Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut (RKI). [Requirements for hygiene in the medical care of immunocompromised patients. Recommendations from the Committee for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (RKI)]

Analysis of Mould Exposure of Immunosuppressed Patients at a German University Hospital

Moulds are ubiquitous components of outdoor and indoor air and local conditions, temperature, humidity and season can influence their concentration in the air. The impact of these factors on mould exposure in hospitals and the resulting risk of infection for low to moderately immunocompromised patients is unclear. In the present retrospective analysis for the years 2018 to 2022, the monthly determined mould contamination of the outdoor and indoor air at the University Hospital Frankfurt am Main is compared with the average air temperature and the relative humidity. Mould infections (Aspergillus spp., Mucorales) of low to moderately immunosuppressed patients of a haematological-oncological normal ward were determined clinically according to the criteria of the European Organisation for Research and Treatment of Cancer (EORTC, Brussels, Belgium) and of the National Reference Centre for Surveillance of Nosocomial Infections (NRC-NI, Berlin, Germany). The data revealed that in the summer months (May-October), increased mould contamination was detectable in the outdoor and indoor air compared to the winter months (November-April). The mould levels in the patient rooms followed the detection rates of the outdoor air. Two nosocomial Aspergillus infections, one nosocomial Mucorales (Rhizopus spp.) infection (according to both NRC-NI and EORTC criteria) and five Aspergillus spp. infections (according to EORTC criteria) occurred in 4299 treated patients (resulting in 41,500 patient days). In our study, the incidence density rate of contracting a nosocomial mould infection (n = 3) was approximately 0.07 per 1000 patient days and appears to be negligible.

Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.

A care-concept of community health nursing interventions for adults with chronic health conditions in an urban area: a study protocol of a randomized controlled field trial (CoSta study) (Preprint)

Background

Implementing community health nursing programs is a new field of application in the primary health sector of Germany. Hence, there is limited evidence of effective community-based and nurse-led interventions with regard to the German health care system. International research findings are mostly not transferable. The Community Health Nursing in der Stadt (CoSta; ie, “Community Health Nursing in the City”) project is the first study that examines a community health nurse–led intervention for adults with chronic health conditions.

Objective

This study protocol describes the design and methods of a randomized controlled field trial that will investigate if a community health nurse–based intervention has an impact on health-related quality of life in adults with chronic conditions.

Methods

The study was designed as a randomized controlled trial that will be conducted under real-life conditions in the field. In a 4-month period, patients with at least 1 chronic International Classification of Diseases, Tenth Revision, diagnosis will be enrolled. Participants will be randomly allocated to an intervention group or a control group. The sample size was assumed based on an effect size of 0.50 with a significance level of .05, using a 2-sided (2-tailed), 2-sample unequal variance t test. The control group will be treated as usual. The intervention group will receive—in addition to the usual treatment—preventive home visits; consultations; and educative training, which will be offered by 2 community health nurses for up to 12 months. Both groups will be followed up at baseline, after 6 months, and after 12 months. The primary outcome measure is the mental component summary score from the 36-Item Short Form Health Survey after 12-months. Secondary patient outcomes will be included. The study received ethics approval from the Competence Health Center’s institutional review board at the University of Applied Sciences Hamburg (procedure number: 2020-14).

Results

The CoSta project was funded by the Federal Ministry of Education and Research Germany (contract number: 13FH019SX8). In total, 187 participants were recruited at the beginning of August 2021. Further, 92 were excluded and 94 were randomized. Data collection will be conducted until the end of 2022.

Conclusions

Our study will provide data with regard to the effectiveness of community nurse–led interventions that focus on the treatment of vulnerable adults with chronic health conditions in a community health center. In secondary analyses, the associations among influencing social factors (education, income, and employment) will be examined. We expect results that will help reduce the research-to-practice gap.

