Epidemiology of healthcare associated infections in Germany: Nearly 20 years of surveillance

Assessing infection prevention and control structures in German hospitals after the COVID-19 pandemic using the WHO infection prevention and control assessment framework (IPCAF): results from 660 hospitals and comparison with a pre-pandemic survey

BACKGROUND

The WHO Infection Prevention and Control Assessment Framework (IPCAF) is a standardized tool to assess infection prevention and control (IPC) structures in healthcare facilities. The IPCAF reflects the eight WHO core components (CC) of IPC. Besides facility self-assessment, the IPCAF can be used for national surveys, and repeated usage can aid in describing trends concerning IPC structures. A previous survey in over 700 German hospitals conducted in 2018, yielded an overall high IPC level in participating hospitals, albeit with potentials for improvement. In 2023, the survey was repeated to describe once again the state of IPC implementation in German hospitals and compare findings to data from 2018.

METHODS

The German National Reference Center for the Surveillance of Nosocomial Infections (NRC) invited 1,530 German acute care hospitals participating in the national surveillance network "KISS", to complete a translated online version of the IPCAF between October 2023 and January 2024. The questionnaire-like nature of the IPCAF, where each answer corresponds to a number of points, allows for calculating an overall IPC score. Based on the overall score, hospitals were allocated to four different IPC levels: inadequate (0-200), basic (201-400), intermediate (401-600), and advanced (601-800). Aggregated scores were calculated and compared with results from 2018.

RESULTS

Complete datasets from 660 hospitals were received and analyzed. The median overall IPCAF score was 692.5 (interquartile range: 642.5-737.5), with 572 hospitals (86.6%) classified as advanced, and 87 hospitals (13.2%) as intermediate. One hospital (0.2%) fell into the basic category. The overall median score was virtually unchanged when compared to 2018 (690; data from 736 hospitals). The median score for the CC on workload, staffing and bed occupancy was markedly higher (85 vs. 75), whereas the median score for the CC on multimodal strategies was slightly lower than in 2018 (75 vs. 80).

CONCLUSIONS

Repeated assessments of IPC structures at the national level with the IPCAF are feasible and a means to gain insights into the evolution of IPC structures. When comparing aggregated scores, a stable and high level of IPC key aspects in Germany was observed, with improvements over time in IPC indicators related to workload and staffing.

A qualitative, multi-centre approach to the current state of digitalisation and automation of surveillance in infection prevention and control in German hospitals

BACKGROUND

Healthcare associated infections (HAI) pose a major threat to healthcare systems resulting in an increased burden of disease. Surveillance plays a key role in rapidly identifying these infections and preventing further transmissions. Alas, in German hospitals, the majority of surveillance efforts have been heavily relying on labour intensive processes like manual chart review. In order to be able to identify further starting points for future digital tools and interventions to aid the surveillance of HAI we aimed to gain an understanding of the current state of digitalisation in the context of the general surveillance organisation in German clinics across all care-levels. The end user perspective of infection prevention and control (IPC) professionals was chosen to identify digital interventions that have the biggest impact on the daily surveillance work routines of IPC professionals. Perceived impediments in the advancement of surveillance digitalisation should be explored.

METHODS

Following the development of an interview guideline, eight IPC professionals from seven German hospitals of different care levels were questioned in semi- structured interviews between December 2022 and January 2023. These included questions about general surveillance organisation, access to digital data sources, software to aid the surveillance process as well as current issues in the surveillance process and implementation of software systems. Subsequently, after full transcription, the interview sections were categorized in code categories (first deductive then inductive coding) and analysed qualitatively.

RESULTS

Results were characterised by high heterogeneity in terms of general surveillance organisation and access to digital data sources. Software configuration of hospital and laboratory information systems (HIS/LIS) as well as patient data management systems (PDMS) varied not only between hospitals of different care levels but also between hospitals of the same care level. Outside research projects, neither fully automatic software nor solutions utilising artificial intelligence have currently been implemented in clinical routine in any of the hospitals.

CONCLUSIONS

Access to digital data sources and software is increasingly available to aid surveillance of HAI. Nevertheless, surveillance processes in hospitals analysed in this study still heavily rely on manual processes. In the analysed hospitals, there is an implementation and funding gap of (semi-) automatic surveillance solutions in clinical practice, especially in healthcare facilities of lower care levels.

Temporal patterns and clinical characteristics of healthcare-associated infections in surgery patients: A retrospective study in a major Chinese tertiary hospital

Background

Given the preventable nature of most healthcare-associated infections (HAIs), it is crucial to understand their characteristics and temporal patterns to reduce their occurrence.

Methods

A retrospective analysis of medical record cover pages from a Chinese hospital information system was conducted for surgery inpatients from 2010 to 2019. Association rules mining (ARM) was employed to explore the association between disease, procedure, and HAIs. Joinpoint models were used to estimate the annual HAI trend. The time series of each type of HAI was decomposed to analyze the temporal patterns of HAIs.

Results

The study included data from 623,290 surgery inpatients over 10 years, and a significant decline in the HAI rate was observed. Compared with patients without HAIs, those with HAIs had a longer length of stay (29 days vs. 9 days), higher medical costs (96226.57 CNY vs. 22351.98 CNY), and an increased risk of death (6.42% vs. 0.18%). The most common diseases for each type of HAI differed, although bone marrow and spleen operations were the most frequent procedures for most HAI types. ARM detected that some uncommon diagnoses could strongly associate with HAIs. The time series pattern varied for each type of HAI, with the peak occurring in January for respiratory system infections, and in August and July for surgical site and bloodstream infections, respectively.

Conclusions

Our findings demonstrate that HAIs impose a significant burden on surgery patients. The differing time series patterns for each type of HAI highlight the importance of tailored surveillance strategies for specific types of HAI.

Individual and institutional predisposing factors of MRSA surgical site infection and outcomes-a retrospective case-control-study in 14 European high-volume surgical centres

Objectives

To assess incidence rates of surgical site infections (SSI) by MRSA and to determine related factors and clinical outcome compared to MSSA, including country-specific, institutional and patient determinants.

Patients and methods

We performed a subgroup analysis of the Europe-wide SALT (NCT03353532) study population with MRSA SSI from 14 centres in France, Germany, Italy, Spain and the UK.

Results

An overall MRSA SSI incidence of 0.06% (n = 104) was found in 178 903 patients undergoing invasive surgery in 2016. Frequently observed comorbidities were chronic cardiovascular disease, diabetes and solid tumours. Compared to the overall MRSA SSI incidence, incidence rates were significantly higher in Spain (58 of 67 934 cases) and lower in Germany (16 of 46 443 cases; both P < 0.05). Centres with antibiotic stewardship (ABS) and infectious disease (ID) consultation programmes (n = 3/14) had lower MRSA rates (17 of 43 556 cases versus 61 of 83 048 cases, P < 0.05). In bivariate analyses, MRSA SSI patients were significantly older, had higher BMI and more comorbidities compared to MSSA (P < 0.05 each). Surgery performed between 6:00 and 12:00 pm led to higher MRSA proportions among S. aureus SSI (17 of 104 cases versus 62 of 640 cases, P < 0.05).

Conclusions

This study shows low overall and country-specific incidence rates of MRSA SSI in Europe. We could show significant differences between countries as well as between centres with established ABS and ID consultation programmes were observed. The number of those programmes seems too small against this background.

Surveillance of infections of surgical sites and lower respiratory tracts should be combined: experiences from the German surveillance module for operated patients (OP-KISS), 2018 to 2022

BackgroundSurveillance of lower respiratory tract infections (LRTI) of operated patients conventionally focuses on intubated patients in intensive care units (ICU). Post-operative immobilisation increases the risk of LRTI not associated with ventilators. Operated patients, however, have thus far not been a primary target for LRTI surveillance.AimWe aimed to describe the applied LRTI surveillance method in the German surveillance module for operated patients (OP-KISS) and to report data between 2018 and 2022.MethodsSurveillance of LRTI can be performed voluntarily in addition to surgical site infection (SSI) surveillance in OP-KISS. We calculated LRTI rates per 100 operations for all procedures combined, as well as for individual surgical groups and procedures. Additionally, a combined post-operative infection rate (SSI and LRTI) was calculated.ResultsSurveillance of LRTI was performed in 4% of all participating OP-KISS departments and for 2% (23,239 of 1,332,438) of all procedures in the OP-KISS database. The pooled LRTI rate was 0.9 per 100 operations, with marked differences between different types of surgery (3.6 for lobectomies, 0.1 for traumatology and orthopaedics). The share of LRTI among all post-operative infections was highly variable. For lobectomies, the LRTI rate was higher than the SSI rate (3.6 vs 1.5 per 100 operations).ConclusionSurveillance of post-operative LRTI is not yet widely adopted by German hospitals. Based on the data in this study, lobectomies represent a prime target for post-operative LRTI surveillance.

Implementation of a new surveillance system for dialysis-associated infection events in outpatient dialysis facilities in Germany

INTRODUCTION

Patients receiving maintenance haemodialysis are at risk of catheter-related infections. Up to now, there has been no standardized surveillance tool in Germany to evaluate infection events in haemodialysis outpatients. As such, this study aimed to implement an online-based surveillance tool in outpatient dialysis facilities, and to report the first national surveillance data for haemodialysis patients in Germany from October 2019 until September 2021.

