Protective Effect of Dual-Strain Probiotics in Preterm Infants: A Multi-Center Time Series Analysis

Objective To determine the effect of dual-strain probiotics on the development of necrotizing enterocolitis (NEC), mortality and nosocomial bloodstream infections (BSI) in preterm infants in German neonatal intensive care units (NICUs). Design A multi-center interrupted time series analysis. Setting 44 German NICUs with routine use of dual-strain probiotics on neonatal ward level. Patients Preterm infants documented by NEO-KISS, the German surveillance system for nosocomial infections in preterm infants with birth weights below 1,500 g, between 2004 and 2014. Intervention Routine use of dual-strain probiotics containing Lactobacillus acidophilus and Bifidobacterium spp. (Infloran) on the neonatal ward level. Main outcome measures Incidences of NEC, overall mortality, mortality following NEC and nosocomial BSI. Results Data from 10,890 preterm infants in 44 neonatal wards was included in this study. Incidences of NEC and BSI were 2.5% (n = 274) and 15.0%, (n = 1631), respectively. Mortality rate was 6.1% (n = 665). The use of dual-strain probiotics significantly reduced the risk of NEC (HR = 0.48; 95% CI = 0.38–0.62), overall mortality (HR = 0.60, 95% CI = 0.44–0.83), mortality after NEC (HR = 0.51, 95% CI = 0.26–0.999) and nosocomial BSI (HR = 0.89, 95% CI = 0.81–0.98). These effects were even more pronounced in the subgroup analysis of preterm infants with birth weights below 1,000 g. Conclusion In order to reduce NEC and mortality in preterm infants, it is advisable to add routine prophylaxis with dual-strain probiotics to clinical practice in neonatal wards

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

Tolerance of biofilm of a carbapenem-resistant Klebsiella pneumoniae involved in a duodenoscopy-associated outbreak to the disinfectant used in reprocessing

Background One possible transmission route for nosocomial pathogens is contaminated medical devices. Formation of biofilms can exacerbate the problem. We report on a carbapenemase-producing Klebsiella pneumoniae that had caused an outbreak linked to contaminated duodenoscopes. To determine whether increased tolerance to disinfectants may have contributed to the outbreak, we investigated the susceptibility of the outbreak strain to disinfectants commonly used for duodenoscope reprocessing. Disinfection efficacy was tested on planktonic bacteria and on biofilm. Methods Disinfectant efficacy testing was performed for planktonic bacteria according to EN standards 13727 and 14561 and for biofilm using the Bead Assay for Biofilms. Disinfection was defined as ≥ 5log10 reduction in recoverable colony forming units (CFU). Results The outbreak strain was an OXA-48 carbapenemase-producing K. pneumoniae of sequence type 101. We found a slightly increased tolerance of the outbreak strain in planktonic form to peracetic acid (PAA), but not to other disinfectants tested. Since PAA was the disinfectant used for duodenoscope reprocessing, we investigated the effect of PAA on biofilm of the outbreak strain. Remarkably, disinfection of biofilm of the outbreak strain could not be achieved by the standard PAA concentration used for duodenoscope reprocessing at the time of outbreak. An increased tolerance to PAA was not observed in a K. pneumoniae type strain tested in parallel. Conclusions Biofilm of the K. pneumoniae outbreak strain was tolerant to standard disinfection during duodenoscope reprocessing. This study establishes for the first time a direct link between biofilm formation, increased tolerance to disinfectants, reprocessing failure of duodenoscopes and nosocomial transmission of carbapenem-resistant K. pneumoniae.Peer Reviewe

An outbreak of carbapenem-resistant OXA-48 – producing Klebsiella pneumonia associated to duodenoscopy

Background Carbapenemase-producing Enterobacteriaceae (CPE) have become a major problem for healthcare systems worldwide. While the first reports from European hospitals described the introduction of CPE from endemic countries, there is now a growing number of reports describing outbreaks of CPE in European hospitals. Here we report an outbreak of Carbapenem-resistant K. pneumoniae in a German University hospital which was in part associated to duodenoscopy. Findings Between December 6, 2012 and January 10, 2013, carbapenem-resistant K. pneumoniae (CRKP) was cultured from 12 patients staying on 4 different wards. The amplification of carbapenemase genes by multiplex PCR showed presence of the bla OXA-48 gene. Molecular typing confirmed the identity of all 12 isolates. Reviewing the medical records of CRKP cases revealed that there was a spatial relationship between 6 of the cases which were located on the same wards. The remaining 6 cases were all related to endoscopic retrograde cholangiopancreatography (ERCP) which was performed with the same duodenoscope. The outbreak ended after the endoscope was sent to the manufacturer for maintenance. Conclusions Though the outbreak strain was also disseminated to patients who did not undergo ERCP and environmental sources or medical personnel also contributed to the outbreak, the gut of colonized patients is the main source for CPE. Therefore, accurate and stringent reprocessing of endoscopic instruments is extremely important, which is especially true for more complex instruments like the duodenoscope (TJF Q180V series) involved in the outbreak described here

