Authors reply: Prevention of the spread of infection – the need for a family-centred approach to hygiene promotion

We agree that promulgating the hygiene hypothesis and related environmental issues to the public can serve to confuse, rather than to inform. The reality is however that these issues have already received widespread coverage by the media, which tends to leave the public concerned and confused about the role of hygiene and cleanliness, particularly in relation to the functioning of the immune system.

Prevention of the spread of infection--the need for a family-centred approach to hygiene promotion

Infectious diseases circulating in the home and community are a continuing and significant burden on the health and prosperity of the European community. They could, however, be significantly reduced by better standards of hygiene. Across Europe, public health is currently structured such that the separate aspects of hygiene in different settings (food hygiene, personal hygiene, handwashing, pandemic flu preparedness, patient empowerment etc.) are dealt with by separate agencies. If efforts to promote hygiene at community level are to be successful in changing behaviour, we need a concerted family-centred approach to ensure that a basic understanding of infectious disease agents and their mechanisms of spread, together with an understanding of a risk-based approach to hygiene, are promoted as part of the school curriculum and as part of public health campaigns. Alongside this, we also need unambiguous communication with the public on issues such as the hygiene hypothesis and environmental issues.

Prevention of the spread of infection – the need for a family-centred approach to hygiene promotion

Infectious diseases circulating in the home and community are a continuing and significant burden on the health and prosperity of the European community. They could, however, be significantly reduced by better standards of hygiene. Across Europe, public health is currently structured such that the separate aspects of hygiene in different settings (food hygiene, personal hygiene, handwashing, pandemic flu preparedness, patient empowerment etc.) are dealt with by separate agencies. If efforts to promote hygiene at community level are to be successful in changing behaviour, we need a concerted family-centred approach to ensure that a basic understanding of infectious disease agents and their mechanisms of spread, together with an understanding of a risk-based approach to hygiene, are promoted as part of the school curriculum and as part of public health campaigns. Alongside this, we also need unambiguous communication with the public on issues such as the hygiene hypothesis and environmental issues.

[Five years of the Robert Koch Institute guidelines for reprocessing of flexible endoscopes. A look back and a look forward]

In a short review the national and international reception of the German guidelines for reprocessing flexible endoscopes is presented. The recommendations of the guidelines are discussed in view of recent knowledge on old problems such as prion inactivation and new infectious diseases and new microorganisms such as SARS, avian influenza and C. difficile. New disinfectants and new methods for endoscope disinfection are mentioned, the importance of careful cleaning is underlined. The German guidelines of the Robert Koch Institute and the US Multi-Society guidelines, published in 2003, are compared. The discrepancies concerning recommendations for water quality for final rinsing and need of microbiological controls of endoscope reprocessing are stressed. Aspects not mentioned in the German guidelines, e.g. duration of storage after reprocessing and risk of infection transmission by the endo-washer, are discussed.

In vitro detection of C4d-fixing HLA alloantibodies: associations with capillary C4d deposition in kidney allografts

Capillary C4d deposition is a valuable marker of antibody-mediated rejection (AMR). In this analysis, flow cytometric detection of alloantibody-triggered C4d deposition to HLA antigen-coated microparticles ([C4d]FlowPRA) was evaluated for its value as a marker for C4d deposition in renal allografts. For comparative analysis, 105 first renal biopsies performed for graft dysfunction and an equal number of concurrent sera were subjected to immunohistochemistry and [C4d] plus standard [IgG]FlowPRA, respectively. C4d deposition/fixation was detected in 17 biopsies and, applying [C4d]FlowPRA HLA class I and II screening, also in a small number of corresponding sera (N = 20). IgG reactivity detected by standard [IgG]FlowPRA was more frequent (49% of sera). Comparing [C4d]FlowPRA screening with capillary C4d staining, we found a high level of specificity (0.92 [95% confidence interval: 0.86-0.98]), which far exceeded that calculated for [IgG]FlowPRA (0.60 [0.50-0.70]). [IgG]FlowPRA screening, however, turned out to be superior in terms of sensitivity (0.94 [0.83-1.05] vs. 0.76 [0.56-0.97] calculated for C4d-fixing panel reactivity). Remarkably, posttransplant single antigen testing for identification of complement-fixing donor-specific alloreactivities failed to improve the predictive value of FlowPRA-based serology. In conclusion, our results suggest that detection of complement-fixing HLA panel reactivity could provide a specific tool for monitoring of C4d-positive AMR.

