How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France.

BACKGROUND: Electronic health records (EHR) are becoming an integral part of the health system in many developed countries, though implementations and settings vary across countries. Some countries have adopted an opt-out policy, in which patients are enrolled in the EHR system following a default nudge, while others have applied an opt-in policy, where patients have to take action to opt into the system. While opt-in systems may exhibit lower levels of active user requests for access, this contrasts with opt-out systems where a notable percentage of users may passively retain access. Thus, our research endeavor aims to explore facilitators and barriers that contribute to explaining EHR usage (i.e., actively accessing the EHR system) in two countries with either an opt-in or opt-out setting, exemplified by France and Austria. METHODS: A qualitative exploratory approach using a semi-structured interview guideline was undertaken in both countries: 1) In Austria, with four homogenously composed group discussions, and 2) in France, with 19 single patient interviews. The data were collected from October 2020 to January 2021. RESULTS: Influencing factors were categorized into twelve subcategories. Patients have similar experiences in both countries with regard to all facilitating categories, for instance, the role of health providers, awareness of EHR and social norms. However, we highlighted important differences between the two systems regarding hurdles impeding EHR usage, namely, a lack of communication as well as transparency or information security about EHR. CONCLUSION: Implementing additional safeguards to enhance privacy protection and supporting patients to improve their digital ability may help to diminish the perception of EHR-induced barriers and improve patients' health and commitment in the long term. PRACTICAL IMPLICATIONS: Understanding the differences and similarities will help to develop practical implications to tackle the problem of low EHR usage rates in the long run. This problem is prevalent in countries with both types of EHR default settings.

Pregnancy outcomes of Fabry disease in Austria (PROFABIA)-a retrospective cohort-study.

BACKGROUND: Pregnancy and delivery outcomes in women with Fabry disease are not well described. METHODS: Retrospective cohort-study of women with Fabry disease in Austria using a specific questionnaire and the Austrian Mother-Child Health Passport. RESULTS: Out of a total of 44 enrolled women (median age at study entry 44 years, p25: 30, p75: 51), 86.4% showed signs and symptoms of Fabry disease with an increase in pain burden during pregnancy, primarily in women with moderate pain before pregnancy. Thirty-two of 44 women with Fabry disease reported a total of 70 pregnancies (median age at first pregnancy 24 years, p25: 21, p75: 31), 61 (87.1%) of which resulted in 64 live births including 3 sets of twins, six miscarriages (8.6%) in five women, and three induced abortions (4.3%) in two women. Risk factors for poor maternal and foetal outcomes during pregnancy, overrepresented in our cohort as compared to the general population, were hypertension (n = 10, 16.4%), proteinuria (n = 17, 27.9%) and smoking (n = 24, 39.3%). Preeclampsia was reported in 7 pregnancies (11.5%). Fifty-one (79.7%) children were born at term and 13 (20.3%) were preterm (including one neonatal death), with a median gestational age of 39 weeks (p25: 38, p75: 40) and delivery by C-section in 15 pregnancies (24.6%). Thirteen (20.3%) children presented with low birth weight and 18 (28.1%) were small for their gestational age. In comparison to global and national data-sets, preeclampsia, prematurity, low birth weight, being small for their gestational age as well as inpatient stay were significantly more common in patients with Fabry disease. CONCLUSIONS: Our cohort-study in women with Fabry disease shows an increase of pain burden during pregnancies and clearly points to an increased risk for preeclampsia, prematurity, and neonates small for gestational age. With a substantial number of high-risk pregnancies, neonatal outcomes are somewhat worse in Fabry disease than in the general public. Thus, we provide valuable data enabling informed decision-making in pregnancy counselling for Fabry disease.

What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland.

PURPOSE: Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries. DESIGN/METHODOLOGY/APPROACH: This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries. FINDINGS: The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries. ORIGINALITY/VALUE: Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

Updated reference values for static lung volumes from a healthy population in Austria.

