Evaluation of the statutory surveillance system for invasive MRSA infections in Germany, 2016-2017.

BACKGROUND: Mandatory notification of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections was introduced for laboratories in Germany in 2009. The aims were to support local health authorities (LHAs) in their mandate to prevent and control infections in hospitals and to improve population-based nationwide surveillance of healthcare associated infections. We evaluated the MRSA surveillance system to assess whether its aims were met and to identify areas for improvement. METHODS: Using the updated guidelines for evaluating public health surveillance systems by the Centers for Disease Control and Prevention we assessed the attributes simplicity, timeliness, data quality, acceptability, and usefulness. In 2016/2017 we interviewed staff in LHAs, state health authorities (SHAs), and laboratories and analyzed surveillance data of cases notified between 2009 and 2016. RESULTS: We interviewed 10% of LHAs (n = 38), 63% of SHAs (n = 10), 5 selected laboratories and analyzed information on 27,706 notified MRSA cases. LHAs reported that on receiving notifications from laboratories they contacted hospitals for clinical information, which was time-consuming and complicated as physicians were hard to reach or refused to answer questions, citing doctor-patient confidentiality. LHAs suggested reducing the amount of information collected as some clinical information was unnecessary for implementing control measures. LHAs stated that they received notifications on time, however surveillance data analysis showed some delay. Data completeness exceeded 90% for most variables, however it was only 68% and 80% for dates of disease onset and hospital admission respectively making it impossible to discriminate between hospital and community acquired infections in half of the cases. The surveillance system was well accepted by half of the interviewees. A third however stated that the benefits of the surveillance system were outweighed by the work associated with it. The majority rated the system to be useful for recognizing trends in the MRSA incidence and the ability to check up on infection control measures in hospitals. CONCLUSIONS: The surveillance system proved to be useful by fulfilling its aims. It was timely, acceptable and provided complete data for most variables. However, the system was complicated; ensuring that only relevant variables are reported could simplify the system without losing any of its usefulness.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases.

INTRODUCTION: In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. MATERIALS AND METHODS: A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. CONCLUSION: The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

How many outbreaks of nosocomial infections occur in German neonatal intensive care units annually?

BACKGROUND: Outbreaks on neonatal intensive care units (NICUs) achieve huge media interest, but the real number of neonatal outbreaks within a country is unknown. METHOD: This calculation is based on the data of the component for nosocomial infections in very low birth weight (VLBW) infants of the German national nosocomial infection surveillance system (NEO-KISS) from 2006 to 2011. Almost all German NICUs caring for VLBW infants participated in this surveillance system. A cluster was defined and an outbreak was assumed when at least two cases of severe neonatal infection (bloodstream infection, pneumonia) occurred within a defined time interval in one center with the same pathogen species in different patients. Four different intervals were used for calculation: 14, 30, 60, and 90 days. Infections with coagulase-negative staphylococci (CoNS) were excluded. RESULTS: A total of 228 NICUs provided data in the six-year study period. A total of 37,038 VLBW infants and 1,361,950 patient days were used for the calculation. 7,405 severe neonatal infections occurred, and a microbiological detection of the pathogen was successful in 2,084 cases. Altogether, between 121 and 280 outbreaks were calculated according to the different time intervals used. Most outbreaks were due to Staphylococcus aureus, followed by Enterococcus spp. and Enterobacter spp. CONCLUSION: It can be assumed that at least between 26 and 61 neonatal outbreaks with at least two severe infections take place in German NICUs per year. The actual number seems to be higher because only laboratory-confirmed infections in a subgroup of patients were used for the analysis.

[Surveillance of antibiotic consumption in hospitals: tasks of the Public Health Service]. / Surveillance des Antibiotikaverbrauchs in Krankenhäusern : Aufgaben des öffentlichen Gesundheitsdienstes.

