Analysis of transmission-related third-generation cephalosporin-resistant Enterobacterales by electronic data mining and core genome multi-locus sequence typing.

BACKGROUND: To contain intra-hospital transmission of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), contact isolation precautions are recommended. AIM: To quantify transmissions of 3GCR Escherichia coli and 3GCR Klebsiella pneumoniae within a hospital. METHODS: An automated outbreak detection system (AODS) was used to identify clusters (N≥2) of 3GCR Enterobacterales for the years 2016, 2018 and 2020. Clusters were defined by phenotypic agreement of microbiological results and spatial and temporal relationship. Core genome multi-locus sequence typing (cgMLST) was used to confirm whether the cluster isolates were transmitted between patients. FINDINGS: A total of 4343 3GCR E. coli and 1377 K. pneumoniae isolates were analysed. Among the 3GCR E. coli isolates, the AODS identified 304 isolates as cluster isolates, the median cluster size was two (range: 2-5). The cgMLST analysis revealed that a total of 23 (7.5%) 3GCR E. coli cluster isolates were transmission-associated, of which 20 isolates (87%) were detected in intensive care patients. Among the 3GCR K. pneumoniae isolates, the AODS identified 73 isolates as cluster isolates, the median cluster size was two (range: 2-4). CgMLST revealed that 35 (48%) 3GCR K. pneumoniae cluster isolates were transmission associated, of which 27 isolates (77%) were detected in intensive care patients. CONCLUSION: For 3GCR K. pneumoniae, cgMLST confirmed the AODS results more frequently than for 3GCR E. coli. Therefore, contact isolation precautions for 3GCR K. pneumoniae may be appropriate on intensive care units, but only in certain circumstances, such as outbreaks, for Enterobacterales with lower transmissibility, such as E. coli.

Sinks in patient rooms in ICUs are associated with higher rates of hospital-acquired infection: a retrospective analysis of 552 ICUs.

BACKGROUND: Sinks in hospitals are a possible reservoir for healthcare-related pathogens. They have been identified as a source of nosocomial outbreaks in intensive care units (ICU); however, their role in non-outbreak settings remains unclear. AIM: To investigate whether sinks in ICU patient rooms are associated with a higher incidence of hospital-acquired infection (HAI). METHODS: This analysis used surveillance data from the ICU component of the German nosocomial infection surveillance system (KISS) from 2017 to 2020. Between September and October 2021, all participating ICUs were surveyed about the presence of sinks in their patient rooms. The ICUs were then divided into two groups: the no-sink group (NSG) and the sink group (SG). Primary and secondary outcomes were total HAIs and HAIs associated with Pseudomonas aeruginosa (HAI-PA). FINDINGS: In total, 552 ICUs (NSG N=80, SG N=472) provided data about sinks, total HAIs and HAI-PA. The incidence density per 1000 patient-days of total HAIs was higher in ICUs in the SG (3.97 vs 3.2). The incidence density of HAI-PA was also higher in the SG (0.43 vs 0.34). The risk of HAIs associated with all pathogens [incidence rate ratio (IRR)=1.24, 95% confidence interval (CI) 1.03-1.50] and the risk of lower respiratory tract infections associated with P. aeruginosa (IRR=1.44, 95% CI 1.10-1.90) were higher in ICUs with sinks in patient rooms. After adjusting for confounders, sinks were found to be an independent risk factor for HAI (adjusted IRR 1.21, 95% CI 1.01-1.45). CONCLUSIONS: Sinks in patient rooms are associated with a higher number of HAIs per patient-day in the ICU. This should be considered when planning new ICUs or renovating existing ones.

Automated surveillance systems for healthcare-associated infections: results from a European survey and experiences from real-life utilization.