BACKGROUND: Reference values for lung volumes are necessary to identify and diagnose restrictive lung diseases and hyperinflation, but the values have to be validated in the relevant population. Our aim was to investigate the Global Lung Function Initiative (GLI) reference equations in a representative healthy Austrian population and create population-derived reference equations if poor fit was observed. METHODS: We analysed spirometry and body plethysmography data from 5371 respiratory healthy subjects (6-80 years) from the Austrian LEAD Study. Fit with the GLI equations was examined using z-scores and distributions within the limits of normality. LEAD reference equations were then created using the LMS method and the generalized additive model of location shape and scale package according to GLI models. RESULTS: Good fit, defined as mean z-scores between + 0.5 and -0.5,was not observed for the GLI static lung volume equations, with mean z-scores > 0.5 for residual volume (RV), RV/TLC (total lung capacity) and TLC in both sexes, and for expiratory reserve volume (ERV) and inspiratory capacity in females. Distribution within the limits of normality were shifted to the upper limit except for ERV. Population-derived reference equations from the LEAD cohort showed superior fit for lung volumes and provided reproducible results. CONCLUSION: GLI lung volume reference equations demonstrated a poor fit for our cohort, especially in females. Therefore a new set of Austrian reference equations for static lung volumes was developed, that can be applied to both children and adults (6-80 years of age).

Burdens and resources of Austrian clinical psychologists: results of a qualitative study two years into the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic increased the mental health burden in the general population, enhancing the demands placed on mental healthcare professionals. METHODS: This study aimed to assess the burdens and resources of clinical psychologists that emerged since the beginning of the pandemic. N = 172 Austrian clinical psychologists participated in a cross-sectional online survey between April and May 2022. The burdens and the sources of support that emerged during the pandemic were analyzed using qualitative content analysis. RESULTS: Mental health-related issues were identified as the greatest burden, followed by work-related themes and restrictions imposed by the government to combat the spreading of the virus. The most important resources mentioned by the clinical psychologists were social contacts and recreational activities. Practising mindfulness and focusing on inner processes and work-related aspects were further important resources mentioned. CONCLUSION: Overall, it seems that clinical psychologists have a high awareness of mental health-related problems related to the pandemic and use adaptive coping strategies to deal with them.

Temporomandibular disorders in individuals with Marfan syndrome: an exploratory analysis.

BACKGROUND: This study aims to analyze to what extent patients with Marfan syndrome (MFS) are affected by temporomandibular disorders (TMD) and its impact on oral health-related quality of life (OHRQoL). To collect data, an online questionnaire was created to recruit participants from Germany, Austria, and Switzerland through social media and support groups. The questionnaire consists of free-text questions, the German versions of the Oral Health Impact Profile (OHIP-G14), the Depression Anxiety Stress Scale (DASS), and the Graded Chronic Pain Status (GCPS). RESULTS: A total of 76 participants with diagnosed MFS were included. Of these, 65.8% showed TMD symptoms, the most common being pain or stiffness of the masticatory muscles in the jaw angle (50.0%). Only 14.5% of the participants were already diagnosed with TMD. Of the participants with an increased likelihood of a depression disorder, 76.9% showed TMD symptoms. Of those with a critical score for an anxiety disorder, 90.9% showed TMD symptoms. 73.3% of participants with TMD symptoms reached the critical score for a stress disorder. TMD symptoms were associated with a higher risk for chronic pain. In the median, participants with TMD showed statistically notably higher OHIP-G14 scores than participants without TMD (11.5 [IQR 17] vs. 1 [IQR 3] points, p ≤ 0.001). CONCLUSION: TMD symptoms had a noticeable impact on OHRQoL in patients with MFS, i.e., chronic pain and psychological impairment. TMD seems underdiagnosed, and more research is needed to prevent the associated chronification of pain and psychological burden to improve the OHRQoL.

A new perspective on balancing life domains: work-nonwork balance crafting.

