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[Importance of Hygiene for the Prevention of Antimicrobial Resistance]

In addition to antibiotic stewardship, infection prevention and control (IPC) measures at the hospital are crucial for containing antimicrobial resistance (AMR). Nosocomial infections can be prevented through the consistent application of recommended IPC measures. This reduces the use of antibiotics and therefore the development of AMR. In this way, antibiotic stewardship and IPC go hand in hand.

Use of indwelling urinary catheters in nursing home residents: results from a cross-sectional study in 21 German nursing homes

BACKGROUND

Indwelling urinary catheters often lead to complications such as symptomatic urinary tract infections. In nursing home residents, catheter prevalence is high, but prevalence differences by sociodemographic characteristics, comorbidities, and health services use have rarely been investigated. The purpose of this work was to describe the use of indwelling urinary catheters in nursing home residents and to examine whether catheter use is associated with individual characteristics.

METHODS

Cross-sectional data of the "Inappropriate Medication in patients with REnal insufficiency in Nursing homes" (IMREN) study conducted in 21 German nursing homes between October 2014 and April 2015 were analyzed. For all residents of the involved care units, nurses of the participating institutions completed an anonymous questionnaire including the Modified Rankin Scale to assess physical impairments. The proportion of nursing home residents with indwelling urinary catheter was determined. Associations between catheter use and individual characteristics were investigated via cluster-adjusted multivariable logistic regression.

RESULTS

Of 852 residents (76.5% female; mean age 83.5 years), 13.4% had an indwelling urinary catheter. The adjusted odds ratios for catheter use for men vs. women was 2.86 (95% confidence interval 1.82-4.50). For residents with "moderate" disability vs. those with "no to slight" disability it was 3.27 (1.36-7.85), for individuals with "moderately severe" disability vs. the reference group it was 9.03 (3.40-23.97), and for those with "severe" disability vs. the reference group it was 26.73 (8.60-83.14). For residents who had been hospitalized within the last 12 months vs. those without a hospitalization it was 1.97 (1.01-3.87). For age, dementia, overweight/obesity, other indwelling devices, and long-term medications no significant associations were found.

CONCLUSIONS

Male nursing home residents, residents with a higher degree of physical impairment, and those who had been hospitalized within the last 12 months were more likely to use an indwelling urinary catheter than their counterparts. Data on circumstances of and indications for catheters, catheter types, and duration of catheterization are needed to evaluate the appropriateness of catheter use in nursing home residents and the need for interventions.

Quality indicators in intensive care medicine for Germany - fourth edition 2022

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

[Resource conservation from the perspective of infection prevention]

BACKGROUND

Procedures to prevent surgical site infections require a high input of human, technical and natural resources. This paper explores ways to optimize the use of resources in caring for patients who undergo a surgical procedure without compromising patient safety.

METHODS

Review of the contribution of selected procedures for infection prevention in surgical patients considering current evidence and recommendations by comparing current guidelines and results of clinical trials. Analysis of interventions to implement and increase compliance.

RESULTS

Knowledge of current evidence-based recommendations enables not only the identification of procedures with proven effect on infection prevention but also those that are ineffective and thus dispensable. There is still need for further controlled studies, e.g. on the use of antiseptics, that can confirm the evidence level of preventive procedures. Infection surveillance in combination with process and compliance monitoring by infection prevention specialists with a feedback system to healthcare workers are suitable control instruments for infection control management. In the case of increased infection rates, the implementation of evidence-based recommended measures through tailored bundle interventions is successful. Technical measures to maintain environmental conditions must be included in the control process.

CONCLUSION

The reduction of healthcare-associated infections by implementing tailored interventions of infection prevention measures and elimination of ineffective procedures conserves resources and promotes patient safety.

Reducing urinary catheter use in geriatric patients - results of a single-center champion-led intervention

BACKGROUND

Indwelling urinary tract catheters (UTC) are a well-known risk factor for urinary tract infections (UTI). Because geriatric patients are at high risk of infection, an intervention with a focus on appropriate and minimal UTC use was introduced in 4 acute care geriatric wards.

