Hadaean to Palaeoarchaean stagnant-lid tectonics revealed by zircon magnetism.

Plate tectonics is a fundamental factor in the sustained habitability of Earth, but its time of onset is unknown, with ages ranging from the Hadaean to Proterozoic eons1-3. Plate motion is a key diagnostic to distinguish between plate and stagnant-lid tectonics, but palaeomagnetic tests have been thwarted because the planet's oldest extant rocks have been metamorphosed and/or deformed4. Herein, we report palaeointensity data from Hadaean-age to Mesoarchaean-age single detrital zircons bearing primary magnetite inclusions from the Barberton Greenstone Belt of South Africa5. These reveal a pattern of palaeointensities from the Eoarchaean (about 3.9 billion years ago (Ga)) to Mesoarchaean (about 3.3 Ga) eras that is nearly identical to that defined by primary magnetizations from the Jack Hills (JH; Western Australia)6,7, further demonstrating the recording fidelity of select detrital zircons. Moreover, palaeofield values are nearly constant between about 3.9 Ga and about 3.4 Ga. This indicates unvarying latitudes, an observation distinct from plate tectonics of the past 600 million years (Myr) but predicted by stagnant-lid convection. If life originated by the Eoarchaean8, and persisted to the occurrence of stromatolites half a billion years later9, it did so when Earth was in a stagnant-lid regime, without plate-tectonics-driven geochemical cycling.

Patient Blood Management in Liver Transplant-A Concise Review.

Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.

Iron-mediated anaerobic ammonium oxidation recorded in the early Archean ferruginous ocean.

The nitrogen isotopic composition of organic matter is controlled by metabolic activity and redox speciation and has therefore largely been used to uncover the early evolution of life and ocean oxygenation. Specifically, positive δ15 N values found in well-preserved sedimentary rocks are often interpreted as reflecting the stability of a nitrate pool sustained by water column partial oxygenation. This study adds much-needed data to the sparse Paleoarchean record, providing carbon and nitrogen concentrations and isotopic compositions for more than fifty samples from the 3.4 Ga Buck Reef Chert sedimentary deposit (BRC, Barberton Greenstone Belt). In the overall anoxic and ferruginous conditions of the BRC depositional environment, these samples yield positive δ15 N values up to +6.1‰. We argue that without a stable pool of nitrates, these values are best explained by non-quantitative oxidation of ammonium via the Feammox pathway, a metabolic co-cycling between iron and nitrogen through the oxidation of ammonium in the presence of iron oxides. Our data contribute to the understanding of how the nitrogen cycle operated under reducing, anoxic, and ferruginous conditions, which are relevant to most of the Archean. Most importantly, they invite to carefully consider the meaning of positive δ15 N signatures in Archean sediments.

Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS).

BACKGROUND: Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established. OBJECTIVE: To develop consensus recommendations for anemia management in surgical patients. METHODS: An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology. RESULTS: The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period. CONCLUSIONS: Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.

Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals.

