Age as a risk factor for surgical site infections: German surveillance data on total hip replacement and total knee replacement procedures 2009 to 2018.

BackgroundOlder age is frequently cited as a risk factor for healthcare-associated infections in general, and surgical site infections (SSIs) specifically.AimWe aimed to investigate the correlation between age and SSI occurrence.MethodsData on total hip replacement (THR) and total knee replacement (TKR) surgeries and resulting SSIs documented in the German national surveillance network from a 10-year period from 2009 to 2018 were selected for analysis. SSI rates and adjusted odds ratios (AOR) were calculated and a multivariable analysis to determine risk factors for SSI occurrence was conducted.ResultsA total of 418,312 THR procedures resulting in 3,231 SSIs, and 286,074 TKR procedures with 1,288 SSIs were included in the analyses. For THR, SSI rates were higher in older age groups when compared with the reference age group of 61-65 years. A significantly higher risk was observed in the 76-80 years age group (AOR: 1.21, 95% CI: 1.05-1.4). An age of ≤ 50 years was associated with a significantly lower SSI risk (AOR: 0.64, 95% CI: 0.52-0.8). For TKR, a similar correlation was observed, with the exception of the youngest age group (≤ 52 years), which was shown to have an SSI risk equal to that of the knee prosthesis reference age group (78-82 years).ConclusionA strong correlation between increasing age and SSI occurrence was observed for both procedure types. The results of our analyses provide a basis to consider future targeted SSI prevention measures for different age groups.

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.

Increase in consumption of alcohol-based hand rub in German acute care hospitals over a 12 year period.

BACKGROUND: Hand hygiene plays a crucial role in the transmission of pathogens and the prevention of healthcare-associated infections. In 2007, a voluntary national electronic surveillance tool for the documentation of consumption of alcohol-based hand rub (AHC) was introduced as a surrogate for hand hygiene compliance (HAND-KISS) and for the provision of benchmark data as feedback. The aim of the study was to determine the trend in alcohol-based hand rub consumption between 2007 and 2018. MATERIALS AND METHODS: In this cohort study, AHC and patient days (PD) were documented on every ward in participating hospitals by trained local staff. Data was collected and validated in HAND-KISS. Intensive care units (ICU), intermediate care units (IMC), and regular wards (RW) that provided data during the study period between 2007 until 2018 were included into the study. RESULTS: In 2018, 75.2% of acute care hospitals in Germany (n = 1.460) participated. On ICUs (n = 1998) mean AHC increased 1.74 fold (95%CI 1.71, 1.76; p < .0001) from 79.2 ml/PD to 137.4 ml/PD. On IMCs (n = 475) AHC increased 1.69 fold (95%CI 1.60, 1.79; p < .0001) from 41.4 ml/PD to 70.6 ml /PD..On RWs (n = 14,857) AHC was 19.0 ml/PD in 2007 and increased 1.71 fold (95%CI 1.70, 1.73; p < .0001) to 32.6 ml/PD in 2018. CONCLUSIONS: AHC in German hospitals increased on all types of wards during the past 12 years. Surveillance of AHC is widely established in German hospitals. Large differences among medical specialties exist and warrant further investigation.

Implementation of an automated cluster alert system into the routine work of infection control and hospital epidemiology: experiences from a tertiary care university hospital.

BACKGROUND: Early detection of clusters of pathogens is crucial for infection prevention and control (IPC) in hospitals. Conventional manual cluster detection is usually restricted to certain areas of the hospital and multidrug resistant organisms. Automation can increase the comprehensiveness of cluster surveillance without depleting human resources. We aimed to describe the application of an automated cluster alert system (CLAR) in the routine IPC work in a hospital. Additionally, we aimed to provide information on the clusters detected and their properties. METHODS: CLAR was continuously utilized during the year 2019 at Charité university hospital. CLAR analyzed microbiological and patient-related data to calculate a pathogen-baseline for every ward. Daily, this baseline was compared to data of the previous 14 days. If the baseline was exceeded, a cluster alert was generated and sent to the IPC team. From July 2019 onwards, alerts were systematically categorized as relevant or non-relevant at the discretion of the IPC physician in charge. RESULTS: In one year, CLAR detected 1,714 clusters. The median number of isolates per cluster was two. The most common cluster pathogens were Enterococcus faecium (n = 326, 19 %), Escherichia coli (n = 274, 16 %) and Enterococcus faecalis (n = 250, 15 %). The majority of clusters (n = 1,360, 79 %) comprised of susceptible organisms. For 906 alerts relevance assessment was performed, with 317 (35 %) alerts being classified as relevant. CONCLUSIONS: CLAR demonstrated the capability of detecting small clusters and clusters of susceptible organisms. Future improvements must aim to reduce the number of non-relevant alerts without impeding detection of relevant clusters. Digital solutions to IPC represent a considerable potential for improved patient care. Systems such as CLAR could be adapted to other hospitals and healthcare settings, and thereby serve as a means to fulfill these potentials.

Perceptions and attitudes regarding antibiotic resistance in Germany: a cross-sectoral survey amongst physicians, veterinarians, farmers and the general public.