According to the German Protection Against Infection Act (IfSG; section 23 paragraph 4, July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring of antibiotic consumption in their institute. The introduction of the surveillance of antibiotic consumption aims to contribute to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The local public health authority is entitled to supervise the implementation of legal requirements in the hospital setting. The main aim of this article is to support local public health authorities in coping with this task by providing background information on the surveillance of antibiotic consumption and its role as a key component of antibiotic stewardship programs. Furthermore, criteria suitable for assessing the implementation of a functioning surveillance system are proposed. The possibilities and limitations of the activities of public health authorities in this context are addressed.

[Prevalence of carbapenemase-producing bacteria in hospitals in Saxony, Germany]. / Prävalenzerhebung zum Vorkommen von Carbapenemase-Bildnern in sächsischen Kliniken.

The presence of pathogenic bacteria with acquired carbapenem resistance constitutes an increasing problem for infection control and infectious disease management. Prompted by an outbreak of infections with Klebsiella pneumoniae producing the carbapenemase KPC-2 at a hospital in Saxony, the Saxon State Ministry of Social Affairs and Consumer Protection (SMS) initiated a point-prevalence survey for carbapenemase-producing gram-negative bacteria. Wards at 53 hospitals in Saxony, mainly intensive care units, were investigated between October 2012 and February 2013. Stool samples and rectal swabs of 1,037 patients were analyzed for the presence of bacteria with resistance against four major groups of antibiotics (4MRGN). Carbapenemase producers were detected in 3 patients [0.3% CI95 (0.0596; 0.843)] and carbapenem-resistant bacteria without carbapenemases were detected in 9 patients [0.9% CI95 (0.397; 1.64)]. Furthermore, antimicrobial susceptibility testing revealed 166 patients [16.0% CI95 (13.82; 18.38)] with extended-spectrum beta-lactamase (ESBL)-producing bacteria. At the time of investigation, K. pneumoniae producing the carbapenemase KPC-2 was diagnosed in 2 patients at one hospital. Moreover, it is necessary to remain vigilant towards other types of carbapenemase producers, as demonstrated by the finding of a Pseudomonas aeruginosa strain harbouring the carbapenemase VIM-1 in another hospital.

Implementation of the WHO core components of an infection prevention and control programme in two sub-saharan African acute health-care facilities: a mixed methods study.

BACKGROUND: The coronavirus pandemic again highlighted the need for robust health care facility infection prevention and control (IPC) programmes. WHO guidelines on the core components (CCs) of IPC programmes provides guidance for facilities, but their implementation can be difficult to achieve in resource-limited settings. We aimed to gather evidence on an initial WHO IPC implementation experience using a mixed methods approach. METHODS: A five-day training on the WHO IPC CCs was conducted at two reference acute health care facilities in the Democratic Republic of Congo and Burkina Faso. This was accompanied by a three-part mixed-methods evaluation consisting of a: (1) baseline and follow-up survey of participants' knowledge, attitudes and practices (KAP), (2) qualitative assessment of plenary discussion transcripts and (3) deployment of the WHO IPC assessment framework (IPCAF) tool. Results were analysed descriptively and with a qualitative inductive thematic approach. RESULTS: Twenty-two and twenty-four participants were trained at each facility, respectively. Baseline and follow-up KAP results suggested increases in knowledge related to the necessity of a dedicated IPC focal person and annual evaluations of IPC training although lack of recognition on the importance of including hospital leadership in IPC training and hand hygiene monitoring recommendations remained. Most participants reported rarely attending IPC meetings or participating in IPC action planning although attitudes shifted towards stronger agreement with the feeling of IPC responsibility and importance of an IPC team. A reocurring theme in plenary discussions was related to limited resources as a barrier to IPC implementation, namely lack of reliable water access. However, participants recognised the importance of IPC improvement efforts such as practical IPC training methods or the use of data to improve quality of care. The facilities' IPCAF scores reflected a 'basic/intermediate' IPC implementation level. CONCLUSIONS: The training and mixed methods evaluation revealed initial IPC implementation experiences that could be used to inform stepwise approaches to facility IPC improvement in resource-limited settings. Implementation strategies should consider both global standards such as the WHO IPC CCs and specific local contexts. The early involvement of all relevant stakeholders and parallel efforts to advocate for sufficient resources and health system infrastructure are critical.

