[Use of Reusable Textile Undergloves for Medical Procedures: A Feasibility Study]. / Einsatz wiederaufbereitbarer textiler Unterziehhandschuhe für medizinische Tätigkeiten: eine Machbarkeitsstudie.

OBJECTIVE: Undergloves are a way to reduce moisture-related skin damage. The aim of this feasibility study was to gain experience with logistics, applicability, acceptability and cost of the routine use of reusable textile undergloves in a hospital setting. METHODS: Undergloves were tested with 18 health-care workers on an intensive care unit over three months. Data on usage as well as logistics were recorded. At baseline, personal data and knowledge and use of cotton undergloves, existing skin problems and the nursing behaviour of the hands by the subjects were determined by means of an input questionnaire. After each wearing, data on usage were collected by a questionnaire. Participants were interviewed by means of a questionnaire with respect to their experience with the use of the undergloves. RESULTS: Acceptance and compliance with the use of undergloves was remarkably good. This was partly due to the properties of the gloves, and partly to the reduction of sweating and very positive effect on the skin of the hands. In the study period 2165 underglove uses were documented, resulting in an average daily consumption of four pairs per person per day. The average wearing time was 28.6 min. The undergloves were suitable for application as well as reprocessing. Reprocessment-related fatigue was relatively low and did not lead to the loss of the properties, only few gloves had to be sorted out. Even if one assumes a complete write-off of the gloves with end of the study, costs for reprocessing were about 0.46 € or 64 % less than the single use. CONCLUSION: The routine use of textile, reprocessable undergloves is feasible. Major challenges for broad usage are within logistics and acceptance by the user.

[Principles of hygiene in ENT endoscopy]. / Grundsätze der Hygiene bei der HNO-Endoskopie.

This article gives a report on principles of reprocessing of rigid and flexible endoscopes used in ENT units including structural and spatial requirements based on the general and also ENT-specific risks of infection associated with diagnostic and therapeutic endoscopy. The underlying legal principles as well as recommendations from scientific societies will be exemplified in order to give the otorhinolaryngologist a practical guidance.Preliminary results of a nation-wide survey on infection control standards based on data of 29 ENT practices in Germany reveal actual deficits of varying degree concerning infection control management including reprocessing of endoscopes. The presented review aims to give support to the establishment of a structured infection control management program including the evaluation of results by means of a prospective surveillance.

Analysis of MRSA-attributed costs of hospitalized patients in Germany.

Infections with methicillin-resistant Staphylococcus aureus (MRSA) are assumed to have a high economic impact due to increased hygienic measures and prolonged hospital length of stay. However, surveys on the real expenditure for the prevention and treatment of MRSA are scarce, in particular with regard to the German Diagnosis-Related Groups (G-DRG) payment system. The aim of our study is to empirically assess the additional cost for MRSA management measures and to identify the main cost drivers in the whole process from the hospital's point of view. We conducted a one-year retrospective analysis of MRSA-positive cases in a German university hospital and determined the cost of hygienic measures, laboratory costs, and opportunity costs due to isolation time and extended lengths of stay. A total of 182 cases were included in the analysis. The mean length of hospital stay was 22.75 days and the mean time in isolation was 17.08 days, respectively. Overall, the calculated MRSA-attributable costs were 8,673.04 per case, with opportunity costs making up, by far, the largest share (77.45 %). Our study provides a detailed up-to-date analysis of MRSA-attributed costs in a hospital. It allows a current comparison to previous studies worldwide. Moreover, it offers the prerequisites to investigate the adequate reimbursement of MRSA burden in the DRG payment system and to assess the efficiency of targeted hygienic measures in the prevention of MRSA.

Efficacy of different carrier gases for barrier discharge plasma generation compared to chlorhexidine on the survival of Pseudomonas aeruginosa embedded in biofilm in vitro.