METHODS

Between 11/2018 and 1/2020, unit-based data on UTC use and nosocomial UTI was collected in accordance with the methods of the German national surveillance system KISS. From 6/2019 to 1/2020, a champion-led intervention was implemented which focused on: (i) feedback of surveillance data, (ii) education and training in aseptic UTC insertion and maintenance, (iii) HCW's daily assessment of UTC necessity based on a checklist and (iv) timely removal of unnecessary UTCs. UTC use, incidence, and incidence densities for catheter-associated UTI (CAUTI) were calculated before and during the intervention. In addition, we analyzed adherence to a scheduled daily assessment of UTC necessity. Rate ratios (RR) with 95% confidence intervals (95%CI) were calculated. Differences based on the quality of checklist completion were evaluated using the Kruskal Wallis test.

RESULTS

We analyzed the data of 3,564 patients with a total 53,954 patient days, 9,208 UTC days, and 61 CAUTI. Surveillance data showed a significant decrease in the pooled UTC utilization rate from 19.1/100 patient days to 15.2/100 patient days (RR = 0.80, 95%CI 0.77-0.83, p < 0.001). CAUTI per 100 patients dropped from 2.07 to 1.40 (RR = 0.68, 95%CI 0.41-1.12, p = 0.1279). Overall, 373 patients received a UTC during the intervention. Of those patients 351 patients had an UTC ≥ 2 days. The analysis of these patients showed that 186 patients (53%) received a checklist as part of their chart for daily evaluation of UTC necessity. 43 (23.1%) of the completed checklists were of good quality; 143 (76.9%) were of poor quality. Patients in the group whose checklists were of good quality had fewer UTC days (median 7 UTC days IQR (3-11)) than patients whose checklists were of poor quality (11 UTC days IQR (6-16), p = 0.001).

CONCLUSION

We conclude that a champion-led, surveillance-based intervention reduces the use of UTC among geriatric patients. Further research is needed to determine to what extent the use of checklists in daily medical UTC assessment affects the prevention of CAUTI. The fact that patients whose checklists were completed well had fewer UTC days should encourage a conscientious and thorough daily review of the need for UTC.

[Healthcare-associated infections and antimicrobial use in long-term care facilities. German results of the third European point prevalence survey HALT-3]

BACKGROUND AND OBJECTIVE

The essential role of infection prevention in long-term care facilities has become evident during the current SARS-CoV‑2 pandemic. In order to obtain a reliable database on nosocomial infections and antibiotic use, the European Centre for Disease Prevention and Control (ECDC) initiated the third point prevalence survey in European long-term care facilities from 2016 to 2017 (HALT-3).

MATERIAL AND METHODS

In Germany, 131 facilities with 10,565 residents participated voluntarily. On a single day in 2016, the number of nosocomial infections and/or uses of antibiotics as well as care characteristics and risk factors of the residents were recorded. Infections were documented based on symptoms using an algorithm in accordance with the McGeer surveillance criteria for long-term care facilities.

RESULTS

A nosocomial infection was documented in 177 residents, which corresponds to a prevalence of 1.7% (95% CI: 1.3-2.1), still low in comparison with the European prevalence (mean value 3.9%). Urinary tract infections were the most common infections at almost 50%, followed by respiratory, skin, and soft-tissue infections. The type of infection was consistent with the most common indications for antibiotic use. Antibiotic use was documented in 143 residents (prevalence of 1.4%, 95% CI: 1.1-1.7). The frequent use of fluoroquinolones with over 20% of all prescriptions was noticeable.

CONCLUSIONS

The establishment of facility-based surveillance of the most common infections and antibiotic consumption, together with the creation of guidelines specifically tailored to the geriatric population, could contribute to improving infection prevention and control as well as a more rational use of antibiotics, thus increasing the quality and safety of care.

"Beyond the Guidelines" - Deviations in Adherence to Infection Control Measures in Tyrolean hospitals, Austria

BACKGROUND

Hospital-acquired infections (HAI) represent increasing problems in health-care facilities worldwide. Adequate infection control measures are key elements in preventing those infections. Expert societies have published recommendations that help to reduce HAI.

