A nosocomial infection (from ancient Greek νόσος nósos , German 'illness' and κομεῖν komein , German ' to maintain' ) or hospital infection ( nosokomeion for 'hospital') is an infection that occurs during a stay or treatment in a hospital or care facility . According to the definition of nosocomial infection, the day of the infection, ie the day with the first symptom, must be day 3 of the hospital stay at the earliest.
By far the most common hospital infections are urinary tract infections , venous catheter septitis , pneumonia during artificial ventilation (ventilation pneumonia ) and wound infections after operations. About 3.5% of all patients in Germany get a hospital infection in general wards and about 15% in intensive care units.
The rate of hospital infections is influenced by factors such as:
- the age structure of hospital patients;
- the frequency and severity of comorbidities , especially those with a weakening of the body's immune system against infection;
- the use of surgical techniques or apparatus-based, invasive measures for diseases that were previously untreatable or difficult to treat;
- the implementation of therapeutic measures that reduce the immune system;
- the level of knowledge of the specialist staff in the hospitals on the subject of hygiene and the prevention of infection; u. a. employing hygiene specialists in hospitals is seen as a means of reducing hospital infection rates;
- the hospital organization;
- the size of the hospital (number of beds);
- Lack of staff;
- Use of antibiotics, especially broad-spectrum antibiotics
At the end of the 20th century, the high has the use of antibiotics in the treatment of bacterial infectious diseases in a significant increase of multiresistant out problem pathogens: Multi-resistant Staphylococcus aureus (MRSA) , vancomycin -resistant enterococci (VRE) and more, the most common cause of nosocomial infections under the collective term ESKAPE pathogens ( Enterococcus faecium , Staphylococcus aureus , Klebsiella pneumoniae , Acinetobacter baumannii , Pseudomonas aeruginosa and Enterobacter ). The increased use of broad-spectrum antibiotics is directly related to the increase in multi-resistant pathogens. As a result, the antibiotic therapy of hospital infections is becoming increasingly complicated, with more than one drug often having to be administered.
“Nosokomeion” was the name given to the rooms in the sanatoriums in ancient Greece (e.g. in Epidauros ), where patients were treated by means of a healing sleep . To this day, the expression denotes a “hospital” in the broadest sense (as opposed to “clinic”, which is derived from “ kline ”, the couch).
Epidemic situation and clinical relevance
Hospital infections make up a large part of all complications occurring in the hospital and therefore have a significant impact on the quality of medical and nursing care for patients. Accordingly, they must be recognized as a serious problem in every hospital. Infections acquired in hospital not only burden the patient themselves due to the pain and discomfort associated with them, they usually also extend the hospital stay - depending on the type of infection by an average of four days - and thus lead at least in health systems in which case flat-rate payments are made , to significant economic losses. The most important preventive measure is regular hygienic hand disinfection with hand disinfectants .
Most of the studies listed are prevalence studies . They record the frequency of nosocomial infections at a specific point in time. With this form of recording, it is rarely possible to draw direct conclusions from high infection rates, which is why prospective, continuous monitoring (recording of infections and their risk factors) is preferred.
The interpretation of epidemiological data on hospital infections is complicated because it is hardly or only partially possible to differentiate between the exogenously ( extrinsically ) caused, avoidable infections and the endogenously ( intrinsically ) caused ones. The comparison between hospitals or specialist disciplines is problematic, since it must always be taken into account according to which criteria (e.g. case definitions) the data were collected and whether the patient populations are comparable with regard to the risk factors.
Studies have shown that the risk of acquiring a hospital infection is lower in clinics with fewer beds than in larger ones. This fact is not surprising, since in specialized clinics with large and specific disciplines, increased diagnostic and aggressive therapeutic interventions are used, which is why higher incidence rates of hospital infections are to be expected. In intensive care units and also in surgical specialist disciplines, the likelihood of contracting hospital infections is also significantly increased.
The most common types of nosocomial infections in the intensive care unit are ventilator-associated pneumonia , intra-abdominal infections after trauma or surgery, and bacteremia caused by intravascular foreign bodies.