METHODS

Outpatient dialysis facilities reported three types of dialysis-associated infection event (DAIE): bloodstream infections, intravenous antimicrobial starts, and local access site infections. Denominator data were provided by the number of haemodialysis treatments at each facility per month. DAIE rates stratified by vascular access type were calculated.

RESULTS

In total, 43 outpatient dialysis facilities reported 723 DAIEs, including 63 bloodstream infections, 439 intravenous antimicrobial starts, and 221 local access site infections. The overall incidence of DAIEs was 0.51 per 1000 dialysis treatments (723/1,413,457) during the surveillance period. The overall incidence of DAIEs was 0.13 per 1000 dialysis treatments among patients with arteriovenous fistulas (AVFs; 126/990,392), 0.41 per 1000 dialysis treatments among patients with arteriovenous grafts (41/99,499), and 1.68 per 1000 dialysis treatments among patients with central venous catheters (CVCs; 535/318,757). The rate ratio of DAIEs between CVC and AVF rates was 13.2 (95% confidence interval 10.9-16.0; P<0.001).

DISCUSSION

These 2-year infection data represent the first standardized data of outpatient dialysis facilities in Germany. Rates of infection were highest among patients with CVCs compared with other vascular access types. This online-based surveillance tool may be helpful to identify effective targets for infection prevention measures in haemodialysis patients.

Surgical site infection surveillance in German hospitals: a national survey to determine the status quo of digitalization

BACKGROUND

Surveillance of surgical site infections (SSI) relies on access to data from various sources. Insights into the practices of German hospitals conducting SSI surveillance and their information technology (IT) infrastructures are scarce. The aim of this study was to evaluate current SSI surveillance practices in German hospitals with a focus on employed IT infrastructures.

METHODS

German surgical departments actively participating in the national SSI surveillance module "OP-KISS" were invited in August 2020 to participate in a questionnaire-based online survey. Depending on whether departments entered all data manually or used an existing feature to import denominator data into the national surveillance database, departments were separated into different groups. Selected survey questions differed between groups.

RESULTS

Of 1,346 invited departments, 821 participated in the survey (response rate: 61%). Local IT deficits (n = 236), incompatibility of import specifications and hospital information system (n = 153) and lack of technical expertise (n = 145) were cited as the most frequent reasons for not using the denominator data import feature. Conversely, reduction of workload (n = 160) was named as the main motivation to import data. Questions on data availability and accessibility in the electronic hospital information system (HIS) and options to export data from the HIS for the purpose of surveillance, yielded diverse results. Departments utilizing the import feature tended to be from larger hospitals with a higher level of care.

CONCLUSIONS

The degree to which digital solutions were employed for SSI surveillance differed considerably between surgical departments in Germany. Improving availability and accessibility of information in HIS and meeting interoperability standards will be prerequisites for increasing the amount of data exported directly from HIS to national databases and laying the foundation for automated SSI surveillance on a broad scale.

Age as a risk factor for surgical site infections: German surveillance data on total hip replacement and total knee replacement procedures 2009 to 2018

BackgroundOlder age is frequently cited as a risk factor for healthcare-associated infections in general, and surgical site infections (SSIs) specifically.AimWe aimed to investigate the correlation between age and SSI occurrence.MethodsData on total hip replacement (THR) and total knee replacement (TKR) surgeries and resulting SSIs documented in the German national surveillance network from a 10-year period from 2009 to 2018 were selected for analysis. SSI rates and adjusted odds ratios (AOR) were calculated and a multivariable analysis to determine risk factors for SSI occurrence was conducted.ResultsA total of 418,312 THR procedures resulting in 3,231 SSIs, and 286,074 TKR procedures with 1,288 SSIs were included in the analyses. For THR, SSI rates were higher in older age groups when compared with the reference age group of 61-65 years. A significantly higher risk was observed in the 76-80 years age group (AOR: 1.21, 95% CI: 1.05-1.4). An age of ≤ 50 years was associated with a significantly lower SSI risk (AOR: 0.64, 95% CI: 0.52-0.8). For TKR, a similar correlation was observed, with the exception of the youngest age group (≤ 52 years), which was shown to have an SSI risk equal to that of the knee prosthesis reference age group (78-82 years).ConclusionA strong correlation between increasing age and SSI occurrence was observed for both procedure types. The results of our analyses provide a basis to consider future targeted SSI prevention measures for different age groups.

SAPS2, APACHE2, SOFA, and Core-10-TISS upon admission as risk indicators for ICU-acquired infections: a retrospective cohort study

PURPOSE

Early identification of high-risk patients is an important component in improving infection prevention. The SAPS2, APACHE2, Core-10-TISS, and SOFA scores are already widely used to estimate mortality, morbidity and nursing workload, but this study evaluated their usefulness in assessing a patient's risk of ICU-acquired infection.

METHODS

We conducted a retrospective cohort study by analyzing all patient admissions to seven ICUs at Charité Berlin, Germany in 2017 and 2018. The four scores were documented by physicians on the day of admission. The infection control staff monitored daily whether the patients experienced lower respiratory tract infections (LRTIs), urinary tract infections (UTIs), or primary blood stream infections (PBSIs). For each combination of scoring system and infection type, an adjusted Fine and Gray model was fitted.

RESULTS

We analyzed 5053 ICU admissions and observed at least one ICU-acquired infection in N = 253 patients (incidence density: 4.73 per 1000 days). 59.0% (N = 2983) of the patients were male, median age was 66 years (IQR 55-77) and median length of stay was 6 days (IQR 4-12). All models showed that patients with a higher score value were at higher risk for ICU-acquired first PBSI, LRTI, or UTI, except for the model of APACHE2 and PBSI. Patients with a SAPS2 score of > 50 points showed an increased risk of infection of sHR = 2.34 for PBSIs (CI 1.06-5.17, p < 0.05), sHR = 2.33 for LRTIs (1.53-2.55, p < 0.001) and sHR = 2.25 for UTIs (1.23-4.13, p < 0.01) when compared to the reference group with 0-30 points.

CONCLUSIONS

The result of this study showed that admission scores of SAPS2, Core-10-TISS, APACHE2, and SOFA might be adequate indicators for assessing a patient's risk of ICU-acquired infection.

The impact of the COVID-19 pandemic on nosocomial infections: a retrospective analysis in a tertiary maternal and child healthcare hospital

Objective

The constant changes in the control strategies of the Corona Virus Disease 2019 (COVID-19) pandemic have greatly affected the prevention and control of nosocomial infections (NIs). This study assessed the impact of these control strategies on the surveillance of NIs in a regional maternity hospital during the COVID-19 pandemic.

Methods

This retrospective study compared the observation indicators of nosocomial infections and their changing trends in the hospital before and during the COVID-19 pandemic.

Results

In total, 2,56,092 patients were admitted to the hospital during the study. During the COVID-19 pandemic, the main drug-resistant bacteria in hospitals were Escherichia coli, Streptococcus agalactiae, Staphylococcus aureus, Klebsiella pneumoniae, and Enterococcus faecalis. The detection rate of S. agalactiae increased annually, while that of E. faecalis remained the same. The detection rate of multidrug-resistant bacteria decreased during the pandemic (16.86 vs. 11.42%), especially that of CRKP (carbapenem-resistant Klebsiella pneumoniae 13.14 vs. 4.39, P < 0.001). The incidence of nosocomial infections in the pediatric surgery department decreased significantly (OR: 2.031, 95% CI: 1.405-2.934, P < 0.001). Regarding the source of infection, a significant reduction was observed in respiratory infections, followed by gastrointestinal infections. In the routine monitoring of the ICU, the incidence of central line-associated bloodstream infection (CLABSI) decreased significantly (9.4/1,000 catheter days vs. 2.2/1,000 catheter days, P < 0.001).

Conclusion

The incidence of nosocomial infections was lower than that before the COVID-19 pandemic. The prevention and control measures for the COVID-19 pandemic have reduced the number of nosocomial infections, especially respiratory, gastrointestinal, and catheter-related infections.

Surveillance of Enterobacter cloacae complex colonization and comparative analysis of different typing methods on a neonatal intensive care unit in Germany

Background

Enterobacter cloacae complex is a group of common opportunistic pathogens on neonatal intensive care units. Active microbiological screening to guide empirical antimicrobial treatment or to detect transmission events is recommended in high-risk preterm neonates. A rise in colonization with E. cloacae complex was observed in a German perinatal centre. The aim of this study was to evaluate the performance of different typing techniques using whole genome sequencing (WGS) as a reference.

Methods

Enterobacter cloacae complex isolates from clinical and screening specimens with an epidemiological link to the neonatal intensive care units were further assessed. Identification and antibiotic susceptibility testing was performed by a combination of VITEK2 (bioMérieux) and MALDI-TOF (Bruker Daltonics), followed by RAPD/rep-PCR and PFGE (XbaI). Retrospectively, all isolates were analyzed by Fourier-transform infrared (FTIR) spectroscopy (IR Biotyper, Bruker Daltonics). Whole genome sequencing with SNP-based clustering was used as the reference method. Furthermore, resistome analysis, sequence type and species identification were derived from the WGS data. Transmission analysis was based on epidemiological and typing data.

