[Deep sternal wound infection after sternotomy - Report of the consensus workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)]. / Der tiefe sternale Wundinfekt nach Sternotomie.

Deep sternal wound infection (TSWI) is a potentially life-threatening complication that may occur after median sternotomy, contributing to prolonged hospital stay and increased health care costs. Bacterial infection is often characterized by biofilm formation on implant material and/or dead bone. Diagnosis is made upon clinical signs and symptoms of local and systemic infection. Early multidisciplinary decision making is needed for optimal patient care. Repeated surgical wound debridements accompanied by wound conditioning are performed until clean circumstances are achieved. Thereafter, wound closure and defect reconstruction are obtained using a variety of pedicled and microvascular flaps.

Intensive care physicians' and nurses' perception that hand hygiene prevents pathogen transmission: Belief strength and associations with other cognitive factors.

Besides habituation, conscious decision-making remains important for healthcare workers' hand hygiene compliance. This study compared 307 physicians and 348 nurses in intensive care at a German university medical centre regarding their belief that hand disinfection prevents pathogen transmission. Physicians perceived less risk reduction ( p < 0.001; variance explained: 4%), a comparison outscored only by lower self-rated guideline knowledge (8%). In both groups, the transmission-preventive belief was associated with high response efficacy, behavioural intention and self-efficacy, but not with self-rated knowledge. Consistent with the Health Action Process Approach, hand hygiene interventions targeting risk reduction beliefs may promote high motivation, but not action control.

Deep Surgical Site Infections after Open Radical Cystectomy and Urinary Diversion Significantly Increase Hospitalisation Time and Total Treatment Costs.

INTRODUCTION: Deep surgical site infections (DSSI) usually require secondary treatments. The aim of this study was to compare the total length of hospitalisation (LOH), intensive care unit (ICU) duration, and total treatment costs in patients with DSSI versus without DSSI after open radical cystectomy (ORC) and urinary diversion. MATERIAL AND METHODS: Prospective case-control study in a tertiary care hospital in patients after ORC with urinary diversion during April 2008 to July 2012. DSSI was defined based on Centers for Disease Control and Prevention criteria. Matched-pair analysis for patients with versus without DSSI was done in 1:2 ratios. Patients with superficial surgical site infections (SSI) were excluded from analysis. RESULTS: In total, 189 operations were performed. Thirty-eight patients (20.1%) developed SSI of which 28 patients (14.8%) had DSSI. Out of 28 patients, 27 (96.4%) were with DSSI and required surgical re-intervention. Due to insufficient matching criteria, 11 patients with DSSI were excluded from analyses. Consequently, 17 patients with DSSI were matched with 34 patients without DSSI. Significant differences were seen for median overall LOH (30 vs. 18 days, p < 0.001), median ICU duration (p = 0.024), and median overall treatment costs (€17,030 vs. €11,402, p = 0.011). CONCLUSIONS: DSSI significantly increases LOH (67%) and treatment costs (49%), adding up to a financial loss for the hospital of approximately €5,500 in patients with DSSI.

The prevalence of nosocomial and community acquired infections in a university hospital: an observational study.

