Redundant Anaerobic Antimicrobial Prescriptions in German Acute Care Hospitals: Data from a National Point Prevalence Survey

Despite limited indications, redundant anaerobic antimicrobial prescriptions (RAAPs) are frequent. The objective of this study was to assess the prevalence and characteristics of RAAPs in German acute care hospitals. In a retrospective data analysis, antimicrobial prescriptions from a point prevalence survey on antimicrobial use in German acute care hospitals in 2016 were analyzed and RAAPs were identified. RAAPs were defined as a patient simultaneously receiving any of the following combinations: Penicillin/beta-lactamase inhibitor (PenBLI) plus clindamycin; PenBLI plus metronidazole; PenBLI plus moxifloxacin; PenBLI plus carbapenem; carbapenem plus clindamycin; carbapenem plus metronidazole; carbapenem plus moxifloxacin; clindamycin plus metronidazole; clindamycin plus moxifloxacin; and metronidazole plus moxifloxacin. Data from 64,412 patients in 218 hospitals were included. Overall, 4486 patients (7%) received two or more antimicrobials. In total, 441 RAAP combinations were identified. PenBLI plus metronidazole was the most common anaerobic combination (N = 166, 38%). The majority of RAAPs were for the treatment of community-acquired (N = 258, 59%) infections. Lower respiratory tract infections (N = 77; 20%) and skin/soft tissue infections (N = 76; 20%) were the most frequently recorded types of infections. RAAPs are common in German hospitals. Reducing redundant antimicrobial coverage should be a key component of future antimicrobial stewardship activities

Lean back and wait for the alarm? Testing an automated alarm system for nosocomial outbreaks to provide support for infection control professionals

INTRODUCTION: Outbreaks of communicable diseases in hospitals need to be quickly detected in order to enable immediate control. The increasing digitalization of hospital data processing offers potential solutions for automated outbreak detection systems (AODS). Our goal was to assess a newly developed AODS. METHODS: Our AODS was based on the diagnostic results of routine clinical microbiological examinations. The system prospectively counted detections per bacterial pathogen over time for the years 2016 and 2017. The baseline data covers data from 2013-2015. The comparative analysis was based on six different mathematical algorithms (normal/Poisson and score prediction intervals, the early aberration reporting system, negative binomial CUSUMs, and the Farrington algorithm). The clusters automatically detected were then compared with the results of our manual outbreak detection system. RESULTS: During the analysis period, 14 different hospital outbreaks were detected as a result of conventional manual outbreak detection. Based on the pathogens' overall incidence, outbreaks were divided into two categories: outbreaks with rarely detected pathogens (sporadic) and outbreaks with often detected pathogens (endemic). For outbreaks with sporadic pathogens, the detection rate of our AODS ranged from 83% to 100%. Every algorithm detected 6 of 7 outbreaks with a sporadic pathogen. The AODS identified outbreaks with an endemic pathogen were at a detection rate of 33% to 100%. For endemic pathogens, the results varied based on the epidemiological characteristics of each outbreak and pathogen. CONCLUSION: AODS for hospitals based on routine microbiological data is feasible and can provide relevant benefits for infection control teams. It offers in-time automated notification of suspected pathogen clusters especially for sporadically occurring pathogens. However, outbreaks of endemically detected pathogens need further individual pathogen-specific and setting-specific adjustments

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 Charite 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

Risk factors for nosocomial SARS-CoV-2 infections in patients: results from a retrospective matched case–control study in a tertiary care university center

Background: Factors contributing to the spread of SARS-CoV-2 outside the acute care hospital setting have been described in detail. However, data concerning risk factors for nosocomial SARS-CoV-2 infections in hospitalized patients remain scarce. To close this research gap and inform targeted measures for the prevention of nosocomial SARS-CoV-2 infections, we analyzed nosocomial SARS-CoV-2 cases in our hospital during a defined time period. Methods: Data on nosocomial SARS-CoV-2 infections in hospitalized patients that occurred between May 2020 and January 2021 at Charite university hospital in Berlin, Germany, were retrospectively gathered. A SARS-CoV-2 infection was considered nosocomial if the patient was admitted with a negative SARS-CoV-2 reverse transcription polymerase chain reaction test and subsequently tested positive on day five or later. As the incubation period of SARS-CoV-2 can be longer than five days, we defined a subgroup of "definite" nosocomial SARS-CoV-2 cases, with a negative test on admission and a positive test after day 10, for which we conducted a matched case-control study with a one to one ratio of cases and controls. We employed a multivariable logistic regression model to identify factors significantly increasing the likelihood of nosocomial SARS-CoV-2 infections. Results: A total of 170 patients with a nosocomial SARS-CoV-2 infection were identified. The majority of nosocomial SARS-CoV-2 patients (n = 157, 92%) had been treated at wards that reported an outbreak of nosocomial SARS-CoV-2 cases during their stay or up to 14 days later. For 76 patients with definite nosocomial SARS-CoV-2 infections, controls for the case-control study were matched. For this subgroup, the multivariable logistic regression analysis revealed documented contact to SARS-CoV-2 cases (odds ratio: 23.4 (95% confidence interval: 4.6-117.7)) and presence at a ward that experienced a SARS-CoV-2 outbreak (odds ratio: 15.9 (95% confidence interval: 2.5-100.8)) to be the principal risk factors for nosocomial SARS-CoV-2 infection. Conclusions: With known contact to SARS-CoV-2 cases and outbreak association revealed as the primary risk factors, our findings confirm known causes of SARS-CoV-2 infections and demonstrate that these also apply to the acute care hospital setting. This underscores the importance of rapidly identifying exposed patients and taking adequate preventive measures

