A prospective cluster trial to increase antibiotic prescription quality in seven non-ICU wards.

Aim: To evaluate general shortcomings and faculty-specific pitfalls as well as to improve antibiotic prescription quality (ABQ) in non-ICU wards, we performed a prospective cluster trial. Methods: An infectious-disease (ID) consulting service performed a prospective investigation consisting of three 12-week phases with point prevalence evaluation conducted once per week (=36 evaluations in total) at seven non-ICU wards, followed by assessment of sustainability (weeks 37-48). Baseline evaluation (phase 1) defined multifaceted interventions by identifying the main shortcomings. Then, to distinguish intervention from time effects, the interventions were performed in four wards, and the 3 remaining wards served as controls; after assessing effects (phase 2), the same interventions were performed in the remaining wards to test the generalizability of the interventions (phase 3). The prolonged responses after all interventions were then analyzed in phase 4. ABQ was evaluated by at least two ID specialists who assessed the indication for therapy, the adherence to the hospital guidelines for empirical therapy, and the overall antibiotic prescription quality. Results: In phase 1, 406 of 659 (62%) patients cases were adequately treated with antibiotics; the main reason for inappropriate prescription was the lack of an indication (107/253; 42%). The antibiotic prescription quality (ABQ) significantly increased, reaching 86% in all wards after the focused interventions (502/584; nDf=3, ddf=1,697, F=6.9, p=0.0001). In phase 2 the effect was only seen in wards that already participated in interventions (248/347; 71%). No improvement was seen in wards that received interventions only after phase 2 (189/295; 64%). A given indication significantly increased from about 80% to more than 90% (p<.0001). No carryover effects were observed. Discussion: ABQ can be improved significantly by intervention bundles with apparent sustainable effects.

Enhanced antibacterial effect of the novel T4-like bacteriophage KARL-1 in combination with antibiotics against multi-drug resistant Acinetobacter baumannii.

The continuing rise of infections caused by multi-drug resistant bacteria has led to a renewed interest in bacteriophage therapy. Here we characterize phage vB_AbaM-KARL-1 with lytic activity against multi-drug resistant clinical isolates of Acinetobacter baumannii (AB). Besides genomic and phenotypic phage analysis, the objective of our study was to investigate the antibacterial outcome when the phage acts in concert with distinct antibiotics. KARL-1 belongs to the family of Myoviridae and is able to lyse 8 of 20 (40%) tested clinical isolates. Its double-stranded DNA genome consists of 166,560 bp encoding for 253 open reading frames. Genome wide comparison suggests that KARL-1 is a novel species within the subfamily Tevenvirinae, sharing 77% nucleotide identity (coverage 58%) with phage ZZ1. The antibacterial efficacy at various multiplicities of infection (MOI) was monitored either alone or in combination with meropenem, ciprofloxacin, and colistin. A complete clearance of liquid cultures was achieved with KARL-1 at an MOI of 10-1 and meropenem (>128 mg/l). KARL-1 was still effective at an MOI of 10-7, but antibacterial activity was significantly augmented with meropenem. While ciprofloxacin did generally not support phage activity, the application of KARL-1 at an MOI of 10-7 and therapeutic doses of colistin significantly elevated bacterial suppression. Hence, KARL-1 represents a novel candidate for use against multi-drug resistant AB and the therapeutic outcome may be positively influenced by the addition of traditional antibiotics.

Differential Effect of Newly Isolated Phages Belonging to PB1-Like, phiKZ-Like and LUZ24-Like Viruses against Multi-Drug Resistant Pseudomonas aeruginosa under Varying Growth Conditions.

In this study, we characterize three phages (SL1 SL2, and SL4), isolated from hospital sewage with lytic activity against clinical isolates of multi-drug resistant Pseudomonas aeruginosa (MDR-PA). The host spectrum ranged from 41% to 54%, with all three phages together covering 79% of all tested clinical isolates. Genome analysis revealed that SL1 (65,849 bp, 91 open reading frames ORFs) belongs to PB1-like viruses, SL2 (279,696 bp, 354 ORFs) to phiKZ-like viruses and SL4 (44,194 bp, 65 ORFs) to LUZ24-like viruses. Planktonic cells of four of five selected MDR-PA strains were suppressed by at least one phage with multiplicities of infection (MOIs) ranging from 1 to 10-6 for 16 h without apparent regrowth of bacterial populations. While SL2 was most potent in suppressing planktonic cultures the strongest anti-biofilm activity was observed with SL4. Phages were able to rescue bacteria-infected wax moth larvae (Galleria melonella) for 24 h, whereby highest survival rates (90%) were observed with SL1. Except for the biofilm experiments, the effect of a cocktail with all three phages was comparable to the action of the best phage alone; hence, there are no synergistic but also no antagonistic effects among phages. The use of a cocktail with these phages is therefore expedient for increasing host range and minimizing the development of phage resistance.

