Intensive Care Units In Germany Research Articles

Effect of Empirical Treatment With Moxifloxacin and Meropenem vs Meropenem on Sepsis-Related Organ Dysfunction in Patients With Severe Sepsis

Early appropriate antimicrobial therapy leads to lower mortality rates associated with severe sepsis. The role of empirical combination therapy comprising at least 2 antibiotics of different mechanisms remains controversial. To compare the effect of moxifloxacin and meropenem with the effect of meropenem alone on sepsis-related organ dysfunction. A randomized, open-label, parallel-group trial of 600 patients who fulfilled criteria for severe sepsis or septic shock (n = 298 for monotherapy and n = 302 for combination therapy). The trial was performed at 44 intensive care units in Germany from October 16, 2007, to March 23, 2010. The number of evaluable patients was 273 in the monotherapy group and 278 in the combination therapy group. Intravenous meropenem (1 g every 8 hours) and moxifloxacin (400 mg every 24 hours) or meropenem alone. The intervention was recommended for 7 days and up to a maximum of 14 days after randomization or until discharge from the intensive care unit or death, whichever occurred first. Degree of organ failure (mean of daily total Sequential Organ Failure Assessment [SOFA] scores over 14 days; score range: 0-24 points with higher scores indicating worse organ failure); secondary outcome: 28-day and 90-day all-cause mortality. Survivors were followed up for 90 days. Among 551 evaluable patients, there was no statistically significant difference in mean SOFA score between the meropenem and moxifloxacin group (8.3 points; 95% CI, 7.8-8.8 points) and the meropenem alone group (7.9 points; 95% CI, 7.5-8.4 points) (P = .36). The rates for 28-day and 90-day mortality also were not statistically significantly different. By day 28, there were 66 deaths (23.9%; 95% CI, 19.0%-29.4%) in the combination therapy group compared with 59 deaths (21.9%; 95% CI, 17.1%-27.4%) in the monotherapy group (P = .58). By day 90, there were 96 deaths (35.3%; 95% CI, 29.6%-41.3%) in the combination therapy group compared with 84 deaths (32.1%; 95% CI, 26.5%-38.1%) in the monotherapy group (P = .43). Among adult patients with severe sepsis, treatment with combined meropenem and moxifloxacin compared with meropenem alone did not result in less organ failure. clinicaltrials.gov Identifier: NCT00534287.

Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey

To determine the decision-making process of withholding and/or withdrawal (WH/WD) of life-sustaining treatment in cardiac intensive care units (ICUs) in Germany. A questionnaire regarding 16 medical and 6 ethical questions of WH/WD of life-sustaining treatment was distributed to the clinical director, senior ICU physician and head nurses of all German heart surgery centres (n = 237 questionnaires). Furthermore, we present a literature survey using the key words 'End-of-life care AND withholding/withdrawal of life support therapy AND intensive care unit'. We received replies from 86 of 237 (36.3%) contacted persons. Concerning medical reasons, cranial computed tomography (CCT) with poor prognosis (91.9%), multi-organ failure (70.9%) and failure of assist device therapy (69.8%) were the three most frequently cited medical reasons for WH/WD life-sustaining treatment. Overall, 32.6% of persons answered that ethical aspects influence their decision-making processes. Poor expected quality of life (48.8%), the patient's willingness to limit medical care (40.7%) and the families' choice (27.9%) were the top three reported ethical reasons. There was a significant difference regarding the perception of the three involved professional groups concerning the decision-making parameters: multi-organ failure (P = 0.018), failure of assist device therapy (P = 0.001), cardiac index (P = 0.009), poor expected quality of life (P = 0.009), the patient's willingness to limit medical care (P = 0.002), intraoperative course (P = 0.054), opinion of family members (P = 0.032) and whether decision-making process are done collaboratively (clinical director, 45.7%; ICU physician, 52%; and head of nursing staff, 26.9%). Palliation medication in patients after WH/WD of life-support consisted of morphine (92%) and benzodiazepines (88%). This survey is a step towards creating standards of end-of-life care in cardiac ICUs, which may contribute to build consensus and avoid conflicts among caregivers, patients and families at each step of the decision-making process.

Severe influenza cases in paediatric intensive care units in Germany during the pre-pandemic seasons 2005 to 2008.

