P. Gastmeier

Reduction of surgical site infection rates associated with active surveillance.

OBJECTIVEnTo evaluate whether surgical site infection (SSI) rates decrease in surgical departments as a result of performing active SSI surveillance.nnnDESIGNnRetrospective multiple logistic regression analyses.nnnSETTINGnA group of 130 surgical departments of German hospitals participating in the Krankenhaus Infektions Surveillance System (KISS).nnnMETHODSnData for 19 categories of operative procedures performed between January 1997 and June 2004 were included (119,114 operations). Active SSI surveillance was performed according to National Nosocomial Infections Surveillance system (NNIS) methods and definitions. Departments SSI rates were calculated individually for each year of surveillance and for each operative procedure category, taking into account when the individual departments had begun their surveillance activities. Multiple logistic regression analyses on a single operation basis were carried out with stepwise variable selection to predict outcomes for patients with SSI. The variables included were as follows: the departments year of participation, NNIS risk index variables, patients age and sex, and the hospitals structural characteristics, such as yearly operation frequency, number of beds, and academic status.nnnRESULTSnFor 14 of 19 operative procedure categories analyzed, there was a tendency toward lower SSI rates that was associated with increasing duration of SSI surveillance. In multiple logistic regression analyses of pooled data for all operative procedures, the departments participation in the surveillance system was a significant independent protective factor. Compared with the surveillance year 1, the SSI risk decreased in year 2 (odds ratio, 0.84; 95% confidence interval, 0.77-0.93) and in year 3 (odds ratio, 0.75; 95% confidence interval, 0.68-0.82), and there was no change in year 4.nnnCONCLUSIONnThe SSI incidence was reduced by one quarter as a result of the surveillance-induced infection control efforts, which indicates the usefulness of a voluntary surveillance system.

Efficacy of heat and moisture exchangers in preventing ventilator-associated pneumonia: meta-analysis of randomized controlled trials.

ObjectiveSeveral randomized controlled trials (RCT) have examined the effect of antibacterial humidification strategies, particularly the replacement of heated humidifiers (HH) by heat and moisture exchangers (HME), in preventing ventilator-associated pneumonia (VAP). The present meta-analysis reviews these RCTs.MethodsRCTs were identified by searching the Medline and Cochrane Central Register of Controlled Trials databases from 1990 to 2003. We included RCTs using HMEs in the treatment group and HHs in the control group and reporting the incidence of pneumonia as a study outcome. Two investigators independently abstracted key data on design, population, intervention and outcome of the studies.ResultsBetween 1990 and 2003 eight RCTs met the inclusion criteria of this analysis. Pooling the results from these studies revealed a reduction in the relative risk of VAP in the HME group (0.7), particularly in MV with a duration of at least 7xa0days (five RCTs, relative risk 0.57).ConclusionsThis meta-analysis found a significant reduction in the incidence of VAP in patients humidified with HMEs during MV, particularly in patients ventilated for 7xa0days or longer. This finding is limited by the exclusion of patients at high risk for airway occlusion from some of the studies. Moreover, contraindications (tenacious secretions, airway obstructive disease, hypothermia) and technical issues of HMEs must be considered. Further RCTs are necessary to examine the wider applicability of HMEs and their extended use.

Device‐Associated Infection Rates for Non–Intensive Care Unit Patients

BACKGROUNDnReference data from intensive care units (ICUs) are not applicable to non-ICU patients because of the differences in device use rates, length of stay, and severity of underlying diseases among the patient populations. In contrast to the huge amount of data available for ICU patients, appropriate surveillance data for non-ICU patients have been missing in Germany.nnnOBJECTIVEnTo establish a new module (DEVICE-KISS) of the German Nosocomial Infection Surveillance System for generating stratified reference data for non-ICU wards.nnnSETTINGnNon-ICU patients from 42 German hospitals.nnnMETHODSnMonthly patient-days, device-days and nosocomial infections (NIs) (using Centers for Disease Control and Prevention definitions) were counted. Device use rates were calculated, and NI rates were stratified by different medical specialities.nnnRESULTSnFrom July 2002 through June 2004, among the 77 wards, there were a total of 536,955 patient-days and 74,188 device-days (for CVC-associated primary bloodstream infections, there were 181,401 patient-days and 8,317 central vascular catheter [CVC]-days in 29 wards; for urinary catheter-associated urinary tract infections, there were 445,536 patient-days and 65,871 urinary catheter-days in 65 wards) and 483 NIs (36 bloodstream infections and 447 urinary tract infections). The mean device use rates were 4.6 device-days per 100 patient-days for CVCs (29 wards) and 14.8 device-days per 100 patient-days for urinary catheters (65 wards), respectively. Mean device-associated NI rates were 4.3 infections per 1,000 CVC-days for CVC-associated bloodstream infections and 6.8 infections per 1,000 urinary catheter-days for catheter-associated urinary tract infections.nnnCONCLUSIONSnDEVICE-KISS allows non-ICUs to recognize an outlier position with regard to NIs by providing well-founded reference data for non-ICU patients.

