S. W. Lemmen

Influence of an Infectious Disease Service on Antibiotic Prescription Behavior and Selection of Multiresistant Pathogens

SummaryBackground: A routine infectious disease service was established in January 1998 in order to optimize the antibiotic usage and prescription pattern of a neurologic intensive care unit (NICU). Methods: Treatment guidelines for the most prevalent infections wer implemented and individual antibiotic regimes were discussed at the bedside with infectious disease experts. Results: This interdisciplinary cooperation reduced the total number of antibiotics prescribed by 38.1%, from 7,789 in 1997 to 4,822 in 1998, without comprimising patient outcomes (mortality rate: 22/313 patients in 1997 vs 32/328 patients in 1998). Total patient days (2,254 days vs 2,296 days) and average length of stay in the NICU (7.2 days vs 7.0 days) were comparable. Antimicrobial expenditure decreased by 44.8% (71,680 Euros in 1997 vs 39,567 Euros in 1998). Taking into account the costs for the infectious disease service (approximately 8,000 Euros in 1998), a total saving of 24,113 Euros was made. The dramatic reduction in antibiotic usage (mainly of carbapenems) resulted in a statistically significant decreased isolation of Stenotrophomonas maltophilia (p < 0.05), Enterobacter cloacae (p < 0.05), multiresistant Pseudomonas aeruginosa (p < 0.05) and Candida spp. (p < 0.05), without any change in the infection control guidelines. Conclusion: These data show that an infectious disease service can optimize and reduce antibiotic usage. This results in a decrease in the occurrence of multiresistant gram-negative pathogens and Candida spp. in intensive care units, and, at the same time, saves costs.

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.

Strategies to enhance rational use of antibiotics in hospital : a guideline by the German society for infectious diseases

IntroductionIn the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.Materials and methodsA structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.ConclusionThe guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Periodic Surveillance of Nosocomial Infections in a Neurosurgery Intensive Care Unit

Background:We assessed data on the epidemiology of nosocomial infections (NIs) in a 14-bed neurosurgical intensive care unit (NSICU) and used surveillance data for the promotion of quality improvement activities.Patients and Methods:Prospective periodic surveillance was performed over five 3-month periods between July 1998 and October 2002 on all patients admitted with a length of stay > 24 hours.Results:763 patients with a total of 4,512 patient days and a mean length of stay of 5.9 days were enrolled within the 15-month study period. A total of 93 NIs were identified in 82 patients. Urinary tract infections (24.7%), pneumonia (23.6%), and bloodstream infections (17.2%) were the most frequent NIs recorded. Device-associated incidence rates were 6.0 (3.8–9.0, CI95%) for urinary tract infection, 4.4 (2.4–7.4, CI95%) for bloodstream infection, and 10.3 (6.3–15.9, CI95%) for pneumonia per 1,000 days at risk. For improvement of infection control-related processes, evidence-based infection control guidelines were established and an NSICU nurse was designated to be responsible for infection control issues on the ward. In addition, several infection control problems arose during the observation periods and were rapidly responded to by introducing specific intervention strategies.Conclusion:Periodic surveillance is a valuable tool for assessing the epidemiology of NIs in the NSICU setting as well as for promoting the initiation of quality improvement activities.

The Reduction in Antibiotic Use in Hospitals.

BACKGROUND Over 350 000 patients are treated in German hospitals for sepsis or pneumonia each year. The rate of antibiotic use in hospitals is high. The growing problem of drug resistance necessitates a reconsideration of antibiotic treatment strategies. METHODS Antibiotics were given liberally in the years 2010 and 2011 in a German 312-bed hospital. Special training, standardized algorithms to prevent unnecessary drug orders, and uniform recommendations were used in 2012 and 2013 to lessen antibiotic use. We retrospectively studied the hospitals mortality figures and microbiological findings to analyze how well these measures worked. RESULTS Antibiotic consumption fell from 67.1 to 51.0 defined daily doses (DDD) per 100 patient days (p <0.001) from the period 2010-2011 to the period 2012-2013. The mortality of patients with a main diagnosis of sepsis fell from 1% (95/305) to 19% (63/327; p = 0.001), while that of patients with a main diagnosis of pneumonia fell from 12% (22/178) to 6% (15/235; p = 0.038). The overall mortality fell from 3.0% (623/ 20 954) to 2.5% (576/22 719; p = 0.005). In patients with nosocomial urinary tract infections with Gram-negative pathogens (not necessarily exhibiting three- or fourfold drug resistance), the rate of resistance to three or four of the antibiotics tested fell from 11% to 5%. CONCLUSION Reducing in-hospital antibiotic use is an achievable goal and was associated in this study with lower mortality and less drug resistance. The findings of this single-center, retrospective study encourage a more limited and focused approach to the administration of antibiotics.

Are chlorhexidine-containing dressings safe for use with ventricular drainages?

The purpose of this report was to assess the safety and application of chlorhexidine (CHG)-containing dressings—shown to reduce central line infection rates markedly—for external ventricular drainages (EVDs) and lumbar drainages (LDs). Cerebrospinal fluid samples of patients receiving standard dressings and CHG-containing dressing (ten each) were analyzed by high-performance liquid chromatography for the presence of CHG. The application was evaluated. CHG was not detectable in all samples. The dressings’ application for EVDs and LDs worked without problems. Thus, the use of CHG-containing dressings for EVDs and LDs seems to be safe. Further studies addressing their infection reduction potential are warranted.

Antibiotic stewardship and horizontal infection control are more effective than screening, isolation and eradication

PurposeThe global rise of multidrug resistant organisms (MDROs) is of major concern since infections by these pathogens are difficult, and in some cases, even impossible to treat. This review will discuss the effectiveness of a pathogen-independent alternative approach consisting of the implementation of antibiotic stewardship (ABS) programs, improvement of hand hygiene compliance, and daily antiseptic body washings instead of “screening, isolation and eradication” as recommended by many infection control guidelines today.MethodsA review of the literature.ResultsThe classical approach composed of screening, isolation and eradication has many limitations, including lack of standardization of the screening methods, risk of medical errors for patients in isolation and failure to eradicate resistant bacteria. Notably, concrete evidence that this current infection control approach actually prevents transmission is still lacking. We found that a novel approach with the training of infectious diseases specialists can reduce the usage of antimicrobials, thereby significantly decreasing the emergence of new MDROs. Moreover, increased hand hygiene compliance not only reduces transmission of MDROs, but also that of sensitive organisms causing the majority of nosocomial infections. Further, instruments, such as continuing education, bed-side observation, and the use of new tools, e.g. electronic wearables and Wi-Fi-equipped dispensers, are all options that can also improve the current low hand hygiene compliance levels. In addition, daily antiseptic body washes were observed to reduce the transmission of MDROs, especially those deriving from the body surface-like MRSA and VRE in specific settings. Finally, antiseptic body washes were seen to have similar effects on reducing transmission rates as screening and isolation measures.ConclusionsIn summary, this review describes a novel evidence-based approach to counteract the growing medical challenge of increasing numbers of MDROs.