Colonization with third-generation cephalosporin-resistant Enterobacteriaceae on hospital admission: prevalence and risk factors.

OBJECTIVES: The objectives of this study were to prospectively assess the rectal carriage rate of third-generation cephalosporin-resistant Enterobacteriaceae (3GCREB) in non-ICU patients on hospital admission and to investigate resistance mechanisms and risk factors for carriage. METHODS: Adult patients were screened for 3GCREB carriage at six German tertiary care hospitals in 2014 using rectal swabs or stool samples. 3GCREB isolates were characterized by phenotypic and molecular methods. Each patient answered a questionnaire about potential risk factors for colonization with MDR organisms (MDROs). Univariable and multivariable risk factor analyses were performed to identify factors associated with 3GCREB carriage. RESULTS: Of 4376 patients, 416 (9.5%) were 3GCREB carriers. Escherichia coli was the predominant species (79.1%). ESBLs of the CTX-M-1 group (67.3%) and the CTX-M-9 group (16.8%) were the most frequent ß-lactamases. Five patients (0.11%) were colonized with carbapenemase-producing Enterobacteriaceae. The following risk factors were significantly associated with 3GCREB colonization in the multivariable analysis (P < 0.05): centre; previous MDRO colonization (OR = 2.12); antibiotic use within the previous 6 months (OR = 2.09); travel outside Europe (OR = 2.24); stay in a long-term care facility (OR = 1.33); and treatment of gastroesophageal reflux disease (GERD) (OR = 1.22). CONCLUSIONS: To our knowledge, this is the largest admission prevalence study of 3GCREB in Europe. The observed prevalence of 9.5% 3GCREB carriage was higher than previously reported and differed significantly among centres. In addition to previously identified risk factors, the treatment of GERD proved to be an independent risk factor for 3GCREB colonization.

Background paper to the recommendation for routine rotavirus vaccination of infants in Germany.

Two rotavirus (RV) vaccines were introduced to the European market in 2006. To support the decision-making process of the German Standing Committee on Vaccination ("Ständige Impfkommission", STIKO) regarding adoption of routine RV vaccination into the national vaccination schedule in Germany relevant scientific background was reviewed. According to STIKO's Standard Operating Procedures for the development of evidence-based vaccination recommendations, a set of key questions was addressed and systematic reviews were performed with a focus on the efficacy, effectiveness, impact and safety of RV vaccines. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to assess the quality of available evidence. Data from 5 randomized controlled trials demonstrated a high efficacy of RV vaccines in preventing severe RV-associated gastroenteritis (91%) and hospitalization (92%) in settings comparable to Germany. Post-marketing observational studies confirmed these findings. In several countries, impact studies suggest that age groups not eligible for vaccination might also benefit from herd effects and demonstrated a decrease in the number of nosocomial RV infections after RV vaccine introduction. The vaccines were considered safe, except for a slightly increased risk of intussusception shortly after the first dose, corresponding to 1-2 additional cases per 100,000 infants vaccinated (relative risk =1.21, 95% confidence interval [CI] 0.68-2.14). RV case-fatality is extremely low in Germany. However, RV incidence among children aged <5 years is high (reported 8-14 cases per 1000 children annually), and of these almost half require hositalization. In view of the available evidence and expected benefits, STIKO recommends routine rotavirus vaccination of children under the age of 6 months with the main goal of preventing RV-associated hospitalizations in Germany, especially among infants and young children.

Changes to the varicella and pertussis immunisation schedule in Germany 2009: background, rationale and implementation.

