Verbesserung der Versorgungsqualität von mit multiresistenten Erregern betroffenen Personen

Kossow A. Verbesserung der Versorgungsqualität von mit multiresistenten Erregern betroffenen Personen. Bielefeld: Universität Bielefeld; 2020.Antibiotikaresistente und multiresistente Erreger (MRE) stellen ein weltweit wachsendes Problem dar. Deren Auswirkungen tragen sowohl der_die individuelle Patient_in als auch die Public Health. Bei einer Infektion mit MRE sind die Therapieoptionen eingeschränkt. Analysen zeigten zudem erhöhte direkte und indirekte Behandlungskosten. Schwieriger zu evaluieren sind die sogenannten intangiblen Kosten, die u. a. die Behandlungs- und Lebensqualität für den_die Patient_in betreffen. Auswirkungen sind dabei sektorübergreifend zu spüren. Eine Analyse der Patient_innensicht kann Faktoren aufzeigen, die aufzugreifen sind, um die Versorgungsqualität der betroffenen Patient_innen zu verbessern. Innerhalb der Versorgungsforschung und basierend auf dem Prinzip der patientenzentrierten Versorgung nach Picker wurden deshalb betroffene Patient_innen als Expert_innen in einem leitfadengestützten Interview zu ihrer Versorgungssituation befragt. Die aus 14 Interviews gewonnenen Daten wurden mit Hilfe der qualitativen Inhaltsanalyse nach Gläser und Laudel analysiert und zusammengefasst. Insgesamt fielen die Antworten heterogen aus. Obwohl ein grundsätzliches Verständnis und eine hohe Motivation zur Einhaltung und Mitarbeit an den Hygienemaßnahmen vorhanden waren, wurden Einschränkungen wahrgenommen. Diese betrafen vor allem die Unterbringung in einem Einzelzimmer und die damit verbundene Bewegungseinschränkung. Häufig wurde über einen Rückgang der ärztlichen Kontakte oder eine verzögerte Pflege berichtet. Viele Patient_innen wären gerne umfassender informiert. Der Umgang mit Angehörigen und anderen betroffenen Personen ist hilfreich und sollte daher ermöglicht werden. Im ambulanten Bereich wurden selten Einschränkungen beschrieben. Von den Expert_innen geäußerte Lösungsvorschläge betrafen vor allem infrastrukturelle Maßnahmen. Basierend auf diesen Ergebnissen und vor dem Hintergrund des theoretischen Rahmens sowie des aktuellen Forschungsstands wurden 16 Handlungsempfehlungen für medizinisches Personal und Verantwortliche von medizinischen Einrichtungen sowie zehn Forschungsempfehlungen formuliert. Diese erfahren bereits erste Umsetzung in der Praxis.Multi-drug resistant organisms (MRE) are a growing public health challenge, burdening health care systems with increased costs. Whereas direct and indirect costs can be objectively measured, intangible costs, i.e. fear, stress and reduced quality of life, are borne by the patients. Patients colonized or infected by MRE are subjected to additional infection control measures like contact isolation and the use of gowns, gloves and face masks. A widely recognized decreased quality of care may lead to insecurities among affected patients and a need for information. The patients’ point of view can reveal otherwise undetected factors that hinder high quality of care and adequate information about MRE. As patients participate in all medical interfaces, their experiences can help to improve infection control strategies to prevent MRE across different sectors. Fourteen semi-structured interviews with patients infected or colonized by methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, and multi-drug resistant gram-negative bacteria were analyzed. The study was set within the context of health service research, focusing on patient orientation. The interview guide was based on Picker’s principle of patient-centered care with emphasis on quality of care and patient information. Interviews were analyzed using the qualitative content analysis of Gläser and Laudel. The interviews revealed that patients’ experiences varied, with their social background and the presence of heterogeneous underlying diseases playing a role. Even though patients were highly motivated to comply with hygiene measures, restraints in the quality of care were experienced. Information can be improved, since there are several uncertainties, e.g. considering the contact to relatives. Protective clothing and inadequate implementation of hygiene measures have a strong effect on the experience of the quality of care. Patients see understaffing as the reason for constraints. Family and friends are important for the patient and contact should be made possible. Based on the results of the study, the theoretical background, and the current state of research, 16 fields of action were formulated, some of which are already being implemented. Ten further research questions evolving from this study are formulated and should answer the question, amongst others, of how to investigate and improve the quality of care of affected patients with a migration background, severe underlying diseases or mental illnesses. A concrete research project deals with the involvement of patients in infection control measures