Background: Red blood cell (RBC) transfusions in surgical patients are associated with increased morbidity a hospital stay. However, little is known about how clinical and economic outcomes differ between appropriately and inappropriately transfused patients. We hypothesized that inappropriate RBC transfusions in elective surgical patients would significantly increase hospital cost. The aim of this study was to quantify the economic burden associated with inappropriate RBC transfusions. Methods: We retrospectively included all adult patients admitted for elective non-cardiac surgery between January 2014 and March 2020. Patients were divided into three groups (not transfused, appropriately transfused and inappropriately transfused). The primary outcome was the excess in hospital cost in patients inappropriately transfused compared to non-transfused patients. Costs were calculated using a bottom-up approach and involving cost calculation on a granular level. According to international guidelines, transfusions were considered appropriate if administered with an ASA score of 1-2 and the last hemoglobin level measured before transfusion < 70 g/L, or with an ASA score ≥ 3 and the last hemoglobin level < 80 g/L. Cases where RBC transfusions were deemed necessary regardless of the Hb levels were reviewed by the patient blood management (PBM) board and classified accordingly. Secondary outcomes included total transfusion rate, transfusion index, and length of hospital stay. Statistical analysis was carried out by multivariable regression models. Results: During the study period there were 54,922 consecutive surgical admissions, of these 1,997 received an RBC transfusion, with 1,125 considered inappropriate. The adjusted cost of each inappropriate RBC transfusions was estimated in United States dollars (USD) 9,779 (95% CI, 9,358 - 10,199; p < 0.001) and totaled USD 11,001,410 in our series. Inappropriately transfused patients stayed 1.6 times (95% CI, 1.5-1.6; p < 0.001) longer in hospital (10.6 days vs. 6.7 days) than non-transfused patients and a mean 2.35 RBC units per patient were administered. Conclusion: Inappropriate RBC transfusions in elective surgical patients seem to be common and may represent a significant economic burden. In our experience, inappropriate transfusions significantly increased hospital costs by an average of USD 9,779 compared to non-transfused patients. Through specific PBM policy, hospitals may improve cost-effectiveness of their elective surgical activity by lowering inappropriate transfusions.

Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up?

Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.

Machine learning-based prediction of massive perioperative allogeneic blood transfusion in cardiac surgery.

BACKGROUND: Massive perioperative allogeneic blood transfusion, that is, perioperative transfusion of more than 10 units of packed red blood cells (pRBC), is one of the main contributors to perioperative morbidity and mortality in cardiac surgery. Prediction of perioperative blood transfusion might enable preemptive treatment strategies to reduce risk and improve patient outcomes while reducing resource utilisation. We, therefore, investigated the precision of five different machine learning algorithms to predict the occurrence of massive perioperative allogeneic blood transfusion in cardiac surgery at our centre. OBJECTIVE: Is it possible to predict massive perioperative allogeneic blood transfusion using machine learning? DESIGN: Retrospective, observational study. SETTING: Single adult cardiac surgery centre in Austria between 01 January 2010 and 31 December 2019. PATIENTS: Patients undergoing cardiac surgery. MAIN OUTCOME MEASURES: Primary outcome measures were the number of patients receiving at least 10 units pRBC, the area under the curve for the receiver operating characteristics curve, the F1 score, and the negative-predictive (NPV) and positive-predictive values (PPV) of the five machine learning algorithms used to predict massive perioperative allogeneic blood transfusion. RESULTS: A total of 3782 (1124 female:) patients were enrolled and 139 received at least 10 pRBC units. Using all features available at hospital admission, massive perioperative allogeneic blood transfusion could be excluded rather accurately. The best area under the curve was achieved by Random Forests: 0.810 (0.76 to 0.86) with high NPV of 0.99). This was still true using only the eight most important features [area under the curve 0.800 (0.75 to 0.85)]. CONCLUSION: Machine learning models may provide clinical decision support as to which patients to focus on for perioperative preventive treatment in order to preemptively reduce massive perioperative allogeneic blood transfusion by predicting, which patients are not at risk. TRIAL REGISTRATION: Johannes Kepler University Ethics Committee Study Number 1091/2021, Clinicaltrials.gov identifier NCT04856618.

Dissemination of patient blood management practices in Swiss intensive care units: a cross-sectional survey.

