Risk factor analysis of blood stream infection and pneumonia in neutropenic patients after peripheral blood stem-cell transplantation.

The purpose of this study was to analyse risk factors for blood stream infection (BSI) and pneumonia in neutropenic patients who have undergone peripheral blood stem-cell transplantation (PBSCT). Data were taken from the ONKO-KISS multicenter surveillance project. Infections were identified using CDC definitions (laboratory-confirmed BSI) and modified criteria for pneumonia in neutropenic patients. The multivariate analysis was performed using the Fine-Gray regression model for the cumulative incidences of the competing events 'infection', 'death' and 'end of neutropenia'. The risk factors investigated were: sex, age, underlying disease and type of transplant. From January 2000 to June 2004, a total of 1699 patients in 20 hospitals were investigated. In the multivariate analysis, male patients had a significantly higher risk of acquiring BSI than female patients (P=0.002). The risk of acquiring BSI is highest in patients with advanced acute myeloid leukaemia (AML). In the univariate and multivariate analysis, unrelated donor allogeneic transplantation constituted a risk factor for pneumonia (P=0.012). ONKO-KISS provides reference data on the incidence of pneumonia and BSI. The increased risk for BSI in males and patients with advanced AML, and the increased risk for pneumonia in unrelated donor allogeneic PBSCT patients should be targeted to prevent infections in these higher risk groups.

Surveillance of antimicrobial use and antimicrobial resistance in German intensive care units (SARI): a summary of the data from 2001 through 2004.

OBJECTIVE: To report the experience gained over 4 years in working with the German SARI project (Surveillance of Antimicrobial Use and Antimicrobial Resistance in Intensive Care Units), and to compare SARI with data from the Swedish STRAMA and the US AUR surveillance system. METHODS: Prospective unit and laboratory based surveillance was carried out in 40 German ICUs from 2001 through 2004. WHO 2004 definitions of defined daily doses (DDD) per 1,000 patient days (pd) were used to express antimicrobial consumption (AD). Apart from the proportion of resistant isolates (RP), the incidence density of resistant isolates (RD) was calculated on the basis of the number of resistant isolates per 1,000 pd. To determine the changes over time, the Wilcoxon signed rank test for paired samples was used. RESULTS: From 1/2001 through 12/2004, 40 ICUs provided data on 53,399 isolates, a total of 789,569 DDD and 597,592 pd. Total AD ranged from 427 to 2,798, with the median being 1,351. There was no statistically significant change in total antimicrobial use, but a statistically significant decrease was observed in the use of aminoglycosides. RD was highest for MRSA with 4.4 resistant isolates/1,000 pd followed by imipenem resistant Pseudomonas aeruginosa with 1.7 resistant isolates/1,000 pd. The corresponding RPs were 21.5% and 23.2%. Over the 4-year period (2001-2004), significant increases were seen in the RDs of third generation cephalosporin and ciprofloxacin resistant Escherichia coli. In 2004, the mean RD reached 0.28 and 1.41, respectively. In comparison, the RP of selected pathogens was highest in the US ICUs and lowest in Swedish ICUs, with the exception of imipenem resistant P. aeruginosa. CONCLUSION: Antibiotic consumption remained stable over a period of 4 years, (the mean being 1,321 DDD/1,000 pd). The same applied to the situation regarding resistance in Staphylococcus aureus, enterococci and P. aeruginosa. For most pathogens the RP was higher in SARI ICUs than in Swedish ICUs, but lower than in US ICUs.

Is the prevalence of Stenotrophomonas maltophilia isolation and nosocomial infection increasing in intensive care units?

The study presented here was conducted over a period of 4 years (2001-2004) to investigate changes in the number of S. maltophilia isolates detected per 1,000 patient days and to look at the incidence density of nosocomial infections caused by S. maltophilia. The analysis was based on data provided by 34 German intensive care units participating continuously in the national project "Surveillance of Antimicrobial Use and Resistance in ICUs"; 31 of these ICUs reported nosocomial infections to the German infection surveillance system, KISS, during the study period.

Stenotrophomonas maltophilia and antibiotic use in German intensive care units: data from Project SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in German Intensive Care Units).