Because of its antimicrobial properties, nonthermal plasma could serve as an alternative to chemical antisepsis in wound treatment. Therefore, this study investigated the inactivation of biofilm-embedded Pseudomonas aeruginosa SG81 by a surface barrier-discharged (SBD) plasma for 30, 60, 150 and 300 s. In order to optimize the efficacy of the plasma, different carrier gases (argon, argon admixed with 1% oxygen, and argon with increased humidity up to approx. 80%) were tested and compared against 0.1% chlorhexidine digluconate (CHG) exposure for 600 s. The antimicrobial efficacy was determined by calculating the difference between the numbers of colony-forming units (CFU) of treated and untreated biofilms. Living bacteria were distinguished from dead by fluorescent staining and confocal laser scanning microscopy. Both SBD plasmas and CHG showed significant antimicrobial effects compared to the untreated control. However, plasma treatment led to a higher antimicrobial reduction (argon plasma 4.9 log10 CFU/cm(2), argon with admixed oxygen 3 log10 CFU/cm(2), and with increased gas humidity 2.7 log10 CFU/cm(2) after 300 s) compared to CHG. In conclusion, SBD plasma is suitable as an alternative to CHG for inactivation of Pseudomonas aeruginosa embedded in biofilm. Further development of SBD plasma sources and research on the role of carrier gases and humidity may allow their clinical application for wound management in the future.

[On the relevance of the official lists for notified products and measures for disinfection, disinfestation and control of vertebrate pests ordered by an authority on the legal basis of § 18 IfSG (German Protection against Infection Act)]. / Zur Bedeutung der Listen bekannt gemachter Mittel und Verfahren für behördlich angeordnete Entseuchungen, Entwesungen und zur Bekämpfung von Wirbeltieren auf Grundlage des § 18 Infektionsschutzgesetz.

In order to protect human health against communicable diseases, the German Protection against Infection Act (IfSG) requires the use of officially approved products and methods for officially ordered disinfection, disinfestation (control of arthropods) as well as measures for the management of vertebrate pests that spread pathogens. Official approval is granted by registration in lists published by the responsible federal health authorities and only for products and methods that have been tested and found to be sufficiently effective and do not have an unacceptable impact on health and the environment (§ 18 IfSG). It is not compulsory for manufacturers to have their products and methods listed in accordance with § 18 IfSG. In particular listing is not a prerequisite for access to the German market. Users are free to choose a product as long as no officially ordered measure, i.e. disinfection, disinfestation or measures against vertebrate pests, according to § 18 IfSG applies. However, it is highly recommended to use approved products included in the abovementioned lists even for routine application, as these registered products and methods have been tested, i.e. the efficacy has been proven by means of specific, recognized and quality assured testing procedures or by expert reports which have been confirmed by independent institutions.

Cost-analysis of PCR-guided pre-emptive antibiotic treatment of Staphylococcus aureus infections: an analytic decision model.

The aim of this study is to examine whether rapid polymerase chain reaction (PCR)-based screening is a cost-efficient tool to optimize pre-emptive antibiotic therapy of methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA, respectively) infections. A decision analytic cost model was developed, based on data from the peer-reviewed literature. Sensitivity analyses were undertaken to investigate the impact of variation in the MRSA rate, cost ratio of the cost of inappropriate antibiotic therapy to the cost of appropriate antibiotic therapy, PCR test cost, and total hospital costs per case. At a current MRSA rate of 24.5 % in Germany, PCR-guided treatment regimens are cost-efficient compared to empirical strategies. The costs of alternative treatment strategies differ, on average, up to 1,780 per case. An empirical MRSA treatment strategy is least costly when the cost ratio is less than 1.06. When the total hospital cost per MRSA case is increased, pre-emptive MSSA treatment with PCR tests achieves the lowest average cost. Early verification and adaptation of an initial pre-emptive antibiotic treatment of S. aureus infections using PCR-based tests are advantageous in Germany and other European countries. PCR tests, accordingly, should be considered as elements in antimicrobial stewardship programs.

Transmission rates, screening methods and costs of MRSA--a systematic literature review related to the prevalence in Germany.