BACKGROUND: Self-initiated and proactive changes in working conditions through crafting are essential for shaping work and improving work-related well-being. Recently, the research stream of job crafting has been extended to other life domains. The present paper aims to study a novel crafting concept-work-nonwork balance crafting-investigating the role of its antecedents and identifying relevant outcomes. Work-nonwork balance crafting is defined as individuals' unofficial techniques and activities to shape their work-nonwork balance, here considering their life domain boundary preferences. METHODS: In the study, 1,060 employees in three European countries (Austria, Germany and Switzerland) were surveyed in a longitudinal three-wave study with three-month intervals. We explored the influences of job/home demands and resources as antecedents of work-nonwork balance crafting. Important constructs for employee health and well-being (i.e., work engagement, work-related burnout, mental well-being and detachment from work) were investigated as outcomes. RESULTS: The findings suggest that resources and demands in the context of work or home are key antecedents of work-nonwork balance crafting. Work-nonwork balance crafting was also predictive for important employee health and well-being outcomes over three months, mainly in a positive and health-promoting way. CONCLUSION: This study provides insights into the antecedents of proactive efforts to balance the complex interplay of life domains. By studying work-nonwork balance crafting, we provide a new perspective on crafting beyond job crafting, which may help maintain or improve employees' mental health and well-being.

Cat and dog owners' expectations and attitudes towards advanced veterinary care (AVC) in the UK, Austria and Denmark.

Modern veterinary medicine offers a level of care to cats and dogs similar to that available to their owners, including blood transfusions, chemotherapy and MRI scans. The potential benefits to the animals of owners who can afford such care are obvious, but there can also be negative consequences if owners with strong emotional attachments to their pets pursue treatments that significantly reduce the quality of the animal's life while attempting to prolong it. Moreover, caring for a chronically or seriously ill animal can lead to emotional distress and financial and practical challenges for the pet owner. A questionnaire was used to survey cat and dog owners from representative samples of citizens in the UK, Austria and Denmark, to investigate owners' expectations and attitudes towards advanced veterinary care, and the factors that might influence those views. Overall, 58.4% of the pet owners surveyed believed that their pets should have access to the same treatment options as humans, while 51.5% believed that they should have access to the same diagnostic tests as humans. Owners were most likely to be neutral on the question of whether advanced veterinary care has 'gone too far' (45.3%), and to disagree with the statement that advanced care is 'unnecessary' (40.1%). In all three countries, the level of attachment owners had to their pets was most strongly associated with attitudes towards advanced care, with owners scoring higher on Lexington Attachment to Pets Scale (LAPS) being more likely to expect advanced care to be available. Other factors such as owner age, living situation (alone or not), income or possession of pet insurance were less consistently with owner attitudes. Our findings will help inform veterinarians and other health care providers about pet owner expectations and attitudes towards advanced veterinary care, and contribute to the debate on increasing specialisation within the profession.

Predictors of adherence in Austrian employees during the COVID-19 pandemic: results of an online survey.

Background: Since the beginning of the pandemic in December 2019, Coronavirus disease 2019 (COVID-19) has been a significant challenge to health care systems throughout the world. The introduction of measures to reduce the incidence of infection had a significant impact on the workplace. Overall, companies played a key and adaptive role in coping with the pandemic. Methods: Cross-sectional data from an online-survey of 1,183 employees conducted during the COVID-19 pandemic in spring 2021 in Austria were used in the analyses. The influence of health beliefs (e.g., perceived severity), modifying factors (e.g., age) and time-dependent factors (e.g., corona fatigue) on individual adherence were evaluated. The conception of the questionnaire was based on the health belief model. Results: The majority of respondents were female (58.3%), worked in companies with more than 250 employees (56.6%) and had been to an academic secondary school or had a university degree (58.3%). Overall, employees were adherent to most of the measures at their company (>80%), except for wearing FFP-2 masks when they were travelling in a car with coworkers (59.3, 95%CI 51.3-66.7%). Overall adherence was associated with high ratings for the meaningfulness of testing (OR: 2.06 95%CI: 1.00-4.22; p = 0.049), the extent to which social norms govern behavior (OR: 6.61 95%CI: 4.66-9.36; p < 0.001), lower perceived difficulties associated with the adoption of health-promoting measures (OR: 0.37 95%CI: 0.16-0.82; p = 0.015) and lower corona fatigue (OR: 0.23 95%CI: 0.10-0.52; p < 0.001). Adherence to four single measures was influenced by different predictors. The most important predictors (important for the adherence to three out of four single measures) were social norms and corona fatigue. Conclusion: The importance attached to testing and social norms, as well as lower perceived barriers to health-promoting measures and low levels of corona fatigue all increase overall adherence to Covid-19 protective measures in companies. Strategies to improve adherence should be adapted depending on the aim (to raise overall adherence or adherence to individual measures) and on the group of persons that is being targeted.