BACKGROUND: Patient blood management (PBM) promotes the routine detection and treatment of anaemia before surgery, optimising the management of bleeding disorders, thus minimising iatrogenic blood loss and pre-empting allogeneic blood utilisation. PBM programmes have expanded from the elective surgical setting to nonsurgical patients, including those in intensive care units (ICUs), but their dissemination in a whole country is unknown. METHODS: We performed a cross-sectional, anonymous survey (10 October 2018 to 13 March 2019) of all ordinary medical members of the Swiss Society of Intensive Care Medicine and the registered ICU nurses from the 77 certified adult Swiss ICUs. We analysed PBM-related interventions adopted in Swiss ICUs and related them to the spread of PBM in Swiss hospitals. We explored blood test ordering policies, blood-sparing strategies and red blood cell-related transfusion practices in ICUs. RESULTS: A total of 115 medical doctors and 624 nurses (response rates 27% and 30%, respectively) completed the surveys. Hospitals had implemented a PBM programme according to 42% of physicians, more commonly in Switzerland's German-speaking regions (Odds Ratio [OR] 3.39, 95% confidence interval [CI] 1.23-9.35; p = 0.018) and in hospitals with more than 500 beds (OR 3.91, 95% CI 1.48-10.4; p = 0.006). The PBM programmes targeted the detection and correction of anaemia before surgery (79%), minimising perioperative blood loss (94%) and optimising anaemia tolerance (98%). Laboratory tests were ordered in 70.4% by the intensivist during morning rounds; the nurses performed arterial blood gas analyses autonomously in 48.4%. Blood-sparing techniques were used by only 42.1% of nurses (263 of 624, missing: 6) and 47.0% of physicians (54 of 115). Approximately 60% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin threshold for the nonbleeding ICU population was 70 g/l and, therefore, was at the lower limit of current guidelines. CONCLUSIONS: Based on this survey, the estimated proportion of the intensivists working in hospitals with a PBM initiative is 42%, with significant variability between regions and hospitals of various sizes. The risk of iatrogenic anaemia is relevant due to liberal blood sample collection practices and the underuse of blood-sparing techniques. The reported transfusion threshold suggests excellent adherence to current international ICU-specific transfusion guidelines.

Patient blood management in oncology in the Russian Federation: Resolution to improve oncology care.

There is accumulating evidence that anemia and iron deficiency, thrombocytopenia, blood loss and coagulopathy are independent risk factors for adverse patient outcomes in oncology and other settings. Patient blood management (PBM) aims to address these factors by managing and preserving a patient's blood. PBM improves patient health, but also reduces resource utilization, including use of allogeneic blood components, which is another risk factor for adverse outcomes. Supported by the World Health Organization and endorsed in WHA63.12, PBM is recommended by an increasing number of health authorities and is about to become a new standard of care. In support of the Russian National Long-Term Oncology Strategy 2030 to improve quality of oncological care, and with support from the National Association of Specialists in PBM, the PBM Oncology Working Group of the Russian Federation was created. In July 2020, this Group met to discuss the rationale and need for PBM in Russian oncology care. The Group recommended to include PBM as an integral part of standard oncology treatment pathways and developed a national resolution as a call to action on this matter, which was adopted in August 2020. This article details the rationale behind the resolution, delineates the action required from facilitating stakeholders (government; healthcare providers; educational facilities; research entities/institutions; funders; patient representatives/advocates), and proposes a roadmap for implementation. The generation of local health-economic and outcome data and the development of educational programs will be important in the implementation of PBM to help alleviate the health, social and economic burden of cancer.

The onset of deep recycling of supracrustal materials at the Paleo-Mesoarchean boundary.

The recycling of supracrustal materials, and in particular hydrated rocks, has a profound impact on mantle composition and thus on the formation of continental crust, because water modifies the physical properties of lithological systems and the mechanisms of partial melting and fractional fractionation. On the modern Earth, plate tectonics offers an efficient mechanism for mass transport from the Earth's surface to its interior, but how far this mechanism dates back in the Earth's history is still uncertain. Here, we use zircon oxygen (O) isotopes to track recycling of supracrustal materials into the magma sources of early Archean igneous suites from the Kaapvaal Craton, southern Africa. The mean δ 18O values of zircon from TTG (tonalite-trondhjemite-granodiorite) rocks abruptly increase at the Paleo-Mesoarchean boundary (ca. 3230 million years ago; Ma), from mantle zircon values of 5‰-6‰ to approaching 7.1‰, and this increase occurs in ≤3230 Ma rocks with elevated Dy/Yb ratios. The 18O enrichment is a unique signature of low-temperature water-rock interaction on the Earth's surface. Because the later phase was emplaced into the same crustal level as the older one and TTG magmas would derive from melting processes in the garnet stability field (>40 km depth), we suggest that this evident shift in TTG zircon O isotopic compositions records the onset of recycling of the mafic oceanic crust that underwent seawater hydrothermal alteration at low temperature. The onset of the enhanced recycling of supracrustal materials may also have developed elsewhere in other Archean cratons and reflects a significant change in the tectonic realm during craton formation and stabilization, which may be important processes for the operation of plate tectonics on early Earth.