Risk Factors for Death Due to Nosocomial Infection in Intensive Care Unit Patients: Findings From the Krankenhaus Infektions Surveillance System

OBJECTIVEnTo determine risk factors for death among patients with nosocomial pneumonia and patients with primary bloodstream infections (BSI) in intensive care units (ICUs).nnnDESIGNnProspective cohort study.nnnSETTINGnData collected from January 1997 through June 2003 from ICUs registered with the Krankenhaus Infektions Surveillance System in Germany.nnnPATIENTSnA total of 8,432 patients with nosocomial pneumonia from 202 ICUs and 2,759 patients with nosocomial primary BSI from 190 ICUs.nnnMETHODSnThe following risk factors were considered in the analysis: age, sex, time in the ICU before onset of infection, type of ICU, type and size of hospital, intubation, central venous catheter use, total parenteral nutrition, and type of pathogen.nnnRESULTSnA total of 750 patients (8.9%) with nosocomial pneumonia and 302 patients (10.9%) with nosocomial primary BSI died. Multiple logistic regression analysis identified treatment in a medical or surgical ICU (odds ratio [OR], 1.55 [95% confidence interval {CI}, 1.32-1.82]) or a hospital with more than 1,000 beds (OR, 2.14 [95% CI, 1.81-2.56]), age older than 65 years (OR, 1.54 [95% CI, 1.31-1.81]), and infection with methicillin-resistant Staphylococcus aureus (OR, 2.39 [95% CI, 1.81-3.12]) or multidrug-resistant Pseudomonas aeruginosa (OR, 3.00 [95% CI, 1.90-4.63]) as independent determinants of death from nosocomial pneumonia. Age older than the median of 63 years (OR, 1.44 [95% CI, 1.12-1.86]) and methicillin-resistant S. aureus as the causative agent (OR, 2.98 [95% CI, 1.81-5.82]) were both associated with increased mortality from primary BSI. The types of infecting pathogens, particularly those resistant to multiple drugs, were also strong outcome predictors among ICU patients.nnnCONCLUSIONSnThe study results underline the need for further investigations of the role of antimicrobial resistance in the outcome of patients with nosocomial pneumonia and patients with primary BSI.

Trends in ventilator-associated pneumonia rates within the German nosocomial infection surveillance system (KISS).

OBJECTIVEnTo investigate trends in ventilator-associated pneumonia (VAP) rates during participation in the German nosocomial infection surveillance system (Krankenhaus-Infektions-Surveillance-System [KISS]).nnnMETHODSnA total of 71 ICUs that began participating in KISS in 1999 or later and continued participation for at least 36 months were selected. Beginning with the first month of participation, the pooled mean rate of VAP in the ICUs was calculated for each year of participation. The incidence densities for the 3 years of participation were compared using the Pearson chi (2) test. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated. VAP rates were calculated for each ICU and year of participation, and rates for years 1 and 3 were compared using the Wilcoxon test for paired samples.nnnRESULTSnTwenty-nine medical-surgical, 18 medical, 20 surgical, 2 neurosurgical, and 2 pediatric ICUs met the selection criteria. Surveillance data were available on 181,275 patients, for whom there were 613,098 patient-days and 224,138 ventilator-days. A total of 2,043 cases of VAP were reported. The ICUs had a pooled VAP rate of 10.5 cases per 1,000 ventilator-days during year 1 of KISS surveillance. In year 2, the rate decreased by 19%, to 8.7 cases per 1,000 ventilator-days (RR, 0.81 [95% CI, 0.73-0.90]). In year 3, the rate decreased by 24% from year 1, to 8.0 cases per 1,000 ventilator-days (RR, 0.76; 95% CI, 0.68-0.85). Both results were significant (P<.001 by the Pearson chi (2) test). Comparison of the VAP rates of the ICUs did not show a significant difference between years 1 and 3 of KISS participation.nnnCONCLUSIONnSurveillance was associated with a significant reduction in the pooled rate of VAP during years 1-3 of KISS participation.

