Care Units In Germany Research Articles

Microbiological Diagnostic and Antibiotic Management of Community Aquired and Nosocomial Pneumonias in Intensive Care Units in Germany

Pneumonien sind die häufigsten nosokomialen Infektionen bei kritisch kranken Patienten und ursächlich verantwortlich für bis zu 50 % des gesamten Antibiotikaverbrauchs auf Intensivstationen [1]. Adäquate mikrobiologische Diagnostik und Antibiotikatherapie verbessern das klinische Outcome von Patienten mit beatmungsassoziierter Pneumonie [2] [3] und vermindern die Wahrscheinlichkeit für eine Infektion mit multiresistenten Erregern [4].

Neue teure Therapie-Optionen in der Intensivmedizin in Deutschland - werden sie genutzt?

The use of new, high-priced therapies in intensive care medicine should be assessed by a questionnaire. Questionnaires were sent to 849 intensive care units in Germany. The use of three new strategies were asked: treatment of methicilline resistant staphylococcus aureus (MRSA) patients (using linezolid), of severe bleeding (using rFVIIa), and of severe sepsis (using activated protein C [aPC]). Approximately 39 % of the questionnaires were answered and analyzed. All three new strategies were only rarely or very rarely used in Germany even in universities and hospitals with more than 1000 beds. This appears to be very astonishing because all substances were subject to extensive marketing campaigns, received scientific prices (linezolid) or were strongly recommended by some scientific societies (aPC). One major concern to the use of the new approaches was based on the high pricing. Prices were assessed as excessive or very excessive. In spite of a mass of information about the substances, a lot of the intensivists reviewed the scientific basis as weak and not justifying the use of the costly substances. Modern, costly pharmaceutical approaches in intensive care medicine are widely not accepted in Germany. Especially a tight financial corset hinders most intensivists to use these strategies that may be life-saving in some patients. A solution to this problem is urgently required that can be reached only in intensive exchange with all who are responsible for this dilemma.

Epidemiology of severe sepsis and septic shock in Germany: results from the German 'Prevalence' study

Although a large number of epidemiological sepsis studies have been performed in Europe and the United States in the past years, sound data for Germany are so far lacking. In the 'Prevalence of Severe Sepsis and Septic Shock in Intensive Care Units in Germany' study, a prospective observational cross-sectional study, the network gathered data from 454 randomly selected ICUs in 310 hospitals in Germany and screened 3877 patients – according to the ACCP/SCCM Consensus Conference criteria – by local 1-day visits of trained physicians from the 17 German Competence Network Sepsis (SepNet) regional study centers. Visits were randomly distributed over a 1-year period (2003) to allow assessment of seasonal variations of sepsis prevalence. The ICU sample was taken from a registry of all German hospitals with ICUs (1380 hospitals with 2075 ICUs). Pediatric ICUs were not considered. The study was completed in January 2004 and the database was closed on 31 May. Seven percent of ICUs were situated in university, 34% in university-affiliated and 53% in general hospitals. Fifty-six percent of ICU directors were anesthesiologists and 26% internists. An infection was microbiologically documented in 22% and diagnosed by clinical criteria alone in 12% of screened patients. Respiratory tract infections were most common (52%), followed by intra-abdominal (15%) and urogenital infections (7%). Gram-negative and Gram-positive infections were nearly equally distributed (33% vs 35%); in 16% a fungal infection was suspected. The prevalence of sepsis was 12%, infection without SIRS was 7%, and severe sepsis/septic shock was 11%. There were significant differences in the prevalence of severe sepsis/septic shock over 1 year with the highest prevalence in May/June 2003 (18%). The infection was ICU acquired in 37%, hospital acquired in 20% and community acquired in 35.5%. ICU mortality in patients with severe sepsis/septic shock was 47% and hospital mortality was 54%. Based on these findings the incidence of severe sepsis/septic shock in German ICUs can be estimated as 75,000 cases per year (110 per 100,000 inhabitants), comparable with the incidence of acute myocardial infarction (143 per 100,000 inhabitants). With an estimated 40,000 deaths per year, severe sepsis/septic shock is the third most frequent cause of death in Germany after coronary artery disease and acute myocardial infarction. Incidence and mortality rate of severe sepsis and septic shock in German ICUs are higher than reported in recent studies. This may be due to the representative sample size, the more standardized diagnostic criteria and a lower interobserver variability.