BACKGROUND: As most automated surveillance (AS) methods to detect healthcare-associated infections (HAIs) have been developed and implemented in research settings, information about the feasibility of large-scale implementation is scarce. AIM: To describe key aspects of the design of AS systems and implementation in European institutions and hospitals. METHODS: An online survey was distributed via e-mail in February/March 2019 among (i) PRAISE (Providing a Roadmap for Automated Infection Surveillance in Europe) network members; (ii) corresponding authors of peer-reviewed European publications on existing AS systems; and (iii) the mailing list of national infection prevention and control focal points of the European Centre for Disease Prevention and Control. Three AS systems from the survey were selected, based on quintessential features, for in-depth review focusing on implementation in practice. FINDINGS: Through the survey and the review of three selected AS systems, notable differences regarding the methods, algorithms, data sources, and targeted HAIs were identified. The majority of AS systems used a classification algorithm for semi-automated surveillance and targeted HAIs were mostly surgical site infections, urinary tract infections, sepsis, or other bloodstream infections. AS systems yielded a reduction of workload for hospital staff. Principal barriers of implementation were strict data security regulations as well as creating and maintaining an information technology infrastructure. CONCLUSION: AS in Europe is characterized by heterogeneity in methods and surveillance targets. To allow for comparisons and encourage homogenization, future publications on AS systems should provide detailed information on source data, methods, and the state of implementation.

No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years.

BACKGROUND: Hand hygiene plays a crucial role in the prevention of healthcare-associated infections and transmission of pathogens. In 2008 the national campaign 'Aktion Saubere Hände' was launched in Germany. It is based on the World Health Organization (WHO) 'Clean Care is Safer Care' initiative. Direct observation and feedback of the results are key components in the improvement of hand hygiene compliance. In 2014 a voluntary national surveillance electronic tool for the documentation of directly observed compliance to hand hygiene was introduced. AIM: Description and evaluation of compliance with the WHO model 'my 5 moments' in German hospitals after implementation. METHODS: Direct observation was performed in the participating hospitals by trained local staff according to the WHO recommendations. We evaluated wards that reported annually at least 150 hand hygiene opportunities (HHOs) of hand hygiene per observation period from January 1st, 2015 until December 31st, 2018. FINDINGS: In all, 1,485,622 HHOs observed on 3337 wards in 525 hospitals were included into analysis. Overall compliance increased from 72% (interquartile range: 61-82) to 76% (66-84). Compliance significantly increased for all individual moments of the WHO model except moment 2. In the multivariate logistic regression analysis the following parameters were independently associated with a high compliance in hand hygiene: intensive care unit, nurse, opportunity observed in 2017 or 2018, as well as all moments except moment 2. CONCLUSION: Overall compliance in German hospitals increased over time. To improve HH compliance 'before aseptic procedures' appears to be difficult and should be addressed explicitly. Underlying reasons need to be the focus of future investigations.

Management of peripheral venous catheters and implementation of guidelines in Germany: a national survey.

BACKGROUND: Due to their frequent use, peripheral venous catheters (PVCs) are of importance in terms of catheter-related infections and their prevention. In 2017, revised national guidelines for the prevention of PVC-related infections were published in Germany. AIM: To describe PVC handling practices and assess the implementation of national guidelines for the prevention of PVC-related infections in German acute care hospitals, 10 months after their release. METHODS: An online survey on the management of PVCs in hospital wards was conducted. For this, 1191 acute care hospitals participating in the national surveillance system for healthcare-associated infections in Germany were invited to participate. Each hospital was asked to complete the survey for an intensive care unit (ICU), as well as a medical ward and a surgical ward. Participation in the survey was voluntary. FINDINGS: In total, 701 hospitals (response rate 59%) participated and provided data on 1449 wards (599 ICUs, 446 medical wards, 404 surgical wards). Approximately 43% of wards reported that they had implemented the new national guidelines where necessary. Structured surveillance for PVC-associated infections was established in only 21% of wards. While 94% of wards reported the inclusion of aspects of PVC handling in their general infection prevention education, questions on the training methods yielded diverse results. Approximately 59% of wards reported that they did not routinely use a combination of alcohol and a remanant disinfectant for skin disinfection before PVC insertion. CONCLUSION: Generally, PVC management in Germany is well organized. However, potential for improvement was identified, particularly considering surveillance and implementation of selected national guidelines.

Decrease of methicillin resistance in Staphylococcus aureus in nosocomial infections in Germany-a prospective analysis over 10 years.