Methicillin-resistant Staphylococcus aureus (MRSA) infections represent a serious challenge for health care institutions, which is inherent in the combination of prevalence, transmission rates and costs. Furthermore, performing an MRSA screening requires information on the complex system of effectiveness, accuracy and costs of different screening methods. The purpose of this study was to give an overview of parameters with decisive significance for the burden of MRSA and the selection of a specific MRSA screening strategy. A systematic literature search for peer-reviewed health economic studies associated with MRSA was performed (from 1995 to the present). Eighty-seven different studies met all inclusion and exclusion criteria. Primary outcomes included the prevalence of MRSA, MRSA transmission rates, performance characteristics of MRSA screening methods, costs for pre-emptive isolation precautions and costs per MRSA case. The prevalence rates reported for all inpatients (1.2-5.3 %) as well as for inpatients with risk factors or patients in risk areas (3.85-20.6 %) vary greatly. The range of cross-transmission rates per day reported for patients with MRSA in isolation is 0.00081-0.009 and for carriers not in isolation is 0.00137-0.140, respectively. For polymerase chain reaction (PCR) methods, the mean sensitivity and specificity were 91.09 and 95.79 %, respectively. Culture methods show an average sensitivity of 89.01 % and an average specificity of 93.21 %. The turn-around time for PCR methods averages 15 h, while for the culture method, it can only be estimated as 48-72 h. This review filtered important parameters and cost drivers, and covered them with literature-based averages. These findings serve as an ideal evidence base for further health economic considerations of the cost-effectiveness of different MRSA screening methods.

Clinical use of the antiseptic polihexanide for genital tract infections.

BACKGROUND: In clinical practice, treatment of genital tract infections is based on administration of either antibiotics or antiseptics. While antibiotics may be applied systemically or topically, antiseptics may be applied only topically. In case of bacterial vaginosis (BV), antibiotic therapy may often be limited and side effects due to systemic administration may develop. Polihexanide (PHMB) is a promising option for the topical treatment of genital tract infections, in particular BV and vaginitis. METHOD: A systematic search for publications on the use of PHMB for the treatment of genital infections in two electronic databases was performed. Titles, abstracts and citations were imported into a reference database. Duplicates were removed and two reviewers assessed each identified publication separately. RESULTS: Among a total of 204 references, 3 prospective randomized trials were identified. Two trials treated BV infections with PHMB in comparison to clindamycin as antibiotic standard therapy with no significant differences either in safety or in efficacy. The third controlled trial investigated the clinical efficacy of PHMB compared to placebo in the treatment of human papilloma virus. Patients treated with PHMB daily for up to 16-weeks showed significantly higher (52%) clearance of genital warts as compared to patients treated with placebo (4%). CONCLUSION: PHMB may be a clinically effective alternative for the treatment of BV and human papilloma virus. Although PHMB-based antiseptics are available since the late 90s, controlled trials to investigate its clinical potential for antiseptic treatment are scant. Clinical use of antiseptics for the treatment of infectious diseases should be explored and supported further.

Efficacy of five alcohol-based skin antiseptics on sebaceous skin used at shorter application times than the current recommendation of 10 minutes.

Alcohol-based skin antiseptics are recommended with a minimum application time of 10 min on skin containing high numbers of sebaceous glands. In clinical practice, a 10-min application time is often too long. Therefore, we determined the efficacy of skin antiseptics on the forehead and lower back using shorter application times. Five alcoholic solutions were tested in a double-blind trial for their colony-forming units (cfu) reduction after 3, 4, 5 and 10 min on the forehead of 20 healthy volunteers and the lower back of 10 healthy volunteers and 10 patients against the reference alcohol 70% propan-2-ol, 10 min. After an application time of 3 min, 3/5 (forehead) and 5/5 (lower back) preparations were at least equally as effective compared to the reference alcohol and an application time of 10 min. Alcohol-based skin antiseptics do not require a 10-min application time. For all of the tested antiseptics, a minimum application time of 3 min on sebaceous skin can be recommended.

Antimicrobial efficacy of the silver wound dressing Biatain Ag in a disc carrier test simulating wound secretion.

AIM: The efficacy of antimicrobial compounds included in wound dressings has been determined using the quantitative suspension test according to EN 13727 before. However, as suspension tests are not an accurate reflection of the conditions under which wound antiseptics are used, it was investigated if a disc carrier test would yield results simulating practical conditions on wound surfaces. A silver-leaching foam wound dressing was used for evaluation of the disc carrier test method. METHOD: The disc carriers consisted of circular stainless-steel discs measuring 2 cm in diameter and 1.5 mm in thickness, complying with the requirements of EN 10088-2. Carriers were contaminated with Staphylococcus aureus, methicillin-resistant S. aureus or Pseudomonas aeruginosa, respectively, together with an artificial wound secretion and left to dry at room temperature for 30 min. The wound dressings being tested were placed on the discs for the length of the exposure time, and after neutralization by thioglycolate in phosphate-buffered saline the number of surviving test organisms was then counted. The logarithmic reduction factor was calculated from the difference between the initial inoculum and the number of recovered test organisms. RESULTS: The disc carrier test allowed determination of an antimicrobial efficacy in a realistic setting. It also imposed more stringent requirements on efficacy over time than the quantitative suspension test. The silver foam wound dressing showed a time-dependent antimicrobial efficacy. After 24-hour application time, the reduction factors against S. aureus, P. aeruginosa and the methicillin-resistant S. aureus were 1.9 ± 0.15, 2.1 ± 0.14 and 3.1 ± 0.18, respectively. CONCLUSION: The disc carrier test was a useful method for testing the antimicrobial efficacy of a foam silver dressing. The antimicrobial dressing exhibited an antimicrobial effect after 3 h and achieved a reduction >2 log against the tested bacterial strains in the presence of a simulated wound secretion after 24 h.

Extensively-drug-resistant Klebsiella pneumoniae ST307 outbreak strain from north-eastern Germany does not show increased tolerance to quaternary ammonium compounds and chlorhexidine.

BACKGROUND: An outbreak of extensively-drug-resistant Klebsiella pneumoniae strain ST307 in a cluster of hospitals in north-east Germany gave rise to the assumption that the epidemiological success of the strain could be based on increased tolerance to biocides. METHODS: The tolerance of the outbreak strain was compared with epidemiologically unrelated clinical isolates of K. pneumoniae, and reference strains of Pseudomonas aeruginosa (ATCC 15442) and Escherichia coli K12 (NCTC 10538). Tests were performed in a miniaturized assay based on European Standard EN 1040. The widely used biocides benzalkonium chloride (BAC) and didecyl dimethyl ammonium chloride (DDAC), their commercial formulation Descosept spezial (DS), and the antiseptic agent chlorhexidine digluconate (CHG) were selected as test substances. These biocides are used regularly in the hospitals involved in the outbreak. FINDINGS: All biocides had a bactericidal effect against all tested strains in the quantitative suspension test within 5 min at typically used concentrations and dilutions. The effectiveness of BAC and DDAC alone and in combination, and CHG antisepsis were not impaired under tested conditions. CONCLUSION: The outbreak strain did not show significantly increased tolerance towards biocides regarding the antiseptic. Thus, the epidemiological success of the strain has to be ascribed to other causes, such as inadequate hand hygiene of visitors.

Standardized comparison of antiseptic efficacy of triclosan, PVP-iodine, octenidine dihydrochloride, polyhexanide and chlorhexidine digluconate.