Development of a surveillance system for nosocomial infections: the component for neonatal intensive care units in Germany

Neonates are at high risk of nosocomial infections and surveillance has been shown to be valuable for the reduction of nosocomial infections. The National Nosocomial Infections Surveillance (NNIS) system established in the US has a special surveillance component for neonatal intensive care units (NICUs) with some fairly specific methods. However, there are no specific definitions of nosocomial infections in this patient group. When creating a surveillance component for NICUs in Germany we therefore decided not to adopt merely all Centers for Disease Control and Prevention definitions and NNIS methods, but also to develop our own surveillance methods for this patient group. For this process four steps became necessary:(1)development of modified definitions for nosocomial infections and their evaluation;(2)testing the NNIS method in three NICUs with infection control nurses;(3)a pilot project for a surveillance component within the national surveillance system in Germany; and(4)establishment of a surveillance component within our national surveillance system.The system is now established in 33 hospital departments and 66 NICUs participate in the surveillance system. We have an overview of 3357 neonates in three birthweight groups. This article explains the reasons for the various steps, and the advantages and disadvantages of modification of the original NNIS methods and definitions.

Drugs in palliative care: results from a representative survey in Germany.

The development of palliative medicine in inpatient units in Germany has been impressive in the last years. As a first step of quality assurance, a core documentation form was developed in 1996. In 2001, 55 of the 83 palliative inpatient units in Germany and one unit each in Switzerland and Austria participated in the third phase of the evaluation of the core documentation. A total of 1304 patients were documented consecutively in the 57 units for a period of up to three months. This study investigates the frequency of drugs used in palliative care units in Germany. During inpatient treatment, the most common drug classes were strong opioids (68% of the patients), nonopioids (59%), corticosteroids (32%), laxatives (31%), antiemetics (27%), gastric protection agents (24%), neuroleptics (19%), sedatives/anxiolytics (18%), antidepressants (16%) and diuretics (15%). These ten drug classes made up for 72% of all prescriptions in the palliative care units. The substances used most frequently were dipyrone (47% of the patients), morphine (42%), fentanyl (28%), dexamethasone (27%), metoclopramide (21%), sodium picosulfate (15%), haloperidol (13%), pantoprazole (11%), macrogol (11%), amtriptyline (11%), furosemide (10%), omeprazole (9%), lactulose (8%), rofecoxib (8%) and lorazepam (7%). The 15 most commonly used drugs accounted for 54% of the prescriptions in the palliative care units in Germany. Drug treatment was related to sex, age and functional status of the patients. Patients who died in a palliative care unit had received significantly more frequent doses of neuroleptics (P < 0.001), corticosteroids (P < 0.001), sedatives/anxiolytics (P < 0.001) and strong opioids (P < 0.001). This study is the first representative and systematic evaluation of drug treatment in palliative care units in a European country. Many of the 'top 15' drugs were drugs included in the list of essential drugs of the World Health Organisation though availability and cultural differences have an effect on the use of drugs, e.g., the high usage of dipyrone in Germany. Age and sex-related differences in drug therapy were seen, and more research is needed to recognize possible undertreatment of symptoms in subgroups of patients, e.g., treatment of depression in older or male patients.

What are the problems in palliative care? Results from a representative survey.

The development of a standardised core documentation for palliative care was initiated in Germany in 1996. Results from previous evaluations have shown the wide variability of the documentation in participating units. A different documentation form was used in 2001 using free text entries to find out what problems palliative care specialists perceive in their patients. Fifty-five of the 83 palliative inpatient units in Germany (66% of the units) as well as one unit each from Austria and Switzerland, documented 1304 patients in the core documentation in 2001. Inpatient care was continued until death for 531 patients, 604 patients were discharged home and 169 patients were transferred to other places of care. Palliative care treatment effectively reduced mean physical symptom intensity. Mean intensities of psychological and social problems also were reduced although not as much as physical symptom load. Nursing problems were reduced for those patients discharged but not for those who died in the unit. Anxiety and depression were the most frequent psychological problems. Nursing problems were focussed on impairment of mobility and other activities of daily living such as washing, nutrition and drinking. Excessive distress on caregivers and the organisation of home care were the predominant social problems. In conclusion, this representative prospective survey with the majority of palliative care units in Germany showed the high effectiveness of symptom relief. Using the categories identified in this study, checklists were constructed and included in the documentation forms that are currently used for the core documentation project.