[Surveillance of antibiotic consumption : clarification of the "definition of data on the nature and extent of antibiotic consumption in hospitals according to § 23 paragraph 4 sentence 2 of the IfSG"]. / Antibiotika-Verbrauchs-Surveillance : Ausführungen und Erläuterungen zur Bekanntmachung "Festlegung der Daten zu Art und Umfang des Antibiotika-Verbrauchs in Krankenhäusern nach § 23 Abs. 4 Satz 2 IfSG"

According to § 23 paragraph 4 of the German Infection Prevention Act (IfSG; July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring system of antibiotic consumption. This is aimed at contributing to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The general requirements (restricted to hospitals) on the method and extent of data collection are provided by the national public health institution after discussion with representatives of various professional societies (Robert Koch-Institut, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 59, 2013). The article aims to clarify these specifications and to provide background details. In agreement with national and European surveillance systems, the Anatomical Therapeutic Chemical (ATC)/Defined Daily Dose (DDD) classification system recommended by the WHO should be used as reference standard. Antibiotic consumption should be expressed as the number of DDDs per 100 patient days and per 100 admissions. The categories of antimicrobials and hospital organizational units to be monitored and the time intervals in which analyses should be conducted are determined. Furthermore, various approaches of data assessment are described.

Epidemiology of healthcare-associated SARS-CoV-2 outbreaks in Germany between March 2020 and May 2022.

BACKGROUND: Outbreaks in healthcare facilities played a pivotal role in the course of the coronavirus (COVID-19) pandemic. AIM: To investigate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in hospitals, outpatient care, and rehabilitation facilities in Germany from March 2020 to May 2022. METHODS: Data from the German mandatory notification system were used to describe outbreaks by number of cases and case fatality ratio (CFR), and outbreak cases by age and gender. Using Pearson correlation, the dynamics of cases in the general population were compared with cases in healthcare-associated infection (HAI) SARS-CoV-2 outbreaks before and after the start of the vaccination campaign. Additionally, a counterfactual scenario was used to estimate numbers of prevented HAI cases, using the phase before vaccination as baseline. FINDINGS: By the end of May 2022, 8941 healthcare-associated outbreaks were observed with 73,626 cases: 51,504 in hospitals, 15,524 in outpatient care, and 6598 in rehabilitation facilities. Median number of cases per outbreak was 4 (range: 2-342) and cases were more frequently reported in women with 46,818 (63.6%). Overall CFR was 8.1%, higher in men (12.4%) than in women (5.7%). After the vaccination campaign was fully introduced, the association between increasing incidence in the general population and consecutive outbreak cases was decreased by a factor of 10. Furthermore, our counterfactual analysis suggests that more than 55,000 outbreak cases could have been prevented until the end of 2021. CONCLUSION: The vaccination campaign in combination with non-pharmaceutical measures was key to reduce number, size and CFR of healthcare-associated outbreaks.

Infection prevention and control between legal requirements and German Society for Hygiene and Microbiology expert assessments: a cross-sectional study in September-November 2022.

BACKGROUND: In contrast to the beginning of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), pandemic, more and more hospital issues are now regulated by policy. AIM: To identify differences between expert recommendations and legal requirements regarding infection prevention and control (IPC) strategies. METHODS: A cross-sectional study was conducted between 29th September 2022 and 3rd November 2022 addressing 1319 members of the German Society for Hygiene and Microbiology. The response rate was 12%. This paper reports the expert recommendations on different IPC strategies. FINDINGS: The majority (66%) of experts recommended universal mask usage, with 34% recommending it seasonally, even after the SARS-CoV-2 pandemic. Medical microbiology (MM) experts were more likely to recommend continuing to wear the masks indefinitely compared with IPC experts. Concerning the mask type, medical masks were recommended more frequently by IPC experts (47.3%), while FFP2 masks were preferred by MM experts (31.8%). The majority (54.7%) of experts recommended universal screening of employees, mainly in settings with extremely vulnerable patients and if regional incidence rates were high, at a frequency of twice per week. The dominant advice (recommended by at least 50% of experts) for employees exposed to SARS-CoV-2 was daily testing and wearing a mask, regardless of the length of exposure. CONCLUSIONS: Expert recommendations deviate from the legal requirements and appear to be more differentiated and proportional. The influence of specific experience and expertise on mask recommendations should be investigated in more detail. For relevant policy decisions, a quick, focused and broad-based consultation of expertise could be of added value.