Results

Between September 2017 and March 2018 32 mostly preterm neonates were found to be colonized with E. cloacae complex and 32 isolates from 24 patients were available for further typing. RAPD/rep-PCR and PFGE showed good concordance with WGS whereas FTIR displayed mediocre results [adjusted rand index (ARI) = 0.436]. A polyclonal increase and two dominant and overlapping clonal clusters of two different E. hormaechei subspecies were detected. Overall, four different species were identified. Genotyping confirmed third-generation cephalosporin resistance development in isolates of the same patient. During the six-month period several infection prevention interventions were performed and no E. cloacae complex isolates were observed during the following months.

Conclusions

Interpretation of the microbiological results alone to detect transmission events is often challenging and bacterial typing is of utmost importance to implement targeted infection control measures in an epidemic occurrence of E. cloacae complex. WGS is the most discriminatory method. However, traditional methods such as PFGE or RAPD/rep-PCR can provide reliable and quicker results in many settings. Furthermore, research is needed to quickly identify E. cloacae complex to the species level in the microbiological laboratory.

Healthcare-Associated Infections (HAIs): Challenges and Measures Taken by the Radiology Department to Control Infection Transmission

Infections contracted during healthcare delivery in a hospital or ambulatory setting are collectively referred to as healthcare-associated infections (HAIs). Healthcare workers and patients alike are vulnerable to serious problems as a result of the risk of HAIs. In the healthcare system, HAIs are considered among the most common and serious health problems. However, the occurrence of HAIs differs between different types of clinical departments within the hospital. Recently, the risk of HAIs has been increasing in radiology departments globally due to the central role of radiology in guiding clinical decisions for the diagnosis, treatment, and monitoring of different diseases from almost all medical specialties. The radiology department is particularly vulnerable to HAIs because it serves as a transit hub for infected patients, non-infected patients, and healthcare workers. Furthermore, as the number of patients referred to radiology and the length of patient contact time has increased, thanks to modern imaging techniques such as computed tomography and magnetic resonance imaging, the risk of HAIs has also increased significantly. With the increasing use of interventional radiological procedures, patients and healthcare workers face a potentially greater risk of contracting HAIs due to the invasive nature of such procedures. Although not exhaustive, we attempted through a literature search to provide a general overview of infection prevention and control practices, address HAIs in the radiology departments, and highlight the challenges and measures taken to control infection transmission in the radiology departments.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

Surgical site infection following minimally invasive lobectomy: Is robotic surgery superior?

Background

Surgical site infection (SSI) in thoracic surgery remains a significant cause of morbidity and prolonged hospitalization. Minimally invasive surgery (MIS) has significantly reduced the risk of SSI. We intended to compare whether there was difference between video‐assisted thoracic surgery (VATS) and robotic‐assisted thoracic surgery (RATS) in SSI and highlight possible factors influencing SSI in lobectomy.

Methods

This retrospective study analyzed patients who underwent minimally invasive lobectomy from January 2018 to December 2019. All patients' clinical characteristics and surgery‐related information which may be related to the likelihood of SSI were recorded.

Results

A total of 1231 patients' records were reviewed with 806 VATS and 425 RATS. SSI was classified as deep or superficial SSI. Eighty‐six (7.0%) patients were found to develop an SSI with 62 patients having deep infections and 24 had superficial infection. No statistical difference in the incidence rate and category of SSI was observed between patients undergoing VATS and RATS.

Conclusions

There was no difference in the incidence of SSI between VATS and RATS lobectomy. Male gender, heavy smoking, uncontrolled diabetes mellitus, body mass index (BMI) > 27.9, more blood loss, and the higher National Healthcare Safety Network (NHSN) risk index score (1 or 2) were the independent risk factors of SSI following minimally invasive lobectomy, while male gender, uncontrolled diabetes mellitus, BMI > 27.9, more blood loss and the higher NHSN risk index score (1 or 2) were the main predictors of deep SSI.

OUP accepted manuscript

Objectives

To describe the propensity of carbapenem-resistant Pseudomonas aeruginosa to spread within a hospital critical care setting.

Methods

The study was conducted in a 700-bed tertiary centre in Cologne, Germany. P. aeruginosa resistant to piperacillin, ceftazidime, cefepime, imipenem, meropenem and ciprofloxacin, isolated from clinical and screening specimens from four critical care units from 2015 to 2020 were analysed. Genotyping was carried out by WGS (Illumina and MinION). MLST, core genome MLST (cgMLST) and resistome analysis was performed and merged with epidemiological data.

Results

Fifty-five out of 79 non-duplicate P. aeruginosa isolates were available, of which 20 were carbapenemase producers as follows: bla_VIM-1 (n = 1), bla_VIM-2 (n = 17), bla_VIM-4 (n = 1), and bla_NDM-1/bla_GES-5 (n = 1). Forty-two of 55 isolates were hospital-acquired. cgMLST revealed three clusters: Cluster 1 (n = 15, ST111, bla_VIM-2, recovered between 2015 and 2020); Cluster 2 (n = 4, ST970, carbapenemase negative); and Cluster 3 (n = 2, ST357, carbapenemase negative). The bla_VIM-2 gene of Cluster 1 was integrated on the chromosome in a class 1 integron (type In59). Using conventional epidemiology, we were only able to confirm two patient-to-patient transmissions and one room-to-patient transmission on three different ICUs within Cluster 1. Isolates from Cluster 2 represented an outbreak occurring in 2019.

Conclusions

These data give insight into the epidemiology of carbapenem-resistant P. aeruginosa. Transmission dynamics differed between carbapenemase- and non-carbapenemase-producing isolates. A continuous acquisition of clonally related ST111 VIM-2 P. aeruginosa, being the main carbapenemase-producing strain, was observed over the whole study period, as well as an overall higher genomic diversity among non-carbapenemase-producing P. aeruginosa.

A scoping review of registry captured indicators for evaluating quality of critical care in ICU

BACKGROUND

Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation.

METHOD

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance.

RESULTS

The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%).

CONCLUSIONS

Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.

Association between the frequency of surgeries for video-assisted thoracic surgery and the incidence of consequent surgical site infections: a retrospective observational study based on national surveillance data

Background

The association between the frequency of surgeries and the incidence of surgical site infections (SSIs) has been reported for various surgeries. However, no previous study has explored this association among video-assisted thoracic surgeries (VATS). Hence, we aimed to investigate the association between the frequency of surgeries and SSI in video-assisted thoracic surgeries.

Methods

We analyzed the data of 26,878 thoracic surgeries, including 21,154 VATS, which were collected during a national surveillance in Japan between 2014 and 2018. The frequency of surgeries per hospital department was categorized into low (< 50/year), moderate (50–100/ year), and high (> 100/year). Chi-squared test or Fisher’s exact test was used for discrete explanatory variables, whereas Wilcoxon’s rank-sum test or Kruskal-Wallis test was used for continuous explanatory variables. Univariate analysis of the department groups was conducted to explore confounding factors associated with both SSIs and the department groups. We used a multiple logistic regression model focusing on VATS and stratified by the National Nosocomial Infections Surveillance System (NNIS) risk index.

Results

The rates of SSIs in the hospital groups with low, moderate, and high frequency of surgeries were 1.39, 1.05, and 1.28%, respectively. In the NNIS risk index 1 stratum, the incidence of SSIs was significantly lower in the moderate-frequency of surgeries group than that in the other groups (odds ratio [OR]: vs. low-frequency of surgeries: 2.48 [95% confidence interval [CI]: 1.20–5.13], P = 0.0143; vs. high-frequency of surgeries: 2.43 [95% CI: 1.44–4.11], P = 0.0009). In the stratum of NNIS risk indices 2 and 3, the incidence of SSI was significantly higher in the low-frequency of surgeries group (OR: 4.83, 95% CI: 1.47–15.93; P = 0.0095).

Conclusion

The result suggests that for departments with low-frequency of surgeries, an increase in the frequency of surgeries to > 50 per department annually potentially leads to a decrease in the incidence of SSIs. This occurs through an increase in the experience of the departmental surgeons and contributes to the improvement of VATS outcomes in thoracic surgeries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06050-6.

Urgency of surgery as an indicator for the occurrence of surgical site infections: data from over 100,000 surgical procedures

BACKGROUND

The risk for surgical site infections (SSIs) is influenced by patient- and procedure-related factors. Urgent surgery represents a challenge in operative medicine and is frequently linked to a variety of complications, including SSIs.

AIM

We aimed to investigate whether urgency was significantly associated with SSI occurrence, and determine whether collection of this variable provided useful information for SSI surveillance.

METHODS

We performed a retrospective data analysis of caesarean sections (C-sections) and colon surgeries conducted between 2017 and 2019 within the German national SSI surveillance network. A multivariable logistic regression model was utilized to determine the influence of urgency on SSI occurrence. For this purpose, data on procedures and SSIs were associated with available department- and patient-related parameters.