In the United States , the proportion of clinical infections increased by 36% from 1975 to 1995; from 7.2 / 1000 to 9.8 / 1000 patients in 1995. In US clinics, 5 to 15% of hospital patients and 25–50% of patients in intensive care units acquire a nosocomial infection. According to the Institute of Medicine in Washington, DC , hospital infections, while preventable, are responsible for 44,000–98,000 deaths each year in the United States. In the USA, nosocomial infections cost between 17 and 29 billion US dollars each year. From 1980 to 1992, the cause of death "infection" in the US increased by 58%. There are so far only a few studies, mostly from the USA, on the number of deaths that occurred as a result of nosocomial infections. In these studies, it was found that around one percent of these patients died directly or indirectly from it. In 2.7% of all hospitalized patients, infections contributed to a fatal course, but were not the actual cause of death.
The European Center for Disease Prevention and Control (ECDC) states in its report around 2.6 million nosocomial infections per year in Europe, as of 2016.
In Italy , between 4,500 and 7,000 people die every year from infections they contracted during a hospital stay. Italy should therefore be in the European average. In its report, the ECDC cites 50,000 attributable deaths per year in Europe.
In Germany , only the "frequent occurrence" of infections was previously notifiable. According to the wording of the Infection Protection Act (IfSG), the occurrence of “two or more” nosocomial infections in which “an epidemic connection is likely or suspected” must not be reported by name . ( (3) IfSG) Such an infection can occur, for example, in hospitals, nursing homes or medical practices. The amendment to the law was expressly made in order to tighten the minimum number to two cases and not to see it in relation to the size of the facility if the cases are in a probable or suspected epidemic context. Such an “epidemic connection” exists “if it can be concluded from the overall circumstances that the occurrence of the same clinical pictures in different patients is related”. Nosocomial infection is defined in number 8 IfSG as “an infection with local or systemic signs of infection as a reaction to the presence of pathogens or their toxins, which is temporally related to an inpatient or outpatient medical measure, unless the infection has already occurred before duration".
The head of the Institute for Hygiene and Environmental Medicine at the Berlin Charité , Petra Gastmeier , estimated the total number of nosocomial infections in Germany at 400,000 to 600,000 for the entire year 2006 with a mortality of 2.6%, which corresponds to around 10,000 to 15,000 deaths per year would correspond. The German Society for Hospital Hygiene (DGKH), on the other hand, gives significantly higher numbers. In 2012 she wrote of 900,000 people infected annually in Germany and up to 40,000 deaths from nosocomial infections. In 2014, the DGKH estimated 900,000 nosocomial infections each year, which led to 30,000 deaths in Germany. In the following year, the DGKH revised its numbers upwards again and reported a total of 1,000,000 nosocomial infections in the context of patient care in German hospitals for 2015. The 2013 quality report of the AQUA Institute assumes 975,000 nosocomial infections in Germany for 2013.
According to reports from 2017, around 3.5 percent of patients in general wards in Germany are infected with a nosocomial infection and 15 percent in intensive care units. It is assumed that there are 1,000 to 4,000 deaths from multi-resistant pathogens across Germany.
The proportion of multi-resistant bacteria is increasing. The most common are wound infections after surgery . Gastmeier estimates the number for Germany at 225,000. Urinary tract infections follow, with 155,000 cases per year and 80,000 deep respiratory infections , including 60,000 pneumonia . The pathogens enter the blood in 20,000 patients, leading to sepsis . The other diseases are due to less common infections.
Hospital infections cause an average of four days longer lying times and additional costs of 4,000 to 20,000 euros per patient.
The epidemic situation for Austria is comparable to Germany. As in Germany or other countries of the European Union, no precise figures are available on the frequency of nosocomial infections in health care facilities or even the death rate of patients who die directly as a direct result of nosocomial infections. According to the Austrian Society for Hospital Hygiene (ÖGKH) - with the exception of bacterial diarrheal diseases caused by Clostridium difficile - this is due to the fact that certain infectious diseases are notifiable, but their direct assignment cannot always be clearly determined. On the other hand, infections occur every year, the causal connection of which is obvious with diagnostic or therapeutic activities in the health care system, but which are not subject to any reporting requirements. This applies, for example, to the group of so-called “device-associated infections” (catheter-associated urinary tract infections, catheter-associated bacteremia, ventilation-associated pneumonia).