MRSA-surveillance in Germany: data from the Antibiotic Resistance Surveillance System (ARS) and the mandatory surveillance of MRSA in blood.

Data from the German Antibiotic Resistance Surveillance system (ARS) and statutory notification of methicillin-resistant Staphylococcus aureus (MRSA) in blood cultures are presented. ARS is a voluntary laboratory-based surveillance system providing resistance data of all clinical pathogens and sample types from hospitals and ambulatory care. Statutory notification includes MRSA detected in blood and cerebrospinal fluid by microbiological laboratories. Resistance data from 2008 to 2010 and MRSA-bacteraemia incidences from 2010 are presented. From 2008 to 2010, resistance data from 70,935 Staphylococcus aureus isolates were transferred to the national health institution. MRSA proportions in hospitals and outpatient care account for 19.2% and 10.6%, respectively. In hospital care high proportions of MRSA were found in nephrological, geriatric, neurological general wards and surgical ICUs (49.4%, 45.8%, 34.2%, and 27.0%, respectively), while in community outpatient care urological practices (29.2%) account for the highest values. In both healthcare settings urinary tract samples stand out with high proportions of MRSA (hospitals, 32.9%; outpatients, 20.5%). In 2010, 3900 cases of MRSA bacteraemia were reported, accounting for an incidence of MRSA bacteraemia of 4.8/100,000 inhabitants/year. Stratification by federal states shows considerable regional differences (range, 1.0-8.3/100,000 inhabitants/year). Vulnerable areas in hospitals and outpatient care have been pointed out as subjects for further inquiries.

Quantitative assessment of passenger flows in Europe and its implications for tracing contacts of infectious passengers.

In contrast to air travel, there are no recommendations on tracing ground transport passengers exposed to infectious pathogens. We analysed European statistics on passenger transport in different conveyances and conducted expert workshops to discuss environmental conditions in ground transport, indications and minimal datasets required for contact tracing. Transport performance in the 27 countries of the European Union increased from 5.3 x 10(12) passenger kilometres (pkm) in 1995 to 6.5 x 10(12) pkm in 2007. Each resident generated on average 13,092 pkm in 2007, of which 2,062 pkm were public ground transport and 1,155 pkm in air transport. In the same year in Germany the total passenger volume in all different conveyances was 67,937 million. Public ground transport accounted for a passenger volume of 11,387 million (16.8%) and air transport for 129 million (0.2%). High efficiency particulate air (HEPA) filtration is frequently used in airplanes but not in ground transport vehicles. Therefore opportunities for disease transmission in public ground transport are not necessarily lower than in air travel. However, contact tracing is rarely conducted in these settings because of immense logistic challenges.Indication for contact tracing should be revisited, including all kinds of passenger transport.

Evidence for airborne infectious disease transmission in public ground transport--a literature review.

While guidelines on contact tracing (CT) after exposure to certain infectious pathogens during air travel exist, no guidance documents are available on CT in response to potential exposure on public ground transport. We reviewed scientific and non-scientific literature on transmission of airborne pathogens in public ground transport and on factors potentially influencing transmission. We identified 32 relevant publications (15 scientific and 17 non-scientific). Most of the selected studies dealt with transmission of tuberculosis. However, the relation between travel duration, proximity to the index case and environmental factors, such as ventilation, on disease transmission in public ground transport is poorly understood. Considering the difficulty and probably limited effectiveness of CT in ground transport, our results suggest that only exceptional circumstances would justify CT. This contrasts with the high level of attention CT in air travel seems to receive in international regulations and recommendations. We question whether the indication for CT should be revisited after a risk­benefit assessment that takes into account exposure in both ground and air transport.