[Nursing skill levels and implementation of Advanced Nursing Practice in Austria: A cross-sectional study]. / Pflegerische Qualifikationsniveaus und Umsetzung von Aufgaben für eine Advanced Nursing Practice in Österreich.

Nursing skill levels and implementation of Advanced Nursing Practice in Austria: A cross-sectional study Abstract: Background: New fields of practice are emerging under the concept of "Advanced Nursing Practice" (ANP) that offer specialised care provided by nurses who hold master's degrees. In Austria, nurses are currently being trained as Advanced Practice Nurses (APN). Aim: The project aimed to investigate which advanced nursing practice tasks according to the Hamric model are undertaken by nurses at different levels of qualification in Austria. Methods: Certified nurses did participate in a cross-sectional survey through an online questionnaire based on the Role Delineation Model and tailored to the Austrian context. The tasks were assigned based on the Hamric model and were tested and evaluated descriptively according to the qualification level through factor analysis. Results: Completed data was available from 105 participants, among them 80% with undergraduate education, 20% with a master's degree. A tendency in the results showed that the level of qualification was related to the activities carried out. The higher the academic degree, the more activities were performed in the field of leadership. The central ANP-competencies, research and education, are rather weak among all respondents. Conclusion: The results show that activities corresponding to the competencies of an ANP are performed by a heterogeneous group of nurses. Conditions and a standardized understanding of ANP need to be established in order to offer a professional practice that matches the competency profile.

Differential susceptibility of geographically distinct Ixodes ricinus populations to tick-borne encephalitis virus and louping ill virus.

Tick-borne encephalitis virus (TBEV) is an emerging pathogen in the Netherlands. Multiple divergent viral strains are circulating and the focal distribution of TBEV remains poorly understood. This may, however, be explained by differences in the susceptibility of tick populations for specific viruses and viral strains, and by viral strains having higher infection success in their local tick population. We investigated this hypothesis by exposing Dutch Ixodes ricinus ticks to two different TBEV strains: TBEV-NL from the Netherlands and TBEV-Neudoerfl from Austria. In addition, we exposed ticks to louping Ill virus (LIV), which is endemic to large parts of the United Kingdom and Ireland, but has not been reported in the Netherlands. Ticks were collected from two locations in the Netherlands: one location without evidence of TBEV circulation and one location endemic for the TBEV-NL strain. Ticks were infected in a biosafety level 3 laboratory using an artificial membrane feeding system. Ticks collected from the region without evidence of TBEV circulation had lower infection rates for TBEV-NL as compared to TBEV-Neudoerfl. Vice versa, ticks collected from the TBEV-NL endemic region had higher infection rates for TBEV-NL compared to TBEV-Neudoerfl. In addition, LIV infection rates were much lower in Dutch ticks compared to TBEV, which may explain why LIV is not present in the Netherlands. Our findings show that ticks from two distinct geographical populations differ in their susceptibility to TBEV strains, which could be the result of differences in the genetic background of the tick populations.

Cost-utility analysis of pharmacogenomics-guided tacrolimus treatment in Austrian kidney transplant recipients participating in the U-PGx PREPARE study.

Chronic kidney disease (CKD) is a global health issue. Kidney failure patients may undergo a kidney transplantation (KTX) and prescribed an immunosuppressant medication i.e., tacrolimus. Tacrolimus' efficacy and toxicity varies among patients. This study investigates the cost-utility of pharmacogenomics (PGx) guided tacrolimus treatment compared to the conventional approach in Austrian patients undergone KTX, participating in the PREPARE UPGx study. Treatment's effectiveness was determined by mean survival, and utility values were based on a Visual Analog Scale score. Incremental Cost-Effectiveness Ratio was also calculated. PGx-guided treatment arm was found to be cost-effective, resulting in reduced cost (3902 euros less), 6% less hospitalization days and lower risk of adverse drug events compared to the control arm. The PGx-guided arm showed a mean 0.900 QALYs (95% CI: 0.862-0.936) versus 0.851 QALYs (95% CI: 0.814-0.885) in the other arm. In conclusion, PGx-guided tacrolimus treatment represents a cost-saving option in the Austrian healthcare setting.

