Infection Prevention – A Global Topic - Infection prevention operating room

Infection Prevention – A Global Topic

Battling hospital germs depends on multiple factors, ranging from staff compliance to national data collection. Reliable data is the foundation of a successful strategy – but what makes surveillance successful?

Fighting infection - A brief overview

Nosocomial infections have always been a dominant topic in hospitals worldwide. Especially affected are older patients and those with multi-morbidities as well as premature babies with underdeveloped immune systems, who are especially vulnerable. To fight the problem, in the mid-1990s many European countries began to develop national surveillance systems. This was sparked by cross-sectional studies that measured the prevalence of nosocomial infections in the various states. These studies had already made hospital employees familiar with infection documentation. Since these initial investigations, more than ten European countries have established their own surveillance systems for postoperative wound infections.

In nearly all participating countries, the respective national surveillance systems are free of charge. The Belgian National Surveillance of Infections in Hospitals (NSIH) even pays participating institutions compensation for their involvement.

The US-American National Nosocomial Infections Surveillance System (NNIS), today known as the NHSN (National Healthcare Safety Network). is sponsored by the Centers for Disease Control (CDC) and has been collecting national data for decades. The data are voluntarily reported by participating hospitals all over the country that monitor specific, high-risk groups. They collect data including demographic characteristics, infections and outcome. As a result, the system estimates trends and risk factors to support the development and evaluation of infection prevention strategies.

Germany: Special Element for NICUs

In Germany, the National Reference Center for Surveillance of Nosocomial Infections (NRZ) in Berlin established the Krankenhaus-Infektions-Surveillance-System (KISS) in 1996. In this nationwide network, hospitals can gather their infection data in accordance with standardized methods. Currently, approximately 1,400 of nearly 2,000 hospitals in Germany are taking part in at least one module of the KISS system. Each hospital can then individually decide which departments will participate. Furthermore, data can be collected for procedures that are performed on a specific frequency2.

Following the initial limitation of data collection to intensive care units and surgical departments, the system has now been extended to include five additional modules. With these offerings KISS has one of the most multi-faceted data collection models in the world. The NEO-KISS element used for collecting epidemiological infection data from neonatal intensive care units is particularly noteworthy. All neonatal hospitals in Germany are connected to this system2,4.

The largest difference between the German NEO-KISS and the American NHSN is in the definition of neonates. The NHSN classifies infants up to one year old as a neonate. "But there are big differences in the treatment of one-year-olds and infants who have not even attained a normal birth weight," declares Professor Petra Gastmeier, head of the National Reference Center and co-founder of the German KISS2,5.

France: Monitoring of hand disinfection, postoperative wound infections and ICUs

Another German invention, the HAND-KISS, is also being used in France. Starting in 2007, the use of hand disinfectants has been precisely documented in France. A grading system is used, ranging from A (very good) to E (very bad). Both countries reported success and since the introduction of data collection, the use of hand disinfectants has increased significantly2,4. In addition, France's surveillance system Réseau d’alerte d’investigation et de surveillance des infections nosocomiales (RAISIN) focuses on postoperative wound infection and infection documentation in intensive care units. There are five surveillance centers located throughout France which collect data for the central public health service. Participation in the French system is voluntary, although fatalities caused by nosocomial infections must be reported as well as very rare or unusual infectious diseases.

Netherlands: Low level of resistant germs

The Netherlands are generally celebrated as the country of infection prevention, although the figures for postoperative wound infections are not better than the European average, the figures for resistant germs are at a low level which is certainly exemplary. A more favorable allocation of staff plus ICUs that are almost exclusively equipped with single rooms are definitely contributing factors to these good results2.

The Dutch surveillance system PREventie van ZIEkenhuisinfecties door Surveillance (PREZIES) was established in 1996 and collects data on device-associated pneumonia, blood poisoning cases and postoperative wound infections. The Dutch surveillance System is coordinated by the national Quality Assurance Institute and the public health service. Participation in the system is voluntary and kept completely confidential. A 2004 court judgement protects hospitals against competitive disadvantages that might result from such reporting, and it explicitly releases them from any obligation to publish their infection data.