Risk factors for the selection of Stenotrophomonas maltophilia were analysed by correlating antimicrobial use and structure parameters (e.g. hospital type) with the incidence density of S. maltophilia and the percentage of S. maltophilia isolated from 39 intensive care units (ICUs). SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in German Intensive Care Units) is a prospective unit- and laboratory-based surveillance system that collects data on the 13 most important organisms responsible for nosocomial infections. The percentage of S. maltophilia among these organisms and the number of S. maltophilia per 1000 patient-days were calculated. The data were subsequently correlated with antibiotic use density calculated in defined daily doses (DDDs) per 1000 patient-days and structure parameters. The data covered a total of 28 266 isolates and 431 351 DDDs. The antibiotic use density ranged from 427 to 2218, with the median being 1346. Over the two-year period, the median of S. maltophilia per 1000 patient-days was 1.4 (range 0-7.6). Calculation of antibiotic use and S. maltophilia per 1000 patient-days showed a significant positive correlation with the use of carbapenems, ceftazidime, glycopeptides and fluoroquinolones, as well as with total antibiotic use. In the multiple logistic regression analysis, carbapenem use and >12 ICU beds were independently and positively associated with a high number of S. maltophilia per 1000 patient-days. Benchmarking data provided for incidence densities of S. maltophilia in ICUs revealed the heterogeneous situation of the burden of S. maltophilia in individual ICUs. The multi-centre data showed that carbapenem use and >12 ICU beds were independent risk factors for the isolation of S. maltophilia.

Antibiotic use in two cohorts of German intensive care units.

Antibiotic use was evaluated in two cohorts of intensive care units (ICUs) in Germany. One cohort included ICUs participating in a surveillance programme (N=34) collecting antibiotic use and bacterial resistance data, with quarterly feedback. The second ICU cohort was from a cross-sectional study and represented a sample from hospitals in South-west Germany (N=58). Two dose definitions were used. These were the World Health Organization/Anatomical Therapeutic Chemical Classification (ATC) 2001 definition of defined daily dose (DDD), and a definition of recommended daily dose (RDD) that better reflected the currently prescribed dosages of parenteral drugs for hospitalized patients. Data were expressed as DDD or RDD per 100 patient-days. It was determined whether hospital size and affiliation, year of study and ICU type had an influence on overall use of antibiotics. Overall use differed between the two ICU cohorts irrespective of the dose definitions used. High use of antibiotics was primarily associated with hospital affiliation (university vs non-university) and hospital size. Mean overall use of antibiotics in non-university hospital ICUs ranged between 106 and 111 DDD/100 (59 and 67 RDD/100) for different hospital size categories, compared with 140 DDD/100 (87 RDD/100) in university hospital ICUs. In conclusion, in order to compare the use of antibiotics between ICU cohorts and to assess trends over time, data adjustment is required for hospital affiliation and size.

Temporal changes in bacterial resistance in German intensive care units, 2001-2003: data from the SARI (surveillance of antimicrobial use and antimicrobial resistance in intensive care units) project.

Conservative testing revealed a stable antibiotic resistance situation for Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae in 32 German intensive care units (ICUs) actively participating in the SARI (surveillance of antimicrobial use and antimicrobial resistance in ICUs) project over a three-year period (2001--2003). No significant changes were shown for methicillin-resistant S. aureus (MRSA) (P=0.501; the MRSA rate increased in 18 ICUs and decreased in 14 ICUs). The only exception was an increase in ciprofloxacin-resistant E. coli.

Pseudocontamination of blood components with Burkholderia cepacia during quality controls.

We report on a pseudooutbreak of Burkholderia cepacia because of the use of a contaminated disinfectant during quality controls in a university blood bank. No septic reactions associated with transfusions had been reported in patients over the last 6 months. Analysis of the individual quality control procedures showed that a disinfectant based on a quaternary ammonium compound (QAC) had been used in order to disinfect the rubber stopper of the blood culture bottle. B. cepacia was found in a sample taken from this disinfectant, which was prepared with concentrate and tap water according to the manufacturer's instructions. The four isolates (one in disinfectant and three in blood components) were found to be identical in their biochemical reactions and resistance patterns. QAC-based disinfectants are not efficacious against a part of the spectrum of gram-negatives and are therefore inadequate. After introduction of an alcohol-based preparation, no more cases of B. cepacia contamination have been identified.

Surveillance of nosocomial sepsis and pneumonia in patients with a bone marrow or peripheral blood stem cell transplant: a multicenter project.

