Postdischarge surveillance for surgical site infection: the continuing challenge.
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Humans↗
Biomedical subjects
Petra Gastmeier
Publications and source records attributed to Petra Gastmeier.
Thoracic organ transplantation may not increase the risk of bacterial transmission in intensive care units.
A transmission study was performed to investigate whether organ recipients suffer more transmissions of bacteria than do non-transplanted patients. We chose enterococci for molecular typing because of their high prevalence, transmissibility, and predominance in causing nosocomial infections. Patients staying longer than 48h in a cardiovascular surgery intensive care unit (ICU) were included in our one-year prospective cohort study. Enterococci identified from clinical or surveillance isolates were collected and typed by PFGE. Episodes of transmission were defined by the identification of genetically indistinguishable isolates in two or more patients who were treated during overlapping intervals or within a 9-day window period in the same ICU. Risk factor analysis was performed. Out of 585 patients microbiological specimens were cultured from 336 patients. From 187 of these, enterococci were isolated. From 81 patients 186 enterococci isolates were typed. Out of 105 different enterococci strains, 16 cluster strains were detected and 30 episodes of transmissions occurred. The transmission rate was 7.8 per 1000 patient days. No significant association was found between "being cluster member "and "patient organ transplanted" (OR 1.5, CI(95%) 0.58; 3.98, p=0.38) or "patient treated in a single-room only" (OR 1.06, CI(95%) 0.36;3, 12, p=0.91), respectively. In contrast, "being cluster member" was associated with a prolonged length of stay (OR per additional days of stay 1.05, CI(95%) 1.01-1.09, p<0.01). Thoracic organ transplantation was not found to be a risk factor for bacterial transmission, but transmission was associated with a prolonged length of stay.
Cardiovascular Surgical Procedures↗
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.
Carrier State↗
Compliance with antiseptic hand rub use in intensive care units: the Hawthorne effect.
OBJECTIVE: To determine the influence the Hawthorne effect has on compliance with antiseptic hand rub (AHR) use among healthcare personnel. DESIGN: Observational study. SETTING: Five intensive care units of a university hospital in Berlin, Germany. PARTICIPANTS: Medical personnel were monitored in 2 periods regarding compliance with AHR use when there were indications for AHR use. In the first period, the personnel had no knowledge of being observed. The second observation period was announced to the staff of the intensive care units in advance and information about what the observer would be monitoring was provided. Potential confounders of compliance with AHR use included occupational groups (nurses, physicians, and other healthcare workers), intensive care units, and indications for AHR use before or after any procedure. RESULTS: Data were collected from 2,808 indications for AHR use. The overall rate of compliance was 29% (95% confidence interval, 26%-32%) in the first period and 45% (95% confidence interval, 43%-47%) in the second period. A logistic regression analysis with potential confounders revealed a significant odds ratio for the comparison between period 2 and period 1. The differences in compliance with AHR use were statistically significant (P<.001) between the occupational groups (nurses had the highest compliance and physicians had middle compliance) and between indication for AHR use before procedures and indication for AHR use after procedures. CONCLUSIONS: The Hawthorne effect has a marked influence on compliance with AHR use, with a 55% increase of compliance with overt observation. This result is consistent throughout subgroups. The rate of compliance with AHR use may in fact be lower than we thought because of results from studies that did not take the Hawthorne effect into account. The results of this study underline the necessity for infection control teams to be on wards as often as possible.
Anti-Infective Agents, Local↗
Impact of the suctioning system (open vs. closed) on the incidence of ventilation-associated pneumonia: Meta-analysis of randomized controlled trials.
OBJECTIVE: Ventilation-associated pneumonia (VAP) is a serious complication of patients in intensive care units (ICU) who require mechanical ventilation. The choice of suctioning system (open vs. closed) remains unresolved in evidence-based guidelines. This meta-analysis was carried out to analyze the effect of the type of suctioning system on the incidence of VAP. DESIGN: A search of the literature was used to identify randomized controlled trials addressing this question. A meta-analysis was then performed to calculate the relative risk of ventilation-associated pneumonia acquisition with the two suctioning systems. RESULTS: Nine trials were included, with 648 patients in the open suctioning group and 644 in the closed suctioning group. VAP occurred in 128 (20%) of the open suctioning group and in 120 (19%) in the closed suctioning group (relative risk 0.95). CONCLUSIONS: At a given pneumonia prevalence of 20% in ICU patients there was no significant advantage for the use of either suctioning system in this meta-analysis. The choice of suctioning system should therefore be based on handling, cost, and individual patient's disease until more data are available.