What Is Palliative Care in Germany? Results from a Representative Survey

The recent development of palliative care inpatient units in Germany has been impressive. As a first step for quality assurance, a core documentation form was developed in 1996. The core documentation form consisted of 4 pages with 35 items documenting physical and psychosocial symptoms at the time of admission, diagnostic and therapeutic procedures before and during inpatient treatment, and outcome of physical and psychosocial dimensions. Checklists were used for most items and free text entries could be added. Of the 65 palliative inpatient units in Germany, 44 participated in the second phase of the evaluation of the core documentation in 2000. Eight units were affiliated with anesthesiology departments, 31 with internal medicine, two with radiotherapy, 1 with a surgical department, and 2 units were not affiliated with a department of the hospital. A total of 1087 patients were assessed in the 44 units during a period of up to 3 months. There was a high variability between units in all checklist items of the core documentation. Compared to units affiliated with internal medicine departments, units affiliated with anesthesiology departments performed less chemotherapy, but more immunotherapy; gave fewer infusions and blood transfusions but more skin and wound care, and more lymphatic drainage and massage; and documented psychosocial interventions more frequently for patients as well as for relatives. In one-third of the patients, a consent for omission of therapeutic options was documented. Inpatient treatment ended with the death of the patient in 45.3% of patients and with discharge in 51.6% (not documented 3.1%). The efficacy of inpatient treatment was rated very high by the staff. In conclusion, we found large variation in the documentation pertaining to palliative care patients at the time of admission, as well as for inpatient treatment, among palliative care units in Germany. This was related to the affiliation of the units at least to some degree, but also to differences in interests and documentation discipline. We suggest that training procedures for documentation should be included in crossectional surveys, as the results may not be comparable otherwise. However, common documentation instruments may be the first step towards an interdisciplinary discussion on aims and methods in palliative care.

In vitro Susceptibility to Everninomycin of Gram-Positive Nosocomial Pathogens Isolated from Intensive Care Units in Germany

Background: Gram-positive bacteria are increasingly found to be causative pathogens in nosocomial infections, and the occurrence of vancomycin resistance in enterococci as well as staphylococci has prompted the investigation of alternative antimicrobial agents active against these strains. Everninomycin, a new oligosaccharide antibiotic, has excellent in vitro activity against gram-positive bacteria, including those resistant to vancomycin. However, avilamycin, a related compound, has been used in Europe as a growth promoter in animal food for years and concern has been raised that cross-resistance in clinical isolates may arise. Methods: We studied a collection of 268 nosocomial gram-positive isolates from intensive care unit patients with nosocomial pneumonia, urinary tract infection and sepsis, using standard in vitro susceptibility testing. Results: It could be shown that all species tested were exquisitely sensitive to everninomycin (MIC₉₀ of 0.38 µg/ml for Staphylococcus aureus, 0.5 µg/ml for enterococci and 0.75 µg/ml for coagulase-negative staphylococci). Furthermore, no difference could be observed between methicillin-resistant and methicillin-sensitive S. aureus or between Enterococcus faecium and Enterococcus faecalis. Conclusions: These results suggest that everninomycin is a promising antibiotic for the treatment of nosocomial infections in intensive care unit patients and that the use of a related substance as an additive in animal food has not yet promoted resistance in clinical isolates.

Antimicrobial susceptibility among nosocomial pathogens isolated in intensive care units in Germany.

Antimicrobial susceptibility among nosocomial pathogens isolated in intensive care units in Germany.

Results of two observational studies in eight medical-surgical intensive care units in Germany to determine the frequency of hand washing by the medical staff and plot these results against the patient:personnel ratio

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