METHODS

In November 2019, a questionnaire-based point-prevalence survey, eliciting the adherence of 14 Tyrolean hospitals to the recommendations of the Centers of Disease Control and Prevention (CDC) was performed. Additionally, standard infection control measures performed by different medical (clinical and infection control specialists) disciplines as well as the performed infection control measures of nurses and physicians were compared.

RESULTS

The survey revealed varying adherence to CDC-recommendations of different medical disciplines, with highest congruence by the infection control specialists and lower congruencies by all surveyed clinical disciplines. Concordance rate between nurses and physicians was high.

DISCUSSION

Explanations for the varying congruencies of clinical disciplines on the one hand and the infection control specialists on the other hand may be versatile. Possible lacks of knowledge about the required hygiene measures should be taken into account.

CONCLUSION

The present survey showed moderate adherence of Tyrolean hospitals to the recommendations provided by CDC, however with noticeable differences between different medical disciplines. Nurses and doctors in most cases reported identically.

[Urinary diversion for acute epididymitis : Transurethral or suprapubic catheter?]

Acute infective epididymitis is the most common cause for scrotal pain in adults. The severe course of the disease requires immediate antimicrobial management, comprised antibiotic treatment and supportive measures. Patients with chronic indwelling catheters and developing epididymitis show a more severe clinical course compared to patients without a catheter. Although it is common clinical practice to place a catheter for the treatment of a systemic infectious condition of the genitourinary tract, there is only limited evidence of support due to the absence of clinical trials.

Application of a new methodology and R package reveals a high burden of healthcare-associated infections (HAI) in Germany compared to the average in the European Union/European Economic Area, 2011 to 2012

BackgroundHealthcare-associated infections (HAIs) pose a major challenge to health systems. Burden of disease estimations in disability-adjusted life years (DALYs) are useful for comparing and ranking HAIs.AimTo estimate the number of five common HAIs, their attributable number of deaths and burden for Germany.MethodsWe developed a new method and R package that builds on the approach used by the Burden of Communicable Diseases in Europe (BCoDE) project to estimate the burden of HAIs for individual countries. We used data on healthcare-associated Clostridioides difficile infection, healthcare-associated pneumonia, healthcare-associated primary bloodstream infection, healthcare-associated urinary tract infection and surgical-site infection, which were collected during the point prevalence survey of HAIs in European acute-care hospitals between 2011 and 2012.ResultsWe estimated 478,222 (95% uncertainty interval (UI): 421,350-537,787) cases for Germany, resulting in 16,245 (95% UI: 10,863-22,756) attributable deaths and 248,920 (95% UI: 178,693-336,239) DALYs. Despite the fact that Germany has a relatively low hospital prevalence of HAIs compared with the European Union/European Economic Area (EU/EEA) average, the burden of HAIs in Germany (308.2 DALYs/100,000 population; 95% UI: 221.2-416.3) was higher than the EU/EEA average (290.0 DALYs/100,000 population; 95% UI: 214.9-376.9). Our methodology is applicable to other countries in or outside of the EU/EEA. An R package is available from https://CRAN.R-project.org/package=BHAI.ConclusionThis is the first study to estimate the burden of HAIs in DALYs for Germany. The large number of hospital beds may be a contributing factor for a relatively high burden of HAIs in Germany. Further focus on infection prevention control, paired with reduction of avoidable hospital stays, is needed to reduce the burden of HAIs in Germany.

Early removal of urinary drainage in patients receiving epidural analgesia after colorectal surgery within an ERAS protocol is feasible

BACKGROUND

ERAS guidelines recommend early removal of urinary drainage after colorectal surgery to reduce the risk of catheter-associated urinary tract infections (CAUTI). Another recommendation is the postoperative use of epidural analgesia (EA). In many types of surgery, EA was shown to increase the risk of postoperative urinary retention (POUR). This study determines the impact of early urinary catheter removal on the incidence of POUR and CAUTI under EA after colorectal surgery.

METHODS

Eligible patients were scheduled for colorectal surgery within the local ERAS protocol between April 2015 and September 2016. Urinary drainage was removed on the first postoperative day while EA was still in place (early removal group (ER)). The incidences of POUR and CAUTIs were recorded prospectively. Results were compared with a historical control (CG), which was operated between October 2013 and March 2015.