Sweden: Individual antibiotic consumption surveillance

A Swedish system specializes in patient-based antibiotic consumption surveillance (ACS). With this system, the administered antibiotics for each patient are recorded on a daily basis. Other European countries also have a form of antibiotic consumption surveillance, but in those cases the figures are based solely on the cumulative data of the supplying hospital pharmacies. Thus, they only collect data for hospital-based use of antibiotics. A patient-based ACS system provides a better base for antibiotic administration and can also show connections to emerging resistances. Hospital participation in this system is voluntary1,2,6.

Austria: Working with indicator operations

The Austrian Nosocomial Infections Surveillance System (ANISS) also operates on a voluntary basis and has been in place since 2004. A national reference center coordinates the data collection. The system makes widespread use of specific indicator operations. In 2013, for example, data from approximately 5,700 hip implant operations, 4,200 cesarean sections and nearly 500 bypass operations were documented. Additional indicator procedures in Austria include various operations on the large intestine, mastectomies, implantations of knee prostheses and cholecystectomies1,7,8.

Great Britain: Obligatory surveillance

Participation in the surveillance system is partly compulsory in Great Britain. The Nosocomial Infection National Surveillance Service (NINSS) was established in 1996 and collects epidemiological data about postoperative wound infections and blood poisoning. Since 2001, it is required that hospitals in the United Kingdom report certain infections to the Health Protection Agency (e.g. orthopedic wound infections or sepsis caused by Staphylokokkus aureus). The Agency uses these data for further documentation and publication1,6.

Poland: Close to the American roots

The best known Eastern European surveillance system has been in existence for 14 years in Poland. This system makes use of NHSN methods from the United States and is also extensively supported by the Americans. For this reason, the same elements – intensive medicine associated infections and postoperative infectious diseases – are documented by the Polish Society for Hospital Infections at the University of Krakow.

Europe looks towards cooperation

The establishment of the European Centre for Disease Prevention and Control (ECDC) in 2005 led to the harmonization of hygiene surveillance among European countries. It was urgently necessary because nosocomial infections remain widespread. On the basis of data collected throughout Europe, the Stockholm-based ECDC shows around 3.2 million hospital infections that occur annually2,6,9.
The largest European countries, Great Britain, France and Germany, are ranked in the lower part of the middle range in the ranking “Prevalence of HAIs and antimicrobial use“. The fact that countries such as Romania and Latvia have better figures to present may seem confusing at first. "One reason for this," explains the German expert Gastmeier, "is that they have an inferior medical infrastructure particularly in the area of microbiological diagnostics. Many nosocomial infections are simply not identified as such and this gives these countries a better ranking2,9.

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1 "Surveillance von nosokomialen Infektionen in Europa" von Prof. Gastmeier Link

2 Interview with Prof. Gastmeier on 8 October 2015

3 Website of the National Healthcare Safety Network (NHSN) Link

4 Nationales Refererenzzentrum für Surveillance von nosokomialen Infektionen/Robert-Koch-Institut Link

5 Robert-Koch-Stiftung, "Robert Koch Award for Hospital Hygiene and Infection Prevention 2015", 07.09.2015 (last accessed on 17 October 2015) Link

6 Correspondence of the author with the European Center for Disease Prevention and Control (ECDC)

7 Veröffentlichung der Universitätsklinik für Krankenhaushygiene und Infektionskontrolle der Medizinischen Universität Wien Link

8 ANISS-Jahresreport 2013 (Referenzdaten zu Indikator-Operationen) Link

9 Gesundheitsstadt Berlin – das Hauptstadtnetzwerk Link

10 Surveillance-Report des ECDC Link

11 WHO Global Report AMR 2014 Link

12 WHO Worldwide country situation analysis (April 2015) Link