Background: Drivers of antibiotic (AB) resistance (ABR) include outpatient treatment, hospital care and animal husbandry. During the first phase of the One Health project RAI (Responsible Antibiotic Use via Information and Communication) surveys were conducted in these sectors. Objectives: To compare perceptions and attitudes towards ABR among general practitioners (GPs), hospital physicians, veterinarians, pig farmers and the general public. Methods: Cross-sectional questions on AB use and ABR were integrated in group-specific surveys of GPs, hospital physicians, veterinarians, pig farmers and the German general population. Results: A total of 1789 participants (340 GPs, 170 hospital physicians, 215 pig farmers, 60 veterinarians and 1004 members of the public) responded. Each group tended to identify drivers of ABR as being from outside its own area of activity. Guidelines were shown to be an important information source for AB therapy for all prescriber groups, but the frequency of routine use differed (39% of GPs, 65% of hospital physicians and 53% of veterinarians). Regarding further information sources, hospital physicians preferred smartphone apps and e-learning, GPs preferred non-sponsored training and veterinarians preferred multidisciplinary networks and e-learning. Farmers were predominantly satisfied with existing solutions. Farmers had three times better basic knowledge of ABR and knew twice as many people with MDR organism problems than the general public. They also received information on ABR more often from their veterinarians than patients did from their doctors. Conclusions: This study reveals considerable differences in perceptions and attitudes to ABR among the groups investigated. The results can help to tailor future interventions. Furthermore, they promote mutual understanding and thus support the One Health approach.

Antibiotic prescribing behavior among general practitioners - a questionnaire-based study in Germany.

BACKGROUND: This study investigates the barriers and facilitators of the use of antibiotics in acute respiratory tract infections by general practitioners (GPs) in Germany. METHODS: A multidisciplinary team designed and pre-tested a written questionnaire addressing the topics awareness of antimicrobial resistance (7 items), use of antibiotics (9 items), guidelines/sources of information (9 items) and sociodemographic factors (7 items), using a five-point-Likert-scale ("never" to "very often"). The questionnaire was mailed by postally to 987 GPs with registered practices in eastern Germany in May 2015. RESULTS: 34% (340/987) of the GPs responded to this survey. Most of the participants assumed a multifactorial origin for the rise of multidrug resistant organisms. In addition, 70.2% (239/340) believed that their own prescribing behavior influenced the drug-resistance situation in their area. GPs with longer work experience (> 25 years) assumed less individual influence on drug resistance than their colleagues with less than 7 years experience as practicing physicians (Odds Ratio [OR] 0.32, 95% Confidence Interval [CI] 0.17-0.62; P < 0.001). 99.1% (337/340) of participants were familiar with the "delayed prescription" strategy to reduce antibiotic prescriptions. However, only 29.4% (74/340) answered that they apply it "often" or "very often". GPs working in rural areas were less likely than those working in urban areas to apply delayed prescription. CONCLUSION: The knowledge on factors causing antimicrobial resistance in bacteria is good among GPs in eastern Germany. However measures to improve rational prescription are not widely implemented yet. Further efforts have to be made in order to improve rational prescription of antibiotic among GPs. Nevertheless, there is a strong awareness of antimicrobial resistance among the participating GPs.

[Antibiotic intake and resistance development - Knowledge, experience and behavior among the German general population]. / Antibiotikaeinnahme und Resistenzentwicklung - Wissen, Erfahrungen und Einnahmeverhalten innerhalb der deutschen Allgemeinbevölkerung.

BACKGROUND: The network project RAI (Rational Use of Antibiotics via Information and Communication) is aimed at developing tailored information and communication tools on the subject of antibiotic (AB) resistance for various stakeholder groups. During the preparation phase, a survey was performed addressing the German general population. OBJECTIVES: To gain insights into the knowledge, attitudes, and behavior of nonprescribers concerning AB and multidrug-resistant organisms (MDRO). METHODS: Using computer-assisted, telephone-based interviews a random sample of 1,004 persons aged 14 years and older was surveyed. Descriptive reporting of data and multivariate analysis were performed, including sociodemographic variables. RESULTS: Only 24 % of participants knew that bacteria (but not viruses or humans) could develop AB resistance. However, this knowledge did not influence the outcome of other questions. Regardless of knowledge, 71 % thought that the subject was important, but 58 % did not believe in the influence of their own behavior on MDRO development. When visiting a physician, patients were given an antibiotic three times as often as information on AB resistance. 17 % did not take the AB as prescribed and 20 % of all participants stated that they personally knew at least one person with MDRO problems. This personal involvement had a significant effect on the rating of self-influence, on the importance of the subject, on the interaction between patient and physician (more information, less AB), and on AB intake compliance (less frequent). DISCUSSION: We found considerable knowledge gaps, but this had no impact on the assessment of the subject. A starting point for an intervention could be patient-physician communication. This seems more effective and safer than a public campaign.

[Analysis of contemporary hospital infrastructure pertaining to infection prevention in Germany]. / Ausstattung mit Händedesinfektionsmittelspendern und Einbettzimmern in Hinblick auf die Infektionsprävention - eine Bestandsaufnahme in Krankenhäusern in Deutschland.

