Dialysis drains as a possible source for carbapenem-resistant pathogens causing an ICU outbreak.

OBJECTIVE DESIGN: We describe a case series of patients colonized with KPC-producing Enterobacteriaceae related to dialysis drains at patient's bedside. SETTING: The study was set at the intensive care unit (ICU) of a tertiary referral hospital. PATIENTS: In March 2016, we discovered four ICU patients to be colonized with KPC-producing Enterobacteriaceae in routine screening. All of these patients had already received contact isolation, and all of them were treated with continuous veno-venous dialysis. Environmental examinations showed KPC-producing Enterobacteriaceae in dialysis drains in different ICU rooms and even in rooms not hosting KPC-colonized patients. INTERVENTIONS: Based on our findings, we suspected the dialysis drains as a reservoir of KPC-producing Enterobacteriaceae with a potential risk for the patients. Therefore, we decided to change the dialysis waste management. RESULTS: As a result, no KCP-producing Enterobacteriaceae were detected during the following weekly screening of the patients. CONCLUSIONS: Installation of dialysis connection units including a drain system at the patient's bedside is a comfortable way to provide water supply. In many ICUs, such dialysis drains are installed near the patients' head and directly besides the infusion systems. When the drains are not used properly, in our opinion, they pose a risk of transmission of pathogens from the drain to the patient. Our findings support the need of specific precautions.

Bibles as a possible source of pathogens in hospitals? A pilot observation.

It is a century-old tradition of furnishing Bibles in the bedside drawers of hospitalized patients. But since the books cannot be disinfected, it might be possible that bacterial pathogens survive on the bibles. The aim of this study was to determine whether Bibles in patient's rooms can act as a vehicle for the spread of nosocomial infections from one to the next patient. We took samples from 50 Bibles in various general wards of the hospital. During the same period, we took contact samples of 99 hymnals from the hospital chapel. The hospital chapel is visited by patients from all departments of the hospital. As expected, microorganisms were detected on all books. They were mainly apathogenic organisms. Molds (Aspergillus spp.) were identified on the surfaces of five books. Two Bibles showed pathogen bacteria in a low number. No invasive infections with those pathogens could be documented during the investigation period, retrospectively. In conclusion, our results do not support Bibles as a possible source of nosocomial infections.

Increased resistance of gram-negative urinary pathogens after kidney transplantation.

BACKGROUND: Urinary tract infection is the most common complication after kidney transplantation. It can cause severe sepsis and transplant loss. Emergence of drug resistance among gram-negative urinary pathogens is the current challenge for urinary tract infection treatment after kidney transplantation. METHODS: This study analyzes the antimicrobial susceptibility of gram-negative urinary pathogens after kidney transplantation from 2009 to 2012 at the Transplant Outpatient Clinic of the University Hospital Essen, Germany. Kidney transplant patients at the University Hospital Essen receive regular follow up examinations after transplantation. Midstream urines were examined for bacteriuria at each follow up visit. RESULTS: From 2009 to 2012 15.741 urine samples were obtained from 859 patients. In 2985 (19%) samples bacterial growth was detected. The most frequently detected gram-negative bacteria were E.coli 1109 (37%), Klebsiella spp. 242 (8%) and Pseudomonas aeruginosa 136 (4.5%). Klebsiella spp. showed a significant increase of resistance to trimethoprim-sulfamethoxazole by 19% (p = 0.02), ciprofloxacin by 15% (p = 0.01) and ceftazidime by 17% (p = 0.004). E.coli and P. aeruginosa isolates presented no significant differences of antimicrobial susceptibility to the analyzed antibiotics. CONCLUSIONS: Antimicrobial resistance of Klebsiella spp. increased significant to trimethoprim-sulfamethoxazole, ciprofloxacin and ceftazidime from 2009 to 2012.

Aflatoxin exposure may not play a role in liver cancer development in Mongolia.

BACKGROUND/AIMS: The incidence of hepatocellular carcinoma (HCC) in Mongolia is growing at an alarming rate. Traditional dried food was suggested as the major reason for high HCC numbers, due to possible aflatoxin contamination during manufacturing. We thus aimed to measure aflatoxin concentrations in Mongolian food samples. METHODS: Samples of traditional Mongolian food ('aaruul', dried meat, and dried noodles; in total 11 samples) were collected and shipped to Germany. The food samples were analyzed for aflatoxins by extraction, immunoaffinity purification, and subsequent HPLC with fluorescence detection. RESULTS: The traditional Mongolian food samples did not contain any detectable amounts of aflatoxin. CONCLUSION: Since Mongolian food does not contain aflatoxins, the cause for the increasing HCC incidence in Mongolia is probably due to a high prevalence of viral hepatitides. Further studies to identify the reason for this development are warranted.