RESULTS

POUR occurred significantly more often in the ER (ER 7.8%; CG 2.6%), while CAUTIs were significantly less frequent in the ER (13.8%) compared with the CG (30.4%). Patients who developed POUR were characterised by a significantly higher rate of abdominoperineal resections, by a higher frequency of rectal cancer, and a higher male-to-female ratio compared with patients who did not develop POUR.

CONCLUSION

Early removal of urinary drainage after colorectal surgery while EA is still in place is feasible; it reduces the incidence of CAUTI but increases the risk of POUR. Thus, screening for POUR in patients with failure to void after six to 8 h is mandatory under these clinical conditions.

[Medical quality standards for selected urological aids and devices : Consensus for patients with neurogenic urinary bladder dysfunction]

BACKGROUND

Using the CE mark of therapeutic appliances is, on its own, not sufficient enough for their appropriate and effective application. In order to treat the patient successfully, not jeopardizing the success of the treatment, medical quality criteria for therapeutic appliances care are necessary to acceptably compensate for a patient's disabilities.

OBJECTIVES

Medical quality criteria are formulated for the most frequently used urological aids and devices, considering hygienic requirements, international literature and the practical experience of physicians and nurses with regard to the care of patients with neurogenic urinary bladder dysfunction.

METHODS

An expert group of urologists, surgeons, rehabilitation physicians and nurses has developed medical quality criteria via a structured consensus procedure. Developing these criteria, the group has taken into account current jurisprudence, the current resource directory of neurourological relevant aids, data from international literature and hygiene requirements.

RESULTS

Medical quality requirements are discussed and defined for selected groups of urological devices (single use catheters, indwelling catheters, external catheters, urine bags, templates and diapers as well as devices for the electrostimulation of nerves).

CONCLUSION

The presented quality requirements offer the possibility to stabilize quality of care with neurourological relevant therapeutic appliances. The catalogue of therapeutic appliances must be urgently updated. Urinal catheters for single use must be classified as an individual product group. Devices for anterior root stimulation and neuromodulation must be included in the resource directory. The incontinence severity classification needs to be reviewed.

[Recurrent and catheter-associated urinary tract infections : Prophylaxis and prevention]

Urinay tract infection (UTI) as one of the most frequent bacterial infections in humans is of utmost relevance. Because of the rising prevalence of antimicrobial resistance, urinalysis should always include urine culture and a resistogram in order to avoid an unspecific selection and overuse of antibiotics. Prevention of recurrent UTI must first of all rule out predisposing uropathogenic conditions. Nowadays, a great variety of drugs, behavioral, and supportive treatment options can effectively minimize UTI recurrence. The growing importance of vaccines (immunotherapy), probiotics (lactobacilli), and standardized herbal preparations meets the need of reducing antibiotic use and the development of antimicrobial resistance. Around 80% of all nosocomial UTIs (nUTIs) are associated with indwelling urinary catheters. It is estimated that up to 70% of all nUTIs occurring in Germany may be avoided by using appropriate preventative measures. Therefore, profound knowledge about the basics of catheter-associated nUTIs and the correct management of urinary catheters are of utmost individual and socioeconomic importance.

[Neuro-urological diagnosis and therapy of lower urinary tract dysfunction in patients with spinal cord injury : S2k Guideline of the German-Speaking Medical Society of Paraplegia (DMGP), AWMF register no. 179/001]

BACKGROUND

Most patients with spinal cord injury (SCI) suffer from neurogenic lower urinary tract dysfunction (NLUTD), bowel dysfunction and sexual dysfunction. If these remain untreated, severe medical complications and serious limitations (restrictions) in quality of life are imminent.

OBJECTIVES

In the long term, there are considerable differences in the treatment results of highly specialized centers versus other treatment facilities.

MATERIALS AND METHODS

Against this background, a consensus-based guideline, according to the AWMF (Association of the Scientific Medical Societies in Germany) criteria (S2k), was developed by the neuro-urology working group of the DMPG (German-Speaking Medical Society of Paraplegia).