OBJECTIVES: Methicillin resistant Staphylococcus aureus (MRSA) remains an important cause of healthcare-associated infections. Here, we describe the development of methicillin-resistant isolates among nosocomial Staphylococcus aureus (SA) infections in Germany between 2007 and 2016. METHODS: We analyzed data from the voluntary German national nosocomial Infection Surveillance System. Data on bloodstream infections (BSI) and lower respiratory tract infections (LRTI) were derived from intensive care units (ICU), whereas data on surgical site infections (SSI) were collected from surgical departments (SD). Univariate analysis was performed on trend of proportion, while multivariable logistic regression was performed to identify risk factors for MRSA-infections. RESULTS: Data of 1218 ICU and 1,556 SD were included. Overall, a decrease in the proportion of MRSA among all nosocomial SA-infections from 32.8% to 20.0% was noted. MRSA decreased from 37.1% to 21.8% (p = 0.01) for BSI, from 38.7% to 19.2% for LTRI (p < 0.01) and. from 21.1% to 7.4% (p < 0.01) in SSI. Logistic regression revealed that SA-infections in Mecklenburg Western-Pomerania were more likely caused by MRSA (Odds ratio (OR): 2.5; 95% CI: 1.7, 3.6). CONCLUSION: We observed a significant reduction of the proportion of nosocomial Staphylococcus aureus infections due to MRSA in Germany over the course of the last 10 years.

Impact of participation in a surgical site infection surveillance network: results from a large international cohort study.

BACKGROUND: Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale. AIM: To determine the time-trend of SSI rates in surveillance networks. METHODS: SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept. FINDINGS: Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63-0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis. CONCLUSION: In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.

Hospital ownership: a risk factor for nosocomial infection rates?

BACKGROUND: In some countries, a relationship between hospital ownership and the occurrence of healthcare-associated infection (HCAI) rates has been described. AIM: To investigate the association between hospital ownership and occurrence of HCAI in Germany. METHODS: Five different components of the German national nosocomial infection surveillance system were analysed with regard to the influence of hospital ownership in the period 2014-2016. Endpoints included ventilator-associated pneumonia, central-venous-catheter-associated bloodstream infections, urinary-catheter-associated urinary tract infections, surgical site infections (SSI) following hip prosthesis and colon surgery, meticillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile infections (CDI) and hand rub consumption per 1000 patient-days. Three hospital ownership types (public, non-profit and private) were analysed using univariate and multi-variate methods. FINDINGS: The distribution of hospitals according to the three ownership types was similar in all components. In total, 661 intensive care units (ICUs), 149 departments performing colon procedures, and 349 departments performing hip prosthesis were included. In addition, 568 hospitals provided their MRSA rates and 236 provided their CDI rates, and 1833 ICUs and 12,934 non-ICUs provided their hand rub consumption data. In general, the differences between the hospital types were rather small and not significant for the ICUs. In the multi-variate analysis, public hospitals had a lower SSI rate following hip prosthesis (odds ratio 0.80, 95% confidence interval 0.65-0.99). CONCLUSION: Hospital ownership was not found to have a major influence on the incidence of HCAI in Germany.

[Development of antimicrobial resistance in Germany : What is the current situation?] / Entwicklung der Resistenzsituation in Deutschland : Wo stehen wir wirklich?

BACKGROUND: The frequency of multidrug-resistant organisms (MDRO) is increasing in Germany and worldwide. OBJECTIVES: Presentation of MDRO resistance rates and prevalence in Germany MATERIALS AND METHODS: Results from the Antibiotic Resistance Surveillance (ARS) and Hospital Infection Surveillance Systems (Krankenhausinfektions-Surveillance-Systems, KISS) and from recent prevalence surveys are presented. RESULTS: MRSA-resistance rates and the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) have remained at a stable level over the last few years. In contrast, vancomycin-resistant enterococci (VRE) and multidrug-resistant gramnegative (MRGN) bacteria have increased considerably. VRE prevalence has more than tripled in the past 5 years, and Escherichia coli resistant to third-generation cephalosporins, acylureidopenicillins, and fluoroquinolones increased by 43% in 2015 compared with the previous year. CONCLUSIONS: New policies to control MDRO should focus on VRE and the heterogeneous group of MRGN bacteria. In the case of the latter, the different bacterial species' characteristics should be taken into consideration.

ICU ward design and nosocomial infection rates: a cross-sectional study in Germany.