Molecular characterization of vancomycin-resistant Enterococcus faecium isolates from two German hospitals.

Introduction: Vancomycin-resistant Enterococcus faecium accounts for around 10-23% of nosocomial enterococcal infections and constitutes a relevant therapeutic problem due to its limited susceptibility to antibiotics. The resistance towards glycopeptide antibiotics is mediated by the so-called van genes. Currently, the most common resistance type in Germany is the vanB-type. Little data are available on the molecular epidemiology in Germany. Therefore, an epidemiological typing of Enterococcus faecium isolates with vanB-type resistance from two German hospitals in Essen and Nuremberg was performed. Two outbreaks and 104 sporadic cases were investigated. Methods: All 128 isolates with vanB-type resistance were collected between 2011-2012 and 2017-2018. They were characterized using multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE). Results: ST 117 was the most common sequence type (ST) in both hospitals, especially since 2017. PFGE divided the isolates of this study into 68 PFGE types and showed a broad genetic diversity. Two epidemiologically assumed in-hospital outbreaks were genetically confirmed. Apart from that, in-hospital transmissions were rare events. Conclusion: The results obtained by MLST confirmed the previously described allocation of STs in Germany. PFGE showed a broad genetic diversity of vanB VRE between the two hospitals and also within each hospital. In-hospital transmissions were rare, but outbreaks did occur. Our data supports the strategy to screen and isolate patients in transmission events in order to detect monoclonality indicating a common source or hygiene mismanagement.

SARS-CoV-2 Seroprevalence in Healthcare Workers in Germany: A Follow-Up Study.

SARS-CoV-2 is a worldwide challenge for the medical sector. Healthcare workers (HCW) are a cohort vulnerable to SARS-CoV-2 infection due to frequent and close contact with COVID-19 patients. However, they are also well trained and equipped with protective gear. The SARS-CoV-2 IgG antibody status was assessed at three different time points in 450 HCW of the University Hospital Essen in Germany. HCW were stratified according to contact frequencies with COVID-19 patients in (I) a high-risk group with daily contacts with known COVID-19 patients (n = 338), (II) an intermediate-risk group with daily contacts with non-COVID-19 patients (n = 78), and (III) a low-risk group without patient contacts (n = 34). The overall seroprevalence increased from 2.2% in March-May to 4.0% in June-July to 5.1% in October-December. The SARS-CoV-2 IgG detection rate was not significantly different between the high-risk group (1.8%; 3.8%; 5.5%), the intermediate-risk group (5.1%; 6.3%; 6.1%), and the low-risk group (0%, 0%, 0%). The overall SARS-CoV-2 seroprevalence remained low in HCW in western Germany one year after the outbreak of COVID-19 in Germany, and hygiene standards seemed to be effective in preventing patient-to-staff virus transmission.

SARS-CoV-2-specific antibody detection in healthcare workers in Germany with direct contact to COVID-19 patients.

BACKGROUND: The novel coronavirus SARS-CoV-2 is associated with a severe respiratory manifestation, COVID-19, and presents a challenge for healthcare systems worldwide. Healthcare workers are a vulnerable cohort for SARS-CoV-2 infection due to frequent and close contact to patients with COVID-19. STUDY DESIGN: Serum samples from 316 healthcare workers of the University Hospital Essen, Germany were tested for SARS-CoV-2-IgG antibodies. A questionnaire was used to collect demographic and clinical data. Healthcare workers were grouped depending on the frequency of contact to COVID-19 patients in high-risk-group (n = 244) with daily contact to known or suspected SARS-CoV-2 positive patients, intermediated-risk-group (n = 37) with daily contact to patients without known or suspected SARS-CoV-2 infection at admission and low-risk-group (n = 35) without patient contact. RESULTS: In 5 of 316 (1.6 %) healthcare workers SARS-CoV-2-IgG antibodies could be detected. The seroprevalence was higher in the intermediate-risk-group vs. high-risk-group (2/37 (5.4 %) vs. 3/244 (1.2 %), p = 0.13). Four of the five subject were tested negative for SARS-CoV-2 via PCR. One (20 %) subject was not tested via PCR since he was asymptomatic. CONCLUSION: The overall seroprevalence of SARS-CoV-2 in healthcare workers of a tertiary hospital in Germany is low (1.6 %). The data indicate that the local hygiene standard might be effective.

