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Background article – MEDICA 2017 No.1

Bring yourself up-to-date in infection prevention - the first MEDICA ACADEMY offers the latest expertise and practical tips on implementation for hospital and practice scenarios.

Imaging, hygiene, surgical procedures, preventing overcharging for care, insufficient or unnecessary care or procedures in GP practices and medical innovations - these are just a few of the topics that MEDICA ACADEMY will focus on. This interdisciplinary further education event will have its premiere as part of the MEDICA program this year. It will offer doctors from all specialties the opportunity for further training during its four-day run – from November 13 – 16, 2017, at the Congress Center Düsseldorf (CCD South). MEDICA is the world’s leading medical trade fair, held annually at the fairgrounds in Düsseldorf, Germany.

The global spread of infection and increase in resistances, particularly multiple resistances, requires that the cooperation between outpatient and inpatient sectors must be improved, along with cooperation between care takers and doctors from all specialties to give an example. The aim is to translate current knowledge from prevention strategies into adequate hygiene measures and guideline-compliant therapies and put them into practice.

“Update your infection prevention measures” is a whole day event which is simultaneously interpreted into English. This event focuses on four central topics in infectiology and hygiene, with each topic being presented by two expert speakers in a concise, practice-oriented manner. On November 16, 2017, from 9:00 am to 4:40 pm, the program centers around the main focus topics of practical hygiene, frequent outpatient and nosocomial infections, infection prevention and antibiotic stewardship in practices and clinics as well as the use of psychological communication strategies to implement infection prevention. An application for CME certification from the North Rhine Medical Association has been submitted.

The seminar, which was developed in cooperation with LADR, the Laboratory Group of Dr. Kramer & co. GbR, is led by Dr Wolfgang Hell MD, from Geesthacht, Prof. Dr Mariam Klouche MD, from Bremen and PD Dr Roland Schulze-Röbbecke MD, from Aachen. These three leaders’ main priority is to promote targeted discussion within and across specialties with expert speakers and the audience so that experiences and practical questions from the participants are actively included in this event. “We intend to use practical, real-life examples, presented by experienced Infectiologists, doctors who specialize in hospital hygiene and hygiene experts and integrate modern communication psychology techniques to share current knowledge and show the tools that allow us to implement this in practice”, said Prof. Dr Mariam Klouche MD. “The aim is to improve infection prevention and the prevention of infectious disease in outpatient and inpatient care,” explained the Consultant for Clinical Pathology, Microbiology, Infectious Disease Epidemiology and Transfusion Medicine.

Basic Hygiene - hugely important for all care actors
Heike Briesch, Chairwoman of the VHD (German Association for Hygiene Specialists) and member of KRINKO (the German Commission for Hospital Hygiene and Infection Prevention) will introduce the first module by giving an update on basic hygiene that prevents transmissible diseases from spreading and serves to protect patients and residents of care facilities as well as their workers and visitors. Briesch points out that hygiene and infection prevention are essential in ensuring patient safety. “Nosocomial infections don’t just affect patients that come to stay in a hospital for treatment. They also affect people that receive inpatient and outpatient care. This means that implementing hygiene measures is of the utmost importance for each patient or resident, regardless of whether we know their infection status or not, and basic hygiene plays an essential role here.”

Hand disinfection - a must for every situation
Hand disinfection is one of the most effective methods for preventing nosocomial infections and the transmission of multiple resistant pathogens, and we have known this for a long time. On the basis of the “Clean Care is Safer Care” campaign from the WHO, significant measures to improve hand disinfection have been implemented in inpatient and outpatient medical facilities within the scope of the Clean Hands Campaign. “We still need to improve compliance with hand disinfection standards” stated Dr Tobias Kramer MD, MSc (Infectious Diseases) and Antibiotic Stewardship Expert (for the German Association for Infectiology, the DGI). As a science expert working on the Clean Hands Campaign at the Charité University Hospital in Berlin, Kramer knows that these measures need to be supported by stakeholders at all levels if successful long-term implementation is to be ensured. “The influence and role-model potential that management-level employees can have, in particular, should not be underestimated. This potential should be used to its fullest extent”, stated Kramer. Which measures should implement to boost compliance further? Kramer thinks that we should generally be looking at tried and tested measures, such as those recommended in the Clean Hands Campaign. These include sharing knowledge, reports on observations on compliance and use of hand disinfection agents at all stations, memory aids and optimized dispenser location and fitting. Furthermore, there is growing evidence that having the station’s employees make their own commitment and having them establish targets to be attained can lead to a sustained improvement in behavior in terms of compliance with hand disinfection standards.

