Strengthening the role of hospital leadership in infection control (LEAD-IC) - a multimodal educational intervention in German acute care hospitals.

BACKGROUND: The effect of leadership support for adherence to infection control and prevention (IPC) measures has been demonstrated. To expand this support, a target group-specific educational study for chief medical officers (CMO) was implemented and its influence on IPC indicators was investigated. METHODS: A controlled cohort study was conducted between 2018 and 2019. The intervention based on an initial workshop, an e-learning course, and a final meeting. Participants' activities involving IPC management were surveyed. Consumption of alcohol hand rub (AHR) and incidence density of hospital-associated (HA) Clostridioides difficile-associated infections (CDI) were analyzed. RESULTS: Eight percent of 360 CMOs invited participated in the initial workshop; 70% of those participants registered for the online course. Overall, 43% completed the post-intervention questionnaire, in which 85% of respondents reported increased collaboration with relevant stakeholders. The pre-intervention median AHR consumption was higher in the intervention group than in the control group. Both groups showed an increase (38.6 (interquartile range (IQR) 33.6; 45.0) to 41.9 ml/patient day (PD) (IQR 35.0; 56.6) and 33.4 (IQR 28.3; 40.8) to 35.8 ml/ PD (IQR 31.6; 43.2), respectively). Pre-intervention median HA CDI cases were lower in the intervention group than in the control group. Both groups reported a decrease (0.22 (IQR 0.17; 0.33) to 0.19 cases/1000 PD (IQR 0.15; 0.26) and 0.32 (IQR 0.2; 0.48) to 0.22 cases/1000 PD (IQR 0.11; 0.33), respectively). CONCLUSION: Multimodal IPC training of CMOs is worthwhile and can lead to changes in IPC-relevant cooperation in hospitals. IPC training of hospital management should be further intensified.

Interdisciplinary Infection Prevention and Control Bundle in Neurosurgical Patients: Results of a Prospective Cohort Study.

BACKGROUND: Surgical site infections (SSIs) account for one of the most common causes of nosocomial infections. Bundle approaches for infection prevention and control do not capture the full complexity of neurosurgical interventions. OBJECTIVE: To study the efficacy of an interdisciplinary infection prevention and control bundle (IPCB) in neurosurgery. METHODS: This was a prospective, single-center, observational study, analyzing 3 periods: before (2014), during (2017), and after (2019) full implementation of IPCB. IPCB included the following infection prevention measures: preoperative decolonization, patient engagement, operating room (OR) hygiene protocol, and pre-, peri-, and postoperative standard operating procedures (SOPs) while infection control measures included intraoperative sonication, blood culture inoculation, and interdisciplinary SSI management. All neurosurgical patients being readmitted to the hospital for SSIs within 90 days after receiving index surgery were included in the trial (403/9305). RESULTS: Implementation of IPCB resulted in more frequently succeeded pathogen isolation in patients with SSI (2014: 138 isolates in 105 (83%) patients with SSI, 2017: 169 isolates in 124 (91%) patients with SSI, and 2019: 199 isolates in 136 (97%) patients with SSI; P < .001). Proportion of gram-positive SSI and virulence was declining ( P = .041, P = .007). The number of repeated revision surgeries decreased from 26 (20%) in 2014 and 31 (23%) in 2017 to 18 (13%) in 2019 ( P = .085). Significantly, fewer patients experienced sepsis in response to SSI (2014: 12%, 2017: 10%, and 2019: 3.6%, P = .035). In-hospital mortality rate was declining from 12 (9.4%) in 2014 to 9 (6.6%) in 2017 to 5 (3.6%) in 2019 ( P = .148). CONCLUSION: Introducing an interdisciplinary IPCB in neurosurgery leads to a significant reduction of sepsis and decreased in-hospital mortality while a pathogen switch toward gram-negative bacteria was observed. Minimizing diagnostic gap of pathogen detection toward a more efficient anti-infective treatment may be the main reason for the substantial decrease in morbidity and mortality.

Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons.

STUDY DESIGN: Questionnaire-based survey. OBJECTIVES: Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research. METHODS: An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy. RESULTS: Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions. CONCLUSIONS: With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials.

Nasal Colonization of Humans with Occupational Exposure to Raw Meat and to Raw Meat Products with Methicillin-Susceptible and Methicillin-Resistant Staphylococcus aureus.

Livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) is widely disseminated as a nasal colonizer of conventionally raised livestock and of humans subjected to occupational exposure. Reports on contamination of raw meat raise the question as to whether occupationally exposed food handlers are at particular risk of nasal colonization by LA-MRSA. Here, we report the results from a cross-sectional study on nasal S. aureus/MRSA colonization of butchers, meat sellers, and cooks in Germany. We sampled 286 butchers and meat sellers in 26 butcheries and 319 cooks handling meat in 16 professional canteen kitchens. Swabs were processed on both blood agar plates and MRSA-selective plates. MRSA were confirmed by PCR for mec genes and by broth microdilution. All isolates were subjected to molecular typing. PCR for markers useful to differentiate human-adapted and animal-adapted subpopulations was performed due to the presence of clonal complexes known to occur in both livestock and humans (CC5, CC7, CC8, CC9, and CC398). Only two participants (0.33%) were colonized by MRSA (Hospital-associated MRSA ST22). Nasal colonization by methicillin-susceptible S. aureus (MSSA) was detected in 16.6% of cooks and in 26.2% of butchers and meat sellers. Among 16 of the isolates attributed to CC7, three were negative for the immune evasion gene cluster, suggesting an animal origin. Isolates attributed to CC5, CC8, and CC398 were negative for markers typical of animal-adapted subpopulations. The occupational handling of raw meat and raw meat products was not associated with nasal colonization by LA-MRSA.

