Zum Stand der Meldungen schwer verlaufender Clostridium-difficile- Infektionen in Deutschland

Die Inzidenz der Clostridium-difficile-Infektion hat in den letzten Jahren auch in Deutschland stark zugenommen. Eine neue Erregervariante, die in der Vergangenheit bereits in mehreren europäischen Ländern, sowie in Kanada und den U.S.A zu Ausbrüchen mit erhöhter Morbidität und Mortalität geführt hat, breitet sich zunehmend auch hierzulande aus. Um die epidemiologischen Veränderungen erfassen und verfolgen zu können, wurden in Deutschland kürzlich Kriterien für eine Meldepflicht gemäß § 6 Abs. 1 Nr. 5 a IfSG für schwer verlaufende Clostridium- difficile-Infektionen eingeführt.The incidence of Clostridium difficile infections has greatly increased in recent years also in Germany. A new variant of the pathogen, which in the past has already lead to outbreaks with increased morbidity and mortality in several European countries, the US and Canada, is now spreading also in Germany. In order to record the epidemiological changes, criteria for a mandatory surveillance according to § 6 Abs. 1 Nr. 5 a IfSG for severe cases of Clostridium difficile infections has recently been implemented

Invasive meningococcal disease with fatal outcome in a Swiss student visiting Berlin

Following the fatal invasive meningococcal disease in a Swiss student who had been visiting Berlin, several public health institutions on local, regional and national level cooperated to ensure that the appropriate measures such as contact tracing and post exposure prophylaxis were taken to prevent further cases. The incidence highlighted the importance of early disease notification and showed that if an infectious disease requiring public health action occurs in an international context, it is vital that relevant information is communicated to all levels of the public health systems of the countries involved

High Seroprevalence of Coxiella burnetii Antibodies in Veterinarians Associated with Cattle Obstetrics, Bavaria, 2009

Q fever is a zoonosis caused by Coxiella burnetii. Infection can result in severe disease. However, little is known about the risk of infection in veterinarians. In a cross-sectional study among German veterinarians, participants provided sera and completed an exposure questionnaire. We investigated predictors for seropositivity using multivariable logistic regression modelling. The 424 participants' median age was 40 (18–74) years, and 276 (65%) were female. Sera of 162 (38%) were positive for Coxiella burnetii phase II IgG antibodies (by ELISA and IFAT). Predictors for seropositivity were occupational exposure to cattle (aOR 2.83, 95% CI 1.64–4.87), occupational exposure to sheep (2.09, 1.22–3.58), male sex (1.9, 1.15–3.13), and increasing age (30–39 years: 4.91, 2.00–12.04; 40-49 years: 5.32, 2.12–13.33; >50 years: 6.70, 2.60–17.25; compared wit

Burden of carbapenem-resistant organisms in the Frankfurt/Main Metropolitan Area in Germany 2012/2013 : first results and experiences after the introduction of legally mandated reporting

Background: The federal state of Hesse, Germany, introduced a laboratory-based reporting scheme for carbapenem-resistant organisms (CROs). Method: The results of the first year of mandated reporting of CROs from April 2012 through March 2013 to the Public Health Authority of Frankfurt/Main, responsible for a population of 700,000 inhabitants, are described. Results: Within a period of 12 months 243 CROs were notified to the health authority. Of these 213 isolates had been reported from 16 of the 17 hospitals in Frankfurt/Main, 6 from ambulatory settings and 24 from clinics outside of Frankfurt/Main. Mean incidence rate per 1,000 patient days in hospitals was 0.138 (range 0.02-0.28). Conclusion: In Frankfurt/Main almost all hospitals have reported CROs in the study period though the frequency of isolation varies strongly and many facilities only report CROs sporadically. Molecular data indicate a high diversity of different carbapenemases. Autochthonous transmission must be assumed despite the absence of major outbreaks. Rapid and coordinated efforts by clinicians and health departments are crucial to control the spread of CRO infections. The mandatory reporting scheme provides important data to guide the implementation of preventive measures