CRIMINAL LAW PROTECTION OF THE CIRCULATION OF MEDICINAL PRODUCTS ACCORDING TO THE LEGISLATION OF THE FEDERAL REPUBLIC OF GERMANY, THE REPUBLIC OF AUSTRIA AND THE SWISS CONFEDERATION.

The purpose of the article is to find out the scope of the criminal law protection of the circulation of medicinal products according to the legislation of the Federal Republic of Germany, the Republic of Austria, and the Swiss Confederation. The materials of the research were the legislation of the Federal Republic of Germany, the Republic of Austria, and the Swiss Confederation. Dialectical, axiological, comparative, and legal methods were applied during the research. Having studied the experience of the scope of criminal law protection of the circulation of medicinal products made it possible to conclude about the importance of having a certain legislative reference point that can help improve the criminal legislation of these and other countries and build a new model of the system of norms that ensure the criminal law protection of circulation of medicinal products. It has been concluded that in the criminal legislation of the Federal Republic of Germany, the Republic of Austria, and the Swiss Confederation there is an "aspiration" of the legislator to ensure the most complete scope of criminal law protection of circulation of medicinal products by creating their own specific systems. It has been proposed to single out separate groups of signs of criminal protection of pharmaceutical activity, since the scope of such protection is not the same in such countries (but has a lot in common). This may be a certain legislative guideline of the systematization of norms that ensure the circulation of medicinal products from the point of view of their criminal law protection.

Comparing risk-adjusted inpatient fall rates internationally: validation of a risk-adjustment model using multicentre cross-sectional data from hospitals in Switzerland and Austria.

BACKGROUND: Inpatient falls in hospitals are an acknowledged indicator of quality of care. International comparisons could highlight quality improvement potential and enable cross-national learning. Key to fair cross-national comparison is the availability of a risk adjustment model validated in an international context. This study aimed to 1) ascertain that the variables of the inpatient fall risk adjustment model do not interact with country and thus can be used for risk adjustment, 2) compare the risk of falling in hospitals between Switzerland and Austria after risk adjustment. METHODS: The data on inpatient falls from Swiss and Austrian acute care hospitals were collected on a single measurement day in 2017, 2018 and 2019 as part of an international multicentre cross-sectional study. Multilevel logistic regression models were used to screen for interaction effects between the patient-related fall risk factors and the countries. The risks of falling in hospital in Switzerland and in Austria were compared after applying the risk-adjustment model. RESULTS: Data from 176 hospitals and 43,984 patients revealed an inpatient fall rate of 3.4% in Switzerland and 3.9% in Austria. Two of 15 patient-related fall risk variables showed an interaction effect with country: Patients who had fallen in the last 12 months (OR 1.49, 95% CI 1.10-2.01, p = 0.009) or had taken sedatives/psychotropic medication (OR 1.40, 95% CI 1.05-1.87, p = 0.022) had higher odds of falling in Austrian hospitals. Significantly higher odds of falling were observed in Austrian (OR 1.38, 95% CI 1.13-1.68, p = 0.002) compared to Swiss hospitals after applying the risk-adjustment model. CONCLUSIONS: Almost all patient-related fall risk factors in the model are suitable for a risk-adjusted cross-country comparison, as they do not interact with the countries. Further model validation with additional countries is warranted, particularly to assess the interaction of risk factors "fall in the last 12 months" and "sedatives/psychotropic medication intake" with country variable. The study underscores the crucial role of an appropriate risk-adjustment model in ensuring fair international comparisons of inpatient falls, as the risk-adjusted, as opposed to the non-risk-adjusted country comparison, indicated significantly higher odds of falling in Austrian compared to Swiss hospitals.