Risikofaktoren und internationale Konzepte für eine nachhaltige globale Gesundheit : Eine Literaturarbeit zum aktuellen Diskussionsstand in der Entwicklungspolitik

Auf dem Weg zu einer nachhaltigen globalen Gesundheit bedarf es umfassender Strategien und Anstrengungen. Im Mai 2007 berieten Fachleute verschiedener Disziplinen auf dem Kongress „Towards sustainable Global Health“ in Bonn über Herausforderungen und Strategien. Vor dem Hintergrund dieses Kongresses wurden in einer Literaturarbeit die Risiken und Herausforderungen, die dem Erreichen einer globalen Gesundheit im Wege stehen, analysiert und Lösungsvorschläge gegeben. Basierend auf den Gemeinsamkeiten in den Beschreibungen einzelner Problemfelder und deren Lösungsstrategien, wurden Thesen formuliert, die als Indikatoren für nachhaltige Entwicklung dienen. Aufgegriffen wurde dabei auch der „Call for Action“, der auf dem Bonner Kongress verabschiedet wurde. Es wurde deutlich, dass Gesundheit einen entscheidenden Faktor zum Erreichen einer nachhaltigen Entwicklung darstellt und zur Bekämpfung von Armut besondere Priorität erhalten muss. Für eine praktische Umsetzung der Thesen wurde eine Checkliste erstellt, die sich sowohl an nationale Programme als auch an Programme von Nichtregierungsorganisationen und Regierungen aus dem Ausland wendet, um ihre Inhalte auf Nachhaltigkeit zu prüfen.Riscfactors and international concepts towards a sustainable global health To achieve sustainable global health, it is necessary to develop and implement a holistic approach of broad strategies and efforts. In May 2007, professionals of different disciplines discussed challenges and strategies at the Congress “Towards Sustainable Global Health” in Bonn, Germany, which were summarised in the so called Bonn declaration. The identified risks and challenges that impede the achievement of global health were analysed in a literary study that also provided approaches to strategies. Based on similarities in the descriptions of several problem areas, their specific strategy, and the “Call to Action” adopted by the Congress, theses were formulated to serve as indicators for sustainable development. It became clear that health is a crucial factor for the accomplishment of sustainable development and should be given high priority in the fight against poverty. A checklist was generated for the practical implementation of the theses. This checklist addresses national programs as well as policies of non-governmental organizations and governments of foreign countries to reassess their programs in terms of the desired result

Vaccination and Transmission Risk during the Outbreak of B.1.1.529 (Omicron)

Since its first description in November 2021, the SARS-CoV-2 variant of concern Omicron (B.1.1.529) has emerged as the dominant strain in the COVID-19 pandemic. To date, it remains unclear if boosted vaccination protects against transmission. Using data from the largest German Public Health Department, Cologne, we analyzed breakthrough infections in booster-vaccinated infected persons (IP; booster-vaccinated group (BVG); n = 202) and fully vaccinated, not boosted SARS-COV2-positive patients (>3 month after receiving the second dose; unboosted, fully vaccinated group (FVG); n = 202) to close contacts compared to an age- and sex-matched unvaccinated control group (UCG; n = 202). On average, IPs had 0.42 ± 0.52 infected contacts in relation to the total number of contacts in the BVG vs. 0.57 ± 0.44 in the FVG vs. 0.56 ± 0.43 in the UVG (p = 0.054). In the median test, pairwise comparison revealed a significant difference between the BVG and both other groups; no difference was found between the fully vaccinated and the unvaccinated control group. Now, these findings must be verified in larger samples, considering the role of Omicron subvariants and the vaccination status of the contact person. However, the importance of the booster vaccination in breaking possible chains of infection in the immune escape variant Omicron is obvious

Occurrence of ESBL-Producing Escherichia coli in Livestock and Farm Workers in Mecklenburg-Western Pomerania, Germany.