Divergent opinions on surface disinfection: myths or prevention? A review of the literature

Virtually no prevention strategy in hospital hygiene has been the focus of such frequent controversial discussions as the role of surface disinfection. Set against that background, the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute founded a working group comprising members with divergent views of risk evaluation as regards the role of disinfection. This working group produced a most carefully drafted guideline on how to deal with various risk areas and also incorporated a new provision into the guideline, stating that: "Cleaning and disinfection procedures must be organized and implemented such that there is no increase in the microbial load or spread of facultatively pathogenic or pathogenic microorganisms on surfaces."Numerous studies have come to the conclusion that surface disinfection constitutes a basic infection control measure with which the spread of pathogens can be controlled. Conversely, when using only detergents such a form of control is not possible, something that must be taken into account in future when engaging in risk evaluation and formulating infection control measures. In view of the burgeoning trend in, for example, norovirus outbreaks, also in hospitals and nursing homes, such insights are of paramount importance and attest to the need for disinfection of surfaces and of areas with frequent hand and skin contacts. This discussion about the need for surface disinfection has, in addition to causing confusion among users, led to a decline in the willingness to accept hygienic practices, thus increasing the risk of occurrence of nosocomial infections as well as of antibiotic-resistant microorganisms.

Association of low-grade inflammation with nephropathy in type 2 diabetic patients: role of elevated CRP-levels and 2 different gene-polymorphisms of proinflammatory cytokines

BACKGROUND

Chronic inflammatory processes are thought to play a key role in the development of micro- and macrovascular complications in type 2 diabetes mellitus. An association between low -grade inflammation and type 2 diabetes has been described in some studies. We assayed the association of two frequent polymorphisms in proinflammatory cytokines: the interleukin 6 G(-174)C promoter polymorphism [IL-6G(-174)C], the exon 2 interleukin receptor antagonist insertion deletion polymorphism [IL1RA]) and serum CRP levels with the prevalence of diabetic nephropathy in patients suffering from type 2 diabetes mellitus.

SUBJECTS AND METHODS

A total of 141 patients with type 2 diabetes mellitus, with and without diabetic nephropathy was genotyped for the above mentioned polymorphisms: 66 with normoalbuminuria, 31 with microalbuminuria and 44 with macroalbuminuria. CRP levels were analysed by a high sensitivity - immunnephelometric assay.

RESULTS

While a significant association be-tween macroalbuminuria and CRP could be observed (p<0,015), no associations were found between IL-6G(-174)C or IL1RA genotype and any stage of nephropathy. CRP-levels were similar in the 3 different IL-6G(-174)C genotypes as well as in the 2 IL1RA genotypes.

CONCLUSIONS

In type 2 diabetic subjects elevated CRP levels are associated with an increased prevalence of albuminuria. The two investigated proinflammatory polymorphisms do not seem to contribute to initiation of nephropathy in type 2 diabetic patients but we cannot exclude effects of these polymorphisms on course of nephropathy.

Wasser als Infektionsquelle in medizinischen Einrichtungen, Prävention und Kontrolle

New epidemiological and microbiological investigations using molecular typing methods to link patient and environmental strains demonstrate a strong association between water-borne pathogens and nosocomial infections. Avoiding patient exposure to these pathogens results in a decreased incidence of water-borne nosocomial infections. There remains a tremendous potential to reduce hospital acquired infections previously viewed as inevitable and unavoidable through intervention and preventive measures. The characteristics of water application in health care facilities, the vulnerability of patients, the spectrum of relevant pathogens and their ecologic aspects, legal issues and important measures for prevention and control are discussed.