FINDINGS

A total of 115,648 procedures were included in the analysis: 78,288 C-sections and 37,360 colon surgeries. For C-sections, the SSI rate per 100 procedures was 0.98 (95% confidence interval: 0.85-1.11) for urgent and 0.46 (0.40-0.53) for elective procedures (P<0.001). For open colon surgeries, SSI rates were 9.66 (8.89-10.49) for urgent and 8.60 (8.13-9.11) for elective procedures (P<0.001). For laparoscopic colon surgeries, SSI rates did not differ significantly. Multivariable analysis revealed that urgency significantly increased the likelihood of SSI occurrence only for C-sections.

CONCLUSION

Urgency significantly increased the SSI risk of C-sections, but not colon surgeries. Hence, collection of this variable is useful for SSI surveillance of C-sections, but may be dispensable for other procedures. Future analyses on the matter should therefore focus on other procedure types.

Efficacy of universal preoperative decolonization with Polyhexanide in primary joint arthroplasty on surgical site infections. A multicenter before-and after-study

Background

Surgical site infections (SSI) are rare but severe complications after total joint arthroplasty (TJA). Decolonization measures prior to elective orthopedic surgeries have shown to reduce the risk of SSI with Staphylococcus aureus (S. aureus).

Objective

To determine the efficacy of universal decolonization with Polyhexanide on SSI rates with a focus on Staphylococcus aureus in patients with TJA.

Methods

Patients scheduled for elective hip or knee TJA in 5 participating certified orthopedic centers were included between 2015 and 2018 into this before and after study. Data on patients, surgeries and infections were prospectively collected. CDC-criteria were used to define and categorize Infections within 90 days after surgery. From January 2017 on, patients received decolonization sets containing Polyhexanide. Patients performed a 5 day decolonization regimen starting 4 days prior to surgery which included wipes, nasal decontamination and oral solution.

Results

Thirteen thousand, three hundred fifteen patients received TJA. During intervention 4437 decolonization sets were distributed among 7175 patients.

Overall SSI rates increased from 0.68 /100 surgeries to 0.91/ 100 surgeries after implementation of the intervention (IRR 1.32; 95% CI 0.90–1.96). Time series analysis identified an increasing trend of SSI prior to the intervention. After implementation overall SSI rates plateaued. Regression analysis revealed surgery during intervention period to be an independent risk factor for developing a SSI (OR 1.34; 95%CI 1.18–1.53).

Initial SSI rates due to S. aureus were 0.24/100 surgeries and decreased to 0.14/100 surgeries (IRR 0.57; 95% CI 0.25–1.22) after introduction of decolonization. Regression analysis revealed surgery during intervention period to be an independent protective factor for developing a SSI with S. aureus (OR 0.57, 95% CI: 0.33–0.99).

Overall deep S. aureus SSI decreased significantly from 0.22/100 surgeries to 0.00/100 surgeries in patients adherent to protocol (IRR 0.00, 95% CI 0.00–.85).

Conclusion

Universal decolonization with Polyhexanide did not reduce overall surgical site infections, but was effective in reducing Staphylococcus aureus - surgical site infections following elective joint arthroplasty. Polyhexanide could extend the list of alternatives to already established decolonization strategies.

Trial registration

The trial was registered at the German Registry for clinical studies www.drks.de (DRKS00011505).

Risk-adjustment models for clean and colorectal surgery surgical site infection for the Spanish health system

OBJECTIVE

To develop risk-adjusted models for two quality indicators addressing surgical site infection (SSI) in clean and colorectal surgery, to be used for benchmarking and quality improvement in the Spanish National Health System.

STUDY DESIGN

A literature review was undertaken to identify candidate adjustment variables. The candidate variables were revised by clinical experts to confirm their clinical relevance to SSI; experts also offered additional candidate variables that were not identified in the literature review. Two risk-adjustment models were developed using multiple logistic regression thus allowing calculation of the adjusted indicator rates.

DATA SOURCE

The two SSI indicators, with their corresponding risk-adjustment models, were calculated from administrative databases obtained from nine public hospitals. A dataset was obtained from a 10-year period (2006-2015), and it included data from 21 571 clean surgery patients and 6325 colorectal surgery patients.

ANALYSIS METHODS

Risk-adjustment regression models were constructed using Spanish National Health System data. Models were analysed so as to prevent overfitting, then tested for calibration and discrimination and finally bootstrapped.

RESULTS

Ten adjustment variables were identified for clean surgery SSI, and 23 for colorectal surgery SSI. The final adjustment models showed fair calibration (Hosmer-Lemeshow: clean surgery χ2 = 6.56, P = 0.58; colorectal surgery χ2 = 6.69, P = 0.57) and discrimination (area under receiver operating characteristic [ROC] curve: clean surgery 0.72, 95% confidence interval [CI] 0.67-0.77; colorectal surgery 0.62, 95% CI 0.60-0.65).

CONCLUSIONS

The proposed risk-adjustment models can be used to explain patient-based differences among healthcare providers. They can be used to adjust the two proposed SSI indicators.

Analysis of the Risk Factors for Nosocomial Bacterial Infection in Patients with COVID-19 in a Tertiary Hospital

Background

Infection surveillance and risk factor analysis are among the most important prerequisites for the prevention and treatment of nosocomial bacteria infections, which are the demands for both infected and non-infected patients.

Purpose

To explore the risk factors for nosocomial bacterial infection of patients with COVID-19, and further to provide a theoretical basis for scientific prevention and control of nosocomial bacterial infection.

Methods

Between 10 January 2020 and 9 March 2020, we collected data of 212 patients with COVID-19 and then explored the influence of age, gender, length of stay, use of ventilator, urinary catheterization, central venous catheterization, white blood cell (WBC) count and procalcitonin on the nosocomial bacterial infection of patients with COVID-19 by a retrospective study.

Results

There were 212 confirmed cases of COVID-19, of which 31 cases had nosocomial bacterial infections, with an incidence of 14.62%. The most common types of nosocomial bacterial infections were lower respiratory tract (12 cases, 38.71%), which was the most frequent site, followed by urinary tract (10 cases, 32.26%), blood stream (7 cases, 22.58%), upper respiratory tract (1 case, 3.23%) and gastrointestinal tract infection (1 case, 3.23%). The incidence of nosocomial bacterial infection was significantly correlated with age, arteriovenous catheterization, urinary catheterization, WBC count and procalcitonin. Moreover, multivariate analysis confirmed that WBC (OR 8.38, 95% CI 1.07 to 65.55), procalcitonin (OR 4.92, 95% CI 1.39 to 17.33) and urinary catheterization (OR 25.38, 95% CI 5.09 to 126.53) were independent risk factors for the nosocomial bacterial infection of patients with COVID-19.

Conclusion

Understanding the risk factors for nosocomial bacterial infection of patients with COVID-19 and strengthening the monitoring of various susceptible factors are helpful to control the occurrence of nosocomial bacterial infection in the COVID-19 isolation wards.

Increase in surgical site infections caused by gram-negative bacteria in warmer temperatures: Results from a retrospective observational study

OBJECTIVE

Surgical site infections (SSIs) occur more frequently during periods of warmer temperatures. We aimed to investigate for which pathogens this association is particularly strong.

DESIGN

A retrospective observational study was conducted.

METHODS

Data from the SSI-module of the German nosocomial infection surveillance system between 2000 and 2016 were linked with data from the German Meteorological Service. Patient- and procedure-related data were associated with monthly aggregated meteorological data. Due to high correlation with other meteorological parameters, we focused on the outside temperature. Adjusted odds ratios were calculated for SSI rates relating to temperature. SSIs were stratified by pathogen. A P value of <.05 was considered significant.

RESULTS

Altogether, 2,004,793 procedures resulting in 32,118 SSIs were included. Generally, warmer temperatures were associated with a higher SSI risk, especially for SSIs with gram-negative pathogens. This association was particularly prominent for Acinetobacter spp, Pseudomonas aeruginosa, and certain Enterobacteriaceae. Per additional 1°C, we observed a 6% increase in the SSI risk for Acinetobacter spp and a 4% increase for Enterobacter spp. Superficial SSIs with Acinetobacter spp were 10 times more likely to occur when comparing surgeries in months with mean temperatures of ≥20°C to mean temperatures of <5°C.

CONCLUSIONS

Higher temperatures were associated with increased SSI rates caused by gram-negative bacteria. Future SSI prevention measures should consider this aspect. Underlying shifts in microbiome composition due to climate factors should be included in further analyses. Given the expected rise of global temperatures until the end of the century, this topic has relevance from multiple perspectives.

Evaluating infection prevention and control programs in Austrian acute care hospitals using the WHO Infection Prevention and Control Assessment Framework

Background

Infection prevention and control (IPC) is crucial for patient safety. The World Health Organization (WHO) has released various tools to promote IPC. In 2018, the WHO released the Infection Prevention and Control Assessment Framework (IPCAF) that enables acute care healthcare facilities to evaluate IPC structures and practices. Data regarding IPC implementation in Austria are scarce. To deliver insights into this topic and promote the IPCAF within the Austrian IPC community, we decided to invite all Austrian hospitals participating in the German nosocomial infection surveillance system to conduct a self-assessment using the WHO IPCAF.