Microbiological contamination of ear, nose and throat (ENT) units.

Aim: In ENT (Ear, Nose and Throat) treatment units, medical devices for examination are commonly stored on open trays. The aim of this study is to investigate whether open storage is a relevant cause for microbiological contamination of ENT instruments during a working day. Methods: Qualitative and quantitative tests, such as imprints and swabs, were performed on the instruments and the surfaces of the treatment units in an ENT outpatient clinic at the beginning and at the end of consultation hours. The microbiological analysis of the samples focused on potential pathogens, e.g., Staphylococcus aureus or Pseudomonas aeruginosa, bacteria of skin and oral microbiota, as well as the number of colony forming units (CFU). The samples were collected at three distinct ENT treatment units over five working days. Results: The samples taken at the beginning of consultation hours showed a low number of CFU and no pathogens. Overall, 5% of the instruments were contaminated with bacteria of skin microbiota. At the end of a working day, this rate increased significantly to 17.5% (p<0.01). At the beginning of the working day, the mean number on the instrument trays was 4 CFU/25 cm², which increased to 34 CFU/25 cm² at the end of the working day. In some cases of the imprints taken at the end of the working day showed that a bacterial lawn had formed. In two cases, the pathogens Ralstonia picketii and Enterobacter cloacae were detected; in another case Bacillus spp. was identified. The contamination of ENT instruments and the ENT treatment unit increased significantly (p<0.01) over the duration of consultation hours. Conclusion: The results show that the current hygiene requirements for storage und reprocessing are not sufficient to conform to the mandatory guidelines of the German Commission on Hospital Hygiene and Infection Prevention. Although we could not find a pressing risk for the patients, we also cannot exclude it in the long term. Thus, new concepts are needed.

Nosokomiale Scabies: Ausbruch bei Personal einer Universitätsklinik.

INTRODUCTION: Outbreaks of scabies are common in community facilities, but rare in hospitals. We report the outbreak of scabies infestations in health care workers in a tertiary care hospital. DESCRIPTION OF THE OUTBREAK: Five staff members developed a scabies infestation, confirmed by a dermatologist. The scabies was acquired obviously while treating a severe ill ICU patient, no other source of the infection could be detected. THERAPY: All staff members were treated with Permethrine and Ivermectine. DISCUSSION: The immunocompromised index patient had undergone antiscabious treatment several months before she was admitted to the ICU, but due to the close physical contact with the staff in the ICU transmissions of mite occurred obviously.This case underlines that scabies may remain contagious over a long period even after an appropriate treatment of a well-known patient. Especially in the conditions of an ICU environment, appropriate personal protective measures are required for a long period of time.

Antibiotic resistance: What is so special about multidrug-resistant Gram-negative bacteria?

In the past years infections caused by multidrug-resistant Gram-negative bacteria have dramatically increased in all parts of the world. This consensus paper is based on presentations, subsequent discussions and an appraisal of current literature by a panel of international experts invited by the Rudolf Schülke Stiftung, Hamburg. It deals with the epidemiology and the inherent properties of Gram-negative bacteria, elucidating the patterns of the spread of antibiotic resistance, highlighting reservoirs as well as transmission pathways and risk factors for infection, mortality, treatment and prevention options as well as the consequences of their prevalence in livestock. Following a global, One Health approach and based on the evaluation of the existing knowledge about these pathogens, this paper gives recommendations for prevention and infection control measures as well as proposals for various target groups to tackle the threats posed by Gram-negative bacteria and prevent the spread and emergence of new antibiotic resistances.

The steady-state pharmacokinetics of nelfinavir in combination with tenofovir in HIV-infected patients.