BackgroundData on complications in children with seasonal influenza virus infection are limited. We initiated a nation-wide three-year surveillance of children who were admitted to a paediatric intensive care unit (PICU) with severe seasonal influenza.MethodsFrom October 2005 to July 2008, active surveillance was performed using an established reporting system for rare diseases (ESPED) including all paediatric hospitals in Germany. Cases to be reported were hospitalized children < 17 years of age with laboratory-confirmed influenza treated in a PICU or dying in hospital.ResultsTwenty severe influenza-associated cases were reported from 14 PICUs during three pre-pandemic influenza seasons (2005-2008). The median age of the patients (12 males/8 females) was 7.5 years (range 0.1-15 years). None had received vaccination against influenza. In 14 (70%) patients, the infection had been caused by influenza A and in five (25%) by influenza B; in one child (5%) the influenza type was not reported. Patients spent a median of 19 (IQR 12-38) days in the hospital and a median of 11 days (IQR 6-18 days) in the PICU; 10 (50%) needed mechanical ventilation. Most frequent diagnoses were influenza-associated pneumonia (60%), bronchitis/bronchiolitis (30%), encephalitis/encephalopathy (25%), secondary bacterial pneumonia (25%), and ARDS (25%). Eleven (55%) children had chronic underlying medical conditions, including 8 (40%) with chronic pulmonary diseases. Two influenza A- associated deaths were reported: i) an 8-year old boy with pneumococcal encephalopathy following influenza infection died from cerebral edema, ii) a 14-year-old boy with asthma bronchiale, cardiac malformation and Addison's disease died from cardiac and respiratory failure. For nine (45%) patients, possibly permanent sequelae were reported (3 neurological, 3 pulmonary, 3 other sequelae).ConclusionsInfluenza-associated pneumonia and secondary bacterial infections are relevant complications of seasonal influenza in Germany. The incidence of severe influenza cases in PICUs was relatively low. This may be either due to the weak to moderate seasonal influenza activity during the years 2005 to 2008 or due to under-diagnosis of influenza by physicians. Fifty% of the observed severe cases might have been prevented by following the recommendations for vaccination of risk groups in Germany.

Increasing consumption of MRSA-active drugs without increasing MRSA in German ICUs

The aim of our study was to analyze changes in the consumption of MRSA-active antibiotics and in the burden of methicillin-resistant S. aureus (MRSA) over a period of 9years in a network of German intensive care units (ICU). Data from 55 ICUs in Germany were analyzed from 2001 through 2009. The term "old MRSA-active antibiotics" included vancomycin, teicoplanin and fosfomycin, whereas the term "new MRSA-active antibiotics" included quinupristin/dalfopristin, linezolid and daptomycin. The burden of MRSA was defined as MRSA per 1,000 patient-days. A total of 1,584,995 patient-days and 32,450 S. aureus isolates were analyzed. The burden of MRSA was 4.4, and the pooled mean MRSA resistance proportion was 21.8%. Both parameters did not change significantly over time. In contrast, MRSA-active antibiotics more than doubled from 44 defined daily doses per 1,000 patient-days in 2001 to 92 in 2009. This was due to the significant increase of new MRSA-active antibiotics (from 1 to 40), whereas old MRSA antibiotics stayed stable (43 in 2001 and 52 in 2009). New MRSA-active antibiotics did not replace old ones, but were added on top. The use of new MRSA-active antibiotics-mainly linezolid-steadily increased over a period of 9years, although the burden of MRSA stayed stable, as did the proportion of MRSA (%).

Virus-associated hemophagocytic syndrome as a major contributor to death in patients with 2009 influenza A (H1N1) infection

IntroductionVirus-associated hemophagocytic syndrome (VAHS) is a severe complication of various viral infections often resulting in multiorgan failure and death. The purpose of this study was to describe baseline characteristics, development of VAHS, related treatments and associated mortality rate of consecutive critically ill patients with confirmed 2009 influenza A (H1N1) infection and respiratory failure.MethodsWe conducted a prospective observational study of 25 critically ill patients with 2009 influenza A (H1N1) infection at a single-center intensive care unit in Germany between 5 October 2009 and 4 January 2010. Demographic data, comorbidities, diagnosis of VAHS, illness progression, treatments and survival data were collected. The primary outcome measure was the development of VAHS and related mortality. Secondary outcome variables included duration of mechanical ventilation, support of extracorporeal membrane oxygenation and duration of viral shedding.ResultsVAHS developed in 9 (36%) of 25 critically ill patients with confirmed 2009 influenza A (H1N1) infection, and 8 (89%) of them died. In contrast, the mortality rate in the remaining 16 patients without VAHS was 25% (P = 0.004 for the survival difference in patients with or without VAHS by log-rank analysis). The patients were relatively young (median age, 45 years; interquartile range (IQR), 35 to 56 years of age); however, 18 patients (72%) presented with one or more risk factors for a severe course of illness. All 25 patients received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia, with a median duration of mechanical ventilation of 19 days (IQR, 13 to 26 days). An additional 17 patients (68%) required extracorporeal membrane oxygenation for a median of 10 days (IQR, 6 to 19 days).ConclusionsThe findings of this study raise the possibility that VAHS may be a frequent complication of severe 2009 influenza A (H1N1) infection and represents an important contributor to multiorgan failure and death.