The cellular lesion of humoral rejection: predominant recruitment of monocytes to peritubular and glomerular capillaries

Accumulation of inflammatory cells within capillaries is a common morphologic feature of humoral renal allograft rejection and is most easily appreciated if it occurs in glomeruli. The aim of our study was to determine the amount and composition of immune cells within glomeruli and peritubular capillaries (PTC) in cellular and humoral allograft rejection. Immunofluorescent double-labeling for CD31 and CD3 or CD68 was used for phenotyping and enumerating immune cells within glomeruli and PTC. The major findings are: (1) accumulation of immune cells in PTC is far more common than it would be anticipated based on the assessment by conventional histology; (2) it is not the absolute number of immune cells accumulating within capillaries, but rather the composition of the intracapillary cell population that distinguishes humoral rejection from cellular rejection and (3) in C4d positive biopsies a predominantly monocytic cell population accumulates not only within glomeruli but also within PTC. The median value of monocyte/T-cell ratio within PTC was 2.3 in C4d positive biopsies but only 1 (p = 0.0008) in C4d negative biopsies. Given their prominent presence within capillaries and their extensive biological versatility monocytes might contribute to the capillary damage observed in acute and chronic allograft rejection.

Rotavirus infections in paediatric oncology patients: a matched-pairs analysis

OBJECTIVE

To conduct a systematic investigation of the clinical relevance of rotavirus infection in the setting of paediatric cancer patients receiving intensive chemotherapy.

MATERIAL AND METHODS

Twenty-eight paediatric cancer patients with positive rotavirus antigen tests were eligible for a retrospective case-control study (January 1995-December 2004). Rota-positive patients were compared with 28 rota-negative patients matched for age, underlying disease and chemotherapy. The National Cancer Institute Common Toxicity Criteria were used to determine clinical severity.

RESULTS

Median duration of rota-related symptoms (diarrhoea, fever and vomiting) was 7 days (range 4-34 days; 75th percentile 9 days). Median duration of viral shedding was 17 days (4-73 days; 75th percentile 39.5 days). The rota infection was nosocomially acquired in 19 patients (68%). The proportions of patients with diarrhoea > or =NCI II, fever >39 degrees C, clinically relevant dehydration, metabolic acidosis, mucositis and neutropenia were significantly higher in rota-positive patients. Rota-positive patients tended to have a prolonged period of hospitalization (median 8 versus 4 days; p=0.008). A higher proportion of rota-positive patients had to receive parenteral nutrition and tube feeding (p<0.001).

CONCLUSIONS

Rotavirus is a clinically relevant but preventable pathogen in paediatric cancer patients, since many cases seem to be nosocomial in origin. Rapid microbiological testing and contact precautions should be strictly applied to any symptomatic patient and to their immediate contacts. Prolonged viral shedding in immunocompromised paediatric patients necessitates repeated testing in order to determine the duration of isolation.

Immunoadsorption in severe C4d-positive acute kidney allograft rejection: a randomized controlled trial

Antibody-mediated rejection (AMR) frequently causes refractory graft dysfunction. This randomized controlled trial was designed to evaluate whether immunoadsorption (IA) is effective in the treatment of severe C4d-positive AMR. Ten out of 756 kidney allograft recipients were included. Patients were randomly assigned to IA with protein A (N = 5) or no such treatment (N = 5) with the option of IA rescue after 3 weeks. Enrolled recipients were subjected to tacrolimus conversion and, if indicated, 'anti-cellular' treatment. All IA-treated patients responded to treatment. One death unrelated to IA occurred after successful reversal of rejection. Four control subjects remained dialysis-dependent. With the exception of one patient who developed graft necrosis, non-responders were subjected to rescue IA, however, without success. Because of a high graft loss rate in the control group the study was terminated after a first interim analysis. Even though limited by small patient numbers, this trial suggests efficiency of IA in reversing severe AMR.

Skin cholesterol: test performance, evaluation of potential determinants and correlation analysis with cardiovascular risk factors and circulating markers of inflammation

BACKGROUND

Skin cholesterol (SkC) has been suggested to be an additional risk predictor, so we evaluated the test performance, potential determinants of this marker as well as a potential correlation of SkC with markers of inflammation and the history of cardiovascular events.