[Antimicrobial resistance in Germany. Four years of antimicrobial resistance surveillance (ARS)]. / Daten zur Antibiotikaresistenzlage in Deutschland. Vier Jahre Antibiotika-Resistenz-Surveillance (ARS).

In 2007, the Robert Koch Institute established the infrastructure for the national Antimicrobial Resistance Surveillance (ARS) system. Laboratories submit data of routine susceptibility testing of clinical samples from hospitals as well as from outpatient care settings in a standardized format to the Robert Koch Institute for central processing. The database for the period 2008-2011 comprises data of about 1.3 million samples from patients in hospital care and almost 800,000 samples from outpatients. Based on SIR interpretations of susceptibility, the trends of methicillin resistance of Staphylococcus aureus (MRSA) and cefotaxime non-susceptibility as an indicator of extended-spectrum beta-lactamases (ESBL) of Escherichia coli and Klebsiella pneumoniae were analyzed for four care settings or categories: hospital care, outpatient care, intensive care units, and isolates from blood cultures. After constant high levels of above 20%, the proportion of MRSA isolates showed a decline for the first time from 2010 to 2011 in hospital care overall, in intensive care units as well as in blood cultures; in outpatient care, MRSA proportions of about 13% were observed. Within the observed period, non-susceptibility to cefotaxime as an indicator of ESBL in E. coli showed an increasing trend in hospital care at a level above 10% in intensive care units, while cefotaxime non-susceptibility in K. pneumoniae was more frequent but without any trend. In outpatient care, the proportions of cefotaxime non-susceptibility increased year by year in both species resulting in nearly a doubling to 6%.

A national cross-sectional study on socio-behavioural factors that influence physicians' decisions to begin antimicrobial therapy.

PURPOSE: Current efforts to prevent antimicrobial resistance include limiting antimicrobial use, providing education about appropriate use, and developing better point-of-care tests, but what do physicians actually think of rational prescribing and potential interventions? We tried to ascertain which factors can influence a physician's decision to start antimicrobial therapy on a patient, and their opinions on measures to promote rational prescribing. METHODS: We conducted a nationwide, cross-sectional survey of 10,600 physicians from medical registries of all known board-certified physicians in Germany. RESULTS: Among respondents (n = 3,492; 33%; detailed non-response bias analysis included), 90% indicated that they decide to start antimicrobial therapy on a patient at least weekly, and 66% reported that they decide daily. We identified correlates for deciding to start antimicrobial therapy on a patient. Predictors were status as a hospital physician (odds ratio (OR) 1.29 (95% confidence interval (CI) 1.00-1.68)), male physician (OR 1.81 (95% CI 1.42-2.31)), being age 50-59 (OR 1.56 (95% CI 1.10-2.21)), and practising in states in the former East Germany (OR 1.60 (95% CI 1.15-2.21)). Each specialist was significantly less likely to decide to start a course of antimicrobial therapy than ENTs and urologists. Other predictors were agreeing to prescribe to be on the safe side (OR 1.34 (95% CI 1.03-1.76)), believing that the quality of prescribing practice improves after receiving continuing education from pharmaceutical companies (OR 1.43 (95% CI 1.11-1.84)), and having experience with failed therapy for resistant pathogens (OR 2.42 (95% CI 1.83-3.19)). CONCLUSIONS: Physicians in our sample decide to start antimicrobial therapy on a patient, and they value intervention to support prudent use, for example continuing education, practice guidelines and implementation of surveillance measures. Socio-behavioural factors, regional variation, gender, and age merit further research to promote rational antimicrobial prescribing and explore related influencing factors.

Cases of community-acquired meticillin-resistant Staphylococcus aureus in an asylum seekers centre in Germany, November 2010.

In an asylum seeker centre in Schleswig-Holstein, a resident was diagnosed with furuncle caused by a Panton-Valentine leukocidine (PVL)-positive community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA). As a result of active case finding, 232 of 427 persons (54% of all residents) were screened for MRSA and two further PVL-positive CA-MRSA cases were identified

Enhanced surveillance during a large outbreak of bloody diarrhoea and haemolytic uraemic syndrome caused by Shiga toxin/verotoxin-producing Escherichia coli in Germany, May to June 2011.