Drug utilisation on a preterm and neonatal intensive care unit in Germany: a prospective, cohort-based analysis

This study aims to describe the drug use on a Neonatal Intensive Care Unit (NICU) at a University Children's Hospital in Germany, to investigate the licensing status of the drugs used and to conclude critical areas in neonatal intensive care to support prioritisation of future research. An 11-month, prospective cohort study was conducted on the NICU at the University Children's Hospital Erlangen, Germany. All products prescribed during the study period were analysed whether or not the SPC contains information on term and preterm neonates. A total of 183 patients (102 male) with a mean gestational age of 33.6 weeks (minimum = 24, maximum = 42) were included. The mean length of hospitalisation was 19.4 days (minimum = 2, maximum = 167). On average, patients received 11.1 drugs (minimum = 0, maximum = 46). The majority of prescriptions were accounted for by antibiotics (n = 515), which were received by 90% of all patients, followed by CNS drugs (n = 448) and respiratory drugs (n = 306). Of all the different drugs prescribed (n = 102) only 38% had information regarding their use in patients aged less than 1 month in their SPC. Analgesics and cardiovascular drugs were prescribed frequently, but without having information for use in neonates. Seventy percent of all patients and 100% of very preterm infants received at least one of these drugs. Treatment strategies on a preterm intensive care unit are complex and little information is available for the drugs used. Analgesics and cardiovascular drugs are of major concern. Efforts will have to be made to conduct well-designed and powered studies in this vulnerable population.

Does the Enteral Feeding Advancement Affect Short‐term Outcomes in Very Low Birth Weight Infants?

Controversy exists regarding the optimal enteral feeding regimen of very low birth weight infants (VLBW). Rapid advancement of enteral feeding has been associated with an increased rate of necrotizing enterocolitis. In contrast, delaying enteral feeding may have unfavorable effects on nutrition, growth, and neurodevelopment. The aim is to compare the short-term outcomes of VLBW infants in tertiary care centers according to their enteral feeding advancement. We prospectively studied the influence of center-specific enteral feeding advancement in 1430 VLBW infants recruited from 13 tertiary neonatal intensive care units in Germany on short-term outcome parameters. The centers were post hoc stratified to "rapid advancement to full enteral feeds" (median duration of advancement to full enteral feeds < or =12.5 days; 6 centers), that is, rapid advancement (RA), or "slow advancement to full enteral feeds" (median duration of advancement to full enteral feeds >12.5 days; 7 centers), that is, slow advancement (SA). VLBW infants born in centers with SA (n = 713) had a significantly higher rate of sepsis compared with VLBW infants born in centers with RA (n = 717), which was particularly evident for late-onset sepsis (14.0% vs 20.4%; P = 0.002). Furthermore, more central venous lines (48.6% vs 31.1%, P < 0.001) and antibiotics (92.4% vs 77.7%, P < 0.001) were used in centers with SA. Center differences in enteral feeding advancement occur and may have a significant impact on short-term outcomes such as nosocomial sepsis. Large, multicenter, prospective trials are required to further elucidate the optimal feeding strategy for VLBW infants.

Surveillance der Antibiotika-Anwendung und bakterieller Resistenzen auf Intensivstationen in Deutschland

SARI (Surveillance of Antibiotic Use and Bacterial Resistance in Intensive Care Units) provides data on antibiotic use, resistance rates (RR) and resistance densities (RD) in 47 interdisciplinary, medical and surgical intensive care units in Germany. Mean total antibiotic use was 1170 defined daily doses per 1000 patient days (pd). RD of MRSA has remained stable since 2001 in contrast to a continuous increase in the RD of 3rd generation cephalosporins E. coli (4.3 and 1.4, respectively, resistant pathogens/1000 pd in 2007). Local data of antibiotic use and bacterial resistance are important for the antibiotic and quality management of the individual ICUs. Pooled data of antibiotic use and bacterial resistance allow trends and extrapolations for Germany, which are relevant for future strategies.