PATIENTS AND METHODS

SkC, determined by the non-invasive PREVU POC Skin Sterol test, as well as serum lipids, the body fat status, high-sensitive CRP (hs-CRP) and serum amyloid A (SAA) were evaluated in consecutive patients with and without documented atherosclerotic disease.

RESULTS

SkC was assessed in 201 patients. The within-day precision (CV) was 3.8%, the day-to-day CV of the right hand was 8.6% and 4.3% for the left hand, respectively. Neither univariate analysis nor multiple regressions identified a significant influence of age, sex, serum lipids, body fat status, smoking or diabetes mellitus on SkC, corresponding results were observed in a further analysis including 174 of these patients concerning hs-CRP and SAA (all p > 0.05). T-test analyses detected no significant differences between patients with and without a history of coronary, peripheral vascular and cerebrovascular events (all p > 0.05).

CONCLUSIONS

The PREVU POC Skin Sterol test for the assessment of SkC proved an acceptable test performance. SkC is independent from serum lipids, traditional cardiovascular risk factors, two sensitive markers of systemic inflammation as well as the history of cardiovascular events indicating that the perception of this parameter as an established marker of vascular disease is premature.

Air sampling of Aspergillus fumigatus and other thermotolerant fungi: comparative performance of the Sartorius MD8 airport and the Merck MAS-100 portable bioaerosol sampler

The purpose of our field study was to compare the performance of two portable bioaerosol samplers (Sartorius MD8 airport, and Merck MAS-100) for sampling Aspergillus fumigatus and other airborne thermotolerant fungi. From October 2001 to November 2001, a total of 336 samples were analyzed at 12 sampling days. During the sampling period fungal plate counts ranged from <1 to 300 CFU/m(3) for total thermotolerant fungi and from <1 to 76 CFU/m(3) for A. fumigatus. As compared to the MD8, the relative recovery of the MAS 100 was 0.96 for total thermotolerant fungi and 0.84 for A. fumigatus. We found a good correlation (Pearson's r=0.94 for single, 0.95 for the mean of two, and 0.96 for the mean of three sequential samples) between both portable bioaerosol samplers. The spectrum of thermotolerat fungal genera and Aspergillus species showed only minor differences. We conclude that under the given conditions the results of both samplers are approximately comparable.

Perfluorinated surfactants in surface and drinking waters

GOAL, SCOPE AND BACKGROUND

In this paper recent results are provided of an investigation on the discovery of 12 perfluorinated surfactants (PS) in different surface and drinking waters (Skutlarek et al. 2006 a, Skutlarek et al. 2006 b). In the last years, many studies have reported ubiquitous distribution of this group of perfluorinated chemicals, especially perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) in the environment, particularly in wildlife animal and human samples (Giesy and Kannan 2001, Houde et al. 2006, Prevedouros et al. 2006). Perfluorinated surfactants (e.g. PFOS and PFOA) have shown different potentials for reproductory interference and carcinogenity in animal experiments as well as partly long half-lives in humans (Guruge et al. 2006, FSA UK 2006a, FSA UK 2006b, 3M 2005, OECD 2002, Yao and Zhong 2005). They possess compound-dependent extreme recalcitrance against microbiological and chemical degradation and, in addition, they show variable potentials for bioaccumulation in animals and humans (Houde et al. 2006).

METHODS

Surface and drinking water samples were collected from different sampling sites: Surface waters: samples taken from the rivers Rhine, Ruhr, Moehne and some of their tributaries. Further samples were taken from the Rhine-Herne-Canal and the Wesel-Datteln-Canal. Drinking waters: samples taken in public buildings of the Rhine-Ruhr area. After sample clean-up and concentration by solid-phase extraction, the perfluorinated surfactants were determined using HPLC-MS/MS.