A Global Definition of Patient Blood Management.

While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: "Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at (1) screening for, diagnosing, and appropriately treating anemia; (2) minimizing surgical, procedural, and iatrogenic blood losses and managing coagulopathic bleeding throughout the care; and (3) supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians, and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress.

Machine Learning-Based Mortality Prediction of Patients at Risk During Hospital Admission.

OBJECTIVES: The ability to predict in-hospital mortality from data available at hospital admission would identify patients at risk and thereby assist hospital-wide patient safety initiatives. Our aim was to use modern machine learning tools to predict in-hospital mortality from standardized data sets available at hospital admission. METHODS: This was a retrospective, observational study in 3 adult tertiary care hospitals in Western Australia between January 2008 and June 2017. Primary outcome measures were the area under the curve for the receiver operating characteristics curve, the F1 score, and the average precision of the 4 machine learning algorithms used: logistic regression, neural networks, random forests, and gradient boosting trees. RESULTS: Using our 4 predictive models, in-hospital mortality could be predicted satisfactorily (areas under the curve for neural networks, logistic regression, random forests, and gradient boosting trees: 0.932, 0.936, 0.935, and 0.935, respectively), with moderate F1 scores: 0.378, 0.367, 0.380, and 0.380, respectively. Average precision values were 0.312, 0.321, 0.334, and 0.323, respectively. It remains unknown whether additional features might improve our models; however, this would result in additional efforts for data acquisition in daily clinical practice. CONCLUSIONS: This study demonstrates that using only a limited, standardized data set in-hospital mortality can be predicted satisfactorily at the time point of hospital admission. More parameters describing patient's health are likely needed to improve our model.

Cellular remains in a ~3.42-billion-year-old subseafloor hydrothermal environment.

Subsurface habitats on Earth host an extensive extant biosphere and likely provided one of Earth's earliest microbial habitats. Although the site of life's emergence continues to be debated, evidence of early life provides insights into its early evolution and metabolic affinity. Here, we present the discovery of exceptionally well-preserved, ~3.42-billion-year-old putative filamentous microfossils that inhabited a paleo-subseafloor hydrothermal vein system of the Barberton greenstone belt in South Africa. The filaments colonized the walls of conduits created by low-temperature hydrothermal fluid. Combined with their morphological and chemical characteristics as investigated over a range of scales, they can be considered the oldest methanogens and/or methanotrophs that thrived in an ultramafic volcanic substrate.

A lithium-isotope perspective on the evolution of carbon and silicon cycles.

The evolution of the global carbon and silicon cycles is thought to have contributed to the long-term stability of Earth's climate1-3. Many questions remain, however, regarding the feedback mechanisms at play, and there are limited quantitative constraints on the sources and sinks of these elements in Earth's surface environments4-12. Here we argue that the lithium-isotope record can be used to track the processes controlling the long-term carbon and silicon cycles. By analysing more than 600 shallow-water marine carbonate samples from more than 100 stratigraphic units, we construct a new carbonate-based lithium-isotope record spanning the past 3 billion years. The data suggest an increase in the carbonate lithium-isotope values over time, which we propose was driven by long-term changes in the lithium-isotopic conditions of sea water, rather than by changes in the sedimentary alterations of older samples. Using a mass-balance modelling approach, we propose that the observed trend in lithium-isotope values reflects a transition from Precambrian carbon and silicon cycles to those characteristic of the modern. We speculate that this transition was linked to a gradual shift to a biologically controlled marine silicon cycle and the evolutionary radiation of land plants13,14.

Making patient blood management the new norm(al) as experienced by implementors in diverse countries.