In recent years, extended-spectrum β-lactamases (ESBL) producing bacteria have been found in livestock, mainly as asymptomatic colonizers. The zoonotic risk for people working in close contact to animal husbandry has still not been completely assessed. Therefore, we investigated the prevalence of ESBL-producing Escherichia spp. in livestock animals and workers to determine the potential risk for an animal-human cross-transmission.In Mecklenburg-Western Pomerania, northeast Germany, inguinal swabs of 73 individuals with livestock contact from 23 different farms were tested for ESBL-producing Escherichia spp. Two pooled fecal samples per farm of animal origin from 34 different farms (17 pig farms, 11 cattle farms, 6 poultry farms) as well as cloacal swabs of 10 randomly selected broilers or turkeys were taken at each poultry farm. For identification, selective chromogenic agar was used after an enrichment step. Phenotypically ESBL-producing isolates (n = 99) were tested for CTX-M, OXA, SHV and TEM using PCR, and isolates were further characterized using multilocus sequence typing (MLST). In total, 61 diverse isolates from different sources and/or different MLST/PCR results were acquired. Five farm workers (three from cattle farms and two from pig farms) harbored ESBL-producing E. coli. All human isolates harbored the CTX-M β-lactamase; TEM and OXA β-lactamases were additionally detected in two, resp. one, isolates. ESBL-producing Escherichia spp. were found in fecal samples at pig (15/17), cattle (6/11) and poultry farms (3/6). In total, 70.6% (24/36) of the tested farms were ESBL positive. Furthermore, 9 out of 60 cloacal swabs turned out to be ESBL positive. All isolated ESBL-producing bacteria from animal sources were E. coli, except for one E. hermanii isolate. CTX-M was the most prevalent β-lactamase at cattle and pig farms, while SHV predominated in poultry. One human isolate shared an identical MLST sequence type (ST) 3891 and CTX-M allele to the isolate found in the cattle fecal sample from the same farm, indicating a zoonotic transfer. Two other pairs of human-pig and human-cattle E. coli isolates encoded the same ESBL genes but did not share the same MLST ST, which may indicate horizontal resistance gene transfer. In summary, the study shows the high prevalence of ESBL-producing E.coli in livestock in Mecklenburg- Western Pomerania and provides the risk of transfer between livestock and farm workers

Evaluation of a Stenotrophomonas maltophilia bacteremia cluster in hematopoietic stem cell transplantation recipients using whole genome sequencing

Abstract Background Stenotrophomonas maltophilia ubiquitously occurs in the hospital environment. This opportunistic pathogen can cause severe infections in immunocompromised hosts such as hematopoietic stem cell transplantation (HSCT) recipients. Between February and July 2016, a cluster of four patients on the HSCT unit suffered from S. maltophilia bloodstream infections (BSI). Methods For epidemiological investigation we retrospectively identified the colonization status of patients admitted to the ward during this time period and performed environmental monitoring of shower heads, shower outlets, washbasins and toilets in patient rooms. We tested antibiotic susceptibility of detected S. maltophilia isolates. Environmental and blood culture samples were subjected to whole genome sequence (WGS)-based typing. Results Of four patients with S. maltophlilia BSI, three were found to be colonized previously. In addition, retrospective investigations revealed two patients being colonized in anal swab samples but not infected. Environmental monitoring revealed one shower outlet contaminated with S. maltophilia. Antibiotic susceptibility testing of seven S. maltophlia strains resulted in two trimethoprim/sulfamethoxazole resistant and five susceptible isolates, however, not excluding an outbreak scenario. WGS-based typing did not result in any close genotypic relationship among the patients’ isolates. In contrast, one environmental isolate from a shower outlet was closely related to a single patient’s isolate. Conclusion WGS-based typing successfully refuted an outbreak of S. maltophilia on a HSCT ward but uncoverd that sanitary installations can be an actual source of S. maltophilia transmissions