Validation of surveillance in the intensive care unit component of the German nosocomial infections surveillance system.

A validation study was performed for the intensive care unit component of the German nosocomial infections surveillance system (Krankenhaus Infektions Surveillance System [KISS]). A total of 286 reported infections and 1,195 medical records with no reported infection from 20 randomly selected KISS intensive care units were reviewed by trained physicians. The mean sensitivity was 66% (median, 81%), and the mean specificity was 99.4% (median, 99.6%).

Surveillance nosokomialer Infektionen in Intensivstationen: Aktuelle Daten und Interpretationen

The German nosocomial infections surveillance system KISS was established in 1996 using a surveillance protocol based on the National Nosocomial Infections Surveillance (NNIS) System. Meanwhile data from a total of 274 intensive care units (ICU) are available, among them 134 interdisciplinary, 71 surgical, 55 medical, 9 neurosurgical and 5 paediatric ICUs. The data comprise about 6,966 surveillance months with more than 500,000 intensive care patients and more than 1.8 million patient days. A total of 6,888 cases of pneumonia and 2,357 cases of central venous catheter (CVC) associated primary bloodstream infections (BSI) were recorded. Ventilator associated pneumonia rates and CVC associated primary BSI rates are presented, stratified according to the type of the ICU and affiliation to a university, a teaching hospital or another type of hospital. The most frequent pathogens associated with ventilator associated pneumonia were S. aureus (24.1%), followed by P. aeruginosa (16.8%) and Klebsiella spp. (12.1%). In the case of CVC associated primary BSI coagulase negative staphylococci dominated (30.9%) followed by S. aureus (15.4%) and Enterococci spp. (11.6%). A remarkable increase of Methicillin Resistant Staphylococcus aureus (MRSA) infections was observed during the period from 1997 to 2002. 19.2% of S. aureus associated pneumonia cases and 25.5% of S. aureus associated primary BSI were due to MRSA. KISS data are useful benchmarks for internal quality management, however a careful interpretation is necessary to stimulate infection control efforts.SummaryThe German nosocomial infections surveillance system KISS was established in 1996 using a surveillance protocol based on the National Nosocomial Infections Surveillance (NNIS) System. Meanwhile data from a total of 274 intensive care units (ICU) are available, among them 134 interdisciplinary, 71, surgical, 55 medical, 9 neurosurgical and 5 paediatric ICUs. The data comprise about 6,966 surveillance months with more than 500,000 intensive care patients and more than 1.8 million patient days. A total of 6,888 cases of pneumonia and 2,357 cases of central venous catheter (CVC) associated primary bloodstream infections (BSI) were recorded.Ventilator associated pneumonia rates and CVC associated primary BSI rates are presented, stratified according to the type of the ICU and affiliation to a university, a teaching hospital or another type of hospital.The most frequent pathogens associated with ventilator associated pneumonia wereS. aureus (24.1%), followed byP. aeruginosa (16.8%) and Klebsiella spp. (12.1%). In the case of CVC associated primary BSI coagulase negative staphylococci dominated (30.9%) followed byS. aureus (15.4%) and Enterococci spp. (11.6%). A remarkable increase of Methicillin Resistant Staphylococcus aureus (MRSA) infections was observed during the period from 1997 to 2002, 19.2% ofS. aureus associated pneumonia cases and 25.5% ofS. aureus associated primary BSI were due to MRSA.KISS data are useful benchmarks for internal quality management, however a careful interpretation is necessary to stimulate infection control efforts.ZusammenfassungDas Krankenhaus-Infektions-Surveillance-System KISS wurde im Jahr 1996 auf der Basis der Methoden des amerikanischen National Nosocomial Infections Surveillance (NNIS) Systemes etabliert. Mittlerweile beinhaltet es Daten von 274 Intensivstationen darunter 134 interdisziplinäre 71 chirurgische, 55 medizinische, 9 neurochirurgische und 5 pädiatrische Intensivstationen. Wir haben einen Überblick über 6966 Beobachtungsmonate mit mehr als 500.000 Intensivpatienten und mehr als 1,8 Millionen Patiententagen. Es wurden 6888 beatmungsassozilierte Pneumonien und 2357 Zentralvenenkatheter (ZVK)-assoziierte Sepsis-Fälle erfasst.Die beatmungsassoziierten Pneumonieraten und ZVK-assoziierten primären Sepsisraten werden nach Art der Intensivstation und Status des zugehörigen Krankenhauses stratifiziert präsentiert.Bei beatmungsassoziierten Pneumonien sindS. aureus die häufigsten Erreger mit einem Anteil von 24,1% aller Fälle, gefolgt vonP. aeruginosa (16,8%) und Klebsiella spp. (12,1%). Im Fall der ZVK-assoziierten Sepsis werden vor allem koagulasenegative Staphylokokken gefunden (30.9%) gefolgt vonS. aureus (15,4%) und Enterococcus spp. (11,6%). Ein bemerkenswerter Anstieg der Methicillin-resistenten Staphylococcus aureus (MRSA) wurde im Zeitraum 1997 bis 2002 beobachtet. Bei denS. aureus-beciigten beatmungsassoziierten Pneumonien beträgt der Anteil der MRSA 19,2%. Bei denS. aureus bedingten Sepsisfällen liegt der MRSA-Anteil bei 25,5%Die KISS-Daten liefern wertvolle Benchmark-Information für das interne Qualitätsmanagement, allerdings ist eine sorgfälitge Interpretation notwendig, um Präventionsmaßnahmen zu stimulieren.