BACKGROUND: Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds. METHODS: Semi-structured interviews were conducted with 1-4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework. RESULTS: A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration. CONCLUSION: The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need.

Activity-based cost of platelet transfusions in medical and surgical inpatients at a US hospital.

BACKGROUND AND OBJECTIVES: Previous studies by the Cost of Blood Consensus Conference (COBCON) have used a comprehensive, standardized and generalizable activity-based costing (ABC) model to estimate the cost of red blood cell transfusions and plasma transfusion. The objective of this study was to determine the total cost of platelet transfusions in a real-world US hospital inpatient setting. MATERIALS AND METHODS: This database analysis study retrospectively collected costs for all activities related to platelet transfusion in a single-acute care US teaching hospital in 2017. Costs were collected in a stepwise manner using a custom ABC model which mapped the technical, administrative and clinical processes involved in the transfusion of platelets. RESULTS: For the 15 024 inpatients included in the analysis, 6335 (42·2%) were given a blood type and screen, and 941 (6·3%) received a transfusion of one or more blood products. A total of 333 platelet units were transfused in 131 patients (mean 2·54 units per patient): 211 (63·4%) units in medical inpatients and 122 (36·6%) in surgical inpatients. The total cost was $1359·99 per platelet unit, corresponding to $3457·06 per inpatient. Acquisition costs made up the largest proportion of the total cost (45·1%) followed by direct and indirect overheads (38·7%) and hospital processes costs (16·3%). CONCLUSION: This is the first study to use an ABC costing model to determine the full cost of platelet transfusions within a US inpatient setting. This provides a useful reference point for comparisons with other transfusion products, and considerations for cost reduction.

[Multi-Resistant Bacteria in Patients in Hospitals and Medical Practices as well as in Residents of Nursing Homes in Saxony - Results of a Prevalence Study 2017/2018]. / Multiresistente Bakterien bei Patienten in Krankenhäusern und Arztpraxen sowie bei Bewohnern von Altenpflegeheimen in Sachsen ­ Ergebnisse einer Prävalenzstudie 2017/2018.

OBJECTIVE: The aim of this study was to determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), multi-resistant gram-negative bacteria (MRGN) and vancomycin-resistant enterococci (VRE) in three study groups (hospital patients, residents in nursing homes for the elderly and patients in GP practices) and additionally, risk factors for carriage of multidrug-resistant organisms (MDRO). METHODS: Screening for MDRO was performed as a point prevalence study by obtaining nasal, pharyngeal and rectal swabs or stool samples from voluntary participants in 25 hospitals, 14 nursing homes for the elderly as well as 33 medical practices in 12 of 13 districts of Saxony. Suspicious isolates were further examined phenotypically and partially by molecular methods. The participants completed a questionnaire on possible risk factors for MDRO colonisation; the data were statistically evaluated by correlation analyses. RESULTS: In total, 1,718 persons, 629 from hospitals, 498 from nursing homes and 591 from medical practices, were examined. MDRO was detected in 8.4% of all participants; 1.3% persons tested positive for MRSA, 5.2% for 3MRGN, 0.1% for 4MRGN and 2.3% for VRE. Nine persons were colonized with more than one MDRO. The following independent risk factors could be significantly associated with the detection of MDRO: presence of a degree of care (MDRO), male sex (MDRO/VRE), current antibiosis (MDRO/VRE), antibiosis within the last 6 months (MDRO/MRSA/MRGN/VRE), current tumour disease (MDRO/3MRGN), peripheral artery disease (PAD) (MRSA) as well as urinary incontinence (3MRGN). CONCLUSIONS: To our knowledge, this study represents the first survey of prevalence of different multiresistant pathogen groups in 3 study groups including outpatients in Germany. 3MRGN were the pathogens most frequently detected and were also found in patients of younger age groups. VRE were found almost exclusively in specific clinics. In addition to current and past antibiotic therapy, in particular the presence of PAD for MRSA detection, urinary incontinence for 3MRGN detection and a current tumour disease for MDRO and 3MRGN detection were determined as independent risk factors.