Prokaryotic real-time gene expression profiling for toxicity assessment.

Examining global effects of toxins on gene expression profiles is proving to be a powerful method for toxicity assessment and for investigating mechanisms of toxicity. This study demonstrated the application of prokaryotic real-time gene expression profiling in Escherichia coli for toxicity assessment of environmental pollutants in water samples, by use of a cell-array library of 93 E. coli K12 strains with transcriptional green fluorescent protein (GFP) fusions covering most known stress response genes. The high-temporal-resolution gene expression data, for the first time, revealed complex and time-dependent transcriptional activities of various stress-associated genes in response to mercury and mitomycin (MMC) exposure and allowed for gene clustering analysis based on temporal response patterns. Compound-specific and distinctive gene expression profiles were obtained for MMC and mercury at different concentrations. MMC (genotoxin) induced not only the SOS response, which regulates DNA damage and repair, but also many other stress genes associated with drug resistance/sensitivity and chemical detoxification. A number of genes belonging to the P-type ATPase family and the MerR family were identified to be related to mercury resistance, among which zntA was found to be up-regulated at an increasing level as the mercury concentration increased. A mechanism-based evaluation of toxins based on real-time gene expression profiles promises, to be an efficient and informative method for toxicity assessment in environmental samples.

Molecular mechanisms of HipA-mediated multidrug tolerance and its neutralization by HipB.

Bacterial multidrug tolerance is largely responsible for the inability of antibiotics to eradicate infections and is caused by a small population of dormant bacteria called persisters. HipA is a critical Escherichia coli persistence factor that is normally neutralized by HipB, a transcription repressor, which also regulates hipBA expression. Here, we report multiple structures of HipA and a HipA-HipB-DNA complex. HipA has a eukaryotic serine/threonine kinase-like fold and can phosphorylate the translation factor EF-Tu, suggesting a persistence mechanism via cell stasis. The HipA-HipB-DNA structure reveals the HipB-operator binding mechanism, approximately 70 degrees DNA bending, and unexpected HipA-DNA contacts. Dimeric HipB interacts with two HipA molecules to inhibit its kinase activity through sequestration and conformational inactivation. Combined, these studies suggest mechanisms for HipA-mediated persistence and its neutralization by HipB.

Finding a method for optimizing risk adjustment when comparing surgical-site infection rates.

OBJECTIVE: To investigate whether stratification of the risk of developing a surgical-site infection (SSI) is improved when a logistic regression model is used to weight the risk factors for each procedure category individually instead of the modified NNIS System risk index. DESIGN AND SETTING: The German Nosocomial Infection Surveillance System, based on NNIS System methodology, has 273 acute care surgical departments participating voluntarily. Data on 9 procedure categories were included (214,271 operations). METHODS: For each of the procedure categories, the significant risk factors from the available data (NNIS System risk index variables of ASA score, wound class, duration of operation, and endoscope use, as well as gender and age) were identified by multiple logistic regression analyses with stepwise variable selection. The area under the receiver operating characteristic (ROC) curve resulting from these analyses was used to evaluate the predictive power of logistic regression models. RESULTS: For most procedures, at least two of the three variables contributing to the NNIS System risk index were shown to be independent risk factors (appendectomy, knee arthroscopy, cholecystectomy, colon surgery, herniorrhaphy, hip prosthesis, knee prosthesis, and vascular surgery). The predictive power of logistic regression models (including age and gender, when appropriate) was low (between 0.55 and 0.71) and for most procedures only slightly better than that of the NNIS System risk index. CONCLUSION: Without the inclusion of additional procedure-specific variables, logistic regression models do not improve the comparison of SSI rates from various hospitals.

Early enteral supply of fiber and Lactobacilli versus conventional nutrition: a controlled trial in patients with major abdominal surgery.

OBJECTIVE: Early enteral nutrition with fiber-containing solutions plus Lactobacillus may reduce bacterial translocation and minimize the incidence of infections after surgery. METHODS: In a prospective, randomized trial in three groups (n = 30/group) of patients after major abdominal surgery, we compared our previous regimen with parenteral nutrition or fiber-free enteral nutrition (group A) with enteral fiber-containing nutrition with living Lactobacillus (group B) and heat-killed Lactobacillus (group C). The main endpoint was the development of bacterial infection. Other analyzed parameters were the durations of antibiotic therapy and hospital stay, non-infectious complications, side effects of the nutrition, and onset of bowel movement. Routine parameters, nutritional parameters, and cellular immune status in the blood were measured preoperatively and on 1, 5, and 10 d postoperatively. RESULTS: The incidence of infections was significantly lower (P = 0.01) in groups B and C with enteral nutrition containing fibers (10% each) than in group A (30%). Patients in group B received antibiotics for a significantly shorter time (P = 0.04) than did the patients in groups A and C. The length of hospital stay and the incidence of non-infectious complications did not differ significantly. Fibers and lactobacilli were well tolerated. There were no general benefits of living Lactobacillus as opposed to heat-killed Lactobacillus in the entire study population, but benefits were observed in the patients with gastric and pancreas resections, although no statistical analysis was done due to their small numbers. CONCLUSIONS: Early enteral nutrition with fiber-containing solutions reduced the rate of postoperative infections in comparison with parenteral nutrition and fiber-free enteral formula. Addition of living Lactobacillus seemed to increase the benefits in patients with gastric and pancreatic resections.