Using surveillance data to investigate risk factors for surgical site infections

Postoperative Wundinfektionen (WI) gehörten bei den bisher in Deutschland durchgeführten Punktprävalenzerhebungen zu den häufigsten nosokomialen Infektionen. Extrapolationen der Prävalenzdaten konnten zeigen, dass WI mit einer erheblichen Krankheitslast und Letalität vergesellschaftet sind. Die Identifikation von Risikofaktoren, die das Auftreten von WI begünstigen, stellt eine Voraussetzung dar, um präventive Strategien zur Vermeidung von WI zu entwickeln und anzupassen. In der Auseinandersetzung mit WI-Risikofaktoren ist eine Unterteilung in operationsbezogene, patientenbezogene und andere Risikofaktoren hilfreich. Ein bislang wenig untersuchter operationsbezogener Risikofaktor ist die Dringlichkeit der durchgeführten Operation. Eine Analyse von Surveillancedaten der Indikator-Operationen „Sectio Caesarea“ und „Eingriffe am Kolon“ des Moduls „OP-KISS“ des Krankenhaus-Infektions-Surveillance-Systems aus den Jahren 2017 bis einschließlich 2019 zeigte, dass notfallmäßig durchgeführte Sectiones mit einem signifikant höheren WI-Risiko assoziiert waren als elektiv durchgeführte Eingriffe. Bei Eingriffen am Kolon waren dahingehend keine signifikanten Unterschiede zu beobachten. Die Geschlechtszugehörigkeit als potentieller patientenbezogener WI-Risikofaktor wurde im Rahmen einer retrospektiven Analyse, die OP-KISS Daten der Jahre 2008 bis einschließlich 2017 beinhaltete, untersucht. Es zeigte sich eine generelle Assoziation zwischen männlichem Geschlecht und einem erhöhten WI-Risiko. Im Hinblick auf einzelne operative Fachgebiete zeigten sich jedoch Unterschiede. Zwar war das WI-Risiko nach abdominalchirurgischen und orthopädischen bzw. traumatologischen Operationen bei männlichen Patienten signifikant höher als bei weiblichen Patientinnen, hinsichtlich herz- und gefäßchirurgischer Operationen war jedoch eine inverse Assoziation zu beobachten. Mit einer weiteren Analyse, die ebenfalls retrospektiv auf OP-KISS Daten basierte und über 2 000 000 Operationen aus 17 Jahren einschloss, konnte dokumentiert werden, dass die Wahrscheinlichkeit des Auftretens von WI saisonalen, durch die durchschnittliche Außentemperatur im Operationsmonat bedingten Schwankungen unterlag. Operationen, die in wärmeren Monaten durchgeführt wurden, waren mit einem höheren WI-Risiko assoziiert. Besonders stark war diese Assoziation bei WI, die durch gramnegative Erreger verursacht wurden, ausgeprägt. Ein wichtiges Ziel der Identifikation von WI-Risikofaktoren ist es zur Wissensgrundlage für angepasste Präventionsmaßnahmen beizutragen.Several point prevalence surveys on healthcare-associated infections, have shown surgical site infections (SSI) to be among the most frequently occurring healthcare-associated infections in German hospitals. Extrapolations of prevalence data have demonstrated that SSI are associated with a substantial burden of disease and mortality. The identification of risk factors for SSI represents a crucial prerequisite to develop and adapt SSI prevention strategies. When considering risk factors for SSI, a distinction into procedure-related, patient-related, and other risk factors is helpful. A procedure-related risk factor that has not been examined extensively yet, is the urgency of the procedure. An analysis of surveillance data of the indicator procedures "Caesarean section" and "Colon surgery" of the module "OP-KISS" of the German Nosocomial Infection Surveillance System (KISS) from 2017 to 2019 revealed that urgently performed caesarean sections were associated with a significantly higher likelihood of SSI occurrence than electively performed procedures. No significant differences were observed in this regard for colon surgeries. Gender as a potential patient-related risk factor for SSI was investigated in a retrospective analysis that included OP-KISS data from 2008 to 2017. A general association between male gender and increased risk of SSI was observed. Differences, however, were discovered concerning specific types of surgery. The risk of SSI following abdominal surgery as well as orthopaedic and trauma surgery was significantly higher in male patients than in female patients. For cardiac and vascular surgery, however, an inverse association was observed. Another retrospective analysis based on OP-KISS data with more than 2 000 000 procedures over 17 years included, revealed that the likelihood of SSI occurrence was heavily influenced by the average outdoor temperature in the month of surgery. Procedures performed during warmer months were associated with a higher risk of SSI. This association was particularly strong for SSI caused by gram-negative pathogens. An important objective of identifying risk factors for SSI is to inform the development of appropriate preventive measures