Cross Infection↗
Surveillance of cystic fibrosis patients with multi-drug resistant Gram-negative rods.
OBJECTIVES: Although several nosocomial outbreaks with multi-drug resistant Gram-negative bacteria (MRGN) are documented, only few are known about the endemic situation of theses pathogens. Especially cystic fibrosis (CF) patients are known to be at risk for MRGN acquisition. We present surveillance data of endemic MRGN in CF patients from a German university hospital during a 3-year period. METHODS: CF inpatients from 2002 to 2004 were included. A MRGN was defined as a Gram-negative rod of which less than two groups of antibiotics had been tested susceptible. MRGN patients who were admitted more than once were counted each time as a new MRGN case. RESULTS: Three hundred and thirty-nine inpatient cases (109 different patients) with MRGN were enrolled. Two hundred and sixty-seven cases were known to be MRGN positive at the time point of admission, 167 cases were affected by pan-resistant pathogens. P. aeruginosa was the MRGN species detected most frequently. MRGN was detected after 48h of hospital stay in 9 patients. CONCLUSIONS: MRGN surveillance is recommended by several experts but unfortunately only few data has been published. To our knowledge this is the first description of the complete endemic MRGN situation in CF patients. MRGN surveillance is necessary and will be continued in our facility.
Adolescent↗
The influence of high-efficiency particulate air filtration on mortality and fungal infection among highly immunosuppressed patients: a systematic review.
BACKGROUND: Patients with hematological malignancies who are treated with intensive chemotherapy or who receive bone marrow transplants are exposed to an increased risk of developing nosocomial fungal infections. The aim of this systematic review was to compare the effectiveness of high-efficiency particulate air (HEPA) filtration with that of non-HEPA filtration in decreasing the rates of mortality and fungal infection among patients with diagnosed hematological malignancies and neutropenia or among patients with bone marrow transplants. METHODS: Articles identified in a Medline search, guidelines, and books, as well as the bibliographies of review articles, monographs, and the articles identified by Medline, were researched. Randomized trials and observational studies comparing HEPA filtration with conventional room ventilation were selected for inclusion in the present review. RESULTS: Sixteen trials (9 with death as an outcome and 10 with fungal infection as an outcome) that compared HEPA filtration with non-HEPA filtration were selected for meta-analyses. We discovered no significant advantages of HEPA filtration in the prevention of death among patients with hematological malignancies with severe neutropenia in randomized controlled trials (RCTs; relative risk [RR], 0.86 [95% confidence interval {CI}, 0.65-1.14]) and in studies of a lower standard (non-RCTs; RR, 0.87 [95% CI, 0.60-1.25]). CONCLUSIONS: The placement in protected areas of patients with hematological malignancies with severe neutropenia or patients with bone marrow transplants appears to be beneficial, but no definitive conclusion could be drawn from the data available.
Air Microbiology↗
Methicillin-resistant Staphylococcus aureus in German intensive care units during 2000-2003: data from Project SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in Intensive Care Units).