BACKGROUND: Nosocomial infections (NI) increase morbidity and mortality. Studies of their prevalence in single institutions can reveal trends over time and help to identify risk factors. METHODS: In March and April 2010, data were prospectively recorded from all inpatients at the Hannover Medical School (Germany) except those treated in the pediatric, psychosomatic, and psychiatric services. The data were acquired systematically by chart review and by interviews with the medical staff. Infections were classified according to the definitions of the Centers for Disease Control and Prevention (CDC). Information was obtained on underlying diseases, invasive procedures, the use of antibiotics, devices (the application of specific medical techniques such as drainage, vascular catheters, etc.), and detected pathogens. RESULTS: Of the 1047 patients studied, 117 (11.2%) had a total of 124 nosocomial infections, while 112 (10.7%) had 122 community-acquired infections. The most common NI were surgical site infections (29%), infections of the gastrointestinal tract (26%) and respiratory tract (19%), urinary tract infections (16%), and primary sepsis (4%). The most common pathogens were Escherichia coli, coagulase-negative staphylococci, Candida spp., Enterococcus spp., and Pseudomonas aeruginosa. Multivariable regression analysis revealed the following independent risk factors for NI: antibiotic treatment in the last 6 months (odds ratio [OR] = 2.9), underlying gastrointestinal diseases (OR = 2.3), surgery in the last 12 months (OR = 1.8), and more than two underlying diseases (OR = 1.7). Each additional device that was used gave rise to an OR of 1.4. Further risk factors included age, length of current or previous hospital stay, trauma, stay on an intensive care unit, and artificial ventilation. CONCLUSION: In this prevalence study, NI were a common complication. Surgical site infections were the single most common type of NI because of the large number of patients that underwent surgical procedures in our institution. More investigation will be needed to assess the benefit of prevalence studies for optimizing appropriate, effective preventive measures.

Hand hygiene compliance in transplant and other special patient groups: an observational study.

BACKGROUND: This study evaluates hand hygiene behavior of health care workers in a German university hospital stratified for treatment of special patient groups (eg, transplant patients). METHODS: From 2008 to 2010, comprehensive education and training of all health care workers was implemented to improve hand hygiene compliance. Consumption rates of alcohol-based hand rub and gloves were collected and evaluated. RESULTS: Of the 5,647 opportunities of hand disinfection evaluated, 1,607 occurred during care for transplant patients. To our knowledge, this is the largest survey of hand hygiene compliance in special patient groups on intensive care units in a university hospital in Germany. Health care workers on surgical intensive care units showed lower hand hygiene compliance compared with health care workers on other types of intensive care units. Compliance toward hand hygiene was significantly higher on hemato-oncologic and pediatric wards. In general, hand disinfection was performed significantly more frequently after an intervention than before (P < .05, 95% confidence interval: 1.24-1.84). Overall, there was no significant difference in hand hygiene compliance when caring for transplant patients or other patients (odds ratio, 1.16; 95% confidence interval: 0.95-1.42). Nurse's and physician's hand hygiene compliance improved because of education. CONCLUSION: Hand hygiene compliance is not increased in the care for transplant patients (despite their predisposition for nosocomial infections) compared with other patients. Additional studies will be necessary to further investigate these findings.

Beliefs about hand hygiene: a survey in medical students in their first clinical year.

Medical students were asked regarding knowledge and beliefs on hand hygiene before entering the clinical phase of education. By this, we noticed a lack of knowledge concerning the correct indications for hand disinfection. Regardless of previous experience in hospitals, the medical students expected that the compliance towards hand hygiene would be worse in more experienced physicians and senior consultants--who are often considered to be role models for medical students.

Antibiotic pretreatment of heart valve prostheses to prevent early prosthetic valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: Prosthetic valve endocarditis (PVE), a rare but major complication after heart valve replacement surgery, has potentially catastrophic consequences despite maximal treatment. Thus, preventive measures are essential. The study aim was to investigate the effect of pretreating heart valve prostheses with the antibiotics baneomycin and daptomycin, with and without surgical sealant fibrin glue as a drug-releasing substance. The biocompatibility of baneocin and daptomycin was also investigated. METHODS: Samples of polyethylene terephthalate (PTE), as used for the sewing cuffs of prosthetic heart valves, were tested; untreated samples served as controls. All samples were contaminated with Staphylococcus epidermidis, and colony-forming units (CFUs) then counted. Cytotoxicity tests were performed using the MTT-assay to evaluate the effects of baneomycin and daptomycin on cell proliferation and wound healing. RESULTS: Untreated and fibrin glue-coated samples were directly infected with a bacterial count of 2.82 +/- 0.63 x 10(5) CFU/ml and 2.80 +/- 1.07 x 10(5) CFU/ml, on average. Baneocin-impregnated samples were sterile for 1.9 +/- 0.38 days, with a subsequent bacterial count of 2.26 +/- 0.6 x 10(5) CFU/ml, while daptomycin-impregnated samples were sterile for 2.9 +/- 0.38 days, with a subsequent bacterial count of 1.81 +/- 0.53 x 10(5) CFU/ml. Samples coated with a fibrin glue-baneocin mixture were sterile for 3.14 +/- 0.38 days, after which the bacterial count was 0.74 +/- 0.47 x 10(5) CFU/ml. After coating with a fibrin glue-daptomycin mixture, samples were sterile for 7.0 +/- 0.58 days, and the bacterial count was 0.70 +/- 0.56 x 10(5) CFU/ml. CONCLUSION: In this in-vitro study, the pretreatment of prosthetic heart valves with antibiotics reduced the risk of bacterial adhesion and consequent infection. The combination of antibiotics with fibrin glue prolonged this preventive effect, with baneocin demonstrating a better biocompatibility than daptomycin. On the basis of its antibacterial efficacy, daptomycin appears to be a more suitable antibiotic to prevent early PVE with Gram-positive bacteria. The soaking of prosthetic heart valves in antibiotic solutions prior to implantation, in combination with fibrin glue in cases of suspected endocarditis, can prevent the development of early PVE. This preventive strategy should be investigated for use as a standard procedure in clinical practice.