Trial Registration

German Clinical Trials Register DRKS00026164; https://tinyurl.com/yckxc5ut

International Registered Report Identifier (IRRID)

DERR1-10.2196/37965

Healthcare-associated foodborne outbreaks in high-income countries: a literature review and surveillance study, 16 OECD countries, 2001 to 2019

BackgroundHealthcare-associated foodborne outbreaks (HA-FBO) may have severe consequences, especially in vulnerable groups.AimThe aim was to describe the current state of HA-FBO and propose public health recommendations for prevention.MethodsWe searched PubMed, the Outbreak Database (Charité, University Medicine Berlin), and hand-searched reference lists for HA-FBO with outbreak onset between 2001 and 2018 from Organisation for Economic Co-operation and Development (OECD) countries and HA-FBO (2012-2018) from the German surveillance system. Additionally, data from the European Food Safety Authority were analysed.ResultsThe literature search retrieved 57 HA-FBO from 16 OECD countries, primarily in the US (n = 11), Germany (n = 11) and the United Kingdom (n = 9). In addition, 28 HA-FBO were retrieved from the German surveillance system. Based on the number of outbreaks, the top three pathogens associated with the overall 85 HA-FBO were Salmonella (n = 24), norovirus (n = 22) and Listeria monocytogenes (n = 19). Based on the number of deaths, L. monocytogenes was the main pathogen causing HA-FBO. Frequently reported implicated foods were 'mixed foods' (n = 16), 'vegetables and fruits' (n = 15) and 'meat and meat products' (n = 10). Consumption of high-risk food by vulnerable patients, inadequate time-temperature control, insufficient kitchen hygiene and food hygiene and carriers of pathogens among food handlers were reported as reasons for HA-FBO.ConclusionTo prevent HA-FBO, the supply of high-risk food to vulnerable people should be avoided. Well working outbreak surveillance facilitates early detection and requires close interdisciplinary collaboration and exchange of information between hospitals, food safety and public health authorities.

Hygiene recommendations for outpatient dermatosurgery

The German Infection Protection Act and country-specific laws demand appropriate measures to prevent nosocomial infections and propagation of pathogens, especially those with resistances. This also concerns outpatient surgery of the skin. Special focus is placed on hand hygiene, antiseptics, hygienic modes of operation and professional instrument reprocessing. Every dermatological institution that operates on an outpatient basis is obliged to organize and be responsible for its hygiene. The legal framework is regulated by various laws and regulations and must be observed.

[Lead in drinking water-an old problem, a new EU directive]

BACKGROUND

Lead pipes have been used in drinking water installations for a long time. Only since 1973 have their use in new buildings been strongly discouraged; nevertheless, they are still found in old buildings. Furthermore, lead-containing alloys are still used today in components such as fittings. This results in an avoidable pollution of drinking water. The health significance of this pollution is acknowledged by a reduction of the currently valid limit value from 10 µg/l to 5 µg/l by the new EU drinking water directive passed in 2020. This directive provides for a transition period of 15 years.

OBJECTIVES

The relevance of a stricter limit value for lead in drinking water will be evaluated based by the results of routine analyses, and the necessary public health measures to prevent exposure of vulnerable groups will be formulated.

MATERIAL AND METHODS

A retrospective analysis of routine samples from the city of Bonn, which an accredited drinking water laboratory had examined in the years 1997-2019, was performed.

RESULTS

Of the 16,060 samples analyzed, 75.36% were below the quantitative limit of quantification. The median of the quantifiable samples was above the future limit for lead in drinking water in each year considered. No effect of the last transition period of 10 years (2003-2013) could be detected.

DISCUSSION

Even though no systematic studies on lead pollution in German municipalities are available, the subject is still highly topical. Lead exposure from drinking water installations is a completely avoidable health risk, but it can only be regulated by consistent enforcement of the applicable rules by the health authorities. The health authorities must be adequately equipped in terms of personnel, material, and financial resources.

