Helga Haefner

Compliance with hand hygiene on surgical, medical, and neurologic intensive care units: Direct observation versus calculated disinfectant usage

BACKGROUND Hand hygiene (HH) is considered the single most effective measure to prevent and control health care-associated infections (HAIs). Although there have been several reports on compliance rates (CRs) to HH recommendations, data for intensive care units (ICUs) in general and for shift- and indication-specific opportunities in particular are scarce. METHODS The aim of this study was to collect data on ICU-, shift-, and indication-specific opportunities, activities and CRs at a surgical ICU (SICU), a medical ICU (MICU), and a neurologic ICU (NICU) at the University Hospital Aachen based on direct observation (DO) and calculated disinfectant usage (DU). RESULTS Opportunities for HH recorded over a 24-hour period were significantly higher for the SICU (188 per patient day [PD]) and MICU (163 per PD) than for the NICU (124 per PD). Directly observed CRs were 39% (73/188) in the SICU, 72% (117/163) in the MICU, and 73% (90/124) in the NICU. However, CRs calculated as a measure of DU were considerably lower: 16% (29/188) in the SICU, 21% (34/163) in the MICU, and 25% (31/124) in the NICU. Notably, CRs calculated from DO were lowest before aseptic tasks and before patient contact. CONCLUSIONS To the best of our knowledge, this study provides the first data picturing a complete day, including shift- and indication-specific analyses, and comparing directly observed CRs with those calculated based on DU, the latter of which revealed a 2.75-fold difference. Worrisomely, CRs were very low, especially concerning indications of greatest impact in preventing HAIs, such as before aseptic task. Thus, the gathering of additional data on CRs and the reasons for noncompliance is warranted.

Impact of Multiresistance of Gram-negative Bacteria in Bloodstream Infection on Mortality Rates and Length of Stay

Background:Bloodstream infections (BSI) with gram-negative bacteria (GNB) are one of the most serious infections in the hospital setting, a situation compounded by the increasing antibiotic resistance of gram-negative bacteria causing BSI. The aim of the study was to assess the impact of antibiotic multiresistance of GNB in BSI on mortality rates and length of stay (LOS).Materials and Methods:The setting was the University Hospital Aachen, a 1,500-bed tertiary-care hospital with over 100 ICU beds providing maximal medical care in all disciplines. We performed a 5-year hospital-wide matched cohort study (January 1996 to February 2001) in which 71 cases and 99 controls were enrolled. Matching criteria were sex, age and GNB isolated in blood cultures. Multiresistance was defined as resistance against at least two different classes of antibiotics such as penicillins (+ β-lactamase-inhibitor), third-generation cephalosporins, fluoroquinolones or carbapenems.Results:BSI were mainly nosocomially acquired, and cases of BSI with multiresistant bacteria were associated with a higher mortality (p = 0.0418) and a prolonged LOS in the intensive care unit (ICU) (p = 0.0049). Risk factors for BSI with multiresistant GNB were antibiotic treatment (p = 0.0191) and mechanical ventilation (p = 0.0283).Conclusion:Multiresistance of GNB causing BSI was associated with higher mortality rates and longer LOS in ICU. The initial antibiotic therapy was significantly more often inadequate and might have had an impact on overall mortality. Thus, an effective strategy to administer an appropriate initial empirical antibiotic therapy, especially in patients with risk factors, must be sought. Moreover, the overall usage of antimicrobials must be limited and infection control guidelines should be followed to reduce the emergence and transmission of multiresistant GNB.

Compliance with hand hygiene in patients with meticillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing enterobacteria.