An exception in Austria are postoperative wound infections, which arose in connection with treatments in a health care facility. These are recorded annually by the ANISS network (Austrian Nosocomial Infection Surveillance System) using a structured and standardized infection record. 42 hospitals with 66 participating surgical departments currently report their operation data to ANISS in anonymised form, with 17 different indicator operations being recorded. Since ANISS is methodologically based on the European HELICS infection record, comparisons between the individual member states are possible.
According to this, postoperative wound infections after heart bypass operations occur in Austria with an incidence density of 1.2 infections per 1000 PT (postoperative patient days), which corresponds to exactly the same incidence density as in Germany. The European average is 1.6, the highest incidence density was reported for 2007 from Spain (3.8 infections / 1000 PT), the lowest from Norway with 0.4 infections / 1000 PT.
A similar picture can be found with postoperative wound infections after hip replacement surgery . Here, infections occur again with the same incidence density as Germany (0.6 infections / 1000 PT), which corresponds exactly to the European average. The highest density of infections after hip replacement surgery was found in Hungary (2.4 infections / 1000 PT), the lowest in France (0.3 infections / 1000 PT).
In total, between 2% and 25% of all infections in Austria after operations are reported to the Austrian surveillance network ANISS on a voluntary basis. The ÖGKH repeatedly calls for compulsory participation in ANISS and compulsory recording and reporting of relevant data for recording postoperative and “device-associated” infections in Austria.
In Switzerland , the average infection rate is 5.9%. An estimated 70,000 people in Swiss hospitals develop healthcare-associated infections (HAIs) every year, and around 2,000 die from them.
Pathogenesis and complications of nosocomial infections
In the context of invasive medical measures (medical apparatus ), foreign bodies are increasingly being introduced into the patient, which act as a source of nosocomial infections, especially when they are in bed for a long time. Invasive medical devices play a far greater role in the development of nosocomial infections than the underlying diseases of the patient. The majority of risk analyzes for the development of nosocomial infections have given clear results that the pathogens, whether they are sensitive or multi-resistant, enter the body during surgical interventions or when invasive aids are used. These tools are, for example, venous catheter as a trigger for nosocomial bloodstream infections , urinary catheter as a trigger nosocomial urinary tract infections, endotracheal intubation and instrumental respiration as a trigger for respiratory pneumonia or Liquorableitungen as a trigger for meningitis .
Vascular access, especially central venous catheters, play the main role in terms of numbers. They are responsible for nearly two-thirds of the nosocomial infections occurring in US hospitals. The first key event in the pathogenesis of these infections is the attachment of microorganisms to the plastic material of the catheter. This is often followed by the creation of a slimy matrix by the pathogen. The resulting biofilm is characterized by increased resistance, reduced cultivability, cooperative strategies and high diversity of microorganisms.
Any nosocomial infection can develop into a severe systemic infection, sepsis as the most severe form or severe systemic complication. As part of the immune defense, an inflammatory reaction (SIRS = systemic inflammatory response or systemic inflammatory response syndrome ) is set in motion with the aim of destroying the invaders ( bacteria , fungi , viruses and parasites ). This leads to an excessive release of inflammatory cytokines (mediator explosion), the effects of which can seriously damage the macroorganism. Despite intensive medical treatment, more than half of the patients die of nosocomial sepsis, especially if septic shock has developed with subsequent multiple organ failure . Nosocomial sepsis is often referred to as the crux of modern intensive care medicine .
