[Tuberculosis Infection Control & Hygiene - Recommendations of the DZK]. / Infektionsprävention & Hygiene bei Tuberkulose ­ Empfehlungen des DZK.

Preventing the spread of the disease is an essential goal in the care and treatment of tuberculosis. In addition to early diagnosis and effective therapies, isolation of infectious patients and adequate hygiene measures are of particular importance for infection prevention. The present recommendations replace the previous recommendations "tuberculosis infection control" from 2012 and take into account the current national and international recommendations and as well as new scientific findings. After a description of the infection and the transmission pathways, the necessary prevention and hygiene measures in health care facilities are comprehensively presented. Since the last revision of the recommendations on infection prevention, international recommendations and the KRINKO recommendation on ending isolation have been changed. In accordance with this, under certain conditions in the case of sensitive tuberculosis, de-isolation in health care facilities can take place after 14 days without taking the sputum findings into account. The second part of the recommendations explains in detail the measures to be taken in special situations and areas, such as general practitioners, ambulance services and care facilities. Here, the recommendations on respiratory protection have been simplified; for staff, an FFP2 mask is now generally considered sufficient.

Microbiologic diagnostics and pathogen spectrum in infective endocarditis of surgically treated patients: a five-year, retrospective, monocentric study.

PURPOSE: The spectrum of causative organisms in infective endocarditis (IE) has changed significantly in the last decades. Reliable pathogen detection is crucial for appropriate antimicrobial therapy for IE. The aim of the study was to evaluate the diagnostic value of microbiological methods for detecting the causative microorganism of IE and to analyze the spectrum of pathogens. METHODS: A total of 224 cases (211 unique patients, some with multiple surgeries) were included into this retrospective study. Patients were diagnosed with IE according to the modified Duke criteria from January 2016 to July 2021 and underwent heart valve surgery in a tertiary hospital. Pathogen detection was performed by blood culture, microbiological culture and 16S rDNA PCR of explanted heart valve material. RESULTS: A causative pathogen of IE was detected in 95.5% (n = 214) of cases. Blood cultures were positive in 83.3%, while a pathogen in the examined heart valve samples was identified in 32.6% by culture and in 88.2% by 16S rDNA PCR. A microorganism was identified by 16S rDNA PCR in 61.1% of blood culture negative cases but only in 19.4% by heart valve culture. The most common pathogens were Staphylococcus aureus (27%), viridans group streptococci (20%), enterococci (19%) and coagulase-negative staphylococci (CoNS 8%). Cutibacterium acnes (7%) was detected in prosthetic valve IE cases only. CONCLUSION: Blood culture as a comparatively non-invasive and straightforward technique remains an important and reliable method for initial detection of the causative organism in IE. Diagnostic stewardship programs should broadly emphasize proper collection of blood cultures, particularly sampling prior to any antibiotic treatment. Additionally, molecular testing using 16S rDNA tissue PCR can be used with culture techniques to increase the diagnostic yield, especially in the case of a negative blood culture.

Short- and Mid-Term Survival of Geriatric Patients with Septic Arthritis of the Knee and the Impact of Risk Factors on Survival.

Septic arthritis is common in older adults and can be related to joint surgery or hematogenous distribution. To date, the risk factors affecting survival are unknown. This study aimed to evaluate the effects of existing implants, positive synovial microbiological culture results, and the American Society of Anesthesiology Physical Status (ASA) classification on the short- and mid-term survival of older patients with primary septic gonarthritis. This retrospective study included 133 older adults >60 years who underwent surgery for primary septic gonarthritis. Data were collected from medical records and public obituaries. Kaplan-Meier survival curves were used to estimate the probability of survival, as well as log-rank tests to measure and compare survival rates over one- and five-year periods. The mean age was 74.9 years (SD ± 9.2), and the 5-year follow-up rate was 74.3% (the mean follow-up was 3000.5 days; SD ± 1771.6). Mean survival was significantly different in patients with implants and without implants (p = 0.015), and between ASA II, ASA III, and ASA IV (p < 0.001). There was no significant difference in the survival of patients with or without a positive synovial microbiological culture (p = 0.08). Older adults with septic monoarthritis and pre-existing medical implants showed impaired survival. The ASA classification prior to surgery for primary septic monoarthritis can be helpful in identifying patients with poorer mid-term outcomes.

Characterization of PVL-Positive MRSA Isolates in Northern Bavaria, Germany over an Eight-Year Period.