Germany has a well established broad statutory surveillance system for infectious diseases. In the context of the current outbreak of bloody diarrhoea and haemolytic uraemic syndrome caused by Shiga toxin/ verotoxin-producing Escherichia coli in Germany it became clear that the provisions of the routine surveillance system were not sufficient for an adequate response. This article describes the timeline and concepts of the enhanced surveillance implemented during this public health emergency.

[Multi-dose packaging of drugs as the causative vehicle for multidrug-resistant Enterobacter cloacae: new results from a case-control study]. / Mehrfach-Verpackungen oraler Medikamente als Ausbruchsvehikel multiresistenter Enterobacter cloacae: neue Erkenntnisse durch eine Fall-Kontroll-Studie.

Hospital hygiene faces cross-cutting and methodological challenges that are time consuming and require specialised knowledge. In outbreak situations German federal states can request assistance from infectious disease epidemiologists at the Robert Koch Institute (RKI). The presented study describes the successful collaboration of local hygienists, microbiologists, clinicians, health authorities and the epidemiologists of the RKI in the investigation of an outbreak of multidrug-resistant Enterobacter (E.) cloacae in 2009 in a children's hospital. The outbreak was discovered in July 2009 when E. cloacae was detected in 12 patients in the neonatal and paediatric intensive care unit (NICU). Hygiene measures were intensified for infection control, and the RKI was invited by the responsible regional health authorities in October 2009 to assist in the outbreak investigation. We conducted a retrospective matched case-control study to identify risk factors for E. cloacae colonisation and infection. We identified a case as any child in the NICU from 1st May to 5th October 2009 with laboratory confirmation of the outbreak clone. Controls were patients staying in the NICU (> 72 h before the case's diagnosis) and swab-negative for the outbreak clone. We used standardised questionnaires to collect demographic and medical information. Matched odds ratios (mOR) were calculated by bivariate and multivariable conditional logistic regression. Environmental investigations were conducted. We identified 28 colonised and 3 bacteraemic cases. 29 matched case-control pairs were included in the study. Multivariable analysis revealed an association between E. cloacae diagnosis and the receipt of oral drugs at the bed-side from multidose packaging (mOR=1.8/drug; p=0.006). No specific drug was identified; microbiological investigation of drugs was negative. This multiresistant E. cloacae outbreak was most likely distributed by oral application using contaminated multidose drug packaging extrinsically contaminated via hands of personnel. No further cases occurred for 6 weeks after protocols for handling oral drugs were changed (smaller packaging, patient-based storage, and limited circulation time). Special attention and thorough hygiene protocols are needed for the distribution of oral medication. In NICUs the use of multi-dose medications should be avoided. The cooperation between locally available expertise and infectious disease epidemiologists enabled the discovery of a previously unidentified risk factor.

Increasing occurrence of multidrug-resistance in Acinetobacter baumannii isolates from four German University Hospitals, 2002-2006.