RESULTS

All measured concentrations (sum of seven mainly detected components) in the Rhine river and its main tributaries (mouths) were determined below 100 ng/L. The Ruhr river (tributary of the Rhine) showed the highest concentration (94 ng/L), but with a completely different pattern of components (PFOA as major component), as compared with the other tributaries and the Rhine river. Further investigations along the Ruhr river showed remarkably high concentrations of PS in the upper reaches of the Ruhr river and the Moehne river (tributary of the Ruhr) (Ruhr: up to 446 ng/L, Moehne: up to 4385 ng/L). The maximum concentration of all drinking water samples taken in the Rhine-Ruhr area was determined at 598 ng/L with the major component PFOA (519 ng/L).

DISCUSSION

The surface water contaminations most likely stem from contaminated inorganic and organic waste materials (so-called 'Abfallgemisch'). This waste material was legally applied to several agricultural areas on the upper reaches of the Moehne. Perfluorinated surfactants could be detected in some suchlike soil samples. They contaminated the river and the reservoir belonging to it, likely by superficial run-off over several months or probably years. Downstream, dilution effects are held responsible for decreasing concentrations of PS in surface waters of the Moehne and the Ruhr river. In analogy to the surface water samples, PS (major component PFOA) can be determined in many drinking water samples of the Rhine-Ruhr area where the water supplies are mainly based on bank filtration and artificial recharge.

CONCLUSIONS

The concentrations found in drinking waters decreased with the concentrations of the corresponding raw water samples along the flow direction of the Ruhr river (from east to west) and were not significantly different from surface water concentrations. This indicates that perfluorinated surfactants are at present not successfully removed by water treatment steps.

RECOMMENDATIONS AND PERSPECTIVES

Because of their different problematic properties (persistence, mobility, toxicity, bioaccumulation), the concentrations of specific perfluorinated surfactants and their precursors in drinking waters and food have to be minimised. Therefore, it is of utmost importance to take the initiative to establish suitable legal regulations (limitations/ban) concerning the production and use of these surfactants and their precursors. Furthermore, it is indispensable to protect water resources from these compounds. A discussion on appropriate limit values in drinking water and foodstuffs is urgently needed. Concerning the assumed soil contamination, the corresponding regulation (Bioabfall-Verordnung 1998--Regulation on Organic Waste 1998) should be extended to allow the control of relevant organic pollutants.

German guidelines for reprocessing endoscopes and endoscopic accessories: guideline compliance in Frankfurt/Main, Germany

Guidelines for reprocessing flexible endoscopes have been published in many countries. The present survey investigated compliance with German guidelines in all hospitals and private practices in Frankfurt/Main, Germany. In 2003, all endoscopic units in Frankfurt/Main [15 hospitals and 23 private practices (10 large practices performing >1,000 endoscopies/year and 13 small practices performing <1,000 endoscopies/year)] were visited by members of the Public Health Service and assessed using a checklist based on the recommendations of the German guidelines. In 2004, a re-evaluation took place, either by analysing the written reports of the institutions or by visiting them again. Meanwhile, one hospital had closed and three small practices had ceased performing endoscopy, so the re-evaluation encompassed 14 hospitals and 20 private practices. In 2003, hospital compliance with the guidelines was satisfactory but many problems were identified in private practices. Between 2003 and 2004, great improvements were made. By the end of 2004, 90% of private practices had adequate storage facilities for reprocessed endoscopes, and were performing reprocessing of bottles and tubes for air-/water-channel flushing correctly (2003: adequate storage 52%; correct reprocessing 74%). Sterilization of endoscopic accessories was satisfactory, and routine testing of endoscopes after reprocessing was performed in all private practices at the end of 2004 (2003: sterilization of accessories 57%; microbiological control tests 56%). In 2003, although hospital compliance with the guidelines was satisfactory, mandatory improvements were required in private practices, notably in smaller units. Infection control advice and the control of public health regulations resulted in the correction of most processing faults between 2003 and 2004.

Nosocomial respiratory syncytial virus infection: Impact of prospective surveillance and targeted infection control

BACKGROUND

Nosocomially acquired respiratory syncytial virus (RSV) infections cause serious problems in hospitalized patients. An increased effort should be made to describe the problems connected with such infections in pediatric hospitals, with the aim of reducing the occurrence of nosocomial RSV infections (NI).