Kramer also believes that patients and their relatives and friends could also help to improve medical professionals’ compliance in hand disinfection by informing them when and where hand disinfection is required in advance and then telling them to request this from staff. “Many patients already check the medication that they are given by hospital staff, and we want to encourage this same activity for hand disinfection. Both patients and staff are unsure of procedures in this respect”, said Kramer.

Urinary Tract Infections - prevent them with new approaches
In addition to traditional sets of hospital hygiene measures, such as hygienic hand disinfection that complies with indications and aseptic techniques, other aspects also play a role in preventing infectious disease. These aspects are not necessarily new, but they are fundamentally different from those named above. This is true for diagnosing a urinary tract infection, for example. The UTI shows up because it matches a certain clinical picture, or in many cases as a result of a microbiological diagnosis. “Both of these involve disturbance variables that can lead to a false diagnosis being given which in turn leads to non-indicated antibiotic exposure”, warned Dr Thomas Schwanz MD, Head of Department for the Institute for Medical Microbiology and Hygiene of the University of Mainz. In his speech, Schwanz has thus decided to point out these various limitations and the possibility that diagnoses which have also been described in the latest literature, may be inaccurately interpreted. He hopes that discussing these will lead to the development of optimized strategies for preventing UTIs in the future.

Clostridium difficile – a global challenge
Prof. Dr Mariam Klouche MD reports on the latest on Clostridium difficile infections and their huge relevance to medical practice. Screening for Clostridium difficile is no longer only being done for patients that have been treated in hospital multiple times. It is increasingly also being screened for in outpatient care. “Clostridium difficile is a global challenge. The pathogen can appear as a colonization of the colon and can lead to serious, or potentially fatal infections as a result of antibiotic therapy or other predisposing factors” explained the Medical Director of LADR GmbH MVZ [Medical Care Centre] Bremen. Recently, we were able to show that the incidence of C. difficile infections could be drastically reduced by infection stewardship programs and, more specifically, through restricting certain antibiotics. In her presentation, she describes the special features of C. difficile, the new risk groups that have become known, most recently in outpatient units and the current therapy options. Potential prevention measures will be presented and discussed with the participants.

Post-Operative Wound Infections - you can’t prevent 100% of them
After the closing round of questions that concludes each module, presented by the leaders to each speaker and the public, the third section focuses on the management of antibiotics. PD Dr Roland Schulze-Röbbecke, Consultant for Hygiene and Medical Microbiology, addresses the issue of Post-Operative Wound Infection (POWI). The approach of reducing POWI by reducing the bacteria that can enter the operating wound from environment has mostly been exhausted in the industrialized countries. “The general belief that POWI occurs because of dirty surgical instruments, air conditioners that don’t work or surgery rooms not being cleaned properly is actually false. In rich industrialized countries at least, this doesn’t play any role at all in practice. Most incidences of POWI are rather caused by bacteria that the patient brings into operating room themselves, and these can only be partly eliminated”, explained Schulze-Röbbecke. Current evidence-based recommendations on how to reduce POWI rates focus on the bacteria on the patient’s own body which inevitably enter the operating wound in each operation. The risk of POWI caused by this type of bacteria, endogenous bacteria, can be reduced by sufficient peri-operative antimicrobial prophylaxis for many operations, for example.