Five-years surveillance of invasive aspergillosis in a university hospital.

BACKGROUND: As the most common invasive fungal infection, invasive aspergillosis (IA) remains a serious complication in immunocompromised patients, leading to increased mortality. Antifungal therapy is expensive and may result in severe adverse effects.The aim of this study was to determine the incidence of invasive aspergillosis (IA) cases in a tertiary care university hospital using a standardized surveillance method. METHODS: All inpatients at our facility were screened for presence of the following parameters: positive microbiological culture, pathologist's diagnosis and antifungal treatment as reported by the hospital pharmacy. Patients fulfilling one or more of these indicators were further reviewed and, if appropriate, classified according to international consensus criteria (EORTC). RESULTS: 704 patients were positive for at least one of the indicators mentioned above. Applying the EORTC criteria, 214 IA cases were detected, of which 56 were proven, 25 probable and 133 possible. 44 of the 81 (54%) proven and probable cases were considered health-care associated. 37 of the proven/probable IA cases had received solid organ transplantation, an additional 8 had undergone stem cell transplantation, and 10 patients were suffering from some type of malignancy. All the other patients in this group were also suffering from severe organic diseases, required long treatment and experienced several clinical complications. 7 of the 56 proven cases would have been missed without autopsy. After the antimycotic prophylaxis regimen was altered, we noticed a significant decrease (p = 0.0004) of IA during the investigation period (2003-2007). CONCLUSION: Solid organ and stem cell transplantation remain important risk factors for IA, but several other types of immunosuppression should also be kept in mind. Clinical diagnosis of IA may be difficult (in this study 13% of all proven cases were diagnosed by autopsy only). Thus, we confirm the importance of IA surveillance in all high-risk patients.

Surgical site infections--economic consequences for the health care system.

PURPOSES: Unfortunately, surgical site infections (SSIs) are a quite common complication and represent one of the major causes of postoperative morbidity and mortality, and may furthermore lead to enormous additional costs for hospitals and health care systems. METHODS: In order to determine the estimated costs due to SSIs, a MEDLINE search was performed to identify articles that provide data on economic aspects of SSIs and compared to findings from a matched case-control study on costs of SSIs after coronary bypass grafting (CABG) in a German tertiary care university hospital. RESULTS: A total of 14 studies on costs were found. The additional costs of SSI vary between $3,859 (mean) and $40,559 (median). Median costs of a single CABG case in the recently published study were $49,449 (€36,261) vs. $18,218 (€13,356) in controls lacking infection (p < 0.0001). The median reimbursement from health care insurance companies was $36,962 (€27,107) leading to a financial loss of $12,482 (€9,154) each. CONCLUSION: Costs of SSIs may almost triple the individual overall health care costs and those additional charges may not be sufficiently covered. Appropriate measures to reduce SSI rates must be taken to improve the patient's safety. This should also diminish costs for health care systems which benefits the entire community.