Hand hygiene is considered to be the single most effective measure to prevent healthcare-associated infection. Although there have been several reports on hand hygiene compliance, data on patients with multidrug-resistant (MDR) organisms in special isolation conditions are lacking. Therefore, we conducted a prospective observational study of indications for, and compliance with, hand hygiene in patients colonised or infected with meticillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum β-lactamase (ESBL)-producing enterobacteria in surgical intensive and intermediate care units. Hand disinfectant used during care of patients with MRSA was measured. Observed daily hand hygiene indications were higher in MRSA isolation conditions than in ESBL isolation conditions. Observed compliance rates were 47% and 43% for the MRSA group and 54% and 51% for the ESBL group in the surgical intensive care unit and the intermediate care unit, respectively. Compliance rates before patient contact or aseptic tasks were significantly lower (17-47%) than after contact with patient, body fluid or patients surroundings (31-78%). Glove usage instead of disinfection was employed in up to 100% before patient contact. However, compliance rates calculated from disinfectant usage were two-fold lower (intensive care: 24% vs 47%; intermediate care: 21% vs 43%). This study is the first to provide data on hand hygiene in patients with MDR bacteria and includes a comparison of observed and calculated compliance. Compliance is low in patients under special isolation conditions, even for the indications of greatest impact in preventing healthcare-associated infections. These data may help to focus measures to reduce transmission of MDR bacteria and improve patient safety.

Improving hand hygiene compliance rates in the haemodialysis setting: more than just more hand rubs

BACKGROUND Haemodialysis patients are at high risk for developing healthcare-associated infections as well as acquiring multidrug-resistant microorganisms. Hand hygiene is considered to be the single most effective tool to prevent healthcare-associated infections. The number of indications and the extent of indication-specific compliance with hand rubs in the haemodialysis setting are currently unknown. METHODS We conducted a prospective, three-phase, observational intervention study on hand hygiene during haemodialysis treatments. Optimized hand hygiene standard operating procedures (SOPs) for dialysis connections (Intervention I) and disconnections (Intervention II) were compiled and implemented during two predefined intervention periods. RESULTS A total of 8897 indications for hand rubs were observed throughout this study. In the course of the study, we identified an increase in the number of hand rubs performed (6-9, mean number per dialysis procedure), parallelled by a decrease in the indications for hand rubs (21-15), resulting in a significant increase of overall hand rub compliance (30-62%). The greatest improvement was seen before aseptic tasks (21-52%), the indication with the greatest impact on preventing healthcare-associated infections. There was no difference between haemodialysis via central venous catheter access or arterio-venous (AV) fistulas. CONCLUSIONS This study provides the first detailed data on the number of and indications for hand rubs during dialysis. An >100% increase in overall hand hygiene compliance could be achieved by a comparably moderate increase in hand rubs performed in combination with optimized hand hygiene SOPs.

Hand hygiene in medical students: Performance, education and knowledge

BACKGROUND Despite several guidelines on hand hygiene (HH), compliance especially in physicians is reported to be low which has huge implications for healthcare-associated infections. To evaluate performance of HH, influence of teaching and influence of monitoring the results in medical students, we conducted an observational study. METHODS Performance of hand disinfection was evaluated in first (N=28), third (N=193) and fifth (N=45) year medical students using fluorescent hand disinfectant. The influence of teaching and information about result control was assessed. The students perception of the impact of HH was also evaluated by a questionnaire. RESULTS Presence of disinfectant gaps was observed significantly more often in first year medical students compared to third year ones (82% vs, 60%; p=0.02). In additional, > 3 gaps were seen significantly more often in first year medical students compared to fifth year students (36% vs. 9%; p=0.007). Both information about teaching and monitoring the results improved outcome significantly. For example, gaps were present in 92% without information and without teaching, in 70% (RR: 1.3 (1.0-1.6); p=0.003) with information about result control only, and in only 18% (5.1 (3.0-8.5); p=0.0001) after teaching. Notably, the medical students ascribed HH to be of a great importance regardless of their level of education. CONCLUSIONS Performance of HH could be improved by practical training as evidenced by best HH performance being documented immediately after teaching and a training effect during the course of medical studies was also observed. Thus, we suggest implementing regular education and practical training on HH from early on in the medical studies curricula to improve overall quality of patient care. regular education and practical training on HH from early on in the medical studies curricula to improve overall quality of patient care.