OBJECTIVES: The objective of this study was to analyze methicillin-resistant Staphylococcus aureus (MRSA) percentages (defined as the percentage of S. aureus isolates that are resistant to methicillin) and antimicrobial consumption in intensive care units (ICUs) participating in Project SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in Intensive Care Units), to look for temporal changes in MRSA percentages and antimicrobial consumption in individual ICUs as an indicator of the impact of an active surveillance system, and to investigate the differences between ICUs with increased MRSA percentages versus those with decreased percentages during a period of 3 years (2001-2003). METHODS: This was a prospective, ICU-based and laboratory-based surveillance study involving 38 German ICUs during 2000-2003. Antimicrobial use was reported in terms of defined daily doses (DDDs) per 1,000 patient-days. Temporal changes in the MRSA percentage and antimicrobial use in individual ICUs were calculated by means of the Wilcoxon signed rank test. The incidence density of nosocomial MRSA infection was defined as the number of nosocomial MRSA infections per 1,000 patient-days. RESULTS: From February 2000 through December 2003, a total of 38 ICUs reported data on 499,694 patient-days and 9,552 S. aureus isolates, including 2,249 MRSA isolates and 660,029 DDDs of antimicrobials. Cumulative MRSA percentages ranged from 0% to 64.4%, with a mean of 23.6%. The MRSA incidence density ranged from 0 to 38.2 isolates per 1,000 patient-days, with a mean of 2.77 isolates per 1,000 patient-days. There was a positive correlation between MRSA percentage and imipenem and ciprofloxacin use (P<.05). Overall, comparison of data from 2001 with data from 2003 showed that MRSA percentages increased in 18 ICUs (median increase, 13.2% [range, 1.6%-38.4%]) and decreased in 14 ICUs (median decrease, 12% [range, 1.0%-48.4%]). Increased use of third-generation cephalosporins, glycopeptides, or aminoglycosides correlated significantly with an increase in the MRSA percentage (P<.05). The cumulative nosocomial MRSA infection incidence density for 141 ICUs that did not participate in SARI and, therefore, did not receive feedback increased from 0.26 to 0.35 infections per 1,000 patient-days during a 3-year period, whereas the rate in SARI ICUs decreased from 0.63 to 0.40 infections per 1,000 patient-days. CONCLUSION: The MRSA situation in German ICUs is still heterogeneous. Because MRSA percentages range from 0% to 64.4%, further studies are required to confirm findings that no change in the MRSA percentage and a decrease in the nosocomial MRSA infection incidence density in SARI ICUs reflect the impact of an active surveillance system.
Anti-Infective Agents↗
Where should one search when confronted with outbreaks of nosocomial infection?
The outbreak database (http://www.outbreak-database.com), containing 1561 records of nosocomial outbreaks published in the medical literature in a systematic format, was used to identify the most frequent outbreak sources for the entire database as well as for specific outbreak pathogens. Overall, in 37.1%, no source was identified. The main sources identified were index patients (40.3%), followed by equipment and devices (21.1%), environment (19.8%), and personnel (15.8%).
Cross Infection↗
The burden of MRSA in four German university hospitals.
In the last few years, a dramatic increase of Methicillin-resistant Staphylococcus aureus (MRSA) detection in German hospitals can be recognized. Under this enormous pressure it is very important for infection control teams to assess the epidemiologic situation correctly. Therefore, a prospective multicenter hospital-based surveillance of MRSA cases was executed in four university hospitals with 1017-1333 beds in Germany. Routine surveillance data were recorded of all patients with MRSA isolates from clinical samples or screening cultures. Patients had been colonized or infected with MRSA during their hospital stay. In 2002 between 183 and 291 MRSA cases were treated in the respective hospitals (between 0.53 and 0.96 MRSA cases per 1000 patient days). Of these, 44.4% were MRSA infections. The most frequent type of MRSA infections were wound infections (56.9%) followed by pneumonia (21.0%) and bloodstream infections (15.1%). Of the infected patients 51.5% were already infected at admission. The median duration of isolation of MRSA patients in private rooms was between 11 and 16 days. Altogether 21,665 isolation days were observed in four hospitals; this means 1.52% of all patient days. On average, 9.0% of roommates were identified as MRSA carriers. Due to the high percentage of imported cases, the four university hospitals introduced a general screening for MRSA at admission in all ICUs and some further departments as well as an automatic alert system for readmitted patient with MRSA during their last hospital stay.
Carrier State↗
Reusable terminal tap water filters for nosocomial legionellosis prevention.
Hospital water supplies often contain Legionella spp. and therefore represent a source of nosocomial infection especially for immunocompromised patients in intensive care or organ transplant units. Therefore, pathogen-free water should be provided for the care of these patients. Approaches of long-term Legionella spp. eradication from the plumbing system are rarely successful. Exposition prophylaxis might be another reasonable approach in high-risk patient care. To investigate the ability to provide water free of Legionella spp. with reusable water filters, a surveillance of splash water samples was performed. After determining the burden of Legionella spp. in the plumbing system of a paediatric oncological ward by ten unfiltered splash water samples, ten designated water taps were provided with terminal tap water filters that could be reprocessed by thermal disinfection. A further 129 samples were taken after a usage interval of 7 days and 10 more samples after a usage interval of 21 days before reprocessing the filters. All samples were checked for growth of Legionella spp. as well as other pathogenic bacteria. A total germ count of all samples was also performed. Half of the unfiltered splash water samples revealed growth of Legionella spp. All filtered water samples remained free of Legionella. Total germ count did not increase before a usage interval of 7 days. We believe the water filters tested are suitable for prevention of nosocomial legionellosis when reprocessed after 7 days as recommended by the manufacturer. To avoid retrograde contamination of filters, education of staff and patients in handling these devices is mandatory.