Causes of infection and prevention
According to the Infection Protection Act , all health care facilities in Germany, in particular
- Facilities for outpatient surgery,
- Preventive or rehabilitation facilities in which medical care comparable to hospitals is provided,
- Dialysis facilities,
- Day clinics,
- Maternity services,
- Treatment or supply facilities that are comparable to one of the facilities mentioned in numbers 1 to 6,
- Doctors' offices, dental offices and
- Practices of other medical health professions
ensure that the measures required by the state of the art of medical science are taken to prevent nosocomial infections and to prevent the spread of pathogens, especially those with resistance. According to the text of the law, compliance with the state of medical science in this area is assumed if the published recommendations of the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute and the Commission Anti-Infectives, Resistance and Therapy at the Robert Koch Institute have been observed. A review of these obligations can be carried out by the health authorities ( IfSG, Paragraph 6).
Final chain and causality
As a rule, it can be assumed that there is a final chain between contact persons, especially nursing staff and visitors, contact with these persons and the infections of the patients. In many cases, however, it is not possible to prove causality. This shows: Even with technical measures, natural weaknesses in medical care, which always require direct contact with the patient, cannot be remedied. In this respect, the medical service remains a service with the obligation of effort, but without guarantee of success.
An improvement in the outcome for patients is therefore more likely to be achieved through systematic prevention in routine clinical practice, for example by observing elementary hand disinfection, by reducing the frequency of people entering and leaving and through qualified periodic cleaning of the rooms including the ventilation systems with subsequent sterilization before re-use as usual in the operating theater. The corresponding effort for any prevention is always lower than the costs of eliminating a pathogen infestation in the individual case and the financially effective loss of reputation for the respective clinic.
Ventilation-associated pneumonia is the most common type of nosocomial infection in intensive care units, both in Germany and internationally.
In Germany, current data from the Hospital Infection Surveillance System (KISS) show that the pneumonia rate in intensive care units is currently around nine to eleven episodes per 1000 days of ventilation. Extrapolated for Germany, 30,000 patients in intensive care units suffer from pneumonia every year. This not only results in significant additional costs due to the extended intensive stay, but also significantly limits the patient's personal prognosis.
For a long time it was controversial how the pathogens of ventilation pneumonia get into the lungs. Today we know that it is either pathogens from the environment of the intensive care unit, which are transported into the oral cavity of the patient due to poor hygiene ( exogenous route of infection ), or pathogens from the patient's own stomach, which are caused by "sloshing up" of stomach contents reach the oral cavity ( endogenous route of infection ).
The importance of the endogenous route of infection has declined significantly in recent years, since the upper body position at an angle of around 30–45 ° to the base became established for ventilated patients. The pathogens enter the trachea and deeper airways from the oral cavity through microaspiration . The further course of the development of ventilation-associated pneumonia initially leads to tracheobronchial colonization via the penetration of the pathogen into the bronchial tree. It is only under certain conditions, such as a weakening of the patient's immune system, that the alveolocapillary membrane (alveolar barrier) is finally broken and tissue inflammation develops.
Preventive measures to prevent microbial colonization of the gastrointestinal tract and the respiratory tract
- Meticulous attention to hand hygiene before and after every manipulation of the ventilation system as well as before and after suction
- Do not change ventilation hoses and closed suction systems routinely, but only in the event of malfunctions or visible contamination
- Do not use in -line ventilation filters ( Heat Moisture Exchanger , HME) on patients with excessive secretion production or haemoptysis
- Change the HME filter every 24 hours or if it is visibly dirty
- Avoid exogenous contamination of the interior of the ventilation tubes when emptying the water traps
Preventive measures to prevent aspiration of contaminated secretions
- Check and maintain tube cuff pressure regularly
- Semi-upright position of the patient at an angle of about 30 °, even during transport
- Empty water traps before moving patient
- To avoid overstretching the stomach, always check the gastric filling condition by aspiration before every intake of food or liquid
- Remove the nasogastric tube as soon as possible
Preventive measures during suction
- With the suction system closed: Use clean disposable gloves. With open suction: sterile gloves
- Store the suction catheter in a clean and dry environment
- Do not place the suction catheter on the ventilator
- Oral suction catheters should not be stored in paper foil packaging, but in clean, resealable packaging
- Vacuum only when really needed. Too frequent suction can cause pathogens to get into the airways
Other essential points
- Avoid nasal intubation
- Fasten the ventilation tube securely so that it cannot be accidentally pulled by the patient or slipped out
- Avoid double or triple antibiotic therapy
- The drug-based stress ulcer prophylaxis is controversial, a final result is still pending.