Sternal surgical site infection prevention - is there any room for improvement?

OBJECTIVE: The objectives of this multicenter study are to evaluate current clinical practices in cardiac surgery concerning the prevention and management of sternal wound infections, to identify room for improvement, and to support implementation of systematic measures. METHODS: As a part of a campaign for infection prevention in cardiac surgery in Germany, a multiple-choice questionnaire with two main sections was developed and submitted to all cardiac surgery units in Germany (79). The project was realized in cooperation with the German Society for Thoracic and Cardiovascular Surgery, the BQS Institute for Quality and Patient Safety, and the National Reference Center for Nosocomial Infection Surveillance. RESULTS: A representative number (54 of 79 or 68%) of German cardiac surgery centers participated in the survey, in which heterogeneous procedures and various standards for prevention were observed. Surveillance, standards, and advanced training regarding hygiene measures are present in almost all participating hospitals. Methicillin-resistant Streptococcus aureus (MRSA) screening is performed in 81.5% (44/54) of all participating departments. A little less than one-tenth (7.4%) perform decolonization measures on all patients, while 85.2% perform decolonization measures only on MRSA-positive patients. Application of perioperative antibiotic prophylaxis ranges from single-shot application to 3 days of treatment. Longer treatment is expensive and time-intensive, and also increases the risk of Clostridium difficile-associated diarrhea. Nearly three-quarters (70.4%) of all participating hospitals perform preoperative hair removal 1 day before surgery. Common techniques are clipping machines (53.7%), razors (40.7%), clipping machines and depilatory cream (1.9%), or depilatory cream only (1.9%). Remanent (37.0%) and non-remanent disinfectants (55.6%) are used for preoperative skin disinfection. The time of the first wound-dressing change varies from the day of surgery (1.9%) over the first (42.6%) or second (46.3%) day after surgery to up to 3 or more days after surgery (9.3%). CONCLUSIONS: The results of the evaluation show that basic measures for infection prevention in cardiac surgery in Germany are well implemented. Nevertheless, a relevant heterogeneity in the use of special measures was observed, although research-based guidelines for infection prevention in surgery do exist and many studies have demonstrated the usefulness and feasibility of these measures.

Prevention of early vascular graft infection using regional antibiotic release.

BACKGROUND: Infections after prosthetic replacement of the aorta remain a serious and life-threatening complication. The only appropriate treatment is the surgical removal of the infected prosthesis. Accordingly, there is a need for new procedures to prevent the infection of vascular prostheses. This in vitro experiment investigated the effect of the pretreatment of vascular prostheses with antibiotics (daptomycin or baneocin) and the effect of antibiotics combined with fibrin sealant as possible prophylaxis of perioperative graft infection. METHODS: Untreated prostheses served as controls. Pretreated prostheses of double woven velour vascular grafts were contaminated with Staphylococcus epidermidis, and colony-forming units were counted each day (CFU/mL). RESULTS: The period of sterility differed significantly as a function of the pretreatment. Uncoated prostheses were immediately non-sterile and exhibited 2.63 ± 0.61 × 10(5) CFU/mL. Baneocin pretreatment resulted in sterility for 1.7 ± 0.6 (95% confidence interval (CI) 1.0-2.4) d before we detected 2.14 ± 0.57 × 10(5) CFU/mL on the prostheses. Pretreatment with daptomycin yielded 2.9 ± 0.4 (CI 2.6-3.2) and fibrin sealant/baneocin compound yielded 3.1 ± 0.3 (CI 2.9-3.3) d of sterility, after which 1.81 ± 0.86 × 10(5) CFU/mL and 1.04 ± 0.77 × 10(5) CFU/mL were recorded. Finally, pretreatment with fibrin sealant/daptomycin led to sterility for 7.1 ± 0.3 (CI 6.9-7.3) d, after which 0.77 ± 0.60 × 10(5) CFU/mL were observed on the prostheses. CONCLUSIONS: The risk of vascular graft infection is reduced by pretreating the prostheses with antibiotics. The antibiotic/fibrin compound exhibited an effect of delayed antibiotic release. Vascular prostheses should therefore be pretreated with antibiotic solution to reduce bacterial adhesion. This procedure might be an effective prophylaxis for perioperative vascular graft infection and provides suitable protection for the prosthetic material.