METHODS

A specialized database was introduced for surveillance and a multifaceted barrier concept based on the CDC recommendations was developed for the control of NI in a university children's hospital in Germany.

RESULTS

Between 1999 and 2002 (November 1-April 30), 283 RSV infections (general population) were prospectively documented. Thirty-nine cases (13.8%) were nosocomial infections (NI) with an incidence density (ID) of 0.99/1000 patient days; 48.7% of all NI were found in prematurely born infants. Following the introduction of a surveillance and prevention policy, a 9-fold decrease of the ID (1.67 vs. 0.18/1000 patient-days) was found when comparing the first and the last season. Intensive care treatment was required in 18% of all documented RSV-infections, in 48.7% of all NI cases and in 43.5% of all RSV-infected prematurely born infants. Overall RSV-related mortality was 0.71%.

CONCLUSIONS

Early diagnosis, a strict cohorting and contact isolation policy, and prospective surveillance contribute to the reduction of nosocomial RSV infection.

Hygiene und Infektionsprävention in Zahnarztpraxen

Recommendations for prevention of infection in dentistry have been published in many countries and in Germany as well. In a pilot project in collaboration with the Public Health Service of the City of Frankfurt and the chamber of dentists in Hesse, compliance with these recommendations was studied in dental practices in Frankfurt/M in 2005. After being informed about the recommendations, more than 50% of the 560 Frankfurt dentists agreed to participate in this project, and 127 of these practitioners were visited by experts of the dentist chamber. Hygienic standards in the practices were examined using a checklist. A proper hygiene schedule was observed in 84% of the practices. Facilities for hand hygiene such as dispensers for soap, disinfectant and towels were available in 98, 93 and 92% of the practices, and personal protective equipment such as gloves, masks, eye wear and gowns was found in 98, 100, 98 and 88% of the practices, respectively. Reprocessing of dental instruments was done either manually (52%), manually in combination with ultrasonic cleaning (48%) or by using special reprocessing machines (32%). Steam sterilization was used in all practices; in some practices gravity displacement sterilizers were used (14%), whereas in most of the practices (61%) a high-speed prevacuum sterilizer was available -- especially in dental surgeon practices (77%). Monitoring and documentation of the sterilization process was done automatically (33%) or by hand (55%). In 80% of the practices, pressure, temperature, time and person responsible were documented. Documents of routine maintenance and regular biological testing of the sterilizers could be shown in 93 and 84% of the practices. The Frankfurt pilot project based on information and advice in combination with control has proven to be successful in the majority of practices enrolled. Encouraged by this experience, the chamber of dentists wants to implement this project all over the state of Hesse. The intention is to inform and to visit all 4,500 dental practices in agreement with the local public health services, which in turn could reduce their own control visits in dental practices. Thus, hygiene control visits of the public health services could focus on other practices such as ambulatory surgery or endoscopy.

Pivotal role of complement-fixing HLA alloantibodies in presensitized kidney allograft recipients

Recipient presensitization represents a major risk factor for kidney allograft loss. Complement fixation may be a critical attribute of deleterious alloantibodies. We investigated clinical impact of complement-fixing HLA presensitization employing [C4d]FlowPRA, a novel assay permitting selective detection of HLA panel reactive antibody (PRA)-triggered C4 complement split product deposition. A cohort of 338 kidney transplants was evaluated for presensitization applying [C4d]FlowPRA together with [IgG]FlowPRA and complement-dependent cytotoxicity (CDC)-PRA. Analysis of HLA class I alloreactivities revealed a high incidence of C4d-positive graft dysfunction in [IgG]FlowPRA(+)/[C4d]FlowPRA(+) and [IgG]FlowPRA(+)/[C4d]FlowPRA(-) recipients (23% and 22% vs. 3% in [IgG]FlowPRA(-) patients). Only patients with complement-fixing HLA class I immunization had inferior graft survival [75% (3 years) vs. 91% and 89%, respectively (p=0.036)]. Despite frequent finding of capillary C4d deposition (28%), complement-fixing HLA class II immunization was not associated with inferior survival rates. This may have been due to reduction of clinical effects by intense immunosuppression in presensitized patients. Evaluating CDC, 29% of CDC-PRA(+)/[C4d]FlowPRA(+) recipients had C4d-positive graft dysfunction. For these patients 3-year graft survival was worst, followed by CDC-PRA(+)/[C4d]FlowPRA(-) and CDC-PRA(-) patients (76% vs. 81% vs. 90%, p=0.014). Results highlight a strong impact of complement-fixing HLA presensitization. Discerning complement-activating abilities of HLA alloantibodies, [C4d]FlowPRA may help identify recipients at particularly high risk for graft rejection and loss.