SARS-CoV-2 infections in cancer outpatients-Most infected patients are asymptomatic carriers without impact on chemotherapy

Oncologic patients are regarded as the population most at risk of developing a severe course of COVID‐19 due to the fact that malignant diseases and chemotherapy often weaken the immune system. In the face of the ongoing SARS‐CoV‐2 pandemic, how particular patients deal with this infection remains an important question. In the period between the 15 and 26 April 2020, a total of 1227 patients were tested in one of seven oncologic outpatient clinics for SARS‐CoV‐2, regardless of symptoms, employing RT‐qPCR. Of 1227 patients, 78 (6.4%) were tested positive of SARS‐CoV‐2. Only one of the patients who tested positive developed a severe form of COVID‐19 with pneumonia (CURB‐65 score of 2), and two patients showed mild symptoms. Fourteen of 75 asymptomatic but positively tested patients received chemotherapy or chemo‐immunotherapy according to their regular therapy algorithm (±4 weeks of SARS‐CoV‐2 test), and 48 of 78 (61.5%) positive‐tested patients received glucocorticoids as co‐medication. None of the asymptomatic infected patients showed unexpected complications due to the SARS‐CoV‐2 infection during the cancer treatment. These data clearly contrast the view that patients with an oncologic disease are particularly vulnerable to SARS‐CoV‐2 and suggest that compromising therapies could be continued or started despite the ongoing pandemic. Moreover the relatively low appearance of symptoms due to COVID‐19 among patients on chemotherapy and other immunosuppressive co‐medication like glucocorticoids indicate that suppressing the response capacity of the immune system reduces disease severity.

Nationwide outbreak of invasive listeriosis associated with consumption of meat products in health care facilities, Germany, 2014-2019

OBJECTIVES

Invasive listeriosis is a severe foodborne infection caused by Listeria(L.)monocytogenes. The aim of this investigation was to verify and describe a molecular cluster of listeriosis patients and identify factors leading to this outbreak.

METHODS

Whole genome sequencing and core genome multilocus sequence typing were used for subtyping L. monocytogenes isolates from listeriosis cases and food samples in Germany. Patient interviews and investigational tracing of foodstuffs offered in health-care facilities (HCF), where some of the cases occurred, were conducted.

RESULTS

We identified a German-wide listeriosis outbreak with 39 genetically related cases occurring between 2014 and 2019. Three patients died as a result of listeriosis. After identification of HCF in different regions of Germany for at least 13 cases as places of exposure, investigational tracing of food supplies in six prioritized HCF revealed meat products from one company (X) as a commonality. Subsequently the outbreak strain was analysed in six isolates from ready-to-eat meat products and one isolate from the production environment of company X. No further Sigma1 cases were detected after recall of the meat products from the market and closure of company X (as of August 2020).

CONCLUSIONS

Interdisciplinary efforts including whole genome sequencing, epidemiological investigations in patients and investigational tracing of foods were essential to identify the source of infections, and thereby prevent further illnesses and deaths. This outbreak underlines the vulnerability of hospitalized patients for foodborne diseases, such as listeriosis. Food producers and HCF should minimize the risk of microbiological hazards when producing, selecting and preparing food for patients.

Tuberkulose und andere durch Luft übertragbare Infektionserkrankungen: Krankenhaushygiene zur Vermeidung und Eindämmung

Die Tuberkulose (TB) gehört weltweit zu den am häufigsten auftretenden Infektionskrankheiten und wird fast ausschließlich über die Luft (aerogen) übertragen. Nachdem in Deutschland die Lungentuberkulosefallzahlen über Jahre hinweg stagnierten, ist seit 2013 wieder ein Anstieg der Inzidenzen zu verzeichnen (RKI 2016). Als Ursache hierfür werden die aktuellen demographischen Entwicklungen (Migration und Mobilität) gesehen. Die Kenntnis der epidemiologischen Situation ist von zentraler Bedeutung, um bei Vorliegen der Verdachtsdiagnose Tuberkulose sowie der Einbeziehung einer möglichen Resistenzproblematik frühzeitig adäquate krankenhaushygienische Maßnahmen einzuleiten. Als aerogen übertragbar werden auch die Aspergillose sowie Masern, Windpocken und Herpes zoster eingestuft (CDC 2007). