[Perspectives for anesthesiologists in hospital hygiene]. / Perspektiven für Anästhesisten in der Krankenhaushygiene.

BACKGROUND: It is mandatory for hospitals in Germany to employ infection control physicians and have an external consultation. The recommended coverage has substantially increased in the last years. Typically, infection control physicians are specialists for hygiene and environmental medicine and/or for microbiology. As there is already a shortage of these specialists, a curricular educational program in infection control was developed by the German Medical Association in 2011. This program addresses specialists of different clinical disciplines. It covers a period of 24 months and includes 200 h of courses, divided into 6 modules. In addition, 7 weeks of internships must be absolved in hospital hygiene, in a microbiological laboratory and in the public health service. During the program, the trainee must be accompanied by a qualified supervisor, who is a specialist in hygiene. The aim of this article is to describe the current status of this program. METHODS: A total of 91 infection control physicians, organized in different networks, were invited by email to take part in a survey with the online tool Survey Monkey (San Mateo, USA). The questions in the survey aimed at the characteristics of the participants as well as the conditions of the program. Further information about the various general regulations and conditions of the course was gathered through internet research, and from telephone and email contact with the State Medical Associations. RESULTS: Approximately 250 physicians completed the program between 2011 and 2017. The graduates were mostly anesthesiologists (45%) and 81% had a leading position (consultant or higher) before beginning the program. Most of them also had further education in antibiotic stewardship and/or infectious diseases. The requirements regarding training hours, examination and certification varied between the State Medical Associations. The supervision, a mandatory part of the program, is also implemented differently from state to state. Of the participants 49% felt well-qualified for the challenges ahead after finishing this program. DISCUSSION: The program was able to increase the number of infection control physicians in a relatively short period of time; however, to guarantee a comparable quality of education it is necessary to standardize the requirements on a national level. The supervision also needs to be further specified. A new program is currently being developed by the German Medical Association, which will hopefully lead to an improvement of the educational program. Special strengths of the new infection control physicians are the broad clinical experience as well as the additional qualifications in antibiotic stewardship and/or infectious diseases. The weaknesses are the lack of practical experience and knowledge of technical hygiene. A mandatory inclusion of antibiotic stewardship and infectious diseases in the program would increase its impact. Anesthesiologists are well-suited for training as infection control physicians. For them, a new, exciting field of activity has opened up with the chance to be the head of their own department.

[Antibiotic stewardship in a basic care hospital : A retrospective observational study]. / Antibiotic stewardship an einem Krankenhaus der Grund- und Regelversorgung : Eine retrospektive Observationsstudie.

BACKGROUND: In response to the global increase in antibiotic resistance, the concept of antibiotic stewardship (ABS) has become increasingly important in recent years. Several publications have demonstrated the effectiveness of ABS, mainly in university facilities. This retrospective observational study describes the implementation of ABS in a basic care hospital. MATERIAL AND METHODS: Following existing national guidelines, an ABS team was set up and measures were launched. These included: hospital guidelines, teaching, weekly antibiotic ward rounds and the restriction of definite substances. The preinterventional/postinterventional data analysis compared the use of antibiotics and blood culture sets as well as the development of resistance, infection with Clostridium difficile (CDI), costs, mortality and length of hospital stay. RESULTS: The measures introduced led to a significant and continuous decline in total antibiotic use of initially 43 recommended daily doses (RDD)/100 patient days (PD) to 31 RDD/100 PD (p < 0.001). The largest decrease was observed in second generation (2G) cephalosporins (-67.5%), followed by 3G cephalosporins (-52.7%), carbapenems (-42.0%) and quinolones (-38.5%). The resistance rate of E. coli to 3G cephalosporins in blood cultures decreased from 26% to 9% (p = 0.021). The rate of blood cultures taken increased from 1.8 sets/100 PD to 3.2 sets/100 PD (+77%, p < 0.001). The pathogen detection rate, defined as one count when a minimum of one sample taken in a day is positive, also increased significantly from 4.0/1000 PD to 6.8/1000 PD (p < 0.001). The ABS had no effect on the overall mortality, the mean dwell time, and the preintervention low CDI incidence. CONCLUSION: The preinterventional/postinterventional comparison showed a significant reduction in the overall consumption of antibiotics with a redistribution in favor of antibiotics with a lower resistance selection. At the same time, the resistance rate of E. coli decreased. The increase of the blood culture rate indicates the optimization of diagnostic procedures. This ABS program had to be established with reduced resources but this seems to have been compensated by the more personal contact addressing the care takers and short chain of commands, as is possible in smaller hospitals. Presumably, the structure of basic care hospitals is particularly suitable for concepts covering entire hospitals. Further clusters of randomized studies are necessary to confirm this.

[Epidemiology, Diagnosis and Treatment of Adult Patients with Nosocomial Pneumonia - Update 2017 - S3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy, the German Radiological Society and the Society for Virology]. / Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie ­ Update 2017.

Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However, infections on general wards are increasing. A central issue are infections with multidrug resistant (MDR) pathogens which are difficult to treat in the empirical setting potentially leading to inappropriate use of antimicrobial therapy.This guideline update was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and treatment of HAP on the basis of quality of evidence and benefit/risk ratio.This guideline has two parts. First an update on epidemiology, spectrum of pathogens and antimicrobials is provided. In the second part recommendations for the management of diagnosis and treatment are given. New recommendations with respect to imaging, diagnosis of nosocomial viral pneumonia and prolonged infusion of antibacterial drugs have been added. The statements to risk factors for infections with MDR pathogens and recommendations for monotherapy vs combination therapy have been actualised. The importance of structured deescalation concepts and limitation of treatment duration is emphasized.

[Epidemiology, diagnosis and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy]. / Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie. S-3 Leitlinie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e.V., der Deutschen Gesellschaft für Infektiologie e.V., der Deutschen Gesellschaft für Hygiene und Mikrobiologie e.V., der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. und der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V.

Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However infections on general wards are also increasing. A central issue are infections with multi drug resistant (MDR) pathogens which are difficult to treat particularly in the empirical setting potentially leading to inappropriate use of antimicrobial therapy. This guideline was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and therapy of HAP on the basis of quality of evidence and benefit/risk ratio. The guideline has two parts. First an update on epidemiology, spectrum of pathogens and antiinfectives is provided. In the second part recommendations for the management of diagnosis and treatment are given. Proper microbiologic work up is emphasized for knowledge of the local patterns of microbiology and drug susceptibility. Moreover this is the optimal basis for deescalation in the individual patient. The intensity of antimicrobial therapy is guided by the risk of infections with MDR. Structured deescalation concepts and strict limitation of treatment duration should lead to reduced selection pressure.

Burden of hospital-acquired SARS-CoV-2 infections in Germany: occurrence and outcomes of different variants.

BACKGROUND: Avoiding in-hospital transmissions has been crucial in the COVID-19 pandemic. Little is known on the extent to which hospital-acquired SARS-CoV-2 variants have caused infections in Germany. AIM: To analyse the occurrence and the outcomes of HAI with regard to different SARS-CoV-2 variants. METHODS: Patients with SARS-CoV-2 infections hospitalized between March 1st, 2020 and May 17th, 2022 in 79 hospitals of the Helios Group were included. Information on patients' characteristics and outcomes were retrieved from claims data. In accordance with the Robert Koch Institute, infections were classified as hospital-acquired when tested positive >6 days after admission and if no information hinted at a different source. FINDINGS: In all, 62,875 SARS-CoV-2 patients were analysed, of whom 10.6% had HAI. HAIs represented 14.7% of SARS-CoV-2 inpatients during the Wildtype period, 3.5% during Alpha (odds ratio: 0.21; 95% confidence interval: 0.19-0.24), 8.8% during Delta (2.70; 2.35-3.09) and 10.1% during Omicron (1.10; 1.03-1.19). When age and comorbidities were accounted for, HAI had lower odds for death than community-acquired infections (0.802; 0.740-0.866). Compared to the Wildtype period, HAIs during Omicron were associated with lower odds for ICU (0.78; 0.69-0.88), ventilation (0.47; 0.39-0.56), and death (0.33; 0.28-0.40). CONCLUSION: Hospital-acquired SARS-CoV-2 infections occurred throughout the pandemic, affecting highly vulnerable patients. Although transmissibility increased with newer variants, the proportion of HAIs decreased, indicating improved infection prevention and/or the effect of immunization. Furthermore, the Omicron period was associated with improved outcomes. However, the burden of hospital-acquired SARS-CoV-2 infections remains high.

Computer-assisted decision support for changing practice in severe sepsis and septic shock.

Computer-assisted decision support systems (CDSS) are designed to improve infection management. The aim of this prospective, clinical pre- and post-intervention study was to investigate the influence of CDSS on infection management of severe sepsis and septic shock in intensive care units (ICUs). Data were collected for a total of 180 days during two study periods in 2006 and 2007. Of the 186 patients with severe sepsis or septic shock, 62 were stratified into a low adherence to infection management standards group (LAG) and 124 were stratified into a high adherence group (HAG). ICU mortality was significantly increased in LAG versus HAG patients (Kaplan-Meier analysis). Following CDSS implementation, adherence to standards increased significantly by 35%, paralleled with improved diagnostics, more antibiotic-free days and a shortened time until antibiotics were administered. In conclusion, adherence to infection standards is beneficial for patients with severe sepsis or septic shock and CDSS is a useful tool to aid adherence.

Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery.

BACKGROUND: Intraoperative stress may suppress the adaptive immune system. Abolished proinflammatory lymphocyte function is associated with higher risk of infection and postoperative complications. We hypothesized that thoracic epidural anaesthesia (TEA) reduces intraoperative stress and thus attenuates lymphocyte decrease and impairment of proinflammatory lymphocyte function. METHODS: Fifty-four patients undergoing major abdominal surgery who had a thoracic epidural catheter inserted were studied. In the TEA-I group, this catheter was used for intraoperative analgesia, whereas the TEA-P group received systemic opioids during surgery. In both groups, patient-controlled epidural analgesia was used for postoperative pain management. Blood samples for immune analyses were obtained before induction of anaesthesia, 2 h after skin incision, and at days 1 and 4 after surgery. Lymphocyte subpopulations, expression of human leucocyte antigen (HLA)-DR on monocytes, plasma concentrations of interleukin (IL)-10, interferon-gamma (IFN-gamma), and IL-12, and concanavalin-A-stimulated concentrations of IFN-gamma and IL-10 were measured. Intraoperative data including bispectral index and plasma concentrations of epinephrine/cortisol were analysed; APACHE-II, SAPS II, and additional postoperative data were documented. RESULTS: Plasma concentrations of epinephrine and cortisol were significantly lower in the TEA-I patients during surgery. IFN-gamma/IL-10 ratio was significantly higher in the TEA-I group from 2 h after skin incision until day 1. Lymphocyte numbers and T-helper cells were significantly higher in the TEA-I group at day 1, whereas no significant differences were detected among IL-12, HLA-DR, and postoperative clinical course. CONCLUSIONS: Intraoperative use of thoracic epidural catheter reduced stress response and prevented stress-induced perioperative impairment of proinflammatory lymphocyte function.

Adherence to standard operating procedures is crucial for intensive care unit survival of elderly patients.

Elderly patients account for 42-52% of intensive care unit (ICU) admissions and for almost 60% of all ICU days in the USA and up to 50% receive inappropriate antibiotic treatment. The aim of this study was to evaluate whether adherence to Standard Operating Procedures (SOPs) reduced ICU mortality in an elderly population. The study included consecutive patients (n = 228) aged > or = 60 years with an ICU stay of > 72 h. SOPs were based on evidence-based medicine guidelines for diagnosis and treatment of infections, and on local resistance rates. According to preset indicators of quality management standards and assessment of different degrees of adherence, an implementation rate > 70% was considered adherent (high adherence group [HAG]) and < or = 70% was considered non-adherent (low adherence group [LAG]). Patients in the HAG (n = 137) had significantly reduced mortality compared with LAG patients (n = 91): 5.8% versus 19.8%, respectively. It was concluded that adherence to SOPs based on evidence-based medicine that consider local resistance rates for antibiotic treatment in elderly ICU patients is associated with a lower mortality rate.

Hyperactive delirium and blood glucose control in critically ill patients.

Delirium is a common complication of critically ill patients and is often associated with metabolic disorders. One of the most frequent metabolic disorders in intensive care unit (ICU) patients is hyperglycaemia. The aim of this retrospective study of 196 adult ICU patients was to determine if there is an association between hyperactive delirium and blood glucose levels in ICU patients. Hyperactive delirium was diagnosed using the delirium detection score. Blood glucose levels were monitored by blood gas analysis every 4 h. Hyperactive delirium was detected in 55 (28%) patients. Delirious patients showed significantly higher blood glucose levels than non-delirious patients Higher overall complication rates, length of ventilation, ICU stay and mortality rates were seen in the delirium group. In a multivariate analysis, glucose level, alcohol abuse, APACHE II score, complication by hospital-acquired pneumonia and a diagnosis of polytrauma on-admission all significantly influenced the appearance of delirium.

Comparison of three models for sepsis patient discrimination according to PIRO: predisposition, infection, response and organ dysfunction.

BACKGROUND: Sepsis remains one of the most challenging burdens of critically ill patients. But for interventional studies significant heterogeneity remains in classifying patients. PIRO (Predisposition, Response, Infection and Organ dysfunction) has been introduced as innovative option for improved patient characterization. Aim of this study was to evaluate precision to predict hospital mortality of three different proposed PIRO classification systems. METHODS: Data were prospectively obtained data in five ICUs in a university hospital in Berlin, Germany including adult patients with sepsis. Three different scoring systems were compared using patient characteristics to classify the population according to all cause hospital mortality risk (Moreno- PIRO, Rubulotta- PIRO and Howell-PIRO). RESULTS: Two-hundred-seventy-eight sepsis patients were included and reclassified using different PIRO models. All cause hospital mortality was 16.2%. Hospital mortality increased with higher PIRO scores with odds ratios of 1.070 (95% CI 1.041-1.100) for Moreno-PIRO, 1.282 (95% CI 1.079-1.524) for Rubulotta-PIRO and 1.256 (95% CI 1.146-1.367) for Howell-PIRO. Area under the curves for Moreno-PIRO was 0.743 (95% CI: 0.687-0.793), for Rubulotta-PIRO 0.646 (95% CI: 0.587-0.702) and for Howell-PIRO 0.751 (95% CI: 0.696-0.801). Moreno-PIRO and Howell-PIRO were statistically different compared with Rubulotta-PIRO (P=0.046 and P=0.035). CONCLUSION: Proposed PIRO classifications demonstrated slight differences between models without prioritization of one approach and all seemed feasible for patient classification. Future PIRO-development is needed to straighten predisposition, infection, and especially the response category.

Observational clinical study on the effects of different dosing regimens on vancomycin target levels in critically ill patients: Continuous versus intermittent application.

Different dosing regimens for vancomycin are in clinical use: intermittent infusion and continuous administration. The intention of using these different dosing regimens is to reduce toxicity, to achieve target levels faster and to avoid treatment failure. The aim of this phase IV study was to compare safety and effectiveness in both administration regimens. The study was conducted in 2010 and 2011 in three postoperative intensive care units (ICUs) in a tertiary care university hospital in Berlin, Germany. Adult patients with vancomycin therapy and therapeutic drug monitoring were included. Out of 675 patients screened, 125 received vancomycin therapy, 39% with intermittent and 61% with continuous administration. Patients with continuous administration achieved target serum levels significantly earlier (median day 3 versus 4, p=0.022) and showed fewer sub-therapeutic serum levels (41% versus 11%, p<0.001). ICU mortality rate, duration of ICU stay and duration of ventilation did not differ between groups. Acute renal failure during the ICU stay occurred in 35% of patients with intermittent infusion versus 26% of patients with continuous application (p=0.324). In conclusion, continuous administration of vancomycin allowed more rapid achievement of targeted drug levels with fewer sub-therapeutic vancomycin levels observed. This might indicate that patients with more severe infections or higher variability in renal function could benefit from this form of administration.

Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study.

OBJECTIVES: Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS. DESIGN: This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation. SETTING: Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital. PARTICIPANTS: Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days. INTERVENTION: Implementation of a CDSS. OUTCOME MEASURES: The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence. MAIN RESULTS: Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31). CONCLUSIONS: Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality. TRIAL REGISTRATION NUMBER: ISRCTN54598675.