BACKGROUND: This study presents a comparative investigation of the antimicrobial efficacy of the antiseptics PVP-iodine, triclosan, chlorhexidine, octenidine and polyhexanide used for pre-surgical antisepsis and antiseptic treatment of skin, wounds and mucous membranes based on internationally accepted standards. METHODS: MICs and MBCs were determined in accordance with DIN 58940-7 and 58940-8 using Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus), Enterococcus faecalis (including vancomycin-resistant Enterococcus), Streptococcus pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Clostridium perfringens, Haemophilus influenzae and Candida albicans. The microbicidal efficacy was determined in accordance with DIN EN 1040 and 1275 using S. aureus, P. aeruginosa and C. albicans. RESULTS: For chlorhexidine, octenidine and polyhexanide, MIC(48) and MBC(24) ranged from 16 to 32 mg/L. Maximum values for triclosan ranged from 256 to 512 mg/L, with an efficacy gap against P. aeruginosa, while the maximum values of PVP-iodine were 1024 mg/L, with a gap against S. pneumoniae. Comparing the minimal effective concentrations, octenidine was most effective. After 1 min, only octenidine and PVP-iodine fulfil the requirements for antiseptics. CONCLUSIONS: Tests under standardized and harmonized conditions help to choose the most efficacious agent. When a prolonged contact time is feasible, ranking of agents would be polyhexanide = octenidine > chlorhexidine > triclosan > PVP-iodine. This is consistent with the recommendations for antisepsis of acute wounds. Polyhexanide seems to be preferable for chronic wounds due to its higher tolerability. If an immediate effect is required, ranking would be octenidine = PVP-iodine>> polyhexanide > chlorhexidine > triclosan.

Review on the efficacy, safety and clinical applications of polihexanide, a modern wound antiseptic.

Infected wounds are still one of the great challenges in medicine. In the last decade, it has become increasingly clear that antimicrobial chemotherapy is limited by the spread of antimicrobial resistance. Fortunately, new, highly effective antiseptic substances with a broad antimicrobial spectrum are available, so local treatment is expected to get increasingly more important in wound therapy. This paper reviews the antiseptic agent polihexanide (polyhexamethylene biguanide, PHMB), one of the most promising substances available today, from a clinical point of view, focusing on efficacy, safety and clinical applications.

Octenidine dihydrochloride, a modern antiseptic for skin, mucous membranes and wounds.

Octenidine dihydrochloride (octenidine) was introduced for skin, mucous membrane and wound antisepsis more than 20 years ago. Until now, a wealth of knowledge has been gained, including in vitro and animal studies on efficacy, tolerance, safety and clinical experience both from case reports and prospective controlled trials. Nowadays, octenidine is an established antiseptic in a large field of applications and represents an alternative to older substances such as chlorhexidine, polyvidone-iodine or triclosan. The review is based on the current literature and unpublished original data as well.

Efficacy of chlorhexidine, polihexanide and tissue-tolerable plasma against Pseudomonas aeruginosa biofilms grown on polystyrene and silicone materials.

BACKGROUND: The formation of biofilms is crucial in the pathogenesis of many acute and subacute microbial infections, including chronic wounds and foreign-body-related infections. Topical antimicrobial therapy with chemical antiseptics or physical treatment with tissue-tolerable plasma (TTP) may be promising to control bacterial infection. METHODS: We assessed the efficacy of 0.1% chlorhexidine digluconate (CHX), 0.02 and 0.04% polihexanide (polyhexamethylene biguanide, PHMB) and of TTP against Pseudomonas aeruginosa SG81 biofilm grown in microtitre plates (polystyrene) and on silicone materials in an artificial wound fluid. RESULTS: Overall, PHMB was as effective as CHX in reducing the total amount of biofilm (gentian violet assay) and in reducing the bacterial metabolism in biofilms (XTT assay). TTP also led to a significant reduction in colony-forming units. CONCLUSION: The antimicrobial activity of PHMB in biofilms is comparable to that of CHX. TTP could become an interesting physical alternative to chemical antisepsis in the future.

[Prevention of infections under anesthetic breathing with breathing filters: concerted recommendations of the Deutsche Gesellschaft für Krankenhaushygiene e.V. (DGKH) and the Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)]. / Infektionsprävention bei der Narkosebeatmung durch Einsatz von Atemsystemfiltern: Gemeinsame Empfehlung der Deutschen Gesellschaft für Krankenhaushygiene e.V. (DGKH) und der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI).