- Rinse the oropharynx daily with chlorhexidine solution (only for cardiac surgery patients)
- Carry out vaccinations ( influenza , pneumococci , hemophilus type b )
Catheter-associated urinary tract infections
Urinary tract infections rank first in many statistics on the incidence of nosocomial infections. In the United States, around three percent of all hospitalized patients, or 15 percent of all patients with a urinary catheter, develop a urinary tract infection. In ten to 15 percent of patients with urinary tract infections, secondary complications such as sepsis or septic shock occur. Whether a urinary tract infection also increases the mortality of hospital patients is debatable. For the United States, it has been projected that around 50,000 hospital deaths are due to urinary tract infections.
The following recommendations for the monitoring, prevention, diagnosis and treatment of urinary tract infections are well established according to methods of evidence-based medicine:
- A registration (surveillance) of asymptomatic bacteriuria is not necessary for patients in long-term care facilities.
- Standardized diagnostic criteria (CDC definition) should be used to record symptomatic urinary tract infections.
- The frequency of nosocomial urinary tract infections should be given as the infection rate / 1000 patient days or / 1000 urinary catheter days.
- Condom catheters should be preferred to transurethral urinary catheters in men if there is justified indication.
- Whenever possible, single-use intermittent catheterization should be preferred to long-term urine drainage.
- No statement about the routine change of long-term urinary catheters and the optimal time for a change.
- Urinary tract infections should always be treated with antibiotics. Local disinfectants are obsolete.
- The duration of therapy should be a maximum of ten to 14 days; shorter cycles can be recommended for women with mild clinical symptoms.
- In the case of recurrent symptomatic urinary tract infection, continuous therapy for 6 weeks can be considered.
- It is not necessary to take a second culture to document the success of the therapy after the antibiotic therapy has ended.
Post-operative wound infections
Wound infections after surgery are among the most common nosocomial infections; in a survey carried out in Germany in 2011, they accounted for 24.3% of nosocomial infections and were therefore ahead of urinary tract infections (23.2%) and lower respiratory infections (21.7%) ).
The patient's own bacterial flora is the most common source of infection. The infection usually takes place during the procedure; this applies to both endogenous (originating from the patient's own bacterial flora) and exogenous (e.g. originating from the surgical staff). The most common pathogens are bacteria of the type Staphylococcus aureus (proportion in the above-mentioned study from 2011 19.8%); coagulase-negative staphylococci , enterobacteria , enterococci and gram-negative (obligate) anaerobes also play a role. Fungi (especially of the Candida albicans species ) also occur as triggers.
There are numerous risk factors for postoperative wound infections, which are initially divided into endogenous (patient's own) and exogenous (outside the patient). The established endogenous risk factors include B. old age, immune deficiency, serious concomitant diseases, infections in other parts of the body and colonization of the nose with Staphylococcus aureus . The secured exogenous risk factors include, among other things, the type of hair removal before the operation, the type of surgical intervention (contamination classes clean, clean-contaminated, contaminated or dirty), dispensing with antibiotic prophylaxis in high-risk interventions and the duration of the Surgery. The frequency of post-operative wound infections differs in different operative subjects. B. low in ophthalmology and dentistry and higher in abdominal and cardiac surgery .
Structural and technical measures are used for prevention. This means z. B. the structural separation of the operating departments from the rest of the hospital area (including through locks) and ventilation systems . The effectiveness of this measure is limited, however, since, as mentioned above, in industrialized countries such as Germany, the source of nosocomial wound infections is usually the patient's bacterial flora and not the environment.
Furthermore, expert recommendations for the prevention of postoperative wound infections provide measures such as B. Refraining from hair removal before the operation (if possible), carrying out antibiotic prophylaxis (only with appropriate risk intervention, then usually once at the beginning of the operation) and correct skin disinfection ( antiseptics ) before the operation.