BACKGROUND: There is increasing interest in the effects of hospital and ward design on multi-faceted infection control. Definitive evidence is rare and the state of knowledge about current ward design is lacking. OBJECTIVE: To collect data on the current status of ward design for intensive care units (ICUs) and to analyse associations between particular design factors and nosocomial infection rates. METHODS: In 2015, operational infrastructure data were collected via an online questionnaire from ICUs participating voluntarily in the German nosocomial infection surveillance system (KISS). A multi-variate analysis was subsequently undertaken with nosocomial infection rates from the KISS database from 2014 to 2015. FINDINGS: In total, 534 ICUs submitted data about their operational infrastructure. Of these, 27.1% of beds were hosted in single-bed rooms with a median size of 18m2 (interquartile range 15-21m2), and 73.5% of all ICU beds had a hand rub dispenser nearby. The authors were able to match 266 ICUs in the multi-variate analysis. ICUs with openable windows in patient rooms were associated with lower device-associated lower respiratory tract infections [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.58-0.90]. ICUs with >40% two-bed rooms were associated with lower primary bloodstream infection rates (OR 0.66, 95% CI 0.51-0.86). CONCLUSION: Only minor associations were found between design factors and ICU infection rates. Most were surrogates for other risk factors.

Colonization with third-generation cephalosporin-resistant Enterobacteriaceae on hospital admission: prevalence and risk factors.

OBJECTIVES: The objectives of this study were to prospectively assess the rectal carriage rate of third-generation cephalosporin-resistant Enterobacteriaceae (3GCREB) in non-ICU patients on hospital admission and to investigate resistance mechanisms and risk factors for carriage. METHODS: Adult patients were screened for 3GCREB carriage at six German tertiary care hospitals in 2014 using rectal swabs or stool samples. 3GCREB isolates were characterized by phenotypic and molecular methods. Each patient answered a questionnaire about potential risk factors for colonization with MDR organisms (MDROs). Univariable and multivariable risk factor analyses were performed to identify factors associated with 3GCREB carriage. RESULTS: Of 4376 patients, 416 (9.5%) were 3GCREB carriers. Escherichia coli was the predominant species (79.1%). ESBLs of the CTX-M-1 group (67.3%) and the CTX-M-9 group (16.8%) were the most frequent ß-lactamases. Five patients (0.11%) were colonized with carbapenemase-producing Enterobacteriaceae. The following risk factors were significantly associated with 3GCREB colonization in the multivariable analysis (P < 0.05): centre; previous MDRO colonization (OR = 2.12); antibiotic use within the previous 6 months (OR = 2.09); travel outside Europe (OR = 2.24); stay in a long-term care facility (OR = 1.33); and treatment of gastroesophageal reflux disease (GERD) (OR = 1.22). CONCLUSIONS: To our knowledge, this is the largest admission prevalence study of 3GCREB in Europe. The observed prevalence of 9.5% 3GCREB carriage was higher than previously reported and differed significantly among centres. In addition to previously identified risk factors, the treatment of GERD proved to be an independent risk factor for 3GCREB colonization.

Organization of infection control in European hospitals.

BACKGROUND: The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) survey was initiated to investigate the status of healthcare-associated infection (HCAI) prevention across Europe. AIM: This paper presents the methodology of the quantitative PROHIBIT survey and outlines the findings on infection control (IC) structure and organization including management's support at the hospital level. METHODS: Hospitals in 34 countries were invited to participate between September 2011 and March 2012. Respondents included IC personnel and hospital management. FINDINGS: Data from 309 hospitals in 24 countries were analysed. Hospitals had a median (interquartile range) of four IC nurses (2-6) and one IC doctor (0-2) per 1000 beds. Almost all hospitals (96%) had defined IC objectives, which mainly addressed hand hygiene (87%), healthcare-associated infection reduction (84%), and antibiotic stewardship (66%). Senior management provided leadership walk rounds in about half of hospitals, most often in Eastern and Northern Europe, 65% and 64%, respectively. In the majority of hospitals (71%), sanctions were not employed for repeated violations of IC practices. Use of sanctions varied significantly by region (P < 0.001), but not by countries' healthcare expenditure. CONCLUSION: There is great variance in IC staffing and policies across Europe. Some areas of practice, such as hand hygiene, seem to receive considerably more attention than others that are equally important, such as antibiotic stewardship. Programmes in IC suffer from deficiencies in human resources and local policies, ubiquitous factors that negatively impact on IC effectiveness. Strengthening of IC policies in European hospitals should be a public health priority.

