Ralf-Peter Vonberg

Economic aspects of deep sternal wound infections.

OBJECTIVES Surgical-site infections are a very expensive complication in cardiac surgery. Thus, the total costs for coronary artery bypass grafting (CABG) surgery may substantially increase when a deep sternal wound infection (DSWI) occurs. This may be due to an extended length of stay (LOS), the need for additional surgical procedures, vacuum-assisted wound dressing and antibiotic therapy. This study compares the LOS in the hospital and on an intensive care unit (ICU) as well as the total costs for patients undergoing CABG depending upon the occurrence of a subsequent DSWI. METHODS A case-control study was performed. Total costs of DSWI cases were analysed and compared to patients undergoing CABG without DSWI. Inclusion criterion for cases was the development of a DSWI according to the CDC criteria during hospital stay after CABG. Two control patients without any signs or symptoms of an infection during hospital stay were matched to each case by (1) type of surgery according to their diagnosis-related group (DRG), (2) age +/-5 years, (3) gender and (4) duration of preoperative hospital stay +/-2 days, but at least as long as the time at risk of cases before infection. RESULTS Between January 2006 and March 2008, 17 CABG patients with DSWI (cases) and 34 matched controls were included. The median overall costs of a CABG case were 36,261 Euro compared with 13,356 Euro per control patient without infection (p<0.0001). The median overall LOS was 34.4 days versus 16.5 days, respectively (p=0.0006). The median LOS on ICU was 6.3 days versus 5.3 days (no significant difference). CONCLUSION DSWI represents an important economic factor for the hospital as they may almost triple the costs for patients undergoing CABG. Thus, appropriate infection control measures for the prevention of DSWI should be enforced.

How often do asymptomatic healthcare workers cause methicillin-resistant Staphylococcus aureus outbreaks? A systematic evaluation

A systematic search was performed to identify outbreaks of methicillin-resistant Staphylococcus aureus infection and colonization caused by healthcare workers (HCWs). Of 191 outbreaks identified, 11 had strong epidemiological evidence that HCWs were the source. In 3 of these outbreaks, asymptomatic carriers were the cause. The frequent practice of screening asymptomatic HCWs should be reconsidered.

Routine bile collection for microbiological analysis during cholangiography and its impact on the management of cholangitis.

BACKGROUND Antibiotic treatment of cholangitis is often insufficient because of inappropriate antibiotic use or bacterial resistance. OBJECTIVE To evaluate the role of routine bile collection during endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography for microbiological analysis in the antibiotic management of cholangitis and to identify risk factors of bacteriobilia. DESIGN Prospective, observational, diagnostic study. SETTING Hannover Medical School, Hannover, Germany. PATIENTS AND INTERVENTION This study involved 243 consecutive patients undergoing endoscopic retrograde cholangiography/percutaneous transhepatic cholangiography for biliary complications after orthotopic liver transplantation (27%), malignancy (27%), primary sclerosing cholangitis (15%), benign strictures (11%), and choledocholithiasis (8%). MAIN OUTCOME MEASUREMENTS Microbiological examination of bile samples. RESULTS Patients with biliary stents or who were receiving repeated interventions after orthotopic liver transplantation were at increased risk of bacteriobilia (P < .05). The rate of gram-positive monomicrobial infection was higher in patients with primary sclerosing cholangitis (P < .01). In 40 examinations, patients presented with preprocedural cholangitis although they were receiving antibiotics. According to bile culture results, the antibiotic treatment was modified to a more specific therapy in 72.5% of patients. In patients who developed cholangitis after endoscopic retrograde cholangiography (27 examinations), specific antibiotic treatment was started or refined in 67% of cases, based on bile culture results. LIMITATIONS Contamination of samples during intervention cannot be totally excluded. CONCLUSION Orthotopic liver transplantation, biliary stenting, and repeated interventions are risk factors of bacteriobilia. In our patients with primary sclerosing cholangitis, gram-positive monomicrobial infections were more common. A bile sample collected during cholangiography for microbiological analysis is a simple, potentially valuable, diagnostic tool in patients with cholangitis. Each center should recognize its own patterns of infection to ensure ideal targeted therapy.

Early- and Late-Onset Pneumonia: Is This Still a Useful Classification?

ABSTRACT The choice of empirical treatment of nosocomial pneumonia in the intensive-care unit (ICU) used to rely on the interval after the start of mechanical ventilation. Nowadays, however, the question of whether in fact there is a difference in the distribution of causative pathogens is under debate. Data from 308 ICUs from the German National Nosocomial Infection Surveillance System, including information on relevant pathogens isolated in 11,285 cases of nosocomial pneumonia from 1997 to 2004, were used for our evaluation. Each individual pneumonia case was allocated either to early- or to late-onset pneumonia, with three differentiation criteria: onset on the 4th day, the 5th day, or the 7th day in the ICU. The frequency of pathogens was evaluated according to these categories. A total of 5,066 additional cases of pneumonia were reported from 2005 to 2006, after the CDC criteria had been modified. From 1997 to 2004, the most frequent microorganisms were Staphylococcus aureus (2,718 cases, including 720 with methicillin [meticillin]-resistant S. aureus), followed by Pseudomonas aeruginosa (1,837 cases), Klebsiella pneumoniae (1,305 cases), Escherichia coli (1,137 cases), Enterobacter spp. (937 cases), streptococci (671 cases), Haemophilus influenzae (509 cases), Acinetobacter spp. (493 cases), and Stenotrophomonas maltophilia (308 cases). The order of the four most frequent pathogens (accounting for 53.7% of all pathogens) was the same in both groups and was independent of the cutoff categories applied: S. aureus was first, followed by P. aeruginosa, K. pneumoniae, and E. coli. Thus, the predictabilities of the occurrence of pathogens were similar for the earlier (1997-to-2004) and later (2005-to-2006) time frames. This classification is no longer helpful for empirical antibiotic therapy, since the pathogens are the same for both groups.