Diagnostik und Therapie invasiver Pilzinfektionen auf der Intensivstation

Invasive fungal infections are associated with a high mortality and have been increasing in incidence over the last few decades. Candidemia and, less commonly, invasive pulmonary aspergillosis are the most relevant fungal infections in critical care medicine. Risk factors for systemic Candida infections are the use of broad-spectrum antibiotics, a prolonged stay in an intensive care unit and gastrointestinal injury or surgery. Invasive aspergillosis usually occurs in immunocompromised patients. The diagnosis of invasive fungal infections remains challenging. The therapeutic spectrum includes fluconazol, conventional and liposomal amphotericin B, and the recently introduced agents caspofungin and voriconazol. For rational and cost-effective use, the clinician requires precise knowledge of the indications and limitations of these agents. This review focuses on the diagnostic and therapeutic options in severe Candida infections and invasive aspergillosis.

Diagnostics and therapy for invasive fungal infections in an intensive care unit

Invasive fungal infections are associated with a high mortality and have been increasing in incidence over the last few decades. Candidemia and, less commonly, invasive pulmonary aspergillosis are the most relevant fungal infections in critical care medicine. Risk factors for systemic Candida infections are the use of broad-spectrum antibiotics, a prolonged stay in an intensive care unit and gastrointestinal injury or surgery. Invasive aspergillosis usually occurs in immunocompromised patients. The diagnosis of invasive fungal infections remains challenging. The therapeutic spectrum includes fluconazol, conventional and liposomal amphotericin B, and the recently introduced agents caspofungin and voriconazol. For rational and cost-effective use, the clinician requires precise knowledge of the indications and limitations of these agents. This review focuses on the diagnostic and therapeutic options in severe Candida infections and invasive aspergillosis.

Tuberkulose und andere durch Luft übertragbare Infektionserkrankungen: Krankenhaushygiene zur Vermeidung und Eindämmung

Zusammenfassung Die Tuberkulose (TB) gehört weltweit zu den am häufigsten auftretenden Infektionskrankheiten und wird fast ausschließlich über die Luft (aerogen) übertragen. Nachdem in Deutschland die Lungentuberkulosefallzahlen über Jahre hinweg stagnierten, ist seit 2013 wieder ein Anstieg der Inzidenzen zu verzeichnen (RKI 2016). Als Ursache hierfür werden die aktuellen demographischen Entwicklungen (Migration und Mobilität) gesehen. Die Kenntnis der epidemiologischen Situation ist von zentraler Bedeutung, um bei Vorliegen der Verdachtsdiagnose Tuberkulose sowie der Einbeziehung einer möglichen Resistenzproblematik frühzeitig adäquate krankenhaushygienische Maßnahmen einzuleiten. Als aerogen übertragbar werden auch die Aspergillose sowie Masern, Windpocken und Herpes zoster eingestuft (CDC 2007). Die Aspergillose ist eine relativ seltene, aber häufig letal verlaufende Pilzinfektion, die überwiegend bei immunsupprimierten Patienten auftritt. Krankenhaushygienische Schutzmaßnahmen können die Risiken einer Exposition und somit das Erkrankungsrisiko minimieren. Die zentralen Maßnahmen zur Kontrolle und Prävention von aerogen übertragbaren Infektionen sind Gegenstand dieses Kapitels.

P110: Influence of signal coloured hand disinfectant dispensers on compliance at an intensive care unit

Improvement of hand hygiene compliance in all-day setting is crucial and thus a multifaceted approach is generally advocated.

Diagnostik und Therapie invasiver Pilzinfektionen auf der Intensivstation@@@Diagnostics and therapy for invasive fungal infections in an intensive care unit

Invasive fungal infections are associated with a high mortality and have been increasing in incidence over the last few decades. Candidemia and, less commonly, invasive pulmonary aspergillosis are the most relevant fungal infections in critical care medicine. Risk factors for systemic Candida infections are the use of broad-spectrum antibiotics, a prolonged stay in an intensive care unit and gastrointestinal injury or surgery. Invasive aspergillosis usually occurs in immunocompromised patients. The diagnosis of invasive fungal infections remains challenging. The therapeutic spectrum includes fluconazol, conventional and liposomal amphotericin B, and the recently introduced agents caspofungin and voriconazol. For rational and cost-effective use, the clinician requires precise knowledge of the indications and limitations of these agents. This review focuses on the diagnostic and therapeutic options in severe Candida infections and invasive aspergillosis.