Preliminary survey of local bacteriophages with lytic activity against multi-drug resistant bacteria.

Bacteriophages (phages) represent a potential alternative for combating multi-drug resistant bacteria. Because of their narrow host range and the ever emergence of novel pathogen variants the continued search for phages is a prerequisite for optimal treatment of bacterial infections. Here we performed an ad hoc survey in the surroundings of a University hospital for the presence of phages with therapeutic potential. To this end, 16 aquatic samples of different origins and locations were tested simultaneously for the presence of phages with lytic activity against five current, but distinct strains each from the ESKAPE-group (i.e., Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter cloacae). Phages could be isolated for 70% of strains, covering all bacterial species except S. aureus. Apart from samples from two lakes, freshwater samples were largely devoid of phages. By contrast, one liter of hospital effluent collected at a single time point already contained phages active against two-thirds of tested strains. In conclusion, phages with lytic activity against nosocomial pathogens are unevenly distributed across environments with the prime source being the immediate hospital vicinity.

Evaluation of hydrogen peroxide vapor for the inactivation of nosocomial pathogens on porous and nonporous surfaces.

BACKGROUND: Clostridium difficile spores and multidrug-resistant (MDR) organisms, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and MDR Acinetobacter baumannii, are important nosocomial pathogens that are difficult to eliminate from the hospital environment. We evaluated the efficacy of hydrogen peroxide vapor (HPV), a no-touch automated room decontamination system, for the inactivation of a range of pathogens dried onto hard nonporous and porous surfaces in an operating room (OR). METHODS: Stainless steel and cotton carriers containing >4 log10 viable MRSA, VRE, or MDR A baumannii were placed at 4 locations in the OR along with 7 pouched 6 log10Geobacillus stearothermophilus spore biologic indicators (BIs). HPV was then used to decontaminate the OR. The experiment was repeated 3 times. RESULTS: HPV inactivated all spore BIs (>6 log10 reduction), and no MRSA, VRE, or MDR A baumannii were recovered from the stainless steel and cotton carriers (>4-5 log10 reduction, depending on the starting inoculum). HPV was equally effective at all carrier locations. We did not identify any difference in efficacy for microbes dried onto stainless steel or cotton surfaces, indicating that HPV may have a role in the decontamination of both porous and nonporous surfaces. CONCLUSION: HPV is an effective way to decontaminate clinical areas where contamination with bacterial spores and MDR organisms is suspected.

Influence of signal colored hand disinfectant dispensers on hand hygiene compliance at a medical intensive care unit.

To assess the influence of signal colors on hand disinfectant dispenser activities, health care workers (HCWs) at a medical intensive care unit were analyzed for a total of 20 weeks with 8 weeks before and 12 weeks after exchange to signal color. No significant increase in hand rubs (HRs) per patient day (PD) was observed (about 40 HRs/PD); however, HCW-adjusted compliance showed a 6% increase with signal colored devices. Therefore, colored devices may help to improve hand hygiene compliance.

Simultaneous placement of multiple central lines increases central line-associated bloodstream infection rates.

BACKGROUND: Surveillance for central line (CL)-associated bloodstream infections (CLABSIs) is generally advocated. However, the standard definition of this surveillance does not take into account the number of CLs in place and thus the possibility of increased infection risk with multiple CLs in place simultaneously. In this study, we tested the hypothesis that simultaneous placement of more than 1 CL is associated with an increased CLABSI rate. METHODS: The number of CLs, CL-days, and CLABSIs and CLABSI rates with regard to the number of CLs in place simultaneously was documented in 2 intensive care units between 2001 and 2011. Standard CLABSI rates, as well as the rates for 1 CL and multiple CLs in place, were calculated. RESULTS: The average CLABSI rate was significantly lower in patients with 1 CL in place compared with those with more than 1 CL in place (3.69 per 1,000 CL-days vs 13.09/1,000 CL-days; incidence rate ratio [IRR], 3.63; 95% confidence interval [CI], 2.61-5.05). Importantly, all differences from the standard rate (5.94/1,000 CL-days) were significant (1 CL vs standard: IRR, 0.61; 95% CI, 0.51-0.74; more than 1 CL vs standard: IRR, 2.23; 95% CI, 1.87-2.65; both P < .0001). CONCLUSIONS: Our data show that the number of CLs in place had a strong influence on CLABSI rates. Thus, we advocate stratifying patients by the number of CLs in place to take this increased risk of infection into account during surveillance.