Comparison of single-port laparoscopy with conventional multi-port laparoscopy in selected urological operations

LESS (engl. Laparo-Endoscopic Single-Site Surgery) ist eine Form der laparoskopischen „Single-Port“ Technik und stellt eine Weiterentwicklung der konventionellen Laparoskopie dar. Bei dieser muss für jedes Operationsinstrument ein eigener Trokar in die Bauchhöhle eingeführt werden. Bei der LESS hingegen wird ein einziger, meist trichterförmiger Trokar (Single-Port), durch den Bauchnabel eingeführt, wobei über die Trichteröffnung mehrere Instrumente gleichzeitig in das Operationsgebiet eingebracht werden können. Je nach Modell und Hersteller verfügt jeder Single-Port über eine variable Anzahl von Instrumentenöffnungen. Befürworter der LESS Technik führen vor allem das verbesserte kosmetische Ergebnis und das geringere Schmerzempfinden bei einer umbilikalen Wunde als Vorteile ins Feld. Gegner dieser Technik verweisen auf die erschwerte Manövrierbarkeit der Instrumente und die damit verbundene lange Lernkurve. An der Urologischen Klinik der Charité Universitätsmedizin Berlin wurde die technische Machbarkeit von LESS anhand der laparoskopischen Varikozelektomie, der pelvinen Staging- Lymphadenektomie (PLA) bei Prostatakarzinom-Patienten und der Nephrektomie bewiesen. Die in dieser Arbeit mit der LESS Technik operierte Kohorte umfasst 43 Patienten. Um eine potentielle Überlegenheit von LESS gegenüber der konventionellen Laparoskopie zu prüfen, wurden deren intra- und postoperative Ergebnisse mit denen von konventionell laparoskopischen Eingriffen retrospektiv verglichen. In dieser Arbeit konnte gezeigt werden, dass LESS eine sichere und effektive Alternative zur konventionellen Laparoskopie für die Durchführung der Varikozelektomie und der PLA darstellt. Nach diesen beiden LESS Eingriffen sahen sich die Patienten signifikant früher in der Lage das Krankenhaus zu verlassen als nach konventioneller Laparoskopie. Beim postoperativen Schmerzempfinden zeigten sich nur geringfügige Unterschiede zugunsten der LESS. Alle mit LESS operierten Patienten waren mit dem kosmetischen Ergebnis äußerst zufrieden. Bei der LESS Nephrektomie waren die Ergebnisse insgesamt noch nicht überzeugend, was an der im Verhältnis zur langen Lernkurve zu geringen Fallzahl liegen könnte. Eine Ausweitung von LESS in der Urologie erscheint, angesichts der raschen Fortschritte auf dem Gebiet der minimalinvasiven Chirurgie und der gestiegenen Patientenansprüche, gerechtfertigt.LESS (English laparo - Endoscopic Single-Site Surgery) represents a new form of conventional laparoscopy. Conventional laparoscopy requires the introduction of a separate trocar into the abdominal cavity for every surgical instrument. LESS, however, employs a single, usually funnel-shaped trocar (single-port) which is inserted through the umbilical region. It allows for multiple instruments to be introduced simultaneously into the operating area through one trocar. Depending on the model and manufacturer, each single-port has a variable number of openings. Proponents of the LESS technique point to the improved cosmetic result and the lower postoperative pain as advantages. Opponents of LESS refer to the difficult manoeuvrability of instruments and the long learning curve associated with it. At the Urological Clinic of the Charité Universitätsmedizin Berlin, the technical feasibility of LESS-based laparoscopic varicocelectomy, staging pelvic lymphadenectomy (PLA) in prostate cancer patients and nephrectomy was demonstrated. The cohort of LESS patients in this study includes 43 patients. To examine a potential superiority of LESS over conventional laparoscopy, the intra-and postoperative results were retrospectively compared with those of conventional laparoscopic surgery. In this study it was shown that LESS is a safe and effective alternative to conventional laparoscopy for the conduction of varicocelectomies and pelvic lymphadenectomies. In these two groups LESS patients were significantly earlier able to leave the hospital than patients after conventional laparoscopy. Postoperative pain showed only minor differences in favour of LESS. All LESS patients were extremely satisfied with the cosmetic outcome. For LESS nephrectomy the overall results were not convincing, which could be due to the small number of cases in relation to the long learning curve. Given the rapid advances in the field of minimally invasive surgery and increased patient demands, an expansion of LESS to other laparoscopic urological procedures appears justified