BACKGROUND: The nucleotide analogue, tenofovir, has been shown to lower plasma atazanavir levels in pharmacokinetic trials, an interaction that may be partly reversed by the addition of ritonavir, whereas plasma tenofovir levels are themselves raised when the drug is combined with lopinavir/ritonavir. OBJECTIVE: To investigate the effect of tenofovir coadministration on the steady-state pharmacokinetics of nelfinavir in HIV-infected patients. METHODS: Eighteen patients received nelfinavir 1250 mg twice daily plus prescribed nucleoside reverse transcriptase inhibitors for at least 14 days, with pharmacokinetic measurements performed on day 15. Treatment with nelfinavir was continued for another 7 days with the addition of 300 mg tenofovir once daily. Pharmacokinetic measurements were repeated on day 22. Plasma samples were analysed by liquid chromatography-tandem mass spectrometry for nelfinavir, its primary metabolite, M8, and tenofovir. The parameters AUC0-12, C0, Cmax and Tmax were compared for nelfinavir with and without tenofovir by calculating geometric mean ratios (GMRs) of the pharmacokinetic parameters with associated 95% confidence intervals (95% CIs). Safety was assessed throughout the study. RESULTS: The addition of tenofovir to the nelfinavir-based regimen had no effect on the pharmacokinetics of nelfinavir. The GMR of the nelfinavir AUC0-12 values was 0.97 (95% CI: 0.80-1.17). There was a slight decrease in M8 metabolite (AUC0-12 ratio, 0.87; 95% CI: 0.68-1.11) but this was not significant. No serious adverse events occurred through the study period. CONCLUSION: Nelfinavir does not require dose adjustment when coadministered with tenofovir and appears to be well-tolerated by HIV-infected patients.

T-cell function after interleukin-2 therapy in HIV-infected patients is correlated with serum cortisol concentrations.

OBJECTIVES: To examine the effects of interleukin (IL)-2 therapy on in-vitro lymphocyte responsiveness in HIV-infected patients and to correlate these data with serum cortisol concentrations. DESIGN: German prospective study. METHODS: In adult patients (n = 32) treated with 9 x 10(6) IU/day interleukin-2, lymphocyte transformation tests (LTT), serum cortisol concentrations and CD4 T-cell counts were assessed before, during and after IL-2 therapy. RESULTS: A significant decrease in responses towards mitogens and recall antigens (P < 0.05) was observed on day 7 after starting a 4- to 5-day IL-2 therapy as compared to baseline. Serum cortisol levels increased (P < 0.0001) reaching a maximum on day 4, and were still elevated on day 7 (P < 0.005). CD4 T-cell counts significantly decreased with a minimum on day 2 before increasing 2.4-fold above baseline on day 7 (P < 0.005 each). A positive correlation (P < 0.05 each) was observed for changes in cortisol levels and in LTT mitogen and antigen reactions (both day 7 - 0), changes in cortisol levels (day 3 - 0) and CD4 cell counts on day 2, and corticotrophin releasing hormone test results and LTT antigen reactions on day 7. LTT responses, cortisol levels and CD4 T-cell counts returned to baseline on day 30. CONCLUSION: Serum cortisol concentrations are predictive of functional and numerical changes of T cells induced by IL-2 therapy.

[Cardiac manifestations in HIV-infected individual]. / Kardiale Manifestationen der HIV-Infektion.

The human immunodeficiency virus (HIV) does not only affect the immune system. Other organs including the cardiovascular system are influenced by the HIV as well. Most common HIV-associated cardiac manifestations are pericardial effusion and chronic active, focal or diffuse myocarditis. In addition to peri- and myocardial disease, endocardiac manifestations occur as infective endocarditis and nonbacterial thrombotic endocarditis in HIV-infected patients. Although most of the cardiac manifestations associated with HIV-infection exhibit a slow progression, rapid courses may lead to fatal complications. Early screening of HIV-infected patients will identify the potentially fatal complications of HIV disease and permit efficient treatment. The use of highly active antiretroviral therapy (HAART) significantly reduced the mortality and morbidity of HIV-infected patients. However, the impact that HAART will have on the incidence and prevalence of cardiac complications in HIV-infected patients is still unknown. It can be predicted, that the long-term viral infection and the increase of cardiovascular risk factors by HAART will probably lead to an increased prevalence of HIV-infected individuals with cardiac complications in the next decade. The present review describes the most frequent HIV-associated cardiac manifestations including diagnostic and therapeutic perspectives.

Refurbishment works in a hospital during normal operation.