Surveillance of nosocomial infections in a neurologic intensive care unit.

OBJECTIVE: To assess data on the epidemiology of nosocomial infection (NI) among neurologic intensive care patients. DESIGN: Prospective periodic surveillance study. SETTING: An 8-bed neurologic intensive care unit (ICU). PATIENTS: All those admitted for more than 24 hours during five 3-month periods between January 1999 and March 2003. METHODS: Standardized surveillance within the German infection surveillance system. RESULTS: Three hundred thirty-eight patients with a total of 2,867 patient-days and a mean length of stay of 8.5 days were enrolled during the 15-month study period. A total of 71 NIs were identified among 52 patients. Urinary tract infections (UTIs) were the most frequent NI (36.6%), followed by pneumonia (29.6%) and bloodstream infections (BSIs) (15.5%). The overall incidence and incidence density of NIs were 21.0 per 100 patients and 24.8 per 1,000 patient-days, respectively. Incidence densities were 9.8 UTIs per 1,000 urinary catheter-days (CI95, 6.4-14.4), 5.6 BSIs per 1,000 central venous catheter-days (CI9s, 2.8-10.0), and 12.8 cases of pneumonia per 1,000 ventilation-days (Cl95, 8.0-19.7). Device-associated UTI and pneumonia rates were in the upper range of national and international reference data for medical ICUs, despite the intensive infection control and prevention program in operation in the hospital. CONCLUSION: Neurologic intensive care patients have relatively high rates of device-associated nosocomial pneumonia and UTI. For a valid comparison of surveillance data and implementation of targeted prevention strategies, we would strongly recommend provision of national benchmarks for the neurologic ICU setting.

[Fulminant meningoencephalitis associated with Mycoplasma pneumoniae infection in adults. Aggressive treatment enabled a good outcome]. / Fulminante Mycoplasma-pneumoniae-assoziierte Meningoenzephalitis des Erwachsenen. Aggressive Therapie ermöglicht gutes Outcome.

Mycoplasma pneumoniae (M. pn.) commonly causes respiratory tract infections in humans. In a certain percentage of cases it may also be associated with various peripheral and central nervous system manifestations. We report a case of a 38-year-old previously healthy man who presented with hemiplegia and somnolence after he had suffered from a febrile respiratory infection 10 days earlier. Clinical features and laboratory investigations supported the diagnosis of an acute M. pneumoniae-associated meningoencephalitis. He was treated by an aggressive antibiotic and immunomodulatory regimen over the course of several weeks in the neurocritical care unit. Decompressive hemicraniectomy was performed due to life-threatening raised intracranial pressure. However, the patient recovered almost completely and presented with a mild neurological deficit after 3 months. Based on this case we give a review of the literature and discuss potential pathomechanisms and diagnostic approaches.

MRSA-retrospective analysis of an outbreak in the burn centre Aachen.

The growing interest in methicillin-resistant Staphylococcus aureus (MRSA) has been caused by its increased appearance in hospital and community populations. In our burn centre, an outbreak of MRSA was noticed during an 8-month period. We were able to isolate MRSA in eight patients. DNA analysis by pulsed-field gel electrophoresis (PFGE) demonstrated the development of five different strains during this period. Only two patients developed an infection caused by MRSA colonisation. The infections were proven by positive blood culture or catheter colonisation. One patient developed a clinical vancomycin-resistant sepsis which was treated successfully with the additional application of Quinupristin/Dalfopristin. THIS ANALYSIS SHOWS THAT: (1) the development of MRSA in a burn unit is often created in a single patient by long-term antibiotic therapy and not a result of cross-infection, (2) manifest MRSA infection seldom occurs even in colonised burn patients, and (3) a clinically vancomycin-resistant MRSA infection in burn patients can be treated sufficiently with Quinupristin/Dalfopristin.