RESULTS

The guideline defines the principles and objectives of the neuro-urological care of patients with SCI and discusses in detail the principles of diagnosis and therapy of NLUTD. The need for video-urodynamic studies as a basis for the classification of the NLUTD and as a foundation for the development of a treatment strategy is emphasized. Both conservative and surgical therapy options and their indications are explained in detail. Possible complications and their prevention in the long-term course of SCI are presented with a particular consideration of the specific features of urinary tract infections and autonomic dysreflexia. Finally, the principles of the provision of urological appliances are discussed.

CONCLUSIONS

The presented S2k guideline provides the current standards in the neuro-urological care of patients with NLUTD due to SCI. Their consistent implementation both in the acute and chronic phase as well as in the context of lifelong surveillance of SCI patients should prevent the impending complications of NLUTD.

[Migration speed of uropathogens : Determination in the ureteral splint in a practice-like in vitro model]

BACKGROUND

A urostomy with an ileum conduit or a skin fistula leads to a high infection risk for the kidneys and the ureter of the patient. Therefore, the prevention of retrograde colonization of the artificial drain (splint) with e. g. contaminated urine is the most important objective of infection prevention measurements. We performed an in vitro experiment to determine the migration speed of clinically relevant bacteria in a commercially available splint catheter system.

METHODS

The migration speed of bacteria in commonly used splint catheters was determined in a practice-like in vitro model. Two storage vessels were connected with splints. The second vessel contained a bacterial suspension of the test bacteria Escherichia coli, Proteus mirabilis, and Staphylococcus aureus in artificial urine. The two vessels were incubated at 36 °C for 24-72 h. The microbial count in the catheters was determined after each experiment to investigate the migration distance.

RESULTS

The average migration speed was 0.63 cm/h for E. coli, 0.80 cm/h for S. aureus, and 0.94 cm/h for P. aeruginosa. This results in a colonization distance of approximately 80 cm in 3 days.

CONCLUSION

If the system, e. g., the stoma pouch is contaminated, it can be expected that during the common application time of a splint of 10-14 days, the complete splint will be contaminated due to the high bacteria migration speed. Consequently there is a high infection risk for kidneys and ureters. A return stop feature in the stoma pouch should minimize this risk. However, it is of upmost importance to not applying the splint through the return stop to prevent any contact with potentially contaminated urine.

Implementation of the updated 2015 Commission for Hospital Hygiene and Infection Prevention (KRINKO) recommendations "Prevention and control of catheter-associated urinary tract infections" in the hospitals in Frankfurt/Main, Germany

Aim: The Commission for Hospital Hygiene and Infection Prevention (KRINKO) updated the recommendations for the prevention of catheter-associated urinary tract infections in 2015. This article will describe the implementation of these recommendations in Frankfurt’s hospitals in autumn, 2015.

Material and methods: In two non-ICU wards of each of Frankfurt’s 17 hospitals, inspections were performed using a checklist based on the new KRINKO recommendations. In one large hospital, a total of 5 wards were inspected. The inspections covered the structure and process quality (operating instructions, training, indication, the placement and maintenance of catheters) and the demonstration of the preparation for insertion of a catheter using an empty bed and an imaginary patient, or insertion in a model.

Results: Operating instructions were available in all hospital wards; approximately half of the wards regularly performed training sessions. The indications were largely in line with the recommendations of the KRINKO. Alternatives to urinary tract catheters were available and were used more often than the urinary tract catheters themselves (15.9% vs. 13.5%). In accordance with the recommendations, catheters were placed without antibiotic prophylaxis or the instillation of antiseptic or antimicrobial substances or catheter flushing solutions. The demonstration of catheter placement was conscientiously performed. Need for improvement was seen in the daily documentation and the regular verification of continuing indication for a urinary catheter, as well as the omission of regular catheter change.

Conclusion: Overall, the recommendations of the KRINKO on the prevention of catheter-associated urinary tract infections were adequately implemented. However, it cannot be ruled out that in situations with time pressure and staff shortage, the handling of urinary tract catheters may be of lower quality than that observed during the inspections, when catheter insertion was done by two nurses. Against this background, a sufficient number of qualified staff and regular ward rounds by the hygiene staff appear recommendable.