BACKGROUND: Acinetobacter baumannii can cause severe infections, mainly in critically ill inpatients. Treatment is complicated by multidrug-resistance (MDR). In Germany, to date, little is known on the extent of MDR in A. baumannii isolated from inpatients in German hospitals and potential factors influencing the emergence of MDR. MATERIALS AND METHODS: We retrospectively analysed the data of A. baumannii isolates from the inpatients of four German university hospitals, tested for antimicrobial resistance with the broth dilution method between 2002 and 2006. We defined MDR as resistance to three or more classes of recommended drugs. After calculating the proportions of MDR in A. baumannii isolates, we investigated the association between MDR in A. baumannii and year of pathogen isolation, hospital, ward type, specimen and demographics.We performed descriptive analysis and multivariable logistic regression. Additionally, proportions of in vitro drug effectiveness against multidrug-resistant and non-multidrug resistant A. baumannii isolates were determined. RESULTS: MDR was found in 66 of 1,190 (5.6%)A. baumannii isolates and increased from 2.1% in 2002 to 7.9% in 2006. The highest proportions of MDR were found in hospital A (8.9%), in intensive care units (7.3%), in isolates from blood (7.6%) and in male patients aged 60 years or older (6.6%). In multivariable analysis, the chance of MDR in A. baumannii isolates increased with the successive years of pathogen isolation (odds ratio [OR] 1.3,95% confidence interval [CI] 1.1-1.5) and there was a higher risk of MDR in A. baumannii in intensive care units(OR 1.8, 95% CI 1.1-2.9). The lowest in vitro antibiotic resistance was found in meropenem, imipenem and ampicillin/sulbactam, with 33, 37 and 39% for multidrug-resistant and 0.4, 1 and 3% in non-multidrug-resistant A. baumannii isolates, respectively. CONCLUSIONS: The increase of MDR in A. baumannii isolates from 2002 to 2006 in four hospitals suggests that clinicians in Germany may expect a rising proportion of MDR inA. baumannii isolates among inpatients. The antimicrobial susceptibility testing of A. baumannii isolates against recommended drugs, combined with in-house antimicrobial resistance surveillance, is needed to ensure appropriate treatment.

Antibiotics for the common cold: expectations of Germany's general population.

Physicians mention patients' expectations as a reason for prescribing antibiotics for common (viral) upper respiratory tract infections despite clinical evidence against their use and the physicians' better judgement. We aimed to assess the prevalence of such expectations and factors of influence (knowledge and attitudes) in Germany's general population. In November 2008, 1,778 persons registered with a large market research company were invited to complete an online questionnaire on expectations concerning prescription of antibiotics and on knowledge and attitudes regarding the effectiveness and use of antibiotics for upper respiratory tract infections. A total of 1,076 persons aged 15-78 years participated (response: 61%), of whom 91.8% reported using antibiotics 'only if absolutely necessary'. Prescription of antibiotics was expected by 113 (10.5%) of the 1,076 respondents for the common cold and by 997 (92.7%) for pneumonia. In a logistic regression analysis, predictors for expecting a prescription for antibiotics for the common cold included the following opinions: 'common cold or flu can effectively be treated with antibiotics' (prevalence: 37.6%; odds ratio (OR): 9.6; 95% confidence interval (CI): 3.8 to 24.3) and 'antibiotics should be taken when having a sore throat to prevent more serious illness' (prevalence 8.6%; OR: 7.6; 95% CI: 3.9 to 14.5). Among those expecting a prescription (n=113), 80 (71%) reported that they would trust their physician when he or she deems a prescription unnecessary; a further eight (7%) would be unsatisfied, but would accept the decision. Our results suggest that only a minority expects antibiotics for the treatment of cold symptoms. Physicians should be educated that their decisions not to prescribe antibiotics for the common cold, even when against patients' expectations, are apparently accepted by the majority.

Mortality of 2009 pandemic influenza A(H1N1) in Germany.

The mortality in Germany caused by the 2009 pandemic influenza A(H1N1) seems to have been one of the lowest in Europe. We provide a detailed analysis of all 252 fatal cases of confirmed infection with the pandemic virus notified between 29 April 2009 and 31 March 2010. The overall mortality was 3.1 (95% confidence interval (CI): 2.7 to 3.5) per one million inhabitants. We observed an increase in the case fatality rate of notified cases over time; notified cases aged 60 years or older had the highest case fatality rate (2.16%; 95% CI: 1.61 to 2.83; odds ratio: 5.4; p<0.001; reference group: 35­59 years). The median delay of four days (interquartile range (IQR): 2­7) between symptom onset and antiviral treatment was significantly longer in fatal cases than for non-fatal cases (median: two days (IQR: 1­3; p<0.001). Analysis of the underlying medical conditions of fatal cases, based on the observed frequency of the conditions in the general population, confirms the risk for fatal outcome, which is most notably due to immunosuppression, diabetes and respiratory diseases. Our results suggest that early treatment might have had an impact on overall mortality. Identification of risk groups for targeted intervention to prevent fatalities needs to take into account the distribution of underlying conditions in the population.