Bacteriological Techniques↗
AMBU-KISS: quality control in ambulatory surgery.
BACKGROUND: Cost-containment measures have led to a constant increase in the number of patients cared for as outpatients. Several studies have demonstrated that surgical site infections result in considerable morbidity and excess health care costs from extended duration of hospitalization and antibiotic use. OBJECTIVE: AMBU-KISS is a protocol designed to create a reference database on surgical site infections for institutions involved in ambulatory surgery. METHODS: This study was carried out using a physician questionnaire. We compared surgical site infection rates for 3 indicator procedures in the ambulatory setting to those observed in the inpatient setting. The 3 indicator procedures chosen for the protocol were arthroscopic knee surgery and inguinal hernia and vein-stripping procedures. RESULTS: The arithmetic mean values of surgical site infection rates in arthroscopic surgery of the knee are 0.09% in the ambulatory setting and 0.11% in the hospital setting. For inguinal hernias, the respective rates are 0.65% and 0.78%. These differences, however, did not reach statistical significance (arthroscopic surgery, P = .8323 and inguinal herniotomies, P = .4895). A marked difference was observed for vein-stripping procedures, with surgical site infection rates of 0.38% in the ambulatory setting and 0.64% in the hospital setting. However, this difference was also not statistically significant, P = .1556. CONCLUSION: The AMBU-KISS protocol appears to be suitable for assessing and defining the magnitude of surgical site infections in ambulatory surgery. The preliminary results of our study show no significant differences for the 3 indicator procedures.
Ambulatory Surgical Procedures↗
Risk factors for surgical site infections in a free-standing outpatient setting.
BACKGROUND: More information about risk factors for surgical site infections in outpatient settings is necessary for creation of surveillance systems in this field. OBJECTIVE: The aim of this study was to determine the incidence of surgical site infections (SSI) in an outpatient setting and to investigate whether the risk index of the National Nosocomial Infections Surveillance (NNIS) System is appropriate for outpatient settings. METHODS: A retrospective cohort design was used to investigate SSI following all hernia repairs and varicose veins operations over a 9-year period in a freestanding outpatient setting. The exposure variables studied were age, sex, and American Society of Anesthesiologists (ASA) score of the patient; duration of operation; performing surgeon's name; type of operation; type of anesthesia; and follow-up period. An univariable and a multivariable analysis were performed to determine risk factors for SSI. RESULTS: A total of 1095 operations were performed: 714 on varicose veins and 381 on hernia repairs. The median follow-up period was 43 days. The crude SSI rate was 1.2% (varicose veins operations, 1.5%; hernia repair operations, 0.5%). According to the results of the logistic regression model, only 1 factor remained significant: Patients with spinal anesthesia were 11 times as likely to develop a SSI as patients with any other type of anesthesia (95% CI, 2.15-200.5). CONCLUSION: The NNIS risk index was not suitable for assessing SSI rates in this outpatient setting and for these specific procedures.
Age Factors↗
Evaluation of the impact of the source (patient versus staff) on nosocomial norovirus outbreak severity.