BACKGROUND: Construction and renovation work in hospitals pose risks of fungal airborne infections for immunosuppressed patients. If possible, reconstruction work will be postponed to periods without patient treatment. However, in many situations urgent damage demands immediate refurbishment works before the transferring of patients to other wards or closure of wards is possible. Reported here are infection control related measures and implemented procedures after two incidents of water damage which occurred on a surgical ward and an intensive care unit at the University hospital of Essen. METHODS: Between January and April 2009 and between September and October 2009, respectively, concentration of air-borne particles and number of viable fungi were measured at two surgical wards and one ICU. Preventive Infection Control Measures included erection of protective walls and HEPA filtration of air from the renovation area. RESULTS: During the renovation work on the surgical ward concentrations of moulds and particles ≥5 µm were significantly higher on the left side of the renovation area than on the right side (p=0.036 and p<0.001). Concentrations of particles ≥1 µm and particles ≥5 µm on both sides of the renovation area were significantly increased when compared with the control ward on the same floor but not when compared with the control ward on the other floor. Particles of all size were significantly elevated on the ICU during the renovation work. Aspergillus fumigatus could neither be cultured of the air of cardiac surgery intensive care unit nor of the intermediate care unit (control ward). During renovation works there was no nosocomial mould infection of patients treated on the two wards. CONCLUSION: Provided that the renovation area is tightly insulated from the areas of patient care on a ward, closure does not seem to be necessary during renovation works because variation of airborne fungi is similar to that of outdoor or control air. However a multidisciplinary team should be established. This team should perform risk assessment and determine necessary protective measures before starting any construction, renovation or maintenance work in health care settings.

Outcome after orthotopic liver transplantation in five HIV-infected patients with virus hepatitis-induced cirrhosis.

BACKGROUND: We report on our experiences with orthotopic liver transplantation (OLT) in HIV-infected patients. Between July 1998 and October 2001, five HIV-infected patients underwent OLT because of virus-induced liver cirrhosis. One patient suffered from hepatitis B virus (HBV)-, three patients from hepatitis C virus (HCV)- and one patient from HCV/HBV/HDV-related cirrhosis (HDV, hepatitis D virus). The mean duration of HIV infection was 15 years. Patients were prospectively followed up with a mean duration of 25.6 months. RESULTS: Three patients died 3, 10 and 31 months after OLT, respectively, due to graft failure. The causes of graft failure were: recurrent thrombosis of the hepatic artery, HCV-associated cholestatic hepatitis and chemotherapy-induced liver damage due to Hodgkin's disease, which was diagnosed 17 months after OLT, in addition to chronic HCV disease. The two survivors show a stable liver function and non-progredient HIV infection under antiretroviral therapy 61 and 23 months after OLT, respectively. CONCLUSIONS: A medium- or even long-term survival after OLT can be achieved in HIV-infected patients without progression of HIV disease under antiretroviral therapy. However, in our study three out of five patients died due to graft failure. Therefore, prognostic criteria have to be defined for the selection of HIV-infected patients, who may benefit from OLT.

Progressive multifocal leukencephalopathy in patients on highly active antiretroviral therapy: survival and risk factors of death.

OBJECTIVE: To describe the clinical course and risk factors of death in highly active antiretroviral therapy (HAART)-treated patients with progressive multifocal leukencephalopathy (PML); to evaluate the efficacy of cidofovir in addition to HAART. METHODS: Retrospective multicenter cohort study of PML in HIV-1-infected patients. Diagnosis of PML was confirmed by histology or by positive polymerase chain reaction for JC virus (JCV) in cerebrospinal fluid (CSF) or was made by typical radiologic and clinical findings. RESULTS: Thirty-five cases of PML were identified. The diagnosis was made by histology (9 cases), detection of JCV in CSF (17 cases), and by radiologic findings (9 cases). Upon manifestation of PML, 15/35 patients had never received HAART, and 11/35 were on HAART for >6 months (median 1126 days). In 9/35 cases, clinical manifestation of PML occurred within 6 months after initiation of HAART. All patients received HAART after PML diagnosis. After a median follow-up of 553 days (range 28-2694 days), the median survival time was not reached. In 12 patients who were treated concomitantly with cidofovir, cumulative survival was significantly shorter than in patients without cidofovir (P = 0.03). Patients in whom PML was diagnosed while on HAART demonstrated a trend toward a shorter survival than HAART-naive patients (P = 0.15). CONCLUSIONS: PML continues to occur in HIV-1-infected patients even when they are treated with HAART. Patients developing PML on HAART had a trend toward a shorter median survival compared with treatment-naive patients, and cidofovir therapy was not associated with improved survival in this cohort.