Epidemiology of healthcare associated infections in Germany: Nearly 20 years of surveillance.

OBJECTIVE: To describe the epidemiology of healthcare-associated infections (HAI) in hospitals participating in the German national nosocomial infections surveillance system (KISS). METHOD: The epidemiology of HAI was described for the surveillance components for intensive care units (ITS-KISS), non-ICUs (STATIONS-KISS), very low birth weight infants (NEO-KISS) and surgical site infections (OP-KISS) in the period from 2006 to 2013. In addition, risk factor analyses were performed for the most important infections of ICU-KISS, NEO-KISS and OP-KISS. RESULTS: Data from a total of 3,454,778 ICU patients from 913 ICUs, 618,816 non-ICU patients from 142 non-ICU wards, 53,676 VLBW from 241 neonatal intensive care units (NICU) and 1,005,064 surgical patients from operative departments from 550 hospitals were used for analysis. Compared with baseline data, a significant reduction of primary bloodstream infections (PBSI) and lower respiratory tract infections (LRTI) was observed in ICUs with the maximum effect in year 5 (or longer participation) (incidence rate ratio 0.60 (CI95 0.50-0.72) and 0.61 (CI95 0.52-0.71) respectively). A significant reduction of PBSI and LRTI was also observed in NEO-KISS when comparing the baseline situation with the 5th year of participation (hazard ratio 0.70 (CI95 0.64-0.76) and 0.43 (CI95 0.35-0.52)). The effect was smaller in operative departments after the introduction of OP-KISS (OR 0.80; CI95 0.64-1.02 in year 5 or later for all procedure types combined). Due to the large database, it has not only been possible to confirm well-known risk factors for HAI, but also to identify some new interesting risk factors like seasonal and volume effects. CONCLUSIONS: Participating in a national surveillance system and using surveillance data for internal quality management leads to substantial reduction of HAI. In addition, a surveillance system can identify otherwise not recognized risk factors which should - if possible - be considered for infection control management and for risk adjustment in the benchmarking process.

Case vignettes to evaluate the accuracy of identifying healthcare-associated infections by surveillance persons.

BACKGROUND: National surveillance systems depend on accurate and reproducible diagnosis of infections. AIM: To investigate the effect of accuracy of diagnosing healthcare-associated infections (HCAIs) on HCAI rates in a national healthcare-associated surveillance system. METHODS: Data from the validation process from the intensive care unit (ICU) surveillance component of the German Krankenhaus Infektions Surveillance System (KISS; Hospital Infection Surveillance System) were used to calculate the accuracy of diagnosing HCAI for each individual surveillance person (SP) responsible for surveillance of HCAI in the ICU of his or her hospital. Multivariate analyses were performed to identify factors that were attributed to surveillance accuracy. FINDINGS: A total of 189 SPs responsible for surveillance in 218 ICUs assessed 30 case vignettes. The chance of belonging to the group of SPs with high accuracy was increased by being a physician (odds ratio: 3.14; P = 0.02) and by being an external SP (odds ratio: 4.69; P ≤ 0.01). ICU HCAI rates depend on the sensitivity of the ICU's SP [incidence rate ratio (IRR): 1.28 (1.07, 1.53); P ≤ 0.01]. High sensitivity increases healthcare-associated urinary tract infection rates [IRR: 1.33 (1.02, 1.75); P = 0.03] and bloodstream infection rates [IRR: 1.33 (1.06, 1.68); P = 0.01]. High specificity was not a significant factor. CONCLUSION: In light of the link between sensitivity of diagnosing HCAI by case vignettes and the ICU HCAI rates, this validation method can be recommended for validation of other surveillance systems.

Regional distribution of nosocomial infections due to ESBL-positive Enterobacteriaceae in Germany: data from the German National Reference Center for the Surveillance of Nosocomial Infections (KISS).