[Establishment of a national database for ICU-associated infections. First results from the "Krankenhaus-Infections-Surveillance-System" (KISS)].

ZusammenfassungDie fortlaufende, systematische Erfassung, Analyse und Interpretation (=Surveillance) nosokomialer Infektionsraten spielt die wesentliche Rolle bei der Problemidentifikation und der nachfolgenden Problemlösung im Rahmen der Infektionsprävention. Ziel des Nationalen Referenzzentrums für Krankenhaushygiene und des Robert Koch-Instituts war die Etablierung einer einheitlichen Surveillance-Methode auf mehreren Intensivstationen und die Bereitstellung der gewonnenen Daten als nationale Referenzdaten. Seit Januar 1997 wird für Deutschland eine Referenzdatenbank zur Surveillance nosokomialer Infektionen auf Intensivstationen aufgebaut. Auf 113 Intensivstationen wurden bisher die Daten von 100.015 Patienten (393.177 Patiententage) erfasst. Als Methode der Standardisierung wird die Anzahl der Infektionen, die während der Anwendung eines Risikofaktors auftreten (Harnwegskatheter, ZVK oder maschinelle Beatmung) auf die Anwendungshäufigkeit des Risikofaktors bezogen (“device”-assoziierte Infektionsrate). Folgende “device”-assoziierten Infektionsraten wurden ermittelt: 4, 0 Harnwegsinfektionen/1.000 Harnwegskathetertage, 1, 8 primäre Septikämien/1000 ZVK-Tage und 11, 2 Pneumonien/1.000 Beatmungstage (Mittelwerte). Durch den Vergleich der eigenen Daten mit denen der Referenzdatenbank haben Intensivstationen Gelegenheit, Anhaltspunkte für eine Optimierung von Präventionsmaßnahmen zu erhalten.AbstractObjectives. To establish a surveillance system as an element of internal quality management, participating intensive care units (ICUs) report their ICU-associated infection surveillance data for aggregation into a national database.nn Methods. In order to provide data on ICU-associated infections, a nosocomial surveillance system in German intensive care units (Krankenhaus-Infektions-Surveillance-System (KISS)) started in 1997. The method of data collection is based on the (adult) ICU surveillance component from the National Nosocomial Infections Surveillance (NNIS)-System. Until now 113 German ICUs (most of them medical/surgical ICUs) were included in this system. We continuously collected and calculated the data from site-specific infections (device-associated pneumonias, blood stream infections and urinary tract infections).nn Results. There are now a total of 393.177 patient-days (100.015 patients) among them 176.415 ventilator-days, 295.221 central line-days and 316.799 urinary catheter-days in the data base. The data analysis showed the following device-associated infection rates: 11.2 pneumonias/1000 ventilator-days, 1.8 primary bloodstream infections/ 1000 central line-days and 4.0 urinary tract infections/1000 urinary catheter-days.nn Conclusion. The project has reached high interest in Germany and animated more ICUs to take part or to apply the same method in order to use the reference data for comparison.