Methods

The IPCAF follows the eight WHO core components of IPC. A German translation of the IPCAF was sent to 127 Austrian acute care hospitals. The survey period was from October to December 2018. Participation in the survey, data entry and transfer to the German national reference center for surveillance of healthcare-associated infections was on a voluntary basis.

Results

Altogether, 65 Austrian hospitals provided a complete dataset. The overall median IPCAF score of all hospitals was 620 (of a possible maximum score of 800), which corresponded to an advanced level of IPC. Of the 65 hospitals, 38 achieved an advanced IPC level. Deeper analysis of the different core components yielded diverse results. Scores were lowest for core components on multimodal strategies for implementation of IPC interventions, and IPC education and training. Around 26% (n = 17) of hospitals reported that the local IPC team was not steadily supported by an IPC committee. Senior clinical staff was not present in the IPC committee in 23% (n = 15) of hospitals. Only 26% (n = 17) of hospitals reported employing at least one IPC professional per ≤250 beds. Surveillance for multidrug-resistant pathogens was not conducted in 26% (n = 17) of hospitals.

Conclusions

Implementation of IPC key aspects is generally at a high level in Austria. However, potentials for improvement were demonstrated, most prominently with regard to staffing, IPC education and training, effective implementation of multimodal strategies, and involvement of professional groups. Our survey demonstrated that the IPCAF is a useful tool for IPC self-assessment and can uncover deficits even in a high-income setting like Austria.

Summer, sun and sepsis-The influence of outside temperature on nosocomial bloodstream infections: A cohort study and review of the literature

BACKGROUND

The incidence of many infections is seasonal e.g. surgical site infections, urinary tract infection and bloodstream infections. We questioned whether there is seasonal variation even in climate-controlled hospitalized patients, and analyzed the influence of climate parameters on nosocomial bloodstream infections.

METHODS AND FINDINGS

The retrospective cohort study is based on two databases: The German national surveillance system for nosocomial infections in intensive care units (ICU-KISS) from 2001 to 2015 and aggregated monthly climate data. Primary bloodstream infection (PBSI) is defined as a positive blood culture with one (or more) pathogen(s) which are not related to an infection on another site and which were not present at admission. Monthly infection data were matched with postal code, calendar month and corresponding monthly climate and weather data. All analyses were exploratory in nature. 1,196 ICUs reported data on PBSI to KISS. The ICUs were located in 779 hospitals and in 728 different postal codes in Germany. The majority of the 19,194 PBSI were caused by gram-positive bacteria. In total, the incidence density of BSI was 17% (IRR 1.168, 95%CI 1.076-1.268) higher in months with high temperatures (≥20°C) compared to months with low temperatures (<5°C). The effect was most prominent for gram-negatives; more than one third (38%) higher followed by gram-positives with 13%. Fungi reached their highest IRR at moderately warm temperatures between 15-20°C. At such temperatures fungi showed an increase of 33% compared to temperatures below 5°C. PBSI spiked in summer with a peak in July and August. PBSI differed by pathogen: The majority of bacteria increased with rising temperatures. Enterococci showed no seasonality. S. pneumoniae reached a peak in winter time. The association of the occurrence of PBSI and temperatures ≥20°C was stronger when the mean monthly temperature in the month prior to the occurrence of BSI was considered instead of the temperature in the month of the occurrence of BSI. High average temperatures ≥20°C increased the risk of the development of a PBSI by 16% compared with low temperatures <5°C.

CONCLUSIONS

Most nosocomial infections are endogenous in nature; the microbiome plays a crucial role in host health. If gut and skin microbiome varies with season, environmental parameters will contribute to the observed incidence patterns. Similarly, the impact of global warming on both local weather patterns and extreme weather events may influence the acquisition of pathogens. A better understanding of the etiology of these infections is needed to provide guidance for future infection control strategies.

Trends, risk factors and outcomes of healthcare-associated infections in a neonatal intensive care unit in Italy during 2013-2017

Background

Healthcare-associated infections (HAIs) occur frequently in intensive care units (NICUs). The aim of this study was to analyze the results of surveillance of HAIs in a III level NICU in Naples, Italy during 2013–2017 and to compare with those obtained during 2006–2010.

Methods

The surveillance included 1265 neonates of all birth weight (BW) classes with > 2 days NICU stay. Infections were defined using standard Centers for Disease Control and Prevention definitions adapted to neonatal pathology.

Results

A total of 125 HAIs were registered during 2013–2017 with a frequency of 9.9% and an incidence density of 3.2 per 1000 patient days. HAIs occurred in all BW classes with a decreasing trend from the lowest to the highest BW classes (p = < 0.001). Central line-associated blood stream infection (CLABSI) was the most frequent infection (69.6%), followed by ventilator associated pneumonia (VAP) (20%), urinary tract infection (UTI) (8.8%) and necrotizing enterocolitis (NEC) (1.6%). Also, CLABSI and VAP incidence density decreased from lower to highest BW classes showing a significant trend (p = 0.007). Most frequent pathogens responsible for CLABSI were: Coagulase-negative staphylococci (CONS) (25.3%), Candida parapsilosis (21.8%), Pseudomonas aeruginosa (5.7), Escherichia coli and Klebsiella pneumoniae (6.8%). No microbiological diagnosis was achieved for 20.7% of CLABSI. Pseudomonas aeruginosa (28%), Stenotrophomonas maltophilia (20%), and CONS (20%) were the most frequent pathogens responsible for VAP. CLABSI incidence density showed no differences between 2006 and 2010 and 2013–2017, while VAP incidence density for the 751–100 g BW class was higher during 2006–2010 than during 2013–2017 (p = 0.006). A higher incidence of the CLABSI caused by Gram positive bacteria (p = 0.002) or by undetermined etiology (p = 0.01) was observed during 2013–2017 than during 2006–2010, while a significant lower incidence of VAP caused by Gram-negative bacteria was found during 2013–2017 than during 2006–2010 (p = 0.007).

Conclusion

HAIs in the NICU developed in all BW classes with a decreasing trend from the lowest to the highest BW classes in both study periods. Differences in the aetiology of CLABSI and VAP were found between the two study periods. This reinforces the importance of HAIs surveillance protocol in the NICU, which monitors microbiological isolates and use of medical devices for all BW classes of neonates.

Methodology minute: An overview of the case-case study design and its applications in infection prevention

The case-case study design is a potentially useful tool for infection preventionists during outbreak or cluster investigations. This column clarifies terminology related to case-case, case-control, and case-case-control study designs. Examples of practical applications of the case-case study design include determining risk factors for health care-onset versus community-onset infections, or antibiotic-resistant versus antibiotic-susceptible infections.

Seasonal effect on the incidence of post-operative wound complications after trauma-related surgery of the foot, ankle and lower leg

INTRODUCTION

Post-operative wound complications remain among the most common complications of orthopedic (trauma) surgery. Recently, studies have suggested environmental factors such as season to be of influence on wound complications. Patients operated in summer are reported to have more wound complications, compared to other seasons. The aim of this study was to identify if "seasonality" was a significant predictor for wound complications in this cohort of trauma-related foot/ankle procedures.

MATERIALS AND METHODS

This retrospective cohort study included all patients undergoing trauma-related surgery (e.g. fracture fixation, arthrodesis, implant removal) of the foot, ankle or lower leg. Procedures were performed at a Level 1 Trauma Center between September 2015 until March 2019. Potential risk factors/confounders were identified using univariate analysis. Procedures were divided into two groups: (1) performed in summer (June, July or August), (2) other seasons (September-May). The number of surgical wound complications (FRIs, SSIs or wound dehiscence) was compared between the two groups, corrected for confounders, using multivariate regression.

RESULTS

A total of 599 procedures were included, mostly performed in the hindfoot (47.6%). Patients were on average 46 years old, and mostly male (60.8%). The total number of wound complications was 43 (7.2%). Age, alcohol abuse, open fracture and no tourniquet use were independent predicting factors. No difference in wound complications was found between summer and other seasons, neither in univariate analysis [4 (3.2%) vs 39 (8.2%), p = 0.086] nor when corrected for predicting factors as confounders (p = 0.096).

CONCLUSIONS

No seasonality could be identified in the rate of wound complications after trauma surgery of the lower leg, ankle and foot in this cohort. This lack of effect might result from the temperate climate of this cohort. Larger temperature and precipitation differences may influence wound complications to a larger extent. However, previous studies suggesting seasonality in wound complications might also be based on coincidence.

Management of peripheral venous catheters and implementation of guidelines in Germany: a national survey

BACKGROUND

Due to their frequent use, peripheral venous catheters (PVCs) are of importance in terms of catheter-related infections and their prevention. In 2017, revised national guidelines for the prevention of PVC-related infections were published in Germany.

AIM

To describe PVC handling practices and assess the implementation of national guidelines for the prevention of PVC-related infections in German acute care hospitals, 10 months after their release.

METHODS

An online survey on the management of PVCs in hospital wards was conducted. For this, 1191 acute care hospitals participating in the national surveillance system for healthcare-associated infections in Germany were invited to participate. Each hospital was asked to complete the survey for an intensive care unit (ICU), as well as a medical ward and a surgical ward. Participation in the survey was voluntary.