BACKGROUND: For surveillance of nosocomial bloodstream infections (BSIs) and pneumonia during neutropenia in adult patients who have undergone bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT), a multicenter study--the Hospital Infection Surveillance System for Patients with Hematologic/Oncologic Malignancies (ONKO-KISS)--was initiated in Germany in 2000. METHODS: Nosocomial infections were identified in neutropenic patients by means of Centers for Disease Control and Prevention definitions for laboratory-confirmed BSI and modified criteria for pneumonia. RESULTS: During the first 38-month period of the study (i.e., through December 2003), a total of 1899 patients associated with 28,273 neutropenic days were investigated. Of these, 1173 (62%) had undergone allogeneic and 726 (38%) had undergone autologous BMT or PBSCT. The mean duration of neutropenia was 14.9 days (9.6 and 18.1 days after autologous and allogeneic transplantation, respectively). Overall, 395 BSIs and 168 cases of pneumonia were identified. The pooled mean site-specific incidence density per 1000 neutropenic days was 14.0 for BSI (12.4 and 18.9 for the allogeneic and autologous transplantation groups, respectively) and 5.9 for pneumonia (6.1 and 5.6 in the allogeneic and autologous transplantation groups, respectively). After allogeneic transplantation, 22.4 BSIs per 100 patients and 11.0 cases of pneumonia per 100 patients occurred, whereas 18.2 BSIs per 100 patients and 5.4 cases of pneumonia per 100 patients occurred after autologous transplantation. The majority (57%) of pathogens associated with BSI were coagulase-negative staphylococci. CONCLUSIONS: The ongoing ONKO-KISS project provides unprecedented reference data about the incidence of pneumonia and sepsis among BMT recipients and PBSCT recipients in Germany. These data will be used for further evaluation of the impact of hygiene measures and therapeutic regimens for these patients.

Comparison of economic and environmental impacts between disposable and reusable instruments used for laparoscopic cholecystectomy.

BACKGROUND: The economic and environmental effects were compared between disposable and reusable instruments used for laparoscopic cholecystectomy. Special consideration was given to the processing of reusable instruments in the Miele G 7736 CD MCU washer disinfector and the resultant cost of sterilization. METHODS: The instruments frequently used in their disposable form were identified with the help of surgeons. Thus, of all the instruments used for laparoscopic cholecystectomy, the disposable and reusable versions of trocars, scissors, and Veress cannula were compared. RESULTS: For the case examined in this study, the performance of laparoscopic cholecystectomy with disposable instruments was 19 times more expensive that for reusable instruments. The higher cost of using disposable instruments is primarily attributable to the purchase price of the instruments. The processing of reusable instruments has little significance in terms of cost, whereas the cost for disposing of disposable instruments is the least significant factor. The number of laparoscopic cholecystectomies performed per year does not substantially influence cost. In the authors' opinion, assessment of the environmental consequences shows that reusable instruments are environmentally advantageous. CONCLUSIONS: Considering the upward pressure of costs in hospitals, disposable instruments should be used for laparoscopic cholecystectomy only if they offer clear advantages over reusable instruments.

Antibiotic use in Germany and European comparison.

In view of increasing rates of antibiotic resistance worldwide and decreased research and development of new antibacterial compounds, programmes helping to better understand the complex relationship between antibiotic consumption and emergence of resistance have gained importance. Consequently, in addition to increased support for research projects that establish prospective surveillance and evaluation of antibiotic resistance and antimicrobial drug use, the EU has passed directives addressing political leadership in this respect. Information on antibiotic use in Germany is now available from databases independent from cost-oriented market research studies. This information allows estimation of antibiotic use in ambulatory and hospital care as compared with to other EU countries. According to results of current projects, the frequency of national antibiotic use in ambulatory care in Germany (4948 defined daily doses per 1000 population per year) falls within the lower third of EU countries. Upper boundaries in regional variation in antibiotic use are still much lower than values for high-use countries like France, Spain and Portugal. Hospital antibiotic use, in contrast, appears to be in the range of that reported for other countries. However, only rough estimates of hospital antibiotic use are available for Germany as well as most other EU countries due to data usually derived from non-representative hospital sampling.

Effects of caspofungin (MK-0991) and anidulafungin (LY303366) on phagocytosis, oxidative burst and killing of Candida albicans by human phagocytes.

The objective of the present study was to investigate the influence of the new echinocandins caspofungin (MK-0991) and anidulafungin (LY303366) on human phagocytes. Phagocytosis, oxidative burst and intracellular killing of Candida albicans were analyzed by flow cytometry. Neither caspofungin nor anidulafungin significantly influenced phagocytosis. Only caspofungin significantly influenced oxidative burst after 15 min of incubation ( P<0.05). Both caspofungin and anidulafungin improved intracellular killing rates of C. albicans after 2 h of incubation (42.4% and 43.2%, respectively, compared to 37.9% in controls; P<0.05). In conclusion, caspofungin significantly improves oxidative burst and intracellular killing, which may be advantageous for clinical therapy.

[SARI: surveillance of antibiotic use and bacterial resistance in German intensive care units. Correlation between antibiotic use and the emergence of resistance]. / SARI: Surveillance der Antibiotikaanwendung und bakteriellen Resistenzentwicklung auf deutschen IntensivstationenZu den Zusammenhängen von Antibiotikaverbrauch und Resistenzsituation.

