Prof. Dr. med. Axel Kramer

Preventing Infection

For effective infection prevention, patients and medical staff need to work together

More than 500 papers authored, more than 300 book contributions and currently 54 patents – these figures represent the research spirit of Prof Axel Kramer. Managing Director of the University of Greifswald Institute for Hygiene and Environmental Medicine, this specialist in hygiene and environmental medicine has been campaigning for years to reduce infection rates following surgery. But how can this be achieved? Professor Kramer has practical ideas.

Prof Kramer, you recently took part in an expert panel discussion on the subject of surgical site infections. How has the number of cases in recent years developed and what are possible reasons for this development?

Prof Axel Kramer: In recent years, the prevalence of postoperative wound infections, or surgical site infections (SSI), has increased. Besides infections of the lower respiratory tract, SSI are the most common form of nosocomial infections, followed by urinary tract infections. In my opinion, however, this is not an absolute increase, but a relative increase. For example, the number of urinary tract infections has decreased because they are easier to prevent. There are also less factors that lead to cases of respiratory infections. That is one reason. The other reason is that today a higher number of complicated procedures are performed compared to 1995, when the last prevalence survey was carried out. And some of these procedures correlate with a higher risk of infection. In addition, we increasingly have older patients whose immune systems may be weaker. As you can see, these statistics depend on many factors.

Various organisations have published recommendations for the prevention of SSI. The CDC in the US has produced its own, the WHO and also the German Commission for Hospital Hygiene and Infection Prevention (KRINKO). What do you think of the international situation in terms of guidelines and recommendations?

Kramer: In principle, you can say that the KRINKO recommendation, the most recent of 2018, does not contradict the CDC or WHO recommendations, of course. But their priorities are sometimes weighted differently. I have compared the CDC guidelines with the KRINKO guidelines to see if they contain different perceptions regarding the evidence, not the interventions. In fact, there are differences. For example, with regard to normothermia. This is rated 1A in the CDC guideline, which is the highest evidence assessment, while the KRINKO guidelines only point out that it is very important.

The different evidence assessment is one reason practitioners find it difficult to consistently implement guidelines and recommendations to prevent SSI in practice. What is your strategy to establish specific methods and support users?

Kramer: A very effective strategy is to bundle the most important measures and implement them in a controlled manner. Measures with the highest evidence in the preoperative or intraoperative phase of SSI prevention are defined and bundled. These “Surgical care bundles” vary from specialty to specialty. Nevertheless, a checklist should ideally be drawn up for all these bundles. Like a pilot who goes through his checklist in the cockpit before taking off, the surgeon or the surgical team must also ask themselves before the operation: Are all defined measures ready and in place?

So far, the main focus has been on research and practitioners. To what extent does it make sense to involve patients themselves in the discussion of SSI prevention?

Kramer: I’d say very important! But unfortunately, at least in Germany, there is no education, for example at school, on infection prevention. We carried out a representative study with over 500 patients. Of these, 93 % of them want to be informed and a large percentage also wants to be actively involved. The patients themselves are, of course, the best early-warning system – for example, when infections begin to develop in their wounds. However, it is much more important that the patient is actively involved in SSI prevention at every stage. At the University Medicine Greifswald, for example, we “translated” the five moments of hand disinfection of the WHO into the five moments of hand disinfection for patients – and these posters now hang in every room. In this way, patients are made aware of the transmission of pathogens and the relevance of hand disinfection right from the start. The patients really appreciate this. In connection with patients’ voluntary evaluation of how well employees perform hand disinfection, disinfectant use was increased by 40 % – without a special educational measure of the team.

In the postoperative phase, wound care is extremely important. In collaboration with other experts, you have drafted a consensus paper on wound antiseptics. Why do we need standards in this area? And what do you mean by the term “antiseptic stewardship”?

Kramer: In wound antiseptics, the evidence is much more difficult than in the prevention of postoperative wound infections because there are hardly any studies that compare active substance A with active substance B. Usually A or B is only compared with a placebo. However, after comprehensive evaluation of results from in-vitro studies and clinical trials with regard to both tolerability and antiseptic efficacy, it was possible to combine them into a plausible synopsis. The results are practical recommendations based on interdisciplinary and interprofessional expert consensus. Basically, in the end there are only a few adequate active substances.

In principle, antibiotics must be reserved for systemic use, because of the risk of developing resistance. Instead, the possibilities of maximum use of antiseptics must be included when considering “antiseptic stewardship”. For antiseptic agents with a global microbiocidal mechanism of activity, such as hypochlorite, polyhexanide and octenidine, there is no known or assumed development of resistance. If a remanent antiseptic effect is needed, especially on sensitive wounds, polyhexanide is the active ingredient of choice. If short-term antiseptic cleansing is the main focus, hypochlorite is suitable, or is the only alternative where there is possible exposure of neurogenic structures and peritoneum.

In antiseptic wound dressings*, polyhexanide is the active ingredient of choice for chronic wounds. In general, an important strategy is always to check whether antibiotics are really necessary, and where you can achieve the same or even better results with antiseptics. This is what I mean by the term “antiseptic stewardship”. One example is wound irrigation, which in some cases is still done with antibiotics. Another example is the decolonisation of the nose in cases of MRSA, which is increasingly carried out with antiseptics and no longer with local antibiotics. Nevertheless, studies must be conducted to put these new ideas of “antiseptic stewardship” into practice. The time is more than ripe. But it can only happen in cooperation with the various clinical disciplines.

FURTHER INFORMATION

  1. Abschlussbericht Deutsche nationale Punkt-Prävalenzerhebung zu nosokomialen Infektionen und Antibiotika-Anwendung 2016, German National Reference Center for Surveillance of Nosocomial Infections

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