FINDINGS

In total, 701 hospitals (response rate 59%) participated and provided data on 1449 wards (599 ICUs, 446 medical wards, 404 surgical wards). Approximately 43% of wards reported that they had implemented the new national guidelines where necessary. Structured surveillance for PVC-associated infections was established in only 21% of wards. While 94% of wards reported the inclusion of aspects of PVC handling in their general infection prevention education, questions on the training methods yielded diverse results. Approximately 59% of wards reported that they did not routinely use a combination of alcohol and a remanant disinfectant for skin disinfection before PVC insertion.

CONCLUSION

Generally, PVC management in Germany is well organized. However, potential for improvement was identified, particularly considering surveillance and implementation of selected national guidelines.

Molecular surveillance of carbapenemase-producing Pseudomonas aeruginosa at three medical centres in Cologne, Germany

Background

Pseudomonas aeruginosa is a common pathogen causing hospital-acquired infections. Carbapenem resistance in P. aeruginosa is either mediated via a combination of efflux pumps, AmpC overexpression, and porin loss, or through an acquired carbapenemase. Carbapenemase-producing P. aeruginosa (CPPA) strains are known to cause outbreaks and harbour a reservoir of mobile antibiotic resistance genes, however, few molecular surveillance data is available. The aim of this study was to analyse the prevalence and epidemiology of CPPA in three German medical centres from 2015 to 2017.

Methods

Identification and susceptibility testing were performed with VITEK 2 system. P. aeruginosa non-susceptible to piperacillin, ceftazidime, cefepime, imipenem, meropenem and ciprofloxacin (4MRGN according to the German classification guideline) isolated from 2015 to 2017 were analysed. A two-step algorithm to detect carbapenemases was performed: phenotypic tests (EDTA- and cloxacillin-combined disk tests) followed by PCR, Sanger sequencing, and eventually whole genome sequencing. CPPA isolates were further genotyped by RAPD and PFGE. In-hospital transmission was investigated using conventional epidemiology.

Results

Sixty two P. aeruginosa isolates were available for further analysis, of which 21 were CPPA as follows: bla_VIM-1 (n = 2), bla_VIM-2 (n = 17), bla_NDM-1/bla_GES-5 (n = 1) and the newly described bla_IMP-82 (n = 1). CPPA were mostly hospital-acquired (71.4%) and isolated on intensive care units (66.7%). All (except one) were from the tertiary care centre. PFGE typing revealed one large cluster of VIM-2-producing CPPA containing 13 isolates. However, using conventional epidemiology, we were only able to confirm three patient-to-patient transmissions, and one room-to-patient transmission, on several intensive care units.

Conclusions

These data give insight into the epidemiology of CPPA in three centres in Germany over a period of 3 years. Carbapenemases are a relevant resistance mechanism in 4MRGN-P. aeruginosa, illustrated by genetically related VIM-2-producing strains that seem to be endemic in this region. Our data suggest that infection control measures should especially focus on controlling transmission on the ICU and support the need for a local molecular surveillance system.

Surveillance of multidrug-resistant bacteria in pediatric and neonatal intensive care units in Rio de Janeiro State, Brazil

INTRODUCTION

Multi-drug-resistant bacteria surveillance (MDR) systems are used to identify the epidemiology of MDR bacteria in neonates and children. This study aimed to describe the patterns by which MDR bacteria colonize and infect neonatal (NICU) and pediatric intensive care unit (PICU) patients in the state of Rio de Janeiro State, Brazil.

METHODS

A cross-sectional survey was performed using electronic data on NICU and PICU patients reported to the Rio de Janeiro State MDR bacteria surveillance system. All healthcare institutions that reported at least one case during the study period were included.

RESULTS

Between 2014 and 2017, 10,210 MDR bacteria cases, including 9261 colonizations and 949 infections, were reported. Among the colonizations, 5379 occurred in NICUs and 3882 in PICUs, while 405 infections occurred in NICUs and 544 in PICUs. ESBL producing Klebsiella sp and E. coli were the most reported colonization-causing agents in NICUs (1983/5379, 36.9%) and PICUs (1494/3882; 38.5%). The main causing bacteria reported in catheter-associated bloodstream infection (CLABSI), ventilator associated pneumonia, and catheter-associated urinary tract infection in NICUs were Klebsiella sp and E.coli (56/156, 35.9%), carbapenem-resistant Gram-negative bacteria (CRGNB) (22/65, 33.9%), and CRGNB (11/36, 30.6%) respectively, while in PICUs, they were MRSA (53/169, 31.4%), CRGNB (50/87, 57.4%), Klebsiella sp and E.coli (18/52, 34.6%), respectively.

CONCLUSIONS

MDR Gram-negative bacteria (ESBL producers and carbapenem-resistant bacteria) were the most reported agents among MDR bacteria reported to Rio de Janeiro surveillance system. Except for CLABSI in children, they caused all device-associated infections in NICUs and PICUs.

Incidence of healthcare-associated infections in a tertiary hospital in Beijing, China: results from a real-time surveillance system

Background

To quantify the five year incidence trend of all healthcare-associated infections (HAI) using a real-time HAI electronic surveillance system in a tertiary hospital in Beijing, China.

Methods

The real-time surveillance system scans the hospital’s electronic databases related to HAI (e.g. microbiological reports and antibiotics administration) to identify HAI cases. We conducted retrospective secondary analyses of the data exported from the surveillance system for inpatients with all types of HAIs from January 1st 2013 to December 31st 2017. Incidence of HAI is defined as the number of HAIs per 1000 patient-days. We modeled the incidence data using negative binomial regression.

Results

In total, 23361 HAI cases were identified from 633990 patients, spanning 6242375 patient-days during the 5-year period. Overall, the adjusted five-year HAI incidence rate had a marginal reduction from 2013 (4.10 per 1000 patient days) to 2017 (3.62 per 1000 patient days). The incidence of respiratory tract infection decreased significantly. However, the incidence rate of bloodstream infections and surgical site infection increased significantly. Respiratory tract infection (43.80%) accounted for the most substantial proportion of HAIs, followed by bloodstream infections (15.74%), and urinary tract infection (12.69%). A summer peak in HAIs was detected among adult and elderly patients.

Conclusions

This study shows how continuous electronic incidence surveillance based on existing hospital electronic databases can provide a practical means of measuring hospital-wide HAI incidence. The estimated incidence trends demonstrate the necessity for improved infection control measures related to bloodstream infections, ventilator-associated pneumonia, non-intensive care patients, and non-device-associated HAIs, especially during summer months.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0582-7) contains supplementary material, which is available to authorized users.

Practice variations and rates of late onset sepsis and necrotizing enterocolitis in very preterm born infants, a review

The burden of late onset sepsis (LOS) and necrotizing enterocolitis (NEC) remains high for newborns in low- and high-income countries. Very preterm born infants born below 32 weeks gestation are at highest risk because their immune system is not yet adapted to ex-utero life, providing intensive care frequently compromises their skin or mucosa and they require a long duration of hospital stay. An epidemiological overview is difficult to provide because there is no mutually accepted definition available for either LOS or NEC. LOS incidence proportions are generally reported based on identified blood culture pathogens. However, discordance in minimum day of onset and whether coagulase negative staphylococci or fungi should be included into the reported proportions lead to variation in reported incidences. Complicating the comparison are the absence of biomarkers, ancillary lab tests or prediction models with sufficiently high positive and/or negative predictive values. The only high negative predictive values result from negative blood culture results with negative lab results allowing to discontinue antibiotic treatment. Similar difficulties exist in reporting and diagnosing NEC. Although most publications base their proportions on a modified version of Bell's stage 2 or 3, comparisons are made difficult by the multifactorial nature of the disease reflecting several pathways to intestinal necrosis, the absence of a reliable biomarker and the unclear differentiation from spontaneous intestinal perforations. Comparable reports in very low birthweight infants range between 5% and 30% for LOS and 1.6% to 7.1% for NEC. Evidence based guidelines to support treatment are missing. Treatment for LOS remains largely empirical and focused mainly on antibiotics. In the absence of a clear diagnosis, even unspecific early warning signals need to be met with antibiotic treatment. Cessation after negative blood culture is difficult unless the child was asymptomatic from the beginning. As a result, antibiotics are the most commonly prescribed medications, but unnecessary exposure may result in increased risk for mortality, NEC, further infections and childhood obesity or asthma. Finding ways to limit antibiotic use are thus important and have shown a large potential for improvement of care and limitation of cost. Over recent decades, none of the attempts to establish novel therapies have succeeded. LOS and NEC proportions remained mostly stable. During the past 10 years however, publications emerged reporting a reduction, sometimes by almost 50%. Most concern units participating in a surveillance system using quality improvement strategies to prevent LOS or NEC (e.g., hand hygiene, evidence based "bundles", feeding onset, providing own mother's milk). We conclude that these approaches display a potential for wider spread reduction of LOS and NEC and for a subsequently more successful development of novel therapies as these often address the same pathways as the prevention strategies.