Catheter-associated infections from central venous catheters
In the United States, more than 5 million central venous catheters are placed annually. On the other hand, although their use in parenteral nutrition, measurement of central venous pressure and the delivery of drugs is essential in many cases, they are one of the most common sources of complications and nosocomial infections. Depending on the length of stay and the type of catheter, local infection or sepsis occurs in around 5–26% of catheters. Each year 250,000 to 500,000 bacteremia associated with vascular catheters occur in the United States alone. Two thirds of all outbreaks of nosocomial bacteremia or candidemia are caused by a vascular catheter, but the majority of endemic nosocomial bacteremia are also catheter-associated. Studies have shown that the presence of a venous catheter is associated with an increased incidence of nosocomial bacteremia.
The presence of a catheter is also the single most important risk factor for developing nosocomial candidemia or bacteremia due to Staphylococcus aureus . Prospective studies have also shown that catheter-associated sepsis leads to a considerable extension of the hospital stay, even if the number and severity of the underlying diseases are taken into account and excluded as a further influencing factor.
The average increase in length of stay compared to control patients of the same age without sepsis is ten to 20 days. This results in increased hospital costs of 4,000 to a maximum of 56,000 US $ per sepsis episode. Of particularly serious importance is the fact that patients with catheter-associated sepsis or bacteremia have an increased mortality rate. Compared to control patients of the same age with a similarly serious underlying disease, the additional mortality rate is 12–35%.
Another influencing factor that determines lethality is the causative agent: The detection of Staphylococcus aureus is associated with a catheter-associated sepsis mortality of 22 to 43%, the detection of Candida spp. in some studies even with a mortality of up to 67%. Catheter-associated septicemia with less pathogenic agents such as coagulase-negative staphylococci and enterococci , on the other hand, were only associated with increased mortality in some studies, but not always.
Before every catheter insertion, the first step is to decide which catheter material or which catheter type should be used. In addition to the conventional catheters made of polyurethane , antimicrobial coated catheters have been available on the US market as well as in Germany for several years. In Germany, only catheters that are coated on the outside with chlorhexidine and silver sulfadiazine , as well as pure silver catheters, have been commercially available. In the USA, there are also catheters impregnated with antibiotics ( rifampicin and minocycline ). The background to the development of these catheters was the fact that the majority of catheter-associated infections are caused by an external colonization of the catheter tip. These have also been available on the German market since 2006.
Randomized clinical studies have shown that catheters coated on the outside with chlorhexidine and silver sulfadiazine are able to reduce the infection rate from 7.6 septicemia per 1000 catheter days (4.6% of catheters) to 1.6 septicemia per 1000 catheter days (1% of Catheter).
The following measures of infection prevention should be observed while infusion therapy is ongoing:
- Hygienic hand disinfection before every manipulation of the catheter
- Disinfect the catheter cone and three-way stopcocks before disconnecting them
- Infusion system change every 72 hours
- Dressing change while observing aseptic precautions, either with gauze or as a transparent dressing
- No routine replacement of the catheter after a certain length of time
- Do not use ointments containing antibiotics at the insertion site.
The diagnosis of a catheter-associated infection is based on clinical signs (fever, reddening or inflammation at the puncture site, improvement after removal of the catheter), which are, however, unreliable and microbiological examinations (determination of the bacterial count at the catheter tip, blood cultures).
Most of the multi-resistant pathogens can be killed off with the simplest of measures such as antibacterial copper . Here, all potential sources of germs such as door handles, bed hangers, light switches, toilet flushers, taps, dishes, furniture and window handles, mouthpieces etc. are replaced by copper parts within the hospital.
To this day, however, hospitals shy away from the costs and are often still dependent on local custom-made products.
In this context, the US environmental protection agency EPA supports the certification of products with the Antimicrobial Copper (Cu +) mark with 99.9% effectiveness against MRSA, Staphylococcus aureus , Klebsiella aerogenes (formerly: Enterobacter aerogenes ), Pseudomonas aeruginosa , E. coli O157: H7 and vancomycin-resistant Enterococcus faecalis .
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