PURPOSE: Community-acquired methicillin-resistant Staphylococcus aureus strains (CA-MRSA) are spread worldwide and often cause recurring and persistent infections in humans. CA-MRSA strains frequently carry Panton-Valentine leukocidin (PVL) as a distinctive virulence factor. This study investigates the molecular epidemiology, antibiotic resistance and clinical characteristics of PVL-positive MRSA strains in Northern Bavaria, Germany, isolated over an eight-year period. METHODS: Strains were identified by MALDI-TOF MS and antibiotic susceptibility was tested by automated microdilution (VITEK 2) or disk diffusion. PVL-encoding genes and mecA were detected by PCR. MRSA clonal complexes (CC) and lineages were assigned by genotyping via DNA microarray and spa-typing. RESULTS: In total, 131 PVL-positive MRSA were collected from five hospital sites between 2009 and 2016. Predominant lineages were CC8-MRSA-[IV+ACME], USA300 (27/131; 20.6%); CC30-MRSA-IV, Southwest Pacific Clone (26/131; 19.8%) and CC80-MRSA-IV (25/131; 19.1%). Other CCs were detected less frequently. Resistance against erythromycin and clindamycin was prevalent, whereas all strains were sensitive towards vancomycin and linezolid. In total, 100 cases (76.3%) were causally linked to an infection. The majority (102/131; 77.9%) of isolates were detected in skin swabs or swabs from surgical sites. CONCLUSIONS: During the sample period we found an increase in the PVL-positive MRSA lineages CC30 and CC1. Compared to less-abundant lineages CC1 or CC22, the predominant lineages CC8, CC30 and CC80 harbored a broader resistance spectrum. Furthermore, these lineages are probably associated with a travel and migration background. In the spatio-temporal setting we investigated, these were arguably drivers of diversification and change in the landscape of PVL-positive MRSA.

COVID-19 Co-infection with Legionella pneumophila in 2 Tertiary-Care Hospitals, Germany.

We describe screening results for detection of co-infections with Legionella pneumophila in patients infected with severe acute respiratory syndrome coronavirus 2. In total, 93 patients were tested; 1 was positive (1.1%) for L. pneumophila serogroup 1. Co-infections with L. pneumophila occur in coronavirus disease patients and should not be missed.

SARS-CoV-2 samples may escape detection because of a single point mutation in the N gene.

We found that a single nucleotide polymorphism (SNP) in the nucleoprotein gene of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a patient interfered with detection in a widely used commercial assay. Some 0.2% of the isolates in the EpiCoV database contain this SNP. Although SARS-CoV-2 was still detected by the other probe in the assay, this underlines the necessity of targeting two independent essential regions of a pathogen for reliable detection.

Protection of healthcare workers against transmission of Mycobacterium tuberculosis in hospitals: a review of the evidence.

BACKGROUND: Employees in contact with infectious tuberculosis (TB) patients in healthcare facilities of low-incidence countries are still at considerable risk of acquiring TB infections. However, formal precautions recommended on the protection of healthcare workers may not only vary from country to country but also within a single country. The objective of this study was to compare current guidelines with respect to hospital infection control of TB, focusing on common shared priorities and discrepancies between sets of recommendations. METHODS: Five types of procedures captured in guidelines of the World Health Organization, the United States of America, the United Kingdom and Germany are compared and the underlying evidence is discussed. RESULTS: Uncontroversially, personal protection by respirators in the TB ward and during aerosol-generating procedures is key to reducing Mycobacterium tuberculosis exposure. However, there is no consensus on the types of masks that should be worn in different situations. Closely connected to this, there is considerable uncertainty with respect to the optimal date of removing sputum smear-negative and multidrug-resistant TB patients from isolation. Indeed, the use of notable new tools for this purpose, such as the highly sensitive PCR tests recommended by the World Health Organization for detecting TB/multidrug-resistant TB, have yet to be sufficiently incorporated into TB guidelines. Perceptions differ, too, as to whether long-term control measures for M. tuberculosis infections in healthcare workers by serial testing for latent TB infection should be established and, if so, how testing results should be interpreted. CONCLUSIONS: Although the current recommendations on protection of healthcare workers are otherwise homogeneous, there are considerable discrepancies that have important implications for daily practice.

Redo aortic valve replacement for prosthesis endocarditis in patients previously classified as high or prohibitive risk: a narrative review.

Transcatheter aortic valve implantation (TAVI) and sutureless aortic valve replacement (Su-AVR) enabled in the last years many patients at high or prohibitive risk to be treated for their severe symptomatic aortic valve stenosis. As often happens in medicine, new techniques bring not only new hopes, but also new problems. In recent years, alongside the lengthening of the life of these patients treated with TAVI or Su-AVR, cardiologists and cardiac surgeons have had to face the long-term complications associated with the implantation of these devices, such as the prosthetic infective endocarditis. The correct management of prosthesis valve endocarditis after TAVI or Su-AVR in high risk patients, and the possible role of surgery are a matter of debate because pushing the limits of the modern medicine and becoming a new challenge for cardiac surgeons of 21st century. In this review, we summarized the incidence, characteristics and evidences for this new and controversial problem of the cardiovascular community. Moreover, we investigated the outcomes reported in literature of the conservative and the surgical strategy. Although the reported mortality rate of surgical treatment is high, seems not prohibitive, mostly if compared to conservative medical therapy. The collaborative exchange between cardiologist, cardiac surgeons, clinical microbiologists and expert of imaging is mandatory to face this challenge.