A national survey on the implementation of key infection prevention and control structures in German hospitals: results from 736 hospitals conducting the WHO Infection Prevention and Control Assessment Framework (IPCAF)

Background

Healthcare-associated infections (HAI) pose a burden on healthcare providers worldwide. To prevent HAI and strengthen infection prevention and control (IPC) structures, the WHO has developed a variety of tools and guidelines. Recently, the WHO released the Infection Prevention and Control Assessment Framework (IPCAF), a questionnaire-like tool designed for assessing IPC structures at the facility level. The IPCAF reflects the eight WHO core components of IPC. Data on the implementation of IPC measures in German hospitals are scarce. Therefore, it was our objective to utilize the IPCAF in order to gather information on the current state of IPC implementation in German hospitals, as well as to promote the IPCAF to a broad audience.

Methods

The National Reference Center for Surveillance of Nosocomial Infections (NRZ) sent a translated version of the IPCAF to 1472 acute care hospitals in Germany. Data entry and transfer to the NRZ was done electronically between October and December 2018. The IPCAF was conceived in a way that depending on the selected answers a score was calculated, with 0 being the lowest possible and 800 the highest possible score. Depending on the overall score, the IPCAF allocated hospitals to four different “IPC levels”: inadequate, basic, intermediate, and advanced.

Results

A total of 736 hospitals provided a complete dataset and were included in the data analysis. The overall median score of all hospitals was 690, which corresponded to an advanced level of IPC. Only three hospitals (0.4%) fell into the category “basic”, with 111 hospitals (15.1%) being “intermediate” and 622 hospitals (84.5%) being “advanced”. In no case was the category “inadequate” allocated. More profound differences were found between the respective core components. Components on multimodal strategies and workload, staffing, ward design and bed occupancy revealed the lowest scores.

Conclusions

IPC key aspects in general are well established in Germany. Potentials for improvement were identified particularly with regard to workload and staffing. Insufficient implementation of multimodal strategies was found to be another relevant deficit. Our survey represents a successful attempt at promoting the IPCAF and encouraging hospitals to utilize WHO tools for self-assessment.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0532-4) contains supplementary material, which is available to authorized users.

Decrease of methicillin resistance in Staphylococcus aureus in nosocomial infections in Germany-a prospective analysis over 10 years

OBJECTIVES

Methicillin resistant Staphylococcus aureus (MRSA) remains an important cause of healthcare-associated infections. Here, we describe the development of methicillin-resistant isolates among nosocomial Staphylococcus aureus (SA) infections in Germany between 2007 and 2016.

METHODS

We analyzed data from the voluntary German national nosocomial Infection Surveillance System. Data on bloodstream infections (BSI) and lower respiratory tract infections (LRTI) were derived from intensive care units (ICU), whereas data on surgical site infections (SSI) were collected from surgical departments (SD). Univariate analysis was performed on trend of proportion, while multivariable logistic regression was performed to identify risk factors for MRSA-infections.

RESULTS

Data of 1218 ICU and 1,556 SD were included. Overall, a decrease in the proportion of MRSA among all nosocomial SA-infections from 32.8% to 20.0% was noted. MRSA decreased from 37.1% to 21.8% (p = 0.01) for BSI, from 38.7% to 19.2% for LTRI (p < 0.01) and. from 21.1% to 7.4% (p < 0.01) in SSI. Logistic regression revealed that SA-infections in Mecklenburg Western-Pomerania were more likely caused by MRSA (Odds ratio (OR): 2.5; 95% CI: 1.7, 3.6).

CONCLUSION

We observed a significant reduction of the proportion of nosocomial Staphylococcus aureus infections due to MRSA in Germany over the course of the last 10 years.

The Prevalence of Nosocomial Infection and Antibiotic Use in German Hospitals

BACKGROUND

In 2011 and again in 2016, the European Centre for Disease Prevention and Control (ECDC) asked all European countries to carry out nationwide studies on the prevalence of nosocomial infection (NI) and antibiotic use (AU). Data on NI and AU constitute an essential basis for the development of measures to prevent infection and lessen antibiotic resistance.

METHODS

The German prevalence study of 2016 was carried out according to the ECDC protocol. Alongside a sample of 49 acute-care hospitals requested by the ECDC that was representative in terms of size (number of beds), further hospitals were invited to participate as well. Analyses were made of the overall group (218 hospitals, 64 412 patients), the representative group (49 hospitals), and the core group (46 hospitals). The core group consisted of the hospitals that had participated in the study of 2011.

RESULTS

The prevalence of patients with NI was 4.6% in the overall group in 2016; it had been 5.1% in 2011 (p <0.01). In the representative group, the prevalence was 3.6% (compared to 5.1% in 2011, p <0.01). In the core group, the prevalence of NI was the same in 2016 as it had been in 2011. The prevalence of patients with ABU in the overall group remained the same, but a fall was seen in the representative group (21.5% versus 23.3%; p <0.01) and a rise in the core group (27.3% versus 26.2%; p = 0.02). The staff-patient ratio among the infection prevention and control professionals improved in all three groups.

CONCLUSION

A decrease in NI and AU prevalence was seen in the representative group, while mixed results were seen in the other analyzed groups. Further efforts to reduce NI and ABA are clearly necessary.

One-year molecular surveillance of carbapenem-susceptible A. baumannii on a German intensive care unit: diversity or clonality

Background

A. baumannii is a common nosocomial pathogen known for its high transmission potential. A high rate of carbapenem-susceptible Acinetobacter calcoaceticus-Acinetobacter baumannii (ACB)-complex in clinical specimens led to the implementation of a pathogen-based surveillance on a 32-bed surgical intensive care unit (SICU) in a German tertiary care centre.

Methods

Between April 2017 and March 2018, ACB-complex isolates with an epidemiological link to the SICU were further assessed. Identification to the species level was carried out using a multiplex PCR targeting the gyrB gene, followed by RAPD, PFGE (ApaI) and whole genome sequencing (WGS, core genome MLST, SeqSphere+ software, Ridom). Additional infection prevention and control (IPC) measures were introduced as follows: epidemiological investigations, hand hygiene training, additional terminal cleaning and disinfection incl. UV-light, screening for carbapenem-susceptible A. baumannii and environmental sampling. Hospital-acquired infections were classified according to the CDC definitions.

Results

Fourty four patients were colonized/infected with one or two (different) carbapenem-susceptible ACB-complex isolates. Fourty three out of 48 isolates were classified as hospital-acquired (detection on or after 3rd day of admission). Nearly all isolates were identified as A. baumannii, only four as A. pittii. Twelve patients developed A. baumannii infections. Genotyping revealed two pulsotype clusters, which were confirmed to be cgMLST clonal cluster type 1770 (n = 8 patients) and type 1769 (n = 12 patients) by WGS. All other isolates were distinct from each other. Nearly all transmission events of the two clonal clusters were confirmed by conventional epidemiology. Transmissions stopped after a period of several months. Environmental sampling revealed a relevant dissemination of A. baumannii, but only a few isolates corresponded to clinical strains. Introduction of the additional screening revealed a significantly earlier detection of carbapenem-susceptible A. baumannii during hospitalization.

Conclusions

A molecular and infection surveillance of ACB-complex based on identification to the species level, classic epidemiology and genotyping revealed simultaneously occurring independent transmission events and clusters of hospital-acquired A. baumannii. This underlines the importance of such an extensive surveillance methodology in IPC programmes also for carbapenem-susceptible A. baumannii.

Nudge to better care - blood cultures and catheter-related bloodstream infections in Germany at two points in time (2006, 2015)

Background

Blood cultures (BCs) are the gold standard for diagnosing sepsis and are prerequisite for a targeted antibiotic treatment and essential for patient outcomes. Aim of the study was to analyze the frequency of BCs, the rate of central line-associated bloodstream infections (CLABSIs) and to study the association between both parameters on intensive care units in Germany over time.

Methods

Cross-sectional studies at two points in time (2006, 2015) on ICUs participating in the German hospital infection surveillance system. CLABSIs were defined according to the Center for Disease Control and Prevention (CDC). Univariable and multivariable analyses were performed using generalized linear models.

Results

A total of 639 ICUs participated in 2006 or 2015 and 90 ICUs (“core group”) in both years. Overall, 2,427,921 patient days from 644,575 patients were analyzed. In the ICU core group the frequency of BCs per 1000 patient days doubled from 57.8 (interquartile range [IQR] 29.8–101.2; 2006) to 128.2 (IQR 71.6–183.2; 2015). In the same time, the pooled median CLABSI rate decreased from 0.8 (IQR 0–1.9; 2006) per 1000 central-line catheter days to 0.2 (IQR 0–0.9; 2015).

Conclusions

From 2006 to 2015 the frequency of BCs increased on ICUs in Germany and is now within the recommended 100 to 200 BCs sets per 1000 patient days.

Preventive bundles to reduce catheter-associated bloodstream infections in neonatal intensive care

This systematic survey includes a total of 27 studies published between 2002 and 2016 on the benefit of preventive bundles for the prevention of central-line associated bloodstream infections (CLABSI) in neonatal intensive care. These studies are mainly cohort studies or studies analyzing an interrupted time series before and after intervention. The studies showed heterogeneity in terms of endpoint definitions (CLABSI), details of the implemented measures, and evidence of a publication bias favoring the use of of preventive bundles. The cumulative analysis showed a statistically and clinically significant benefit of preventive bundles to avoid CLABSI in neonatal intensive care.