Intensive care units (ICUs) are considered to be high-risk areas for the emergence and spread of multiresistant bacterial pathogens. In Germany, there are no representative epidemiological data on antibiotic resistance, on the use of antibiotics in ICUs, or on the correlation between antibiotic use and the emergence of resistance. Project SARI (surveillance of antibiotic use and bacterial resistance in ICUs), which as a part of the epidemiological network Spread of Nosocomial Infections and Resistant Pathogens (SIR) is supported by the German Ministry of Science and Education, started in February 2000 and meanwhile includes data on antibiotic use and resistance rates in 38 medical, surgical, and interdisciplinary ICUs. To date (February 2000-June 2003), a total of 1142 months, 413,065 patient days, and 550,288 defined daily doses (DDDs in accordance with the WHO) have been covered with a mean antibiotic usage density (AD) of 1335 DDDs/1000 patient days and resistance data on 37,612 isolates from ICUs. Ciprofloxacin use and MRSA correlate significantly, as do imipenem use and the rate of imipenemresistant P. aeruginosa. The genodiversity of P. aeruginosa is lower in ICUs with high resistance rates and low use of imipenem than in ICUs with high resistance rates and high use. This is an indirect parameter of transmission of identical strains. The epidemiological data of SARI form a basis for improved antibiotic and infection control management in ICUs (http://www.sari-antibiotika.de).

Hospital infection control in Europe: evaluation of present practice and future goals.

The objective of this study was to assess current infection control practice in Europe and its structure, future research priorities, and how infection control should be organised. A questionnaire was sent to 223 hospital infection control physicians throughout Europe, of whom 54 in 18 countries responded. With respect to future research priorities in infection control in Europe, the largest proportion (69%) of the infection control specialists sampled expressed the need for standardisation of surveillance systems for international comparison of nosocomial infection rates. The results of this survey might help to create a basis for standardised guidelines which take into account European-wide interests.

[Quality assurance in intensive care medicine. SARI-surveillance on antibiotic use and bacterial resistance in intensive care units]. / Qualitätssicherung in der Intensivmedizin. SARI-Surveillance der Antibiotikaanwendung und bakteriellen Resistenzentwicklung auf Intensivstationen.

Intensive care units (ICUs) are high risk areas for emergence and spread of multiresistant bacterial pathogens. In Germany, there are no representative epidemiological data on antibiotic resistance, prophylactic or therapeutic use of antibiotics in ICUs, or on the correlation between antibiotic use and emergence of resistance. Supported by the German Ministry of Science and Education, project SARI (Surveillance on antibiotic use and bacterial resistance in ICUs) started in 02/2000 and now includes data on antibiotic use and resistance rates in 35 medical, surgical and interdisciplinary ICUs. To date (2/2000-12/2002), a total of 939 participant months, 339,461 patient days and 452,282 defined daily doses (DDD) have been covered with a mean antibiotic usage density (AD) of 1,332 DDDs/1,000 patient days and resistance data on 31,189 isolates from ICUs. The design of the project and first results of SARI are presented. The epidemiological data of SARI form a basis for improved antibiotic and infection control management in ICUs (http://www.sari-antibiotika.de).

Does the architecture of hospital facilities influence nosocomial infection rates? A systematic review.

OBJECTIVE: To review the evidence regarding the effects of interventions to improve hospital design and construction on the occurrence of nosocomial infections. METHODS: Systematic review of experimental and non-experimental, architectural intervention studies in intensive care units (ICUs), surgical departments, isolation units, and hospitals in general. The studies dated from 1975, and were in English, French, German, Italian, and Spanish. Regardless of format, the studies were identified through seven medical databases, reference lists, and expert consultation. RESULTS: One hundred seventy-eight scientific articles were identified; however, none of these described a meta-analysis, systematic review, or randomized, controlled trial. Most of the articles were categorized at the lowest level of evidence (expert judgment or consensus statements). Only 17 described completed concurrent or historical cohort studies matching the inclusion criteria (ICUs, 9; surgical departments, 4; isolation units, 2; hospitals in general, 2). The interventions generally included a move to other premises or renovation. However, in many studies, the staff-to-patient ratio was also improved. Some studies showed lower infection rates after intervention, but this finding cannot be generalized because of confounding and frequently small study populations. CONCLUSIONS: The lack of stringent evidence linking hospital design and construction with the prevention of nosocomial infection is partly attributable to the multifactorial nature of these infections, and some improvement will be seen if basic conditions such as the availability of sufficient space, isolation capacity, and facilities for handwashing are met. However, to our knowledge, other factors, especially the improper hand hygiene of medical staff, have greater impact.

Nosocomial outbreak of norovirus gastroenteritis and investigation of ABO histo-blood group type in infected staff and patients.

The blood groups were analysed of staff and patients (N=45) infected during two nosocomial outbreaks of norovirus gastroenteritis at a German University hospital. Persons with O phenotype were significantly less affected than was expected from the normal distribution of blood group types in Southwest Germany (OR 2.45; 95% CI 1.22-4.95; P=0.01).