Prevention and control of catheter-associated urinary tract infections - implementation of the recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) in nursing homes for the elderly in Frankfurt am Main, Germany

Introduction: Urinary tract infections range among the most frequent infections not only in hospital patients but also in residents of long-term care facilities for the elderly. Urinary catheters are the greatest risk factor for urinary tract infections. In the guidance paper on the “prevention of infections in nursing homes” (2005) as well as in the updated recommendations for the “prevention and control of catheter-associated urinary tract infections” (2015), the Commission for Hospital Hygiene and Infection Prevention (KRINKO) has recommended adequate preventive measures. In 2015, the implementation of these KRINKO recommendations was investigated.

Method: All of Frankfurt’s 40 nursing homes were evaluated using a checklist based on the KRINKO recommendations. The evaluation included assessing the availability of operating instructions, appropriate indications for the placement of catheters etc. Age, sex and duration of catheterization, as well as current and previous infections within the past 6 months were documented for every resident with a catheter.

Results: In 35 (87.5%) of the nursing homes, operating instructions for the handling of urinary tract catheters were available. The decision as to whether a catheter is indicated is made by physicians, while its placement is often delegated to the nursing service. Typically, silicon catheters are used. In three-quarters of the nursing homes, regular intervals of 4–6 weeks for changing catheters were reported. On the respective survey day, 7.3% of the residents were catheterized. On the survey day, 3.6% (4.2%) and in the previous 6 months a total of 28% (28.9%) of the residents had a urinary tract infection (prevalence of antibiotic therapy in parentheses). Ciprofloxacin was used most often followed by cefuroxime and cotrimoxazole.

Discussion: In the current evaluation, fewer nursing home residents were catheterized than in previous years and the rate of urinary tract infections was low. This indicates an increasingly cautious and apparently appropriate usage of urinary tract catheters. Also, the prevalence of antibiotic therapy was low for residents with urinary tract catheters (4.2%). However, broad spectrum antibiotics are still preferentially administered (particularly quinolones), which may favor the high rate of colonization with ESBL-producing bacteria and 3MRGN. Given this background, a coordinated approach including resistance-based antibiotic stewardship appears increasingly important in nursing homes and other health care facilities.

Hygiene auf der IMC-Station

Im Kapitel Hygiene auf der IMC-Station wird dargelegt, dass die Einhaltung von Hygienemaßnahmen nach den neuesten wissenschaftlichen Erkenntnissen zu den Basismaßnahmen einer jeden IMC-Station gehört. Neben den Standard-Hygienemaßnahmen einer IMC-Station werden die besonderen Aspekte der hygienischen Körperpflege beschrieben. Die erforderlichen Interventionen zur Vermeidung von Katheterinfektionen werden begründet. Die Vorbereitung, Anlage und Pflege der Katheter werden detailliert dargestellt, sodass jeder Lernende dies als Handlungsanweisung verwenden kann und dem Erfahrenen eine Detailprüfung ermöglicht wird. Wichtige Aspekte der Wund-, Drainagen- und Stomapflege werden besprochen und eine Kurzübersicht zur Pflege von Patienten mit MRE gegeben.

[Prevention of catheter-associated urinary tract infections: established and new aspects for the clinical routine : Revised recommendations on "prevention and control of catheter-associated urinary tract infections" of the commission for hospital hygiene and infection prevention at the Robert Koch Institute]

Catheter-associated urinary tract infections (CAUTI) are one of the most common healthcare-associated infections (HAI) in Germany and are of particular relevance for intensive and standard care units. The revised guidelines of the commission for hospital hygiene and infection prevention (KRINKO) provide an update on prevention of CAUTI. The guidelines consider and evaluate the new literature published after the initial publication in 1999. The KRINKO recommendations should be implemented to protect patients from such infections, especially as CAUTIs are one of the most preventable types of HAI. In this respect tailor-made infection prevention bundles seem to be most effective and continuous infection surveillance procedures are of particular importance. Thus, a comparison with the reference data provided by the (German) National Reference Center for surveillance of nosocomial infections is possible. This article explains the recommendations for prevention measures included in the new KRINKO guidelines.