Clostridium-difficile-Ribotyp 027: Epidemiologie und Klinik des erstmaligen endemischen Auftretens in Deutschland

Hintergrund: Im September 2007 trat eine Häufung von ungewöhnlich schwer verlaufenden Clostridium-difficile-assoziierten Infektionen (CDI) in einem Trierer Krankenhaus auf. Es wurde vermutet, dass ein neuer Stamm (PCR-Ribotyp 027) mit diesen Ereignissen im Zusammenhang stehen könnte. Zur Untersuchung der Erkrankungsfälle wurde das Gesundheitsamt Trier auf Einladung des Landes Rheinland-Pfalz von einem Feldteam des Robert Koch-Instituts unterstützt. Ziel der Untersuchung war die Aufklärung und Unterbrechung der vermuteten Infektkette. Methoden: Neben einer retrospektiven Fallsuche von schwer verlaufenden CDI durch Analyse von Patientenakten und Totenscheinen erfolgte eine intensivierte Surveillance von schweren CDI in den Krankenhäusern der betroffenen Region. Dazu wurden bei allen neu auftretenden Verdachtsfällen parallel ein Toxin-A/B-Nachweis und eine selektive Anzucht auf C. difficile durchgeführt. Die Isolate wurden mittels PCR ribotypisiert. Daten zum Krankheitsverlauf und zur Letalität wurden mit einem standardisierten Erhebungsbogen erfasst und statistisch in einer multivariaten Analyse ausgewertet. In dem Index-Krankenhaus wurden Personaluntersuchungen durchgeführt. Ergebnisse: Bis zum 31.1.2008 wurden insgesamt 27 schwere CDI ohne Ribotypisierung und 21 bestätigte Fälle von C.-difficile-Ribotyp-027-Infektionen der Region Trier identifiziert. Im Rahmen der intensivierten Surveillance wurden 399 Patienten untersucht, von denen 76 (19 %) C.-difficile-Isolate angezüchtet werden konnten. Bei 20 Patienten wurde der PCR-Ribotyp 027 nachgewiesen. Insgesamt kam es zu 9 Todesfällen (19 %). Eine bestehende immunsupressive Therapie (Odds Ratio 35,8; 95 %-Konfidenzintervall 2,8 - 464,5) war unabhängiger Risikofaktor für einen letalen Krankheitsverlauf. Schwer verlaufende Infektionen wurden auch bei anderen, Nicht-027-Ribotypen beobachtet. Im Screening vom Krankenhauspersonal des Indexkrankenhauses (n = 161) waren 6 % der Mitarbeiter C.-difficile-Toxin positiv. Diskussion: In dieser Untersuchung konnte erstmalig die endemische Verbreitung von C.-difficile-PCR-Ribotyps 027 in einer Region Deutschlands nachgewiesen werden. Als direkte Konsequenz des Ausbruchs wurde Ende 2007 die Ärztliche Meldepflicht für schwer verlaufende CDI eingeführt. Neben krankenhaushygienischen Maßnahmen ist die kritische Verwendung von Antibiotika eine wichtige Maßnahme zur Verhinderung einer weiteren Zunahme von CDI

Carbapenem-resistant Gram-negative bacteria – analysis of the data obtained through a mandatory reporting system in the Rhine-Main region, Germany, 2012–2015

