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

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

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

Pathogen-specific mortality in very low birth weight infants with primary bloodstream infection.

Mortality in very low birth weight infants following microbiology confirmed primary bloodstream infections varies with the type of causative pathogen. Given evidence from other studies that infections with gram negative bacteria and fungi cause a higher case fatality risk. We tried to confirm this in a nation-wide multi-center trial.A cohort of 55,465 very low birth weight infants from 242 neonatal departments participating in the German national neonatal infection surveillance system NEO-KISS was used to investigate differences in the case fatality risk of microbiology confirmed primary bloodstream infections according to individual pathogens. Cox proportional hazard regression analyses were performed with the outcomes death and time from microbiology confirmed primary bloodstream infections. The results were adjusted to the recorded risk factors and hospital and department characteristics.A total of 4 094 very low birth weight infants with microbiology confirmed primary bloodstream infections were included in the analysis. The crude case fatality risk was 5.7%. The Cox proportional hazard regression analysis with adjustment for available risk factors revealed that microbiology confirmed primary bloodstream infections caused by Klebsiella spp. (HR 3.17 CI95 1.69-5.95), Enterobacter spp. (HR 3.42 CI95 1.86-6.27), Escherichia coli (HR 3.32 CI95 1.84-6.00) and Serratia spp. (HR 3.30 CI95 1.44-7.57) were associated with significantly higher case fatality risk compared to Staphylococcus aureus. After adjusting, case fatality risk of Candida albicans causing microbiology confirmed primary bloodstream infections was not higher than that of S. aureus.In very low birth weight infants, bloodstream infections caused by gram negative pathogens have an increased case fatality risk compared to bloodstream infections caused by gram positive pathogens. This should be considered for prevention and therapy. Further research should address the specific risk factors for case fatality of C. albicans bloodstream infections

SARS-Coronavirus-2 cases in healthcare workers may not regularly originate from patient care: lessons from a university hospital on the underestimated risk of healthcare worker to healthcare worker transmission

Background: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents an unprecedented healthcare challenge. Various SARS-CoV-2 outbreaks in healthcare facilities have been reported. Healthcare workers (HCWs) may play a critical role in the spread of the virus, particularly when asymptomatic. We examined four healthcare-associated outbreaks of SARS-CoV-2 infections that occurred at a university hospital in Berlin, Germany. We aimed to describe and analyze the spread of the virus in order to draw conclusions for effective containment of SARS-CoV-2 in healthcare facilities. Methods: Healthcare-associated outbreaks of SARS-CoV-2 infections were defined as two or more laboratory confirmed infections with SARS-CoV-2 where an epidemiological link within the healthcare setting appeared likely. We focused our analysis on one of three sites of the Charite-University Medicine hospital within a 2 month period (March and April 2020). Results: We observed four healthcare-associated outbreaks of SARS-CoV-2 infections, with a total of 24 infected persons (23 HCWs and one patient). The outbreaks were detected in the departments of nephrology and dialysis (n = 9), anesthesiology (n = 8), surgical pediatrics (n = 4), and neurology (n = 3). Each outbreak showed multiple unprotected contacts between infected HCWs. A combination of contact tracing, testing, physical distancing and mandatory continuous wearing of face masks by all HCWs was able to contain all four outbreaks. Conclusions: HCW to HCW transmission represented the likely source of the four outbreaks. Ensuring proper physical distancing measures and wearing of protective equipment, also when interacting with colleagues, must be a key aspect of fighting COVID-19 in healthcare facilities