Risk Factors for Long-Term Vancomycin-Resistant Enterococci Persistence—A Prospective Longitudinal Study

Vancomycin-resistant enterococci (VRE) are important nosocomial pathogens that require effective infection control measures, representing a challenge for healthcare systems. This study aimed at identifying risk factors associated with prolonged VRE carriage and determining the rate of clearance that allows the discontinuation of contact precautions. During a 2-year study, screening was performed in patients with a history of VRE or at risk of becoming colonized. After bacterial identification and antibiotic susceptibility testing, glycopeptide resistance was confirmed by PCR. Isolates were compared via whole genome sequence-based typing. Risk factors were recorded, and follow-up screening was performed upon readmission, defining patients as long-term carriers if still colonized ≥10 weeks after first detection. Of 1059 patients positive for VRE, carriage status was assessed upon readmission in 463 patients. VRE was cleared in 56.4% of the cases. Risk factors associated with long-term persistence were hospital stays (frequency, length), hemato-oncological disease, systemic treatment with steroids, and use of antibiotics. No specific genotypic clustering was observed in patients with VRE clearance or persistence. VRE clearance is possibly underestimated. The identification of risk factors favoring long-term carriage may contribute to a targeted implementation of infection control measures upon readmission of patients with history of VRE

Hospital acquired vancomycin resistant enterococci in surgical intensive care patients – a prospective longitudinal study

Abstract Background Vancomycin resistant enterococci (VRE) occur with enhanced frequency in hospitalised patients. This study elucidates the prevalence of VRE on admission among surgical intensive care unit (SICU) patients, whether these patients are at special risk for VRE acquisition and which risk factors support this process. Methods Patients admitted to SICUs of the University Hospital Münster were examined during August–October 2017. VRE screening was performed within 48 h after admission and directly prior to discharge of patients. In parallel risk factors were recorded to estimate their effect on VRE acquisition during SICU stay. Results In total, 374 patients (68% male) with a median age of 66 years were admitted to one of the SICUs during the investigation period. Of all, 336 patients (89.8%) were screened on admission and 268 (71.7%) on discharge. Nine patients were admitted with previously known VRE colonisation. Twelve (3.6%) further patients were VRE positive on admission. During ICU stay, eight (3.0%) additional patients turned out to be VRE colonised. Risk factors found to be significantly associated with VRE acquisition were median length of stay on the ICU (14 vs. 3 days; p = 0.01), long-term dialysis (12.5% vs. 2.0% of patients; p = 0.05), and antibiotic treatment with flucloxacillin (28.6% vs. 7.2% of patients; p = 0.01) or piperacillin/tazobactam (57.1% vs. 26.6% of patients; p = 0.01). Conclusions SICU patients are not at special risk for VRE acquisition. Previous stay on a SICU should therefore not be considered as specific risk factor for VRE colonisation

Weekly screening supports terminating nosocomial transmissions of vancomycin-resistant enterococci on an oncologic ward – a retrospective analysis

Abstract Background To investigate the impact of weekly screening within the bundle of infection control measures to terminate vancomycin-resistant enterococci (VRE) transmissions on an oncologic ward. Methods A cluster of 12 VRE colonisation and five infections was detected on an oncologic ward between January and April 2015. Subsequently, the VRE point prevalence was detected and, as part of a the bundle of infection control strategies to terminate the VRE cluster, we isolated affected patients, performed hand hygiene training among staff on ward, increased observations by infection control specialists, intensified surface disinfection, used personal protective equipment and initiated an admission screening in May 2015. After a further nosocomial VRE infection in August 2015, a weekly screening strategy of all oncology patients on the respective ward was established while admission screening was continued. Whole genome sequencing (WGS)-based typing was applied to determine the clonal relationship of isolated strains. Results Initially, 12 of 29 patients were VRE colonised; of these 10 were hospital-acquired. During May to August, on average 7 of 40 patients were detected to be VRE colonised per week during the admission screening, showing no significant decline compared to the initial situation. WGS-based typing revealed five different clusters of which three were due to vanB- and two vanA-positive enterococci. After an additional weekly screening was established, the number of colonised patients significantly declined to 1/53 and no further nosocomial cases were detected. Conclusions Weekly screening helped to differentiate between nosocomial and community-acquired VRE cases resulting in earlier infection control strategies on epidemic situations for a successful termination of nosocomial VRE transmissions