OBJECTIVE: To study the dependence of infection risk and outbreak size on the type of index case (i.e., patient or staff). METHODS: Nosocomial outbreaks were reviewed and categorized into those started by patients and those started by staff. Infection risks and outbreak sizes were evaluated taking into account the index case category. RESULTS: Of the 30 nosocomial outbreaks of norovirus with person-to-person transmission, 20 (67%) involved patients as the index cases. Patient-indexed outbreaks affected significantly more patients than did staff-indexed outbreaks (difference in means, 16.25; 95% confidence interval [CI95], 5.1 to 27.0). For the numbers of affected staff, no dependence on the index case category was detectable (difference in means, -1.05; CI95, -9.0 to 6.9). For patients exposed during patient-indexed outbreaks, the risk of acquiring a norovirus infection was approximately 4.8 times as high as the corresponding risk for patients exposed during staff-indexed outbreaks (odds ratio [OR], 4.79; CI95, 1.82 to 8.28). The infection risk for exposed staff during patient-indexed outbreaks was approximately 1.5 times as high as the corresponding risk during staff-indexed outbreaks (OR, 1.51; CI95, 0.92 to 2.49). CONCLUSIONS: Patient-indexed norovirus outbreaks generally affect more patients than do staff-indexed outbreaks. Staff appear to be similarly affected by both outbreak index category groups. This study demonstrates the importance of obtaining complete outbreak data, including the index case classification as staff or patient, during norovirus outbreak investigations. Such information may be useful for further targeting prevention measures
Australia↗
How outbreaks can contribute to prevention of nosocomial infection: analysis of 1,022 outbreaks.
OBJECTIVE: To describe the epidemiology of nosocomial outbreaks published in the scientific literature. DESIGN: Descriptive information was obtained from a sample of 1,022 published nosocomial outbreaks from 1966 to 2002. METHODS: Published nosocomial outbreaks of the most important nosocomial pathogens were included in the database. A structured questionnaire was devised to extract information in a systematic manner on nosocomial outbreaks published in the literature. The following items were used: the reference, type of study (case reports or studies applying epidemiologic or fingerprinting methods), type of microorganism, setting, patients and personnel involved, type of infection, source of infection, mode of transmission, risk factors identified, and preventive measures applied. RESULTS: Bloodstream infection was the most frequently identified type of infection (37.0%), followed by gastrointestinal infection (28.5%) and pneumonia (22.9%). In 37% of the outbreaks, the authors were not able to identify the sources. The most frequent sources were patients (25.7%), followed by medical equipment or devices (11.9%), the environment (11.6%), and the staff (10.9%). The mode of transmission remained unclear in 28.3% of the outbreaks. Transmission was by contact in 45.3%, by invasive technique in 16.1%, and through the air in 15.0%. The percentage of outbreaks investigated by case-control studies or cohort studies over the years was small (21% and 9%, respectively, for the whole time period). CONCLUSION: Outbreak reports in the literature are a valuable resource and should be used for educational purposes as well as for preparing outbreak investigations.
Adolescent↗
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.
Bacteria↗
How many infections are caused by patient-to-patient transmission in intensive care units?
OBJECTIVE: The proportion of intensive care unit (ICU)-acquired infections that are a consequence of nosocomial cross-transmission between patients in tertiary ICUs is unknown. Such information would be useful for the implementation of appropriate infection control measures. DESIGN: A prospective cohort study during 18 months. SETTING: Five ICUs from two university hospitals. PATIENTS: All patients admitted for >/=48 hrs. MEASUREMENT: ICU-acquired infections were ascertained during daily bedside patient and chart reviews. Episodes of potential cross-transmission were identified by highly discriminating genetic typing of all clinical and surveillance isolates of the ten bacterial species most frequently associated with nosocomial infections in ICUs. Isolation of indistinguishable isolates in two or more patients defined potential transmission episodes. MAIN RESULTS: During 28,498 patient days, 431 ICU-acquired infections and 141 episodes of nosocomial transmissions were identified. A total of 278 infections were caused by the ten species that were genotyped, and 41 of these (14.5%) could be associated with transmissions between patients. CONCLUSION: Infections acquired during treatment in modern tertiary ICUs are common, but a causative role of direct patient-to-patient transmission can only be ascertained for a minority of these infections on the basis of routine microbiological investigations.
Bacterial Infections↗
Efficacy of heat and moisture exchangers in preventing ventilator-associated pneumonia: meta-analysis of randomized controlled trials.
OBJECTIVE: Several 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. METHODS: RCTs 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. RESULTS: Between 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 7 days (five RCTs, relative risk 0.57). CONCLUSIONS: This meta-analysis found a significant reduction in the incidence of VAP in patients humidified with HMEs during MV, particularly in patients ventilated for 7 days 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.
Air Conditioning↗