A national survey on the implementation of key infection prevention and control structures in German hospitals: results from 736 hospitals conducting the WHO Infection Prevention and Control Assessment Framework (IPCAF)

Abstract Background Healthcare-associated infections (HAI) pose a burden on healthcare providers worldwide. To prevent HAI and strengthen infection prevention and control (IPC) structures, the WHO has developed a variety of tools and guidelines. Recently, the WHO released the Infection Prevention and Control Assessment Framework (IPCAF), a questionnaire-like tool designed for assessing IPC structures at the facility level. The IPCAF reflects the eight WHO core components of IPC. Data on the implementation of IPC measures in German hospitals are scarce. Therefore, it was our objective to utilize the IPCAF in order to gather information on the current state of IPC implementation in German hospitals, as well as to promote the IPCAF to a broad audience. Methods The National Reference Center for Surveillance of Nosocomial Infections (NRZ) sent a translated version of the IPCAF to 1472 acute care hospitals in Germany. Data entry and transfer to the NRZ was done electronically between October and December 2018. The IPCAF was conceived in a way that depending on the selected answers a score was calculated, with 0 being the lowest possible and 800 the highest possible score. Depending on the overall score, the IPCAF allocated hospitals to four different “IPC levels”: inadequate, basic, intermediate, and advanced. Results A total of 736 hospitals provided a complete dataset and were included in the data analysis. The overall median score of all hospitals was 690, which corresponded to an advanced level of IPC. Only three hospitals (0.4%) fell into the category “basic”, with 111 hospitals (15.1%) being “intermediate” and 622 hospitals (84.5%) being “advanced”. In no case was the category “inadequate” allocated. More profound differences were found between the respective core components. Components on multimodal strategies and workload, staffing, ward design and bed occupancy revealed the lowest scores. Conclusions IPC key aspects in general are well established in Germany. Potentials for improvement were identified particularly with regard to workload and staffing. Insufficient implementation of multimodal strategies was found to be another relevant deficit. Our survey represents a successful attempt at promoting the IPCAF and encouraging hospitals to utilize WHO tools for self-assessment

Point prevalence survey of peripheral venous catheter usage in a large tertiary care university hospital in Germany

Abstract Background Bloodstream infections (BSI) are among the most frequently documented healthcare-associated infections (HAI). Central and peripheral venous catheters (CVC and PVC) are relevant risk factors for BSI. Although the risk for BSI is higher for CVC, PVC are utilized more frequently and are therefore relevant in the context of HAI prevention. Robust data on the prevalence of PVC and associated infections in German hospitals are scarce to this date. The objectives of this survey were to estimate the prevalence of PVC and PVC-associated infections on peripheral wards of a large tertiary care hospital in Germany. The collected data may be utilized for a tailored infection prevention intervention in the future. Methods A point prevalence survey was conducted on peripheral wards of a tertiary care hospital with more than 3.000 beds. Data were collected between August 2017 and February 2018. Standardized data collection forms were used for collecting ward, patient and PVC-related data. As endpoints, prevalence of patients with PVC, PVC-associated infections and PVC without usage in the 24 h prior to the survey and without documentation of intended usage in the 24 h after the survey (“unused PVC”) were chosen. For data analysis, Kruskal-Wallis test was employed for continuous variables and Chi-squared test or Fisher’s exact test for categorical variables. Multivariable analysis and logistic regression were performed for the endpoint unused PVC. Results Data from 2.092 patients on 110 wards were collected. The overall prevalence of patients with PVC was 33%. Infections were recorded in 16 patients. Except one case of BSI, these were all local infections at the site of insertion. Of 725 documented PVC, 77 (11%) were unused PVC. Multivariate analysis and logistic regression revealed wards with the practice of regularly obtaining blood from PVC, PVC with dirty or loose insertion dressing, pediatric ward specialty and last inspection of the PVC more than 1 day ago as significant risk factors for unused PVC. Conclusions A substantial proportion of patients presented with a PVC on the day of survey. Too few infections were recorded to allow for more detailed analyses. Various risk factors for unused PVC were identified. We hereby present a solid method to obtain an overview about PVC use and to increase awareness for PVC-associated risks. The limitations of point prevalence surveys have to be recognized