[Triclosan-coated sutures in colorectal surgery : Assessment and meta-analysis of the recommendations of the WHO guideline]

BACKGROUND

In the global guidelines for the prevention of surgical site infections (SSI), the World Health Organization (WHO) recommends the general use of triclosan-coated sutures irrespective of the type of surgical intervention.

OBJECTIVE

Can this recommendation on the use of triclosan-coated sutures be confirmed by a meta-analysis specifically for colorectal surgery?

METHODS

Randomized and non-randomized clinical trials comparing triclosan-coated and uncoated sutures for the efficacy in reducing the SSI rate in colorectal surgery were identified by a systematic literature review. In addition, various quality criteria were set for the studies to be included: SSI definition according to the Centers for Disease Control and Prevention (CDC), a priori sample size calculation and a maximum SSI rate of 20%. The odds ratios were pooled using a fixed and random effects model, the 95% confidence intervals (CI) were calculated and subgroup analyses were carried out.

RESULTS

Included in the meta-analysis were 3 prospective randomized trials (RCT) and 3 non-randomized trials involving a total of 2957 subjects. The average SSI rate was 6.90% (76/1101) in the triclosan group and 9.11% (169/1856) in the control group, resulting in an odds ratio of 0.62 (95% CI: 0.29-1.31). Subgroup analysis showed a decreased risk for SSI in monocentric trials (OR = 0.39, 95% CI: 0.25-0.60) but an increased SSI risk in multicenter trials (OR = 1.75, 95% CI: 1.11-2.77).

CONCLUSION

Against the background of a moderate to high risk of bias and the partially contradictory findings of the studies, the general recommendation of the WHO on the use of triclosan-coated sutures for colorectal surgery could not be confirmed.

Usefulness of Serum Procalcitonin as a Markerfor Coexisting Infection in Patients With Acute Myocardial Infarction

A significant proportion of patients with acute myocardial infarction (AMI) also present with clinical manifestations of inflammatory response, which may be confused with a concomitant infection. This leads to a dilemma regarding the empiric use of antibiotics. We explored if serum procalcitonin (PCT), which is known to be elevated in bacterial infections, may be utilized to rule-out bacterial infection in AMI patients. In this prospective, single center study, PCT was collected within 48 hours from AMI patients. Patients' demographic, clinical, and laboratory data were collected prospectively. Two experienced infectious diseases specialists blinded to the PCT results independently determined the presence of infection in every patient. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristic curve were calculated to determine the accuracy of PCT, fever, white blood cell (WBC) count, and C-reactive protein (CRP) levels for the diagnosis of the infection. The analysis included 230 AMI patients (age 63.0 ± 13.0 years) of whom 36 (15.6%) had coexisting infections. The best cutoff for PCT as a differentiating marker between patients with and without coexisting infection was 0.09 ng/dl (sensitivity 94.4%, specificity 85.1%, area under the curve 0.94). PCT outperformed CRP, WBC, and fever for diagnosing infection. In conclusion, compared with CRP, fever, and WBC, serum PCT had a better performance in differentiating infected from noninfected AMI patients and thus should be considered as an adjunct test when facing the dilemma of initiating empiric antibiotic in AMI patient demonstrating inflammatory signs.

Comparison of governance approaches for the control of antimicrobial resistance: Analysis of three European countries

Policy makers and governments are calling for coordination to address the crisis emerging from the ineffectiveness of current antibiotics and stagnated pipe-line of new ones - antimicrobial resistance (AMR). Wider contextual drivers and mechanisms are contributing to shifts in governance strategies in health care, but are national health system approaches aligned with strategies required to tackle antimicrobial resistance? This article provides an analysis of governance approaches within healthcare systems including: priority setting, performance monitoring and accountability for AMR prevention in three European countries: England, France and Germany. Advantages and unresolved issues from these different experiences are reported, concluding that mechanisms are needed to support partnerships between healthcare professionals and patients with democratized decision-making and accountability via collaboration. But along with this multi-stakeholder approach to governance, a balance between regulation and persuasion is needed.

Electronic surveillance and using administrative data to identify healthcare associated infections

PURPOSE OF REVIEW

Traditional surveillance of healthcare associated infections (HCAI) is time consuming and error-prone. We have analysed literature of the past year to look at new developments in this field. It is divided into three parts: new algorithms for electronic surveillance, the use of administrative data for surveillance of HCAI, and the definition of new endpoints of surveillance, in accordance with an automatic surveillance approach.

RECENT FINDINGS

Most studies investigating electronic surveillance of HCAI have concentrated on bloodstream infection or surgical site infection. However, the lack of important parameters in hospital databases can lead to misleading results. The accuracy of administrative coding data was poor at identifying HCAI. New endpoints should be defined for automatic detection, with the most crucial step being to win clinicians' acceptance.

SUMMARY

Electronic surveillance with conventional endpoints is a successful method when hospital information systems implemented key changes and enhancements. One requirement is the access to systems for hospital administration and clinical databases.Although the primary source of data for HCAI surveillance is not administrative coding data, these are important components of a hospital-wide programme of automated surveillance. The implementation of new endpoints for surveillance is an approach which needs to be discussed further.

Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) at a palliative care unit: A prospective single service analysis

BACKGROUND

The emergence of multidrug-resistant bacterial microorganisms is a particular challenge for the health care systems. Little is known about the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Gram-negative bacteria (MDRGNB) in patients of palliative care units (PCU).

AIM

The primary aim of this study was to determine the carriage of MRSA among patients of a PCU at a German University Hospital and to assess whether the positive cases would have been detected by a risk-factor-based screening-approach.

DESIGN

Between February 2014 and January 2015 patients from our PCU were tested for MRSA carriage within 48 hours following admission irrespective of pre-existing risk factors. In addition, risk factors for MRSA colonization were assessed. Samples from the nostrils and, if applicable, from pre-existing wounds were analysed by standardized culture-based laboratory techniques for the presence of MRSA and of other bacteria and fungi. Results from swabs taken prior to admission were also recorded if available.

RESULTS

297 out of 317 patients (93.7%) fulfilled one or more MRSA screening criteria. Swabs from 299 patients were tested. The detection rate was 2.1% for MRSA. All MRSA cases would have been detected by a risk-factor-based screening-approach. Considering the detected cases and the results from swabs taken prior to admission, 4.1% of the patients (n = 13) were diagnosed with MRSA and 4.1% with MDRGNB (n = 13), including two patients with MRSA and MDRGNB (0.6%). The rate of MRSA carriage in PCU patients (4.1%) was elevated compared to the rate seen in the general cohort of patients admitted to our University Hospital (2.7%).

CONCLUSIONS

PCU patients have an increased risk to carry MRSA compared to other hospitalized patients. Although a risk factor-based screening is likely to detect all MRSA carriers amongst PCU patients, we rather recommend a universal screening to avoid the extra effort to identify the few risk factor-negative patients (<7%). As we did not perform a systematic MDRGNB screening, further studies are needed to determine the true prevalence of MDRGNB amongst PCU patients.

Novel approaches to surgical site infections: what recommendations can be made?

INTRODUCTION

Surgical site infections (SSI) are one of the most frequent healthcare-associated infections worldwide, representing a substantial burden on the healthcare system and the individual patient. Various risk factors for SSI have been identified, which can be separated into patient-related, procedure-related and other risk factors. Areas covered: Other risk factors relevant for SSI are the season in which surgery is performed, the volume of surgeries in a department, the working atmosphere in the operating room and the indications for surgery. Overall, the risk of SSI is higher during summertime. Higher-volume departments appear to be protective against SSI as does a calm working atmosphere. The frequency of certain types of surgery differs greatly among European countries. The decision to perform surgery appears to be dependent on the patient's condition as well as the healthcare system and financial incentives. Expert commentary: When possible, elective surgery should not be executed during summertime but during cooler times of year. Departments with a high volume of surgical procedures should be given preference. The establishment of a calm working atmosphere is beneficial to a surgeon's performance and can reduce SSI rates. The indications for performing surgery should be carefully reevaluated whenever possible.

Impact of nosocomial infections surveillance on nosocomial infection rates: A systematic review

BACKGROUND

According to previously studies, nosocomial infections (NIs) surveillance could effectively reduce infection rates. As NIs surveillance systems have been implemented in some hospitals for several years, their impact on NIs need to be explored. Therefore, the purpose of this review is to evaluate the tendency of NI rates during the surveillance period and the impact of surveillance on NI rates.

METHODS

A systematic literature search of the PubMed database to identify papers that evaluated effect of surveillance on NIs, all kinds of NIs occurred during hospitalization or discharged were included. Exclude articles investigated the surveillance combined with other infection control measures.

RESULTS

Twenty-five articles were included. NI rates had different levels of reduction during surveillance period, the reduction were not limited by state, department, surveillance system, and NI type. Continuous surveillance had a positive impact on NI, OR/RR were ranged from 0.43 to 0.95.

CONCLUSION

Participation in NI surveillance is associated with reducing infection rates, though RCTs need to further prove the effective role of surveillance. Hospitals may consider to perform NIs surveillance systems according to its own conditions.