Antibiotic stewardship and horizontal infection control are more effective than screening, isolation and eradication.

PURPOSE: The global rise of multidrug resistant organisms (MDROs) is of major concern since infections by these pathogens are difficult, and in some cases, even impossible to treat. This review will discuss the effectiveness of a pathogen-independent alternative approach consisting of the implementation of antibiotic stewardship (ABS) programs, improvement of hand hygiene compliance, and daily antiseptic body washings instead of "screening, isolation and eradication" as recommended by many infection control guidelines today. METHODS: A review of the literature. RESULTS: The classical approach composed of screening, isolation and eradication has many limitations, including lack of standardization of the screening methods, risk of medical errors for patients in isolation and failure to eradicate resistant bacteria. Notably, concrete evidence that this current infection control approach actually prevents transmission is still lacking. We found that a novel approach with the training of infectious diseases specialists can reduce the usage of antimicrobials, thereby significantly decreasing the emergence of new MDROs. Moreover, increased hand hygiene compliance not only reduces transmission of MDROs, but also that of sensitive organisms causing the majority of nosocomial infections. Further, instruments, such as continuing education, bed-side observation, and the use of new tools, e.g. electronic wearables and Wi-Fi-equipped dispensers, are all options that can also improve the current low hand hygiene compliance levels. In addition, daily antiseptic body washes were observed to reduce the transmission of MDROs, especially those deriving from the body surface-like MRSA and VRE in specific settings. Finally, antiseptic body washes were seen to have similar effects on reducing transmission rates as screening and isolation measures. CONCLUSIONS: In summary, this review describes a novel evidence-based approach to counteract the growing medical challenge of increasing numbers of MDROs.

Reduction of central venous line-associated bloodstream infection rates by using a chlorhexidine-containing dressing.

PURPOSE: The reduction of central venous line (CVL)-associated bloodstream infections (CLABSIs) is generally advocated. However, despite implementing infection prevention recommendations, CLABSI rates remain high at some institutions. Therefore, a chlorhexidine-containing dressing should be assessed for its potential for infection reduction, adverse events (AEs) and practicability. METHODS: The number of CVLs, CVL days, CLABSIs and CLABSI rates with regard to the kind of dressing (standard vs. chlorhexidine-containing) were documented from November 2010 to may 2012 (1,298 patients with 12,220 CVL days) at two intensive care units (ICUs) and compared to historical controls. The practicability and safety of the chlorhexidine-containing dressing and reasons for not using this dressing were assessed. RESULTS: Forty CLABSIs occurred in 34 patients, resulting in a significantly lower overall CLABSI rate in patients with the chlorhexidine-containing dressing [1.51/1,000 CVL days; confidence interval (CI): 0.75-2.70] compared to patients with the standard dressing (5.87/1,000 CVL days; CI: 3.93-8.43; p < 0.0001). The CLABSI rate in historical controls receiving the standard dressing was 6.2/1,000 CVL days. The main reason for not using chlorhexidine-containing dressing was bleeding at the insertion site. AEs occurred in five patients and represented self-healing skin macerations (3 cases) and superficial skin necrosis (2 cases). CONCLUSIONS: In case of high CLABSI rates despite the implementation of standard recommendations, our findings suggest that a chlorhexidine-containing dressing safely decreases CLABSI rates.

[Fever of unknown origin in the intensive care unit]. / Fieber unklarer Ursache auf der Intensivstation.

Fever is common in patients in intensive care units. Sources of fever can be infectious or non-infectious. The most common sources of infectious fever include ventilator-associated pneumonia, intravascular catheter-related infections, infection with Clostridium difficile or sinusitis. Typical examples of non-infectious fever include thromboembolic events, myocardial infarction, autoimmune disease, withdrawal symptoms or a drug-fever. Every new onset of fever prompts diagnostic decisions, treatment with antipyretics should be discussed critically.

[Prevention of wound infections: basic measures]. / Prävention von Wundinfektionen: Basismaßnahmen.

Individual patient risk factors for wound infections, such as alcohol abuse, smoking or obesity can usually only be modified to a small extent. Studies have shown a reduction of surgical site infections due to the implementation of a benchmarking surveillance system. In order to prevent surgical site infections a variety of interventions are available, such as glucose control, correction of anemia and malnutrition and antibiotic therapy of infections before elective surgery. Reduction of the microbial skin flora by whole body washing procedures, avoidance of sharp razor shaving, application of antibiotic prophylaxis and correct surgical hand disinfection are additional measures. Intraoperative hypothermia should be avoided and strict compliance with asepsis is mandatory. Postoperative preventive measures include appropriate wound care and rapid removal of wound drainage.

T cell activation by recombinant FcepsilonRI gamma-chain immune receptors: an extracellular spacer domain impairs antigen-dependent T cell activation but not antigen recognition.

T cells can be endowed with antigen specificity by grafting with a chimeric receptor consisting of an extracellular antigen binding moiety (scFv) derived from an antibody and an intracellular signaling domain. Conflicting data exist on the impact of an extracellular spacer domain between the antigen binding and the signaling domain with respect to cellular activation. Here, we recorded conjugate formation and antigen-driven cellular activation of T cells grafted with receptor molecules that contain the same antigen binding site (anti-CD30 HRS3-scFv) and signaling domain (FcepsilonRI gamma-chain), however, with and without an IgG1 CH2CH3 (Fc) spacer domain between the scFv and transmembrane moiety. Receptors of both configurations mediate equally efficient conjugate formation between receptor grafted T cells and antigen-positive target cells. Specific signaling by the spacer containing receptor, however, is blocked by five- to 10-fold lower concentrations of soluble antigen than by the spacer-less receptor indicating a higher avidity of the spacer containing receptor to soluble antigen. In contrast, cellular activation upon binding to antigen-positive cells is mediated more efficiently by the spacer-less receptor. This demonstrates that the extracellular spacer domain impairs antigen-dependent cellular activation by the chimeric immune receptor, but not intercellular conjugate formation.