Economic implications of infections of implantable cardiac devices in a single institution.

INTRODUCTION: The use of medical devices, such as cardiac pacemakers, prosthetic heart valves and vascular prostheses, has become a routine treatment procedure in cardiovascular medicine. Unfortunately, bacterial infections of these devices are a serious and sometimes life-threatening for the patient, necessitating explantation. Despite implementing different prophylactic strategies to avoid contamination of the device, infections do occur. This study analysed the additional hospital costs associated with managing cardiac device infections, with special focus on cardiac pacemakers/defibrillators, prosthetic heart valves and vascular prostheses. METHODS: Out of more than 2000 operations performed in our institution in 2006, we had 462 implantations/replacements of cardiac pacemakers/implantable cardioverter defibrillators (ICDs), 577 valve replacement procedures and 613 vascular operations. Among these, we analysed all patients who received operations because of an infection of their cardiac or vascular device. Our investigations focussed on standard parameters regarding additional hospital costs, including length of stay in hospital, required time in the operating room and time in the intensive care unit. RESULTS: In 2006, we had nine cases (n=9) of prosthetic valve endocarditis in our hospital. The average length of stay in hospital for these patients was 25 days, resulting in euro72096 of additional hospital costs per case. Infection of vascular prostheses (n=6) leads to euro35506 per case and 28 days in the hospital. If an infection of cardiac pacemakers (n=7) does occur, the therapy causes a mean additional hospital cost of euro7091. CONCLUSION: Cardiac device infections are serious and sometimes life-threatening. Therapy and eradication are difficult and protracted and cause high additional hospital costs. Based on our statistical data and the mean incidence of cardiac device infections, we presume for Germany between euro38 and euro140 million in additional hospital costs per year are incurred by infections of implantable cardiovascular devices. Active surveillance and establishment of a central register with documentation of every implantation and the occurrence of any infection can only realise detailed estimates of the economic damage caused by infection of cardiovascular implants. In consideration of the economic consequences, successful strategies must be developed to reduce the incidence of infections.

Economic aspects of deep sternal wound infections.

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

Decrease of deep sternal surgical site infection rates after cardiac surgery by a comprehensive infection control program.

When we noticed an increasing incidence of deep sternal surgical site infections (DSSI), a bundle of interdisciplinary infection control measures was initiated in order to prevent further cases of DSSI. Adherence to infection control measures was re-inforced, which included (1) methicillin-resistant Staphylococcus aureus (MRSA) screening, (2) bacterial decolonisation measures, (3) hair clipping instead of shaving, (4) education, (5) good stewardship for antibiotic prophylaxis, (6) change of surgical gloves after sternotomy and after sternal wiring, (7) new bandage techniques, (8) leaving the wound primarily covered for at least 48 h. We checked for potential risk factors in a case-control study (120 patients each) by multivariate analysis. A significant decrease of DSSI from 3.61% (CI 95: 2.98-4.35) down to 1.83% (CI 95: 1.08-2.90) occurred. Independent significant risk factors for DSSI were age >68 years (OR=2.47; CI 95: 1.33-4.60), diabetes mellitus (OR=4.84; CI 95: 2.25-10.4), and intra-operative blood glucose level >8 mmol/l (OR=2.27; CI 95: 1.17-4.42). Protective factors were preoperative antibiotic prophylaxis (OR=0.31; CI 95: 0.13-0.70) and extubation on the day of surgery (OR=0.25; CI 95: 0.11-0.55). Close co-operation between clinical physicians and the infection control team significantly reduced the rate of DSSI. Thus, cardiac surgeons should know the local baseline DSSI rate, e.g. by surveillance, and should be aware of the risk factors for DSSI cases.