[Current hygiene status in endoscopic practice. Results from monitoring the reprocessing of flexible endoscopes in hospitals and private practices in Frankfurt on the Main, Germany, 2003/4]

Flexible endoscopy is essential for the practice of modern medicine. However, with inadequate reprocessing of endoscopes and additional instruments, infections can be transmitted. Therefore, guidelines for reprocessing flexible endoscopes have been published in many countries. The goal of the present survey was to examine the current compliance with German Guidelines in a German urban region, covering all hospitals (15 hospitals) and private practices (23 practices) of this area, without any exception. All endoscopic units in Frankfort on the Main were visited by members of the Public Health Service, using a checklist based on the recommendations of the German Guidelines. In 2004, a reevaluation of 14 hospitals and 20 private practices took place, either by analysing the written reports of the institutions or by revisiting the institutions. In 2003, compliance with the guidelines in hospitals was satisfactory. In practices, however, many problems were identified in 2003. Between 2003 and 2004, great improvements could be seen (data of 2003 in parentheses). At the end of 2004, in 90% of the practices adequate storage of the endoscope without risk of recontamination (2003:52%), correct reprocessing the bottle and the tube for air/water channel flushing including filling with sterilized water was observed (2003:74% and 52%). In 100% of the practices, ultrasonic cleaning (2003:26%) and sterilizing of endoscopic accessories was guaranteed (2003:57%) and routine tests of endoscopes after reprocessing (2003:56%) were performed. In conclusion the relevance and the effect of the advising and control of public health have been so efficient that between 2003 and 2004 most faults have been corrected. Therefore control visits of the Public Health Services should not only cover hygiene in reprocessing the endoscopes but also hygiene in reprocessing endoscopic accessories as well.

Peritubular capillary damage in acute humoral rejection: an ultrastructural study on human renal allografts

The ultrastructural features of peritubular capillary (PC) damage was studied in 12 kidney allografts with acute humoral rejection (AHR). AHR manifested in diffuse linear PC staining for C4d, and histology consistent with Banff grade III in 7 recipients and Banff grade II in 5. Allografts with acute tubular necrosis served as controls. First biopsies (post-transplantation day 16.2 +/- 2.2): The intra-capillary exudate comprised monocytes (59%), polymorphonuclears (14%), lymphocytes (12%) and not otherwise specified mononuclears (15%). Three patterns of focal PC endothelial injury were observed: lysis, an increased rate of apoptosis and fragmentation. No correlation was found between the respective damage types and the inflammatory cell types or the Banff grades. Controls revealed endothelial swelling, detachment from basement membrane and fragmentation. Follow-up biopsies: Monocytes transformed into macrophages intra-luminally. The reparative changes comprised endothelial cytoplasmic protrusions, binucleated endothelial cells and capillary sprouts. Early transplant capillaropathy and transplant glomerulopathy were noted in 2 recipients. Literature data indicate that lysis is mediated by anti-HLA alloantibodies; apoptosis, demonstrated first in the present study, may be induced by non-HLA-type anti-endothelial antibodies. Fragmentation is caused by ischemia. Ongoing endothelial injury leads to transplant capillaropathy and transplant glomerulopathy, the characteristic lesions of chronic rejection.