High prevalence of MRSA and multi-resistant gram-negative bacteria in refugees admitted to the hospital-But no hint of transmission.

With high numbers of refugees arriving in Europe uncertainty exists as to whether multidrug-resistant organisms are imported into the healthcare system. In our study, we identified 383 refugee-inpatients admitted to the University Hospital Münster, Germany between September 2015 and September 2016. For this patient cohort screening for Methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Gram-negative bacteria (MDR-GNB) and Vancomycin-resistant enterococci (VRE) was recommended in our institution. Until May 2016 pre-emptive isolation was applied to all refugee-inpatients until the exclusion of these multidrug-resistant organisms. MRSA were found in 34 refugee-patients (9.8%), MDR-GNB in 25 refugee-patients (12.9%) and VRE in none of the refugee patients. We did not find any strains carrying carbapenemases. Whole genome sequencing (WGS) data demonstrated that the respective isolates were genetically heterogeneous and revealed no transmission of refugee-patient isolates to other patients. We therefore omitted pre-emptive isolation as an infection control measure for this group of patients. Furthermore, molecular typing did not show evidence for nosocomial transmission from refugee-patients to other patients. Standard hygiene measures successfully prevented the transmission of refugee-patient isolates to other patients and as a result introduction into the healthcare system. This underlines that any multidrug-resistant organisms present within this cohort are not of any extraordinary concern for health systems

Self-Reported Pre-Pandemic Physical Activity and Likelihood of COVID-19 Infection: Data from the First Wave of the CoCo-Fakt Survey

Abstract Objectives To investigate the potential protective role of exercise on the odds of COVID-19 infection in unvaccinated contact persons (CPs) who were at higher risk of infection due to confirmed contact with infected persons. Methods Before the onset of the vaccination campaign, the first wave of the CoCo-Fakt online survey was conducted with SARS-CoV-2-positive persons and their confirmed contacts who were isolated/quarantined between 1 March 2020 and 9 December 2020. Within this analysis, 5338 CPs were included and divided into those who subsequently tested positive (CP-P) and those who remained negative (CP-N). We assessed demographics as well as pre-pandemic lifestyle characteristics including physical activity (PA; type, frequency, time, intensity; duration clustered as ‘below PA guidelines’, ‘meeting PA guidelines’, and ‘above PA guidelines’; intensity clustered as ‘low intensity’ and ‘moderate-to-vigorous intensity’) and sedentary behaviour. Results A greater percentage of CP-Ns reported being active before the pandemic compared to CP-Ps (69% vs. 63%; p = .004). Moreover, CP-Ns reported higher PA duration (164.1 min/week vs. 143.2 min/week; p = .038) and higher PA intensities than CP-Ps (67% vs. 60% moderate-to-vigorous intensity, 33% vs. 40% low intensity; p = .003). Adjusting for age, sex, socioeconomic status, migration background, and pre-existing chronic diseases, the odds of infection were negatively associated with exercise (yes/no) (Nagelkerke R2 = 1.9%), PA levels above PA guidelines (Nagelkerke R2 = 2.0%), and PA intensity (Nagelkerke R2 = 1.8%). Conclusion Due to the beneficial effects of PA on the odds of infection, an active lifestyle should be promoted especially during possible subsequent pandemics (while taking into account necessary hygiene measures). Moreover, inactive and chronically ill persons should be especially encouraged to adopt a healthier lifestyle