Background: Multidrug-resistant Gram-negative bacteria (MRGN) and the infections they cause are a serious threat and a challenge to the healthcare system. This particularly applies to carbapenem-resistant Gram-negative bacteria (CRGN). Currently, the introduction of a nationwide mandatory notification system for CRGN in Germany is under consideration. Against this background, this paper presents an analysis of the mandatory reporting system for CRGN in effect since November 2011 in the federal state of Hesse (Germany). Materials and methods: All carbapenem-resistant Gram-negative bacteria and the detected carbapenemases reported to the public health department of the city of Frankfurt am Main, Hesse, Germany, on the basis of the mandatory notification system were analyzed.Results: 827 CRGN cases were reported to the public health department of Frankfurt/Main between April 2012 and December 2015. The following bacterial species were reported: spp. (n=268), spp. (n=183), spp. (n=195), spp. (n=77), (n=75) and others (n=29). Between 2012 and 2015, a reduction of the CRGN reports was noticed, mainly due to changes in the reporting of spp. Between 2012 and 2015, the total number of notifications decreased slightly, although the number of reported CRGN in screening samples increased, thus giving no indication of a decreased testing frequency. For 10.5% of the patients, the place of residence was not Germany, 18.0% of the patients had previously stayed in hospitals abroad, often in countries with a high CRGN prevalence. CRGN bacteria were reported from all of Frankfurt’s hospitals, and 3.9% were reported from out-patient care facilities. Carbapenemases were detected and reported in 251 CRGN bacteria, including 73 OXA-48, 76 OXA-23, 56 NDM subtypes, and 21 KPC subtypes. There have been no major epidemiological signs of outbreak scenarios.Discussion: CRGN bacteria are already widespread in patients from hospitals and out-patient care facilities. Clearly, infection control measurements should therefore not only include hospital patients but also those receiving out-patient care. Screening strategies focused on patients from foreign countries with high MRGN prevalence is not sufficient, as only 10.5% of MRGN patients resided in those countries, and only 18% of the patients had been previously treated in a foreign hospital. In a public health context, infection control measures should therefore encompass broader screening strategies

HIV-GRADE: A Publicly Available, Rules-Based Drug Resistance Interpretation Algorithm Integrating Bioinformatic Knowledge

Background: Genotypic drug resistance testing provides essential information for guiding treatment in HIV-infected patients. It may either be used for identifying patients with transmitted drug resistance or to clarify reasons for treatment failure and to check for remaining treatment options. While different approaches for the interpretation of HIV sequence information are already available, no other available rules-based systems specifically have looked into the effects of combinations of drugs. HIV-GRADE (Genotypischer Resistenz Algorithmus Deutschland) was planned as a countrywide approach to establish standardized drug resistance interpretation in Germany and also to introduce rules for estimating the influence of mutations on drug combinations. The rules for HIV-GRADE are taken from the literature, clinical follow-up data and from a bioinformatics-driven interpretation system (geno2pheno [resistance] ). HIV-GRADE presents the option of seeing the rules and results of other drug resistance algorithms for a given sequence simultaneously. Methods: The HIV-GRADE rules-based interpretation system was developed by the members of the HIV-GRADE registered society. For continuous updates, this expert committee meets twice a year to analyze data from various sources. Besides data from clinical studies and the centers involved, published correlations for mutations with drug resistance and genotype-phenotype correlation data information from the bioinformatic models of geno2pheno are used to generate the rules for the HIV-GRADE interpretation system. A freely available online tool was developed on the basis of the Stanford HIVdb rules interpretation tool using the algorithm specification interface. Clinical validation of the interpretation system was performed on the data of treatment episodes consisting of sequence information, antiretroviral treatment and viral load, before and 3 months after treatment change. Data were analyzed using multiple linear regression. Results: As the developed online tool allows easy comparison of different drug resistance interpretation systems, coefficients of determination (R 2 ) were compared for the freely available rules-based systems. HIV-GRADE (R 2 = 0.40), Stanford HIVdb (R 2 = 0.40), REGA algorithm (R 2 = 0.36) and ANRS (R 2 = 0.35) had a very similar performance using this multiple linear regression model. Conclusion: The performance of HIV-GRADE is comparable to alternative rulesbased interpretation systems. While there is still room for improvement, HIV-GRADE has been made publicly available to allow access to our approach regarding the interpretation of resistance against single drugs and drug combinations