Hospitals: many small measures against infections and sepsis

Interview with Prof. Frank Brunkhorst, Jena University Hospital, Center of Sepsis Control and Care (CSCC)

If neither the immune system nor antibiotics are able to control an infection, a sepsis can arise out of it - an infection that attacks several organs at the same time and causes the immune system to overreact. This is a life-threatening condition.


Photo: Physician in a white coat, with glasses and short brown hair - Prof. Frank Brunkhorst; Copyright: Wolfgang Hanke

Prof. Frank Brunkhorst; ©Wolfgang Hanke

At, Prof. Frank Brunkhorst from the Jena University Hospital talks about the difficulty of sepsis diagnosis. He explains how small hygiene measure can significantly reduce the amount of sepsis cases. This is important, since the most common cause of sepsis are nosocomial infections that patients acquire during a hospital stay.

Prof. Brunkhorst, what is sepsis and what causes it?

Prof. Frank Brunkhorst: In more than 90 percent of all cases, sepsis is caused by a bacterial infection or a mycosis. It initially is localized. If the patient is immunosuppressed or suffers from a severe secondary disorder, the localized infection can turn into a systemic infection or sepsis. In this case, pathogens migrate to other organs via the bloodstream and generate a generalized, excessive immune response by the organism, which eventually leads to organ failure.

Why is it generally so difficult to diagnose sepsis in time?

Brunkhorst: We are talking about a very complex disease pattern here. The temporal dynamics of infection development varies significantly. The transition from localized to systemic infection is very difficult to determine.

There are no classic signs for sepsis like with a myocardial infarction for instance, which you can diagnose relatively safely via ECG and blood work. You need a lot of experience to be able to recognize severe sepsis in time. Critical care physicians, who treat those types of patients more often, tend to have this experience of course compared to staff in other hospital departments. Sepsis is also earlier diagnosed in intensive care units thanks to better monitoring of patients.
Photo: Man at the ICU, physician next to his bed; Copyright: Olson

Many patients in hospitals and intensive care units are susceptible to sepsis because of pre-existing conditions; © Tyler Olson

According to the SepNet Study, 70 percent of severe sepsis cases are caused by nosocomial infections, that being infections patients acquire during a hospital stay. Why is this particular cause so common?

Brunkhorst: Hospitals are host to a large number of critically ill patients, who need to undergo surgeries, receive chemotherapy or have multiple secondary disorders for example. We are able to treat many diseases thanks to modern medicine and all its advances, but the price we also often pay is sepsis.

There are large open wound surfaces during extensive surgeries for instance, where bacteria can get into the bloodstream. In patients that receive artificial feeding and respiration, bacteria can move along catheters and tubes and get deeper into the body. Multiple factors lead to sepsis in these high-risk patients. Improved hygiene measures could avoid 20 to 30 percent of these cases.

What are important steps in infection prevention in this instance?

Brunkhorst: The most important measure at the hospital is regular hand disinfection with alcohol-based solutions before and after contact with the patient. This is where the biggest deficit is. In a large study called the ALERTS study, we currently monitor how often employees disinfect their hands. We often notice that they perform the required disinfection process in only 40 percent of those cases where they should actually perform them. So there is still an enormous potential in this area.
Photo: Physician is cleaning his hands at a desinfectant dispenser; Copyright:

Already regular disinfection of hands can reduce the amount of nosocomial infections by 20-30 percent; © vzmaze

Aside from disinfection, there are other steps to prevention. Ninety percent of all sepsis cases stem from four classic hospital-acquired infections. For starters, there are infected wounds after surgeries. Regular inspection of the wound and of course sterile wound contact should occur in these cases. Vascular and urinary catheters and breathing tubes can also promote infection. These are extraneous materials, through which bacteria can get into the body. The most important measure here would be to assess daily whether the patient is still dependent on the catheter or tube.

Do you have recommendations for physicians and staff with which the risk of infection could be lowered even further?

Brunkhorst: In the past, large-scale disinfection took center stage, but it is truly the many small measures that influence the rate of infection. Research on infection prevention has clearly shown that the hands of employees have a dominating influence here. Frequent disinfection can prevent bacterial transmission between patients. The already mentioned measures for hand disinfection also correspond to the WHO recommendations and its "SAVE LIVES: Clean Your Hands" campaign. We are in close contact with its director Professor Didier Pittet in Geneva.

You will never be able to achieve one hundred percent success in prevention. It is important to prevent bacteria from entering the body alongside plastic materials. This is very difficult and - as I have already mentioned - the price we pay for modern medicine where there are also many high-risk patients.

If you assume 400,000 - 600,000 hospital-acquired infections per year in Germany and assume the potential to reduce the infection rate by 20 percent, this already amounts to 80,000 – 100,000 preventable cases. And that is a lot.
Photo: Timo Roth; Copyright: B. Frommann

© B. Frommann

The interview was conducted by Timo Roth and translated from German by Elena O'Meara.