Clinical relevance of and risk factors for HSV-related tracheobronchitis or pneumonia: results of an outbreak investigation

IntroductionHerpes simplex virus (HSV) type 1 was identified in respiratory specimens from a cluster of eight patients on a surgical intensive care unit within 8 weeks. Six of these patients suffered from HSV-related tracheobronchitis and one from HSV-related pneumonia only. Our outbreak investigation aimed to determine the clinical relevance of and risk factors associated with HSV-related tracheobronchitis or pneumonia in critically ill patients, and to investigate whether the cluster was caused by nosocomial transmission.MethodsA retrospective cohort study was performed to identify risk factors for the outcomes of HSV-related tracheobronchitis or pneumonia and death using univariable analysis as well as logistic regression analysis. Viruses were typed by molecular analysis of a fragment of the HSV type 1 glycoprotein G.ResultsThe cohort of patients covering the outbreak period comprised 53 patients, including six patients with HSV-related tracheobronchitis and one patient with pneumonia only. HSV-related tracheobronchitis or pneumonia was associated with increased mortality (100% in patients with versus 17.8% in patients without HSV-related tracheobronchitis or pneumonia; P < 0.0001). The interaction of longer duration of ventilation and tracheotomy was associated with HSV-related tracheobronchitis or pneumonia in multivariable analysis.Identical HSV type 1 glycoprotein G sequences were found in three patients and in two patients. The group of three identical viral sequences belonged to a widely circulating strain. The two identical viral sequences were recovered from bronchoalveolar lavages of one patient with HSV-related tracheobronchitis and of one patient without clinical symptoms. These viral sequences showed unique polymorphisms, indicating probable nosocomial transmission.ConclusionHSV-related tracheobronchitis or pneumonia is associated with increased mortality in critically ill patients. Care should be taken to avoid nosocomial transmission and early diagnosis should be attempted.

Infection control measures in intensive care units. Results of the German Nosocomial Infection Surveillance System (KISS)

ZusammenfassungHintergrundZiel dieser Befragung ist es zu ermitteln, inwieweit auf deutschen Intensivstationen (ITS) evidenzbasierte Empfehlungen zur Prävention nosokomialer Infektionen umgesetzt werden.MethodeEs wurden 230 deutsche ITS des Krankenhaus-Infektions-Surveillance-Systems (KISS) zum Umgang mit Beatmungstuben, zentralen Gefäßkathetern (ZVK), Harnwegkathetern (HWK) und Methicillin-resistentem-Staphylococcus-aureus- (MRSA-)positiven Patienten befragt.ErgebnisseAuf 9% der ITS wird überwiegend nasal intubiert. Alle Präventionsmaßnahmen zur ZVK-Anlage werden auf 43% der ITS eingehalten. Jede dritte ITS betreibt ein mikrobiologisches Routinescreening an Urin. Harnwegkatheter werden auf 37% der ITS routinemäßig gewechselt. MRSA positive Patienten werden auf 5% der ITS nicht isoliert. Ein Aufnahmescreening von MRSA-Risikopatienten unterbleibt auf 16% der ITS.SchlussfolgerungenAuf vielen deutschen ITS sind evidenzbasierte Empfehlungen nicht implementiert. Fortbildung zur Qualitätssicherung ist unerlässlich.AbstractBackgroundAim of this study was to determine to what extent evidence-based infection control recommendations are applied in German intensive care units (ICUs).MethodsA questionnaire concerning handling of tubes, central vascular catheters (CVC), urinary tract catheters and methicillin-resistant Staphylococcus aureus (MRSA) positive patients was sent to 230 participants of the German Nosocomial Infection Surveillance System (KISS).ResultsNasal intubation is routinely performed in 9% of ICUs, all recommended measures for CVC insertion were obeyed by 43% of ICUs and one-third of ICUs conduct regular screening of urine in catheterized patients. Urinary tract catheters are replaced at defined time intervals in 37% of ICUs. MRSA positive patients are not isolated in 5% of ICUs. MRSA screening on admission is not performed for high risk patients in 16% of ICUs.ConclusionsThere are still many German ICUs in which evidence-based recommendations are not implemented. Training of staff is necessary to improve quality of patient care.