Global Perspectives
Five years working with the German nosocomial infection surveillance system (Krankenhaus Infektions Surveillance System)*,**

https://doi.org/10.1067/mic.2003.66Get rights and content

Abstract

A national surveillance system for nosocomial infections, Krankenhaus Infektions Surveillance System (KISS), was established in Germany as a joint effort by the National Reference Center for Hospital Epidemiology (currently called the National Reference Center for the Surveillance of Nosocomial Infections) and the Robert Koch Institute. To begin with a well-accepted and proven method, surveillance protocols were developed on the basis of the National Nosocomial Infections Surveillance system. Hospitals from all parts of Germany took part voluntarily. There were 4 surveillance components: intensive care departments (227), patients undergoing operation (231 departments), neonatal intensive care departments (23 hospitals), and patients undergoing bone marrow and peripheral blood stem cell transplants (10 hospitals). Five years after the introduction of KISS many hospitals have introduced continuous surveillance activities whereby the various definitions and methods have attained wide acceptance. This has lead to much better understanding and cooperation between clinicians and infection control personnel in preventing nosocomial infections. KISS is considered the national reference database, but continuous evaluation and development of KISS are necessary to react adequately. (Am J Infect Control 2003;31:316-21.)

Section snippets

Initiation

To begin with an accepted and well-established method, a surveillance protocol was developed on the basis of the National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC) in 1996.2, 3 Two surveillance components were chosen—the intensive care department (ICU) and patients undergoing operation—and established with a set of 20 selected operative procedures. Infection control personnel from the first 20 hospitals were invited to participate.

Component for icu

Like the NNIS, we decided on a unit-based surveillance system in ICUs to save time for the recording of device-days. In the unit-based system all patients present in the ICU at midnight are included. This means that patients with a stay of less than 48 hours, ie, with little chance of already having been nosocomially infected, are not excluded. Only pneumonia, primary bloodstream infections, and urinary-tract infections have to be reported to KISS. Some ICUs collect information on further types

Component for patients undergoing operation

Like the NNIS, we decided to concentrate on groups of indicator operations. We used the International Classification of Diseases, Ninth Revision, Clinical Modification codes6 of the NNIS manual and converted the information to the current German operation codes. Hospitals select the procedures they wish to follow. Some hospitals perform surveillance for only one procedure, whereas others collect information from a number of indicator operations.

Patient identification, the 3 NNIS risk-index

Component for patients in nicu

Before introducing the NNIS component for NICU, a pilot study was planned in such a unit in Berlin, Germany. However, as a result of the particular physiologic situation of neonates compared with that of older children, the neonatologists did not accept all the CDC definitions, even though some are specified for infants younger than 1 year of age. We, therefore, modified CDC definitions for this particular age group, trying to integrate as much objective criteria as possible, eg, temperature,

Component for patients undergoing bone marrow and peripheral blood system cell transplants

A new component without any existing NNIS model was created for patients undergoing bone marrow and peripheral blood stem cell transplants in 2001. Therefore, we modified CDC definitions for this particular patient group and concentrated on bloodstream infections and pneumonia during the period of neutropenia. Infection rates are given as infections/1000 neutropenic-days. At the end of the first year we had an overview of 449 patients with 6701 days in neutropenia in 10 hospitals (Table 5).

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Surveillance performance in hospitals

In the majority of hospitals, surveillance personnel are responsible for data recording and informing the KISS center. Answering a questionnaire, they stated that they needed an average of 2 to 3 h/wk for surveillance in an individual ICU (on average: 11 beds) or operative department. Most hospitals carry out continuous surveillance because they appreciate the close contact with the wards that it achieves. A few hospitals have organized a rotating system of surveillance so as not to exclude

German law for protection against infection and surveillance of nosocomial infection

With the year 2001, a new law for protection against infection (Infektionsschutzgesetz) was introduced in Germany. One central theme is reorganizing the surveillance of infectious diseases. Paragraph 23 will provide an incentive for introducing the surveillance of nosocomial infections. Hospitals will have to choose at least one type of nosocomial infection in one specific risk area when initiating surveillance. For the coordination of surveillance data from any one particular hospital with

The future

In addition to the 2 existing surveillance components, a pilot project has begun evaluating the possibility of creating 2 further surveillance components for device-associated infection rates (urinary-tract infections and primary bloodstream infections) in peripheral wards and for postoperative surgical site infections in outpatient settings.

Further, as with the Intensive Care Antimicrobial Resistance Epidemiology (ICARE) project, 35 ICUs are collecting data to establish a system (Surveillance

Discussion

More than 200 of 2200 hospitals in all of Germany now participate in KISS. To retain an overview of hospital participation and to manage meetings for the exchange of information, we have discontinued inviting all of the hospitals to participate. We encourage only those hospitals to participate who are able to supply information about specific patient groups not yet sufficiently represented in our surveillance system.

Despite extensive activities in training to diagnose nosocomial infection, a

Acknowledgements

We thank Teresa C. Horan of the Centers for Disease Control and Prevention, Atlanta, Ga, for coming to Berlin, Germany, and answering our questions while planning the surveillance activities. We also wish to acknowledge colleagues from the Hospitals in Europe Link for Infection Control through Surveillance; European Project for Harmonization of Surveillance Activities group for their expertise, stimulating discussions regarding the advantages and disadvantages of various surveillance methods,

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*

Supported by the Robert Koch Institute and by a grant from the Federal Ministry of Health (support no. 1369-233).

**

Reprint requests: Petra Gastmeier, MD, Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.

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