Surveillance systems for hospital infections are reporting increasing rates of extended-spectrum ß-lactamase (ESBL)-positive Enterobacteriaceae in Europe. We aimed to perform a national survey on this trend and on the regional distribution of nosocomial infections due to ESBL-positive Enterobacteriaceae in German hospitals. Data from 2007 to 2012 from two components of the German national nosocomial infection surveillance system were used for this analysis. The data derive from intensive care units and surgical departments. Independent factors determining the proportion of ESBL-positive Enterobacteriaceae among nosocomial infections due to Enterobacteriaceae and changes in its regional distribution (broken down into German federal states) were calculated by regression analysis. From 2007 to 2012, the data showed a significantly increasing proportion of ESBL-positive Enterobacteriaceae in surgical site infections (from 11.46 to 15.38, 134%, p 0.003), urinary tract infections (9.36 to 16.56, 177%, p <0.001) and lower respiratory tract infections (11.91 to 14.70, 123%, p <0.001) due to Enterobacteriaceae. Factors independently associated with a growing proportion were: Thuringia (p 0.009; odds ratio (OR) 1.53), North Rhine-Westphalia (p <0.001; OR 1.41) and general surgery ward (p 0.002; OR 1.47). The proportion of ESBL-positive Enterobacteriaceae in nosocomial infections has significantly increased in Germany over the last 6 years. Hospitals in Central Germany and surgical departments in all of Germany are especially affected by this development.

Prevalence of carbapenem-resistant organisms and other Gram-negative MDRO in German ICUs: first results from the national nosocomial infection surveillance system (KISS).

PURPOSE: Standardized prevalence and incidence data on carbapenem-resistant organisms (CRO) and, as a relevant subgroup, carbapenem-resistant Enterobacteriaceae (CRE) are scarce. CRO-surveillance within the German nosocomial infection surveillance system (KISS) aims to provide epidemiological surveillance data on CRO colonizations and infections. METHODS: CRO-surveillance is part of a KISS-module for the surveillance of multidrug-resistant organisms (MDRO). MDRO-KISS methods require surveillance of all patients admitted to the ward and standardized documentation of imported and ICU-acquired cases. Data on all MDRO-carriers including colonization and infection with MDRO are collected. All presented data were routine data collected from January 1st 2013 until December 1st 2013 in accordance with the German Protection against Infection Act (IfSG). RESULTS: 341 ICUs submitted data on MDRO during the first year. In total, 5,171 cases of multidrug-resistant Gram-negative bacteria (MRGN) were identified. 848 were CRO (16%). 325 CRO-cases were acquired within the ICU (38%), and 373 CRO-patients had an infection (44%). CRO-prevalence was 0.29 per 100 patients. Acquisition rate of MRGN was 1.32 per 1,000 patient days. This rate is more than doubled the acquisition rates of other MDRO under surveillance within MDRO-KISS (0.57 MRSA, 0.49 VRE). CRO-acquisition rate was 0.3 per 1,000 patient days. Incidence density of MRGN infections bacteria was 0.58 per 1,000 patient days (CRO 0.15/1,000 patient days). CONCLUSIONS: To date, CRO are common in German ICUs and the relatively large proportions of ICU-acquired CRO and infections emphasize their potential to cause outbreaks. High MRGN infection rates and high ESBL prevalence data from clinical studies suggest a lack of MRGN identification in asymptomatic carriers.

Female sex protects from organ failure and sepsis after major trauma haemorrhage.

INTRODUCTION: Biological sex is considered a risk factor for adverse outcome after major trauma. We hypothesized that female sex is protective against organ failure, sepsis and mortality in patients with traumatic haemorrhage. PATIENTS AND METHODS: We selected patients from TraumaRegister DGU(®) (TR-DGU) with primary admission for blunt trauma with an injury severity score ≥ 16 and an ICU stay ≥ 3 days that presented with relevant bleeding in the years 2007-2012. Relevant bleeding was defined as Abbreviated Injury Scale (AIS) ≥ 3 with an estimated blood loss exceeding 20%, any femoral shaft fracture, any pelvic clamp as surrogate for unstable pelvic fracture or the presence of at least one criteria of haemorrhagic shock: shock index of 0.8-1.4; base excess of -2.0 to -10.0 mmol/L; body temperature ≤ 34°C; transfusion of ≥ 4 units of packed red blood cells; application of recombinant activated factor VII; any embolization during trauma room phase and pre-hospital resuscitation volume ≥ 3000 ml or any catecholamine use during pre-hospital care in the absence of cardiopulmonary resuscitation. A total of 7560 males and 2774 females were selected and analyzed for sex differences. RESULTS: Higher rates of multiple organ failure (24.4 vs. 21.3%, Odds ratio [OR] 1.19 (95% confidence interval [95%CI] 1.07-1.33), p=0.001*) and sepsis (16.5 vs. 11.3%, OR 1.55 (95%CI 1.35-1.77), p<0.001*) were observed in males. Organ function of lung, cardio-circulatory system, liver and kidney were better in females, however, there was no difference in mortality. Stratification by age group revealed that in particular age-group 16-44 years was related to improved organ function which may indicate effects of sex hormones in females at reproductive age. Increased rates of sepsis in males were observed throughout virtually all age groups starting at 16 years of age, except in age group 54-64 years. This may suggest suppressive effect of testosterone on immune function. CONCLUSIONS: Our study supports the hypothesis that female sex is associated with improved organ function following traumatic injury and haemorrhagic shock, in particular in age groups that are at reproductive age. However, further studies are warranted before sex steroids can be deployed as therapeutic intervention in critically ill trauma patients.