A spinal epidural abscess due to Streptobacillus moniliformis infection following a rat bite: case report.

The authors describe the case of a 40-year-old man suffering from an epidural abscess in the thoracic spine due to a rarely isolated pathogen, Streptobacillus moniliformis, the causative agent of rat bite fever. Besides diffuse abdominal pain, ataxia, paresthesia, hypesthesia, and enhanced reflexes of the lower extremities, the patient suffered from a decreased sensation of bladder filling. His history was also positive for a rat bite 6 weeks earlier. Magnetic resonance imaging showed an epidural, space-occupying lesion compressing the spinal cord at the vertebral levels of T6-8. Neurosurgery revealed an epidural abscess, which was drained via laminectomy (T-7) and excision of the ligamentum flavum (T6-8). The etiological agent S. moniliformis was identified by 16S rRNA-based polymerase chain reaction and sequencing as well as by culture and mass spectrometry. Treatment with penicillin G led to complete resolution of the abscess and clinical recovery of the patient, who regained his bladder-filling sensation and free walking ability. This case demonstrates that careful attention to the patient's history is essential in suspecting unusual bacterial pathogens as the cause of an epidural abscess and initiating the optimal diagnostic procedure and antimicrobial therapy.

Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department.

The in-hospital mortality of patients with severe sepsis and septic shock (SSSS) is high. In this study we examined the diagnostic and prognostic accuracy of the emergency severity index (ESI), the modified early warning score (MEWS), and the mortality in emergency department (ED) sepsis (MEDS) score. This is a single-centre, prospective and observational study of 151 consecutive patients presenting to the ED of the Nuremberg Hospital with suspected sepsis (age 68.3 ± 18 years, 54.3 % men, 45 % with SSSS, in-hospital mortality of SSSS: 27.8 %). In this study, 37.7 % of the studied patients had a urinary tract infection (n = 57/151), 33.8 % a pneumonia (n = 51/151), 8.6 % an acute abdominal infection (n = 13/151), and in 12.6 % the focus of infection was not further specified or identifiable (n = 19/151). The diagnostic and prognostic accuracy was analyzed by means of the receiver operating characteristic (ROC) curve. The areas under curve (AUC) in terms of diagnostic accuracy were 0.609, 0.641, and 0.778 for the ESI, MEWS, and MEDS score respectively. The AUCs concerning prognostic accuracy were 0.617, 0.642, and 0.871 for ESI, MEWS, and MEDS score respectively.By using the MEDS score systematically, critically ill patients with sepsis could be detected in the ED. Finally, the MEDS score provides the basis for a risk adjusted disposition management that follows objective criteria.

Vancomycin-resistant vanB-type Enterococcus faecium isolates expressing varying levels of vancomycin resistance and being highly prevalent among neonatal patients in a single ICU.

BACKGROUND: Vancomycin-resistant isolates of E. faecalis and E. faecium are of special concern and patients at risk of acquiring a VRE colonization/infection include also intensively-cared neonates. We describe here an ongoing high prevalence of VanB type E. faecium in a neonatal ICU hardly to identify by routine diagnostics. METHODS: During a 10 months' key period 71 E. faecium isolates including 67 vanB-type isolates from 61 patients were collected non-selectively. Vancomycin resistance was determined by different MIC methods (broth microdilution, Vitek® 2) including two Etest® protocols (McFarland 0.5/2.0. on Mueller-Hinton/Brain Heart Infusion agars). Performance of three chromogenic VRE agars to identify the vanB type outbreak VRE was evaluated (BrillianceTM VRE agar, chromIDTM VRE agar, CHROMagarTM VRE). Isolates were genotyped by SmaI- and CeuI-macrorestriction analysis in PFGE, plasmid profiling, vanB Southern hybridisations as well as MLST typing. RESULTS: Majority of vanB isolates (n = 56, 79%) belonged to a single ST192 outbreak strain type showing an identical PFGE pattern and analyzed representative isolates revealed a chromosomal localization of a vanB2-Tn5382 cluster type. Vancomycin MICs in cation-adjusted MH broth revealed a susceptible value of ≤4 mg/L for 31 (55%) of the 56 outbreak VRE isolates. Etest® vancomycin on MH and BHI agars revealed only two vanB VRE isolates with a susceptible result; in general Etest® MIC results were about 1 to 2 doubling dilutions higher than MICs assessed in broth and values after the 48 h readout were 0.5 to 1 doubling dilutions higher for vanB VRE. Of all vanB type VRE only three, three and two isolates did not grow on BrillianceTM VRE agar, chromIDTM VRE agar and CHROMagarTM VRE, respectively. Permanent cross contamination via the patients' surrounding appeared as a possible risk factor for permanent VRE colonization/infection. CONCLUSIONS: Low level expression of vanB resistance may complicate a proper routine diagnostics of vanB VRE and mask an ongoing high VRE prevalence. A high inoculum and growth on rich solid media showed the highest sensitivity in identifying vanB type resistance.