Diversität des Antibiotikaverbrauchs auf Intensivstationen in Deutschland

The aim of the study was to present data from the SARI study (Surveillance of Antibiotic Use and Bacterial Resistance in Intensive Care Units) on antibiotic use in Intensive care Units (ICU) in Germany and to determine parameters responsible for involved in the diversity of antibiotic usage. Antibiotic administration in 43 intensive care units in Germany was recorded. Antibiotic usage density (AD) was measured: it describes the use of antibiotics and is expressed as defined daily doses (DDD) and is normalized per 1000 patient-days (pd). Prescribing parameters were the number of antibiotics administered, the amount of the most frequently used antibiotics as a percentage of total antibiotic use and the percentage of selected antibiotic groups as part of total use. Median antibiotic use was 1156 DDDs per 1000 patient-days in the year 2005. However, antibiotic administration was very heterogeneous and ranged from 450 to 1 799 DDDs/1 000 pd. There was no statistically significant association between total use and status or type of hospital and type of ICU. Use of antibiotic groups was also heterogeneous: if pooled data are taken, penicillins and cephalosporins each accounting for a quarter of total antibiotic use. In individual ICUs the use of quinolones was more than 35% of all drugs given, 3rd and 4th generation cephalosporins almost 40% and carbapenems up to 30%. The most frequently used antibiotic per ICU made up 17% (median) of total antibiotic use, the three most frequently administered antibiotics accounting for up to 40%. The great heterogeneity of antibiotic use may indicate room for improvement. Prescribing parameters such as the percentage of antibiotic groups among total antibiotic usage provide additional information on the selective pressure of antibiotics used in the ICU beyond quantitative data on drug administration.

Use of very old and very new antibiotics in intensive care units in Germany

Institute of Environmental Medicine and Hospital Epidemiology, University Medical Centre Freiburg, Breisacher Str. 115B, 79106 Freiburg, Germany; Institute of Hygiene and Environmental Medicine, Charite—University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 27, 12203 Berlin, Germany; National Reference Centre for Surveillance of Nosocomial Infections, Heubnerweg 6, 14059 Berlin, Germany; Institute of Medical Microbiology and Hospital Epidemiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany

Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post‐operative cardiac surgery patients in Germany: results from a postal survey

In Germany, more than 100,000 patients are monitored and treated in 80 intensive care units (ICUs) following cardiac surgery each year. The controversies concerning the different methods of hemodynamic monitoring and the appropriate agents for volume therapy and inotropic support are well known. However, little is known about how monitoring and treatment are currently performed. A questionnaire with 39 questions was sent to the leading physicians of 80 ICUs in Germany, treating patients after cardiac surgery. The questions to be answered covered the current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support and transfusions in patients after cardiac surgery. Sixty-nine per cent of the questionnaires were completed and returned. All ICUs used basic monitoring as recommended by the societies. The use of advanced hemodynamic monitoring included the pulmonary artery catheter (58.2%), transesophageal echocardiography (38.1%) and transpulmonary dilution techniques (13%). Crystalloids (21.2%) and colloids (73%) were used for volume replacement. Epinephrine (41.8%) and dobutamine (30.9%) were the first-choice inotropic drugs for the treatment of low cardiac output syndrome, followed by phosphodiesterase inhibitors (14.5%). Second-choice drugs for the treatment of low cardiac output syndrome were enoximone (29%), milrinone (25%) and dobutamine (25%). A written transfusion protocol and a transfusion threshold for red blood cells existed in 59% and 79% of ICUs, respectively. Hemodynamic monitoring and the variability in clinical practice with regard to volume replacement, transfusion triggers and the use of vasopressors/inotropes in cardiac surgery patients tend to follow the results of traditional experience rather than current scientific knowledge. Guidelines are therefore necessary to help to improve the standards of intensive care after cardiac surgery and thus the outcome of patients.