[Compliance with national guidelines for the prevention of central venous catheter-associated-infections in German intensive care units]. / Umsetzung nationaler Empfehlungen zur Prävention zentraler Gefäßkatheter-assoziierter Infektionen auf deutschen Intensivstationen.

BACKGROUND AND OBJECTIVE: Aim of the survey was to determine the compliance with national guidelines for the prevention of central venous catheter (CVC)-associated bloodstream infection in German intensive care units (ICUs). METHODS: Within the pan-European PROHIBIT (Prevention of Hospital Infections by Intervention and Training) survey on infection control an online-questionnaire was answered by German ICU staff. Questions concerned insertion and handling of CVC. Continuous data are presented in median including interquartile range (IQR); categorical parameters are summarized by percentage. RESULTS: Ninety-two percent of ICUs created local guidelines for the prevention of CVC-associated sepsis according to national guidelines. Eleven percent did not provide educational sessions for health care workers concerning sepsis prevention routinely. The subclavian vein was the favored insertion site in 17 % of ICUs. A standardized approach for daily assessment of the need of the CVC was established in 39 % of ICUs. Impregnated (antiseptic or antibiotic) CVCs were used by every fourth ICU. Single-use vials were not used as single-use vials by a third of ICUs. CONCLUSION: There are still many German ICUs in which national guidelines are not implemented. Training of staff is necessary to raise awareness for prevention measures and to contribute to a good quality of patient care.

Three years of national hand hygiene campaign in Germany: what are the key conclusions for clinical practice?

The World Health Organization (WHO) started the 'Clean Care is Safer Care' campaign in 2005. Since then, more than 120 countries have pledged to improve hand hygiene as a keystone of their national or subnational healthcare-associated infection prevention programmes. Thirty-eight countries have implemented national campaigns. Germany started a national campaign to improve hand hygiene compliance on 1 January 2008. The campaign, 'AKTION Saubere Hände', is funded by the German Ministry of Health and was initiated by the National Reference Centre for the Surveillance of Nosocomial Infections, the Society for Quality Management in Health Care and the German Coalition for Patient Safety. The campaign is designed as a multi-modal campaign based on the WHO implementation strategy. Since the end of 2010, more than 700 healthcare institutions have been actively participating in the campaign, among which are 28 university hospitals. Voluntarily participating hospitals have to implement the following measures: active support by hospital administrators of local campaign implementation, participation in a one-day introductory course, education of healthcare workers at least once a year, measurement of alcohol-based hand-rub consumption (AHC) and feedback on resulting data, implementation of the WHO 'My Five Moments for Hand Hygiene' model, increase in hand-rub availability, participation in national hand hygiene day at least every two years, and participation in national campaign network workshops at least once every two years. Observational studies to measure hand hygiene compliance are optional. Overall, there has been a significant increase of 11% in hand hygiene compliance in 62 hospitals that observed compliance before and after intervention. A total of 129 hospitals provided AHC data for three years and achieved an overall increase of 30.7%. The availability of alcohol-based hand rub increased from 86.8% to > 100% in intensive care units and from 63.6% to 91.3% in non-intensive care units. Overall, the implementation of a national campaign using the WHO multi-modal intervention strategy has led to improved hand hygiene compliance and hand-rub availability in participating settings.