An interdisciplinary working group from the German Society of Hospital Hygiene (DGKH) and the German Society for Anesthesiology and Intensive Care (DGAI) worked out the following recommendations for infection prevention during anesthesia by using breathing system filters (BSF). The BSF shall be changed after each patient. The filter retention efficiency for airborne particles is recommended to be >99% (II). The retention performance of BSF for liquids is recommended to be at pressures of at least 60 hPa (=60 mbar) or 20 hPa above the selected maximum ventilation pressure in the anesthetic system.The anesthesia breathing system may be used for a period of up to 7 days provided that the functional requirements of the system remain unchanged and the manufacturer states this in the instructions for use. The breathing system and the manual ventilation bag are changed immediately after the respective anesthesia if the following situation has occurred or it is suspected to have occurred: Notifiable infectious disease involving the risk of transmission via the breathing system and the manual bag, e.g. tuberculosis, acute viral hepatitis, measles, influenza virus, infection and/or colonization with a multi-resistant pathogen or upper or lower respiratory tract infections. In case of visible contamination e.g. by blood or in case of defect, it is required that the BSF and also the anesthesia breathing system is changed and the breathing gas conducting parts of the anesthesia ventilator are hygienically reprocessed.Observing of the appropriate hand disinfection is very important. All surfaces of the anesthesia equipment exposed to hand contact must be disinfected after each case.

[Influence of floor disinfection on microbial and particulate burden measured under low turbulance air flow in ophthalmological operation theatres]. / Einfluss der Fußbodendesinfektion auf die mikrobielle und partikuläre Belastung der Raumluft in Augen-OP-Räumen mit Verdrängungslüftungsbereichen.

AIM: The necessity for routine disinfection of floors between two surgical procedures or disinfection only after visible contamination was assessed in two identical ophthalmological operating theatres equipped with laminar air flow ventilation. METHOD: Over a period of four weeks, one of the two tested operating rooms was disinfected after every surgical procedure, and the other only in the case of visible contamination. This regimen was inverted every week. To compare the air quality, particle count and total bacteria count were measured inside and outside the laminar air flow. Additionally, bacteria count was measured in the operating field, consisting of the operating table and the instrument tray. Patients were monitored for surgical site infection over a period of one year after operation. RESULTS: No difference in particle count or number of viable bacteria was found between the two investigated procedures. Also, no wound infections were observed after one year of surveillance for surgical site infection. CONCLUSION: It appears that frequent cleaning disinfection of floors is not necessary if a laminar air flow ventilation system is installed. Under these conditions, targeted disinfection of visibly soiled surfaces appears to be sufficient. Generally, the duration of surgical procedures should be kept as short as possible.

[Economic aspects of the management and control of MRSA]. / Okonomische Aspekte des Hygienemangements von MRSA.

Methicillin resistance of Staphylococcus aureus strains (MRSA) has become a steadily growing cost factor for the German and international health system. Besides direct costs for diagnostics and therapy, indirect and intangible costs are a considerable part in the total expenses. Because of the massive increase of MRSA in medical centres as well as in the population and further worsening of forced rationalizing in the health care systems, the interest in the economic effects of this phenomenon has increased greatly during the last years. For managing MRSA and for effective cost containment, especially in hospitals, infection control measures have not only to prevent the further spread of MRSA but actively reduce the number of colonised patients. In the last years the efficiency of several infection control measures and their combination to prevent the spread of MRSA has been shown. However, these measures are linked to considerable direct costs in the first place. Nevertheless, an overall economic assessment of hygiene measures is only possible after a complete cost-benefit analysis, where costs are compared to effects achieved. Moreover, analyses that focus on effects for single institutions only are as inappropriate as purely monetary analyses or analyses that include the direct additional only. Despite of at first considerable expenditures, not only infection control measures but proactive strategies to reduce the total number of MRSA cases (accordingly of the "Search and Destroy" philosophy) are shown to be cost efficient, even in low prevalence situations, based on examples in literature. Hence, effective programmes to reduce MRSA are not only necessary from a medical and ethical focus but are also cost efficient in medium term for health care providers and the community.