Gastrointestinal failure in intensive care: a retrospective clinical study in three different intensive care units in Germany and Estonia

BackgroundWhile gastrointestinal problems are common in ICU patients with multiple organ failure, gastrointestinal failure has not been given the consideration other organ systems receive. The aim of this study was to evaluate the incidence of gastrointestinal failure (GIF), to identify its risk factors, and to determine its association with ICU mortality.MethodsA retrospective analysis of adult patients (n = 2588) admitted to three different ICUs (two ICUs at the university hospital Charité-Universitätsmedizin Berlin, Germany and one at Tartu University Clinics, Estonia) during the year 2002 was performed.Data recorded in a computerized database were used in Berlin. In Tartu, the data documented in the patients' charts was retrospectively transferred into a similar database. GIF was defined as documented gastrointestinal problems (food intolerance, gastrointestinal haemorrhage, and/or ileus) in the patient data at any period of their ICU stay. ICU mortality, length of stay, and duration of mechanical ventilation were assessed as outcome parameters.ResultsGIF was identified in 252 patients (9.7% of all patients). Only 20% of GIF patients were identifiable at admission. GIF was related to significantly higher mortality (43.7% vs. 5.3% in patients without GIF), as well as prolonged length of ICU stay (10 vs. 2 days) and mechanical ventilation (8 vs. 1 day), p < 0.001, respectively. Patients' profile (emergency surgical or medical), APACHE II and SOFA scores and the use of catecholamines at admission were identified as independent risk factors for the development of GIF. Development of GIF during ICU stay was an independent predictor for death.ConclusionGastrointestinal failure represents a relevant clinical problem accompanied by an increased mortality, longer ICU stay and mechanical ventilation.

Implementing the International Liaison Committee on Resuscitation guidelines on hypothermia after cardiac arrest. The German experience: still a long way to go?

Two prospective randomised landmark trials were recently published comparing mild hypothermia for 12–24 hours with normothermia in comatose patients who had survived out-of-hospital cardiac arrest [1,2]. In 2003 the International Liaison Committee on Resuscitation ALS Task Force published the following recommendations [3] on the basis of the aforementioned evidence: unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32–34°C for 12–24 hours when the initial rhythm was ventricular fibrillation; and such cooling may also be beneficial for other rhythms or inhospital cardiac arrest. Recent evidence, however, suggests that the implementation of guidelines and scientific evidence in clinical routine is very difficult. This fact is circumstantiated by a recently published study reporting a wide variation in the management of acute respiratory distress syndrome that appears to be related to limited awareness of relevant research and adherence to local practice patterns [4]. We therefore conducted a telephone survey to address the implementation of the International Liaison Committee on Resuscitation guidelines in anesthesiological intensive care units in Germany in spring 2005. We either called the head of the department or the head of the intensive care unit of all 39 university hospital departments of anesthesiology and intensive care medicine in Germany. Twenty-eight out of these 39 (71.8%) departments provided information on their management of hypothermia after cardiac arrest in this telephone survey. We asked three simple questions: Do you treat patients after cardiac arrest in your intensive care unit? Do you use therapeutic hypothermia in patients after cardiac arrest? Do you have written standard operating procedures for therapeutic hypothermia after cardiac arrest? In the intensive care units of those departments responding to our survey, a median of 1900 patients (interquartile range, 1000–2500) were treated per year. The median proportion of ventilated patients was 73% (interquartile range, 60–83). Twenty-six out of 28 (92.9%) intensive care units treated patients after cardiac arrest. Sixteen of these 26 (61.5%) departments were not using therapeutic hypothermia. Only 10 departments out of 26 treating patients after cardiac arrest (38.5%) were using therapeutic hypothermia. Eight out of 26 (30.8%) departments had written standard operating procedures (SOP) for therapeutic hypothermia, eight out of 26 (61.5%) had no written SOP and two out of 26 (7.7%) did not provide information on this topic. The low proportion of university intensive care units adhering to published recommendations may be due to several reasons. There might be deep-rooted concern that prolonged mild hypothermia has adverse effects on the immune system, on enzyme function and on the coagulation system. Hypothermia may directly or indirectly impair neutrophil function [5]. Leukocytopenia has been described significantly more frequently in patients with induced mild hypothermia [5]. Some studies reported higher rates of pneumonia in patients treated with mild hypothermia [6]. This was, however, not reported in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest [1,2]. The widespread belief that therapeutic hypothermia with exact temperature control can be only achieved with special equipment might also result in the fact that less intensive care units use this therapy. However, adequate management of therapeutic hypothermia can be achieved with basic equipment (e.g. an ice-cube maker and a refrigerator to store cold intravenous fluids). Another reason might be that the increased work load imposed on doctors in Germany – with increased nonmedical documentation tasks and the drastically increased clinical work caused by cost-cutting reforms such as the introduction of the Diagnosis Related Group – might slow down the implementation of published guidelines due to shortcomings in medical continuing education [7]. The prompt implementation of guidelines in routine patient care might possibly be difficult as generation and implementation of SOP is a time-consuming process. Unless these SOP are generated in individual department routines, care seems to be influenced by adherence to – sometimes outdated – local practice patterns. Given the low rate of complication with short-term therapeutic hypothermia and the published beneficial effects [1,2,5], therapeutic hypothermia should be a standard treatment within the indications recommended by published guidelines and each hospital should generate or adopt written SOP for the indication and clinical use of therapeutic hypothermia [3]. Even if the optimal duration and temperature of therapeutic hypothermia as well as different cooling techniques still remain a subject of investigation, the implementation of current recommendations by international organisations based on the published evidence should be promoted and adhered to in order to guarantee optimal state-of-the-art treatment for our patients.