BACKGROUND: A high percentage of single-bed rooms and antiseptic hand rub dispensers in hospitals are required for infection prevention OBJECTIVE: Data acquisition of the hospitals' current status of infrastructure pertaining to infection prevention MATERIALS AND METHODS: A electronic questionnaire was sent in March 2015 to all hospitals participating in the nosocomial infection surveillance system (KISS) to collect operational infrastructure data. RESULTS: Completed questionnaires were received from 621 hospitals (response rate 46 %) and provided data about the building infrastructure of 534 intensive care units and 621 representative medical wards. While most beds in the intensive care unit are equipped with an antiseptic hand rub dispenser at the bedside, only 31.5 % of the medical ward beds are so equipped. Moreover, only 27.1 % of intensive care beds and 6.4 % of medical ward beds are in single-bed rooms. The intensive care room size showed a median of 18 m² for single-bed rooms and 28 m² for two-bed rooms. In the medical wards, 28.2 % of the patient rooms are not equipped with an ensuite toilet. CONCLUSIONS: The paucity of bedside antiseptic hand rub dispensers in medical wards should be rectified at once to optimize hand hygiene compliance of health care workers. Likewise, the lack of single-bed rooms on medical wards and intensive care units should be considered when renovating old or planning new buildings in the near future.

Dramatic increase in vancomycin-resistant enterococci in Germany.

OBJECTIVES: Among European countries, Germany has one of the highest proportions of vancomycin-resistant Enterococcus faecium bloodstream infections. The aim of this study was to investigate the development of vancomycin-resistant enterococci (VRE) in German hospitals and to consider the regional distribution of VRE in Germany. METHODS: Data from three components of the German national nosocomial surveillance system (KISS) from the period 2007-12 were used for analysis: ICU-KISS data on nosocomial primary bloodstream infections and urinary tract infections from intensive care units (ICUs); OP-KISS data on surgical site infections from surgical departments; and Pathogen-KISS data concentrating on VRE cases (infections and colonizations) in ICUs. Trends over time were calculated and a map according to German federal states was prepared. RESULTS: Data from up to 645 ICUs and 681 surgical departments for 2 year periods from 2007 to 2012 were analysed. The proportion of VRE increased significantly for surgical site infections (526%; P < 0.01) and bloodstream infections (265%; P < 0.01) and non-significantly for urinary tract infections (278%; P = 0.07). A large subgroup of ICUs also reported VRE cases in the same period, with a significant increase of 282%. The mapping of federal states showed large variation in VRE proportions and incidence rates in a belt of states with significantly higher VRE proportions from west (North Rhine-Westphalia) to east (Saxony). CONCLUSIONS: The high overall VRE proportion in Germany is mainly due to the situation in four states. There is an urgent need to analyse the epidemiology of VRE in detail to develop appropriate infection control strategies.

Appropriate antibiotic use and antimicrobial resistance: knowledge, attitudes and behaviour of medical students and their needs and preferences for learning.

BACKGROUND: The impact of an appropriate use of antibiotics on the prevention of antimicrobial resistance (AMR) has been demonstrated. Surveys have shown, however, that medical students do not feel sufficiently trained to use antibiotics wisely. The aims of our study were (1) to describe what medical students currently know about appropriate antibiotic use, and (2) to identify students' learning preferences as a basis for developing student-centred teaching modules to convey the basics of AMR prevention. METHODS: We performed an online survey at Charité Universitätsmedizin Berlin and the Julius-Maximilians-University Würzburg on the knowledge, attitudes, and behaviour (KAB) of medical students concerning AMR, antibiotic treatment options, and their perceptions of AMR topics addressed in the medical curriculum. Participants were able to fill out an online questionnaire between December 2019 and February 2020. In addition, we conducted focus group discussions with lecturers and medical students in winter 2019/2020 to identify AMR-related learning needs and preferences. Data were analysed descriptively. RESULTS: Overall, 356 students (response rate 5.1%) participated in the KAB survey. Of these, 192 (54%) strongly agreed that the topic of AMR is relevant to students' clinical practice and 48% (171/355) stated that their future antibiotic prescription behaviour will have an influence on AMR development in their region. Participating students seemed to be interested in the topic of AMR and antibiotic therapy. But even of them, only 46% answered the question about the length of antibiotic use for community-acquired pneumonia correctly and 57% the question about the appropriate use of antibiotics in Staphylococcus aureus infections. Focus group discussions with students (n = 7) and lecturers (n = 9) identified a lack of competence in the responsible use of antibiotics and the prevention of AMR. Respondents stated that the teaching formats and AMR-related content should emphasize clinical applications, interaction with peers/clinicians, and repeated formative feedback from instructors. CONCLUSIONS: Our results show that even medical students who were interested in the AMR problem were not able to use antibiotics appropriately due to gaps in knowledge and a lack of clinical skills. Based on the insights gained in the learning preferences of students and their content priorities, improved student-centred teaching materials should be developed.