Research for infection protection

Hygiene against multidrug-resistant bacteria – everything stays different

Anyone who goes travelling has stories to tell. Everything patients should remember when coming from their patient journey through a hospital – from admission to discharge – is the healing success. But the 400 000 to 600 000 patients, who acquire an infection during their hospital stay in Germany each year, tell a completely different story.

In Germany, four to twelve people die of a preventable nosocomial infection every day. The risk of mortality is particularly high when multidrug-resistant pathogens are involved. 30 000 to 35 000 patients acquire an infection due to these bacteria that are multi-resistant to antibiotics. The spectrum of resistant, problem-causing pathogens continues to rise; in contrast, the therapy options fade away.

What are the most common risks of infection for patients during their journey through a hospital? Recent figures indicate that with a share of 24.3 per cent postoperative surgical site infection is the most common nosocomial infection, followed by urinary tract infection with 23.2 per cent, lower respiratory tract infection with 21.7 per cent, and bloodstream infection with 5.7 per cent.

Improved processes along the patient journey

Based on these data, the BODE SCIENCE CENTER has identified important nursing tasks along the patient journey that involve the risk of nosocomial infection when hygiene is not performed properly – and developed standardised operating procedures (SOPs) for the most frequent nursing activities that consider all infection-relevant steps of the respective task. Hand hygiene is of great importance here.

Even though the new SOPs do not reinvent hygiene, their holistic approach offers better implementability. Additionally, they focus on aseptic tasks, which normally involve a high risk of infection and for which the compliance is particularly low.

In the event of multidrug-resistant pathogens, patients and hospitals benefit twice from hygiene measures: prevented infections decrease the use of antibiotics. Every saved antibiotic therapy reduces the selection pressure and, with it, further development of resistances.

The new hygiene processes cover the most frequent activities along the patient journey such as the placement of peripheral venous accesses and urinary catheters, the change of wound dressings and the management of ventilated patients. Every sixth patient has an indwelling urinary catheter inserted during hospital stay, every third intensive patient is ventilated mechanically – hygienically optimised processes can decrease infections with all nosocomial pathogens.

For optimising the nursing activities, the BODE SCIENCE CENTER observed the respective tasks and divided them into individual steps. All actions involving a risk of infection were checked for evidence and were then, together with the other work steps, brought into a logical order easy to understand for the employees. A multimodal intervention package comprising checklists, e-leaning tools, classroom training and e-health Apps helps establish the SOPs as standard.

Recent studies show that optimised processes can considerably increase compliance with hygiene, especially with hand hygiene. The introduction of the SOPs increased hand hygiene compliance from 65 per cent to 97 per cent during blood sampling and dressing change. Hand disinfection compliance before aseptic tasks could be doubled. But not only hand hygiene improves through hygienically optimised processes: according to a study, the use of a sterile cover for puncture sites – which is so important for infection protection – increased from 25 per cent to 73 per cent.

And there is positive feedback on the SOPs from the pilot clinic St. Nikolaus-Stiftshospital GmbH, Andernach, Germany. Within only a few months after the SOP for the wound dressing change was introduced, the willingness to adhere to all steps relevant to hygiene during aseptic dressing change increased from 75 per cent to 88 per cent.

Infections with multidrug-resistant pathogens are particularly severe

Processes that are safe from a hygienic point of view protect against all infections – regardless of the type of pathogen. Yet, infections with resistant strains are more seldom than with those susceptible to antibiotics. However, disease burden and mortality risk are far higher with infections due to multidrug-resistant microorganisms. Infections caused by MRSA (methicillin-resistant Staphylococcus aureus), for example, involve a mortality that is 64 per cent higher than infections “only” caused by antibiotic-susceptible bacteria. A new problem are the multi-resistant Gram-negative pathogens. In case of bloodstream infections, they for instance increase the mortality by a factor of three to six.

Hospital-acquired infections due to multidrug-resistant bacteria do not only affect older people or patients with an underlying disease. This is also impressively shown by a case of a young police officer, who acquired an MRSA infection after knee surgery and almost lost her leg. The attending physician at Charité Berlin, Germany conducted a targeted diagnosis of the involved bacteria to derive a specific antibiotic therapy and thus could effectively combat the infection.

In addition to hygiene measures, the rational antimicrobial use and the development of new drugs without a doubt are important elements of the strategy against multidrug-resistant microorganisms in hospitals. However, consistent hygiene is the measure that has immediate impact on patient protection. Its role, also with regards to fighting antibiotic resistance, should therefore be investigated and supported more intensively.

Sources (in alphabetical order)
Becker C. (17 Nov. 2016). Like the domino effect – the impact of improved hygiene processes.*
German National Point Prevalence Survey on Nosocomial Infections and antimicrobial use. 2011. Final report.
Frank U. (17 Nov. 2016). Post-antibiotic era – already a reality in German clinics?*
Gastmeier P et al. Wie viele nosokomiale Infektionen sind vermeidbar? DMW Deutsche Medizinische Wochenschrift 2010; 135 (3): S. 91-93.
Kampf G et al. Improving patient safety during insertion of peripheral venous catheters: an observational intervention study. GMS Hygiene and Infection Control 2013; 8(2).
Mallwitz H. (17 Nov. 2016). From very close – hygiene along the patient journey.*
Robert Koch-Institute. FAQ on antibiotic resistances. 2016.
Scheithauer S et al. Improving hand hygiene compliance rates in the haemodialysis setting: more than just more hand rubs. Nephrol Dial Transplant (2012) 27: 766–770.
Son C et al. Practically speaking: Rethinking hand hygiene improvement programs in health care settings. American Journal of Infection Control. 2011; 39(9):716-24.

* All speeches were held at the Lunchtime Symposium “Pathogens resistant to antibiotics: new hygiene strategies along the patient journey”, 17 November 2016, Berlin, arranged by the BODE SCIENCE CENTER, Hamburg, scientific centre of excellence of PAUL HARTMANN AG, Heidenheim.