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.

Microbiological isolates associated with nosocomial infections in intensive care units: data of 274 intensive care units participating in the German Nosocomial Infections Surveillance System (KISS)

To describe the frequency and distribution of microbiological isolates in association with nosocomial infections (NI) in intensive care units (ICUs) in Germany. The hospital infection surveillance system (KISS = Krankenhaus-Infektions-Surveillance-System) started in Germany in January 1997 as a nationwide surveillance project for the voluntary registration of nosocomial infections. For ICUs reporting focuses on device-associated primary bloodstream infections, urinary tract infections, as well as on pneumonia and bronchitis. The data collected for each patient who acquires a nosocomial infection include the site of infection and patient demographics. Up to 4 pathogens can be recorded for each infection. From 1997 until 2002 274 ICUs were participating. The data of 590 695 patients with 18 073 device associated infections (ventilator-associated pneumonia and bronchitis, central line-associated bloodstream infection (BSI) and urinary catheter-associated urinary tract infection (UTI)) were analyzed. In the group of device-associated NI S. aureus was most frequently isolated (16.5/100NI) followed by Ps. aeruginosa (14.2/100NI), E. coli (13.9/100NI), enterococci (13.4/100NI) and C. albicans (11.2/100NI). Of all S. aureus isolates 20.0 % were MRSA. There was an increase of the MRSA rate from 8 % in 1997 to 26.9 % in 2002. The most frequent pathogen in BSI was coagulase-negative staphylococcus (31.0/100NI). In ventilator-associated pneumonia and bronchitis S. aureus was the most frequent pathogen (24.2 and 24.9/100NI). In more than half of all catheter-associated UTI E. coli (25.7/100NI) and enterococci (25.4/100NI) were found. After stratification for the type of ICU differences in the distribution of pathogens could be shown. The KISS data give an overview of the most important pathogens associated with nosocomial infections on ICUs in Germany.

Ciprofloxacin in the treatment of hospital-acquired pneumonia: a surveillance study in 676 patients

Controlled clinical trials have shown efficacy of high-dose ciprofloxacin for hospital-acquired (HAP) or nosocomial pneumonia. But it has yet to be demonstrated whether this good efficacy also holds true for routine intensive-care patients outside of controlled trials. In a post-marketing surveillance study at 87 intensive-care units in Germany we analyzed 676 cases of nosocomial pneumonia treated with intravenous ciprofloxacin in a daily dosage of at least 400 mg. 538 (80 %) patients were evaluable for efficacy. Cure or improvement was reported in 76 % of the cases. Clinical success rate was higher in previously untreated patients receiving ciprofloxacin as monotherapy (85.3 %) or in combination with other antibiotics (78.4 %) than in those who received ciprofloxacin as monotherapy (73.1 %) or as combination therapy (69.2 %) after an antibiotic pretreatment. In the 66 patients with Pseudomonas aeruginosa as causal pathogen, clinical success rate was 86.4 %. 32 adverse events classified as possibly or probably related to ciprofloxacin occurred in 3.1 % of patients; all of those were reversible. Due to the high success rate, even in cases with failed antimicrobial pretreatment, and the favourable risk-benefit ratio of high-dose ciprofloxacin, ciprofloxacin appears to be an attractive choice in the empiric treatment of hospital-acquired pneumonia.

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.