A web-based app to provide personalized recommendations for COVID-19

Peer Reviewe

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

Seasonal variations of nosocomial infections

Für viele Infektionskrankheiten sind saisonale Schwankungen in der Inzidenz bekannt, aber es ist bisher nicht in großem Umfang und systematisch untersucht worden, ob diese Schwankungen auch bei nosokomialen Infektionen bestehen. Dies ist von Bedeutung, da relevante saisonale Schwankungen bei der Planung von Studien zur Infektionsprävention berücksichtigt werden müssten und zudem eventuell zu saisonalen Anpassungen von Hygienemaßnahmen führen würden. Im Rahmen dieser Untersuchung sollten saisonale Schwankungen in der Inzidenzdichte der wichtigsten nosokomialen Infektionen und ihrer häufigsten Erreger ermittelt werden. Hierzu wurde die Referenzdatenbank der Surveillance- Module für Intensivpatienten (ITS-KISS) und operierte Patienten (OP-KISS) des Krankenhaus-Infektions-Surveillance-Systems (KISS) für den Zeitraum Januar 2000 bis Dezember 2009 analysiert. Die Definition der Jahreszeiten erfolgte anhand von frei verfügbaren Klimadaten des Deutschen Wetterdienstes. Für ITS- KISS wurden Inzidenzdichten (Infektionen/1000 Patiententage) und Inzidenzdichteverhältnisse, für OP-KISS wurden Inzidenzen (Infektionen/100 operierte Patienten) und Relative Risiken, jeweils mit den 95%-Konfidenzintervallen berechnet. In die Analyse gingen 8.680.283 Patiententage und 42.603 Infektionen aus 597 Intensivstationen sowie 767.970 Operationen und 13.586 postoperative Wundinfektionen aus 595 operativen Abteilungen ein. Es wurde gegenüber der Übergangszeit im Frühling/Herbst sowohl eine signifi-kante Zunahme der primären Sepsis im Sommer (Inzidenzdichteverhältnis 1,10 [1,05-1,16]) und eine signifikante Abnahme im Winter (Inzidenzdichteverhältnis 0,89 [0,84-0,94]) als auch eine signifikante Zunahme der Infektionen der unteren Atemwege im Sommer (Inzidenzdichte- verhältnis 1,08 [1,05-1,12]) und eine signifikante Abnahme im Winter (Inzidenzdichteverhältnis 0,96 [0,93-0,999]) festgestellt. Auch im Bereich der postoperativen Wundinfektionen wurde eine signifikante Zunahme im Sommer (Relatives Risiko 1,11 [1,06-1,15]) und eine signifikante Abnahme im Winter (Relatives Risiko 0,95 [0,91-0,99]) ermittelt. Bei den Erregern noso-komialer Infektionen konnten Nonfermenter wie Pseudomonas aeruginosa und Acinetobacter baumannii, Enterobakterien wie Enterobacter spp. und Klebsiella spp. und einige andere Erreger als saisonale Infektionserreger ermittelt werden.For many infectious diseases, seasonal variations in incidence are known, but it has not yet been investigated extensively and systematically whether these variations also exist in nosocomial infections. This is important because seasonal fluctuations should be considered relevant in the planning of studies on infection control and may result in seasonal adjustments of infection control measures. This study was performed in order to determine seasonal variations in the incidence density of nosocomial infections and their most important pathogens. For this purpose, the national reference database for the surveillance of nosocomial infections in intensive care patients (ICU-KISS) and operated patients (OP-KISS) of the German hospital infection surveillance system (KISS) was analyzed for the period from January 2000 to December 2009. The definition of the seasons was based on freely available climate data from the German weather service "Deutscher Wetterdienst". For ICU-KISS, incidence densities (infections/1000 patient-days) and incidence density ratios, for OP- KISS incidences (infections/100 operated patients) and relative risks, were calculated respectively with the 95% confidence intervals. The analysis was based on 8,680,283 patient-days and 42,603 infections from 597 intensive care units and 767,970 operated patients and 13,586 surgical site infections in 595 surgical departments. The results showed both a significant increase in primary sepsis in the summer period (incidence density ratio 1.10 [1.05 to 1.16]) and a significant decrease in winter period (incidence density ratio 0.89 [0.84 -0.94]) and also a significant increase in lower respiratory tract infections in the summer period (incidence density ratio 1.08 [1.05 to 1.12]) and a significant decrease in winter (incidence density ratio 0.96 [0.93 -0.999]) period. The surgical site infections also showed a significant increase in summer (relative risk 1.11 [1.06 to 1.15]) and a significant decrease in winter (relative risk 0.95 [0.91 to 0.99]). Among the most important pathogens of nosocomial infections nonfermenting bacteria such as pseudomonas aeruginosa and acinetobacter baumannii, enterobacteria such as enterobacter spp. and klebsiella spp. and some other pathogens were identified as seasonal infectious agents. The finding that seasonal effects exist in nosocomial infections makes it necessary to consider these effects in the planning, implementation and evaluation of studies. Since the extent of seasonal effects is relatively low, further studies will be necessary to evaluate the effect of the introduction of seasonally adjusted hygiene measures

The step from a voluntary to a mandatory national nosocomial infection surveillance system: the influence on infection rates and surveillance effect

Abstract Background The German national nosocomial infection surveillance system, KISS, has a component for very low birth weight (VLBW) infants (called NEO-KISS) which changed from a system with voluntary participation and confidential data feedback to a system with mandatory participation and confidential feedback. Methods In order to compare voluntary and mandatory surveillance data, two groups were defined by the surveillance start date. Neonatal intensive care unit (NICU) parameters and infection rates of the NICUs in both groups were compared. In order to analyze the surveillance effect on primary bloodstream infection rates (BSI), all VLBW infants within the first three years of participation in both groups were considered. The adjusted effect measures for the year of participation were calculated. Results An increase from 49 NICUs participating in 2005 to 152 in 2006 was observed after the introduction of mandatory participation. A total of 4280 VLBW infants was included in this analysis. Healthcare-associated incidence densities rates were similar in both groups. Using multivariate analysis with the endpoint primary BSI rate and comparing the first and third year of participation lead to an adjusted incidence rate ratio (IRR) of 0.78 (CI95 0.66-0.93) for old (voluntary) and 0.81 (CI95 0.68-0.97) for new (mandatory) participants. Conclusions The step from a voluntary to a mandatory HCAI surveillance system alone may lead to substantial improvements on a countrywide scale.</p