In July 2009, the German Standing Committee on Vaccination (STIKO) modified its recommendations for varicella and pertussis vaccination, based on newly available data on disease epidemiology, vaccine effectiveness (VE) and safety, and an evaluation of the feasibility of the recommended immunisation strategy. The recommendation for varicella vaccine now includes a routine two-dose schedule with the administration of the first dose at the age of 11 to 14 months and the second dose at the age of 15 to 23 months, with a minimum interval of four weeks between these doses. Furthermore, STIKO recommended adding a one-time pertussis booster to the adult vaccination schedule to expand the cocoon strategy in place since 2004. The recommendation of a booster vaccination with an acellular pertussis vaccine every 10 years for persons employed in the care of pre-school children and for healthcare personnel in paediatric, gynaecologic and obstetric health facilities was extended to persons employed in schools and in other institutions caring for older children, and to all healthcare personnel. These recommendations were based on available epidemiological data showing an increase in incidence from 7-10 cases per 100,000 inhabitants in 2002-2004 to over 30 by 2007. Moreover, the high burden of pertussis in infants at 94 hospitalised cases per 100,000 infants in 2007 suggested that the previous cocoon strategy was insufficient.

Comparative varicella vaccine effectiveness during outbreaks in day-care centres.

BACKGROUND: Routine varicella vaccination for children >11 months was introduced in Germany in 2004 with three different vaccine brands available. In 2008 and 2009, we investigated seven varicella outbreaks in day-care centres (DCC). METHODS: Varicella disease and vaccination status of 1084 children was reviewed to evaluate vaccination coverage (VC), brand-specific varicella vaccine effectiveness (VE), and risk factors of breakthrough varicella (BV, >42 days after vaccination). A case was defined as a child with acute onset of varicella attending one of the respective DCC at the time of outbreak. Children with a previous history of varicella, age<11 months, vaccinated at age<11 months or <42 days before disease onset or during the outbreak were excluded from VE and BV risk factors analyses (adjusted for gender, age and DCC). FINDINGS: Of 631 children with available vaccination information, 392 (62%) were vaccinated at least once. Overall VE among 352 children eligible was 71% (95% confidence interval (CI) 57-81, p<0.001) and differed significantly by disease severity and number of doses administered. Risk for BV was higher for 1 dose of Varilrix (RR=2.8, 95%CI 1.0-7.8, p=0.05) or Priorix-Tetra (RR=2.4, 95%CI 0.7-8.3, p=0.18) but lower for 2 doses of Priorix-Tetra (RR=0.5, 95%CI 0.1-2.7, p=0.41) than for 1 dose of Varivax. INTERPRETATION: Enhanced efforts to increase VC in Germany and 2 doses varicella vaccine might be successful to reduce the risk for BV. The evidence that VE and risk of BV are associated with vaccine brand needs further investigation.

Needs and obstacles of uniform immunisation schedules in the European Union.

Immunisation schedules are developed by national committees on immunisation and may differ considerably between the European Union (EU) member states (MS). The European Commission has launched an initiative for a council recommendation with the aim to establish a scientifically substantiated reference childhood immunisation schedule for the EU. In our view this initiative implies the establishment of one European childhood immunisation schedule, which could lead to the perception that this schedule is the only one scientifically justified. The expectations that one uniform immunisation schedule will facilitate mobility of EU residents, improve data collection and increase vaccination coverage are either quantitatively or qualitatively not relevant or even ethically problematic. Arguments that uniform schedules would lead to lower vaccine prices and reduce the need for clinical trials appear to be more relevant but could be addressed more effectively by other measures. On the other hand the following factors may differ substantially between MS and thus support different immunisation schedules, such as (a) values and goals, (b) epidemiological situation, (c) health care delivery system, (d) logistics of vaccine delivery and (e) economic situation. We argue that uniform schedules should not be perceived as a goal in itself but rather as a possibly desired by-product following increasing agreement on goals and values between MS and improved evidence base to be used by national committees on immunisation.

[Community-based MRSA. A new challenge for dermatology]. / Community MRSA. Eine neue Herausforderung für die Dermatologie.

Treatment options for infections with MRSA are extremely limited because of resistance to all beta-lactam antibiotics and primarily because of the fast acquisition of further antibiotic resistance. During the past six years MRSA possessing the genomic determinant of an additional virulence factor emerged. This virulence factor, Panton-Valentine-Leukocidin, seems to be responsible for deep skin infections as well as necrotizing pneumonia. In order to avoid a continuous spread of MRSA, consequent prevention measures both in dermatological practices and for colonized patients in their general environment are essential.