters was retrospectively observed for both the prevalence day and another 6 days. The device utilization rate was 27.3% for peripheral and 6.1% for central catheters with higher rates in west Germany. The associated incidence density of primary nosocomial bloodstream infections per 1000 catheter-days was 0.3 for noncentral and 0.8 for central lines. In 61.4%, the primary bloodstream infections were microbiologically confirmed. In 52.6% of cases, Gram-positive bacteria were isolated (Staphylococcus aureus: 15.8%, other coagulase negative Staphylococcus species: 34.2%) and in 47.4%, Gram-negative ones (mostly: Escherichia coli: 13.2% and Klebsiella species: 10.5%). Prevention to reduce nosocomial bloodstream infections is possible by antimicrobial establishing specially trained infusion therapy teams, using antimicrobial or antiseptic impregnated bloodstream catheters and a strict review of the indication for a vascular catheter together with a minimization of catheter days.

[Reduction of nosocomial infections by public health quality management in surgical patients. 2: No reduction in low initial infection rate]. / Reduktion nosokomialer Infektionen durch ein hygienisches Qualitätsmanagement bei chirurgischen Patienten. 2. Mitteilung: Keine Reduktion bei niedriger Ausgangsinfektionsrate.

In the framework of a prospective controlled study in surgical and intensive care units of four study and four control hospitals it was tried to set up an infection control quality management concept for reduction of nosocomial infections in hospital D. With an incidence density of 5.4 nosocomial infections per 1,000 patient days the most favorable situation among the four study hospitals was found initially in this hospital. However, after a small decrease of infection rate during the first study year, no benefit of intervention was achieved in this hospital at the end of the study (6.4 nosocomial infections per 1,000 patient days). Possible explanations may be a very small potential for reduction at the beginning, a change of patient mix due to a new head of the department and the phenomenon of the "regression to the mean". Distinct improvements of the situation were achieved on the level of process quality. Meanwhile surveillance of nosocomial infections became an integral part of quality management in this hospital. The quality circle method was not well accepted for the longterm. But the concept of link nurses was introduced successfully.