Recovery of plastic packaging from mixed municipal solid waste. A case study from Austria.

Austria must recycle more packaging materials. Especially for plastic packaging waste, significant increases are necessary to reach the EU recycling targets for 2025 and 2030. In addition to improving separate collection and introducing a deposit system for specific fractions, the share of plastic packaging in mixed municipal solid waste (MSW) could be utilized. In Austria, about 1.8milliontonnes of mixed MSW are generated. This includes about 110,000 t/a of plastic packaging waste. Most of the mixed MSW (94 %) is sent directly or via residues from pre-treatment, such as mechanical-biological treatment or waste sorting, to waste incineration. While materials such as glass and metals can also be recovered from the bottom ash, combustible materials such as plastics must be recovered before incineration. This work aims to evaluate the recovery potential of plastic packaging waste in mixed MSW with automated waste sorting. For this purpose, two of the largest Austrian waste sorting plants, with a total annual throughput of about 280,000 t/a, were investigated. The investigation included regular sampling of selected output streams and sorting analysis. The results show that the theoretical recovery potential of plastic packaging from these two plants is 6,500 t/a on average. An extrapolation to Austria results in a potential of about 83,000 t/a. If losses due to further treatment, such as sorting and recycling, are considered, about 30,000 t/a of recyclate could be returned to plastic production. This would correspond to an increase in plastic packaging recycling rate from 25 % to 35 %.

COVID-19 infection in patients with history of pediatric heart transplant in Germany, Austria, and Switzerland.

COVID-19 is a heterogenous infection-asymptomatic to fatal. While the course of pediatric COVID-19 infections is usually mild or even asymptomatic, individuals after adult heart transplantation are at high risk of a severe infection. We conducted a retrospective, multicenter survey of 16 pediatric heart transplant centers in Germany, Austria and Switzerland to evaluate the risk of a severe COVID-19 infection after pediatric heart transplantation between 02/2020 and 06/2021. Twenty-six subjects (11 male) with a median age of 9.77 years at time of transplantation and a median of 4.65 years after transplantation suffered from COVID-19 infection. The median age at time of COVID-10 infection was 17.20 years. Fourteen subjects had an asymptomatic COVID-19 infection. The most frequent symptoms were myalgia/fatigue (n = 6), cough (n = 5), rhinitis (n = 5), and loss of taste (n = 5). Only one subject showed dyspnea. Eleven individuals needed therapy in an outpatient setting, four subjects were hospitalized. One person needed oxygen supply, none of the subjects needed non-invasive or invasive mechanical ventilation. No specific signs for graft dysfunction were found by non-invasive testing. In pediatric heart transplant subjects, COVID-19 infection was mostly asymptomatic or mild. There were no SARS-CoV-2 associated myocardial dysfunction in heart transplant individuals.

A comparative study on antibiotic resistant Escherichia coli isolates from Austrian patients and wastewater-influenced Danube River water and biofilms.

Antimicrobial resistance (AMR) poses a major threat to human health worldwide. AMR can be introduced into natural aquatic ecosystems, for example, from clinical facilities via wastewater emissions. Understanding AMR patterns in environmental populations of bacterial pathogens is important to elucidate propagation routes and develop mitigation strategies. In this study, AMR patterns of Escherichia coli isolates from urinary tract infections and colonised urinary catheters of inpatients and outpatients were compared to isolates from the Danube River within the same catchment in Austria to potentially link environmental with clinical resistance patterns. Susceptibility to 20 antibiotics was tested for 697 patient, 489 water and 440 biofilm isolates. The resistance ratios in patient isolates were significantly higher than in the environmental isolates and higher resistance ratios were found in biofilm in comparison to water isolates. The role of the biofilm as potential sink of resistances was reflected by two extended-spectrum beta-lactamase (ESBL) producing isolates in the biofilm while none were found in water, and by higher amoxicillin/clavulanic acid resistance ratios in biofilm compared to patient isolates. Although, resistances to last-line antibiotics such as carbapenems and tigecycline were found in the patient and in the environmental isolates, they still occurred at low frequency.