Health care workers causing large nosocomial outbreaks: a systematic review.

BackgroundsStaff in the hospital itself may be the source of a nosocomial outbreak (NO). But the role of undetected carriers as an outbreak source is yet unknown.MethodsA systematic review was conducted to evaluate outbreaks caused by health care workers (HCW). The Worldwide Outbreak Database and PubMed served as primary sources of data. Articles in English, German or French were included. Other reviews were excluded. There were no restrictions with respect to the date of publication.Data on setting, pathogens, route of transmission, and characteristics of the HCW was retrieved. Data from large outbreaks were compared to smaller outbreaks.Results152 outbreaks were included, mainly from surgery, neonatology, and gynecology departments. Most frequent corresponding infections were surgical site infections, infection by hepatitis B virus, and septicemia. Hepatitis B virus (27 NO), S. aureus (49 NO) and S. pyogenes (19 NO) were the predominant pathogens involved. 59 outbreaks (41.5%) derived from physicians and 56 outbreaks (39.4%) derived from nurses. Transmission mainly occurred via direct contact. Surgical and pediatric departments were significantly associated with smaller outbreaks, and gynecology with larger outbreaks. Awareness of carrier status significantly decreased the risk of causing large outbreaks.ConclusionsAs NO caused by HCW represent a rare event, screening of personnel should not be performed regularly. However, if certain species of microorganisms are involved, the possibility of a carrier should be taken into account.

ISOLATION OF INFECTIOUS CYSTIC FIBROSIS PATIENTS: RESULTS OF A SYSTEMATIC REVIEW

OBJECTIVE Respiratory tract infections significantly contribute to morbidity and mortality among cystic fibrosis (CF) patients. Therefore, pathogen transmission needs to be prevented. There are several guidelines for the care of CF patients, but no transparent systematic literature review has been published. METHODS We conducted a systematic literature review (January 1966 to September 2004) dealing with segregation of CF patients colonized with Burkholderia cepacia species, Pandoraea species, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, or Alcaligenes species. Quality of studies was evaluated by taking patient population size, existence of control-patients, patient randomization, diagnostic approach, and bacteria typing methods into account. RESULTS One hundred ninety-nine studies were found. Evidence and quality of 102 publications were evaluated. In 99 publications, recommendations concerning segregation measures for infectious CF patients were determined including a total of 11,576 patients. No randomized, controlled trials had been conducted. Fifty of 56 authors strongly recommended isolation of CF patients infected with B. cepacia or Pandoraea species. In 31 of 39 studies, interpatient spread of Pseudomonas aeruginosa was documented or had been brought to an end by isolation of patients. Only five studies had addressed S. maltophilia or Alcaligenes species. CONCLUSIONS Patients colonized with B. cepacia or Pandoraea species are to be separated from noncolonized patients in single rooms. Patients harboring multidrug-resistant Pseudomonas aeruginosa, S. maltophilia, or Alcaligenes species may not share a room with immunocompromised patients, in intensive care units, or with other CF patients anywhere in the hospital.

Clostridium difficile in Discharged Inpatients, Germany

To the Editor: Using discharge diagnoses from US hospitals in 2000–2003, McDonald et al. recently documented a dramatic increase in the rate of Clostridium difficile–associated disease (CDAD) (1). During the same period, a new strain of C. difficile was identified; this strain appears more virulent, at least in part because it produces higher levels of toxin (2). To our knowledge, this strain has not been identified in Germany. However, to address this emerging threat, we conducted a similar analysis of discharge data to compare findings from the United States with data from Germany. We therefore determined the absolute number of inpatient discharges from all hospitals in Germany with the number of discharge diagnoses of CDAD reported in the national Statistische Bundesamt for the years 2000–2004. We then calculated the incidence of CDAD as a discharge diagnosis for each year and stratified our results by age groups (Figure). Figure Incidence of Clostridium difficile–associated disease per 100,000 inpatients upon discharge from hospitals in Germany. Our results confirm the observations from the United States. The effect of C. difficile on illness of patients in hospitals in Germany has escalated dramatically. This is true especially for patients >60 years of age. This trend indicates the need for increased awareness of this pathogen and a concerted effort to control CDAD by reducing unnecessary antimicrobial drug use and implementing currently recommended infection control measures. It also highlights the need to develop more rapid and accurate diagnostic tools and more effective prevention and treatment strategies.

Surgical site infections—economic consequences for the health care system

PurposesUnfortunately, surgical site infections (SSIs) are a quite common complication and represent one of the major causes of postoperative morbidity and mortality, and may furthermore lead to enormous additional costs for hospitals and health care systems.MethodsIn order to determine the estimated costs due to SSIs, a MEDLINE search was performed to identify articles that provide data on economic aspects of SSIs and compared to findings from a matched case-control study on costs of SSIs after coronary bypass grafting (CABG) in a German tertiary care university hospital.ResultsA total of 14 studies on costs were found. The additional costs of SSI vary between

Worldwide Outbreak Database: the largest collection of nosocomial outbreaks

3,859 (mean) and

Consumer Attitudes About Health Care—Acquired Infections: A German Survey on Factors Considered Important in the Choice of a Hospital

40,559 (median). Median costs of a single CABG case in the recently published study were