Further evidence-based preventive measures focus on maintaining normal levels of body temperature and blood sugars, as well as on achieving optimal blood flow ratios and oxygen supply to the operated tissue so that the patient’s physiological defence mechanisms are impaired as little as possible. Pre-operative antiseptic skin preparation (washing) with products which contain alcohol, an agent which works quickly, and Chlorhexidine, as a residual active agent, is also relevant. The recording and evaluation (monitoring) of POWI incidence is very important as reducing POWI rates is impossible without this data being present. “Complete elimination of POWI is impossible, at our current level of knowledge”, said Schulze-Röbbecke, “this is because many of the significant risk factors cannot be influenced, for example severe primary disease, old age, obesity and nicotine abuse”.

Antibiotic Stewardship - decreases the rate of pathogens’ resistance to antibiotics in clinics
Anne Eva Lauprecht, a hospital doctor specializing in hygiene at the Essen-Mitte clinic group, shows that the “Clean and Isolate” strategy alone is not enough to bring about a reduction in hospital infections. On the contrary, this costs hospitals a lot of money although there isn’t any scientific evidence in favor of many of these measures. In addition, the individual outcomes for isolated patients are poorer than those for patients treated without these hygiene measures. This is because isolated patients have less contact with care staff and doctors. The national German Prevalence Survey for 2016 showed that the prevalence of nosocomial infections in hospitals was 4.6%, just slightly lower than it was five years ago when it was 5.1%. The primary objective must be to improve infection prevention significantly and to implement strategies for a reasonable level of antibiotic therapy in line with Antibiotic Stewardship (ABS) in hospitals as well as in the outpatient sector. “Using ABS, we can do more than simply significantly reduce the local rate of pathogens’ resistance to antibiotics in local hospitals within a short time” summed up Lauprecht, “moreover, studies overwhelmingly show that Clostridium difficile infections can be drastically reduced by ABS and by restricting prescription of certain groups of antibiotics”. The ABS expert also remarked that a consistently high rate of resistance to many antibiotics and the constant rise in 3MRGN E-coli in hospitals are generally problems that are caused in-house. This is crucial, particularly for calculated antibiotic therapy. A low rate of pathogen resistance to antibiotics results in safer medical treatment and thus ensures a better quality of care, continued Lauprecht.

In terms of concrete implementation, she said that this meant that, “ABS measures need to be set up in clinics so that they are used in all aspects of the daily antibiotic prescribing process. To do this, knowledge on antibiotics and antimicrobial therapies must be improved for service providers. In-house guidelines on antibiotics and information on local resistance development are just first steps in this measure. Individual ABS measures need to be designed so that they are completely understandable and reproducible for the service providers, and above all so that they can be implemented easily. Data on the amounts of antibiotic used and how frequently they are used enable service providers to evaluate and adjust their own prescribing patterns”, said Lauprecht.

We’ve found the problem - we just need to remedy it
“We know that we’ve got a way to go in hospital hygiene. The issue is implementing measures”, says Dr Wolfgang Hell MD, Head of the Specialist Hygiene Service at LADR Geesthacht, in the final module. Organization is a problem in infection prevention - who does what? Hell attempts to answer this question in his speech. For him, it’s also important to scrutinize the difference between the actual conditions and the objectives with hygiene specialists and to look at this within the various contexts that different facilities provide, from hospitals to rehabilitation clinics, from outpatient clinics to doctors’ practices.

Implementing hygiene measures without coming up against communicative resistance
The day will come to a close with an awareness session on the communication situations with a view to providing strategic and sustainable implementation of important infection prevention measures. Birgit Jacobowsky, Social Psychologist and Coach, will play out different scenarios that we see in hospitals and practices every day and will demonstrate different types of communication and the effect and significance they have. Communicating about implementing hygiene measures without meeting with resistance is the goal that all participants in this workshop will try to achieve!

For further information about the MEDICA ACADEMY program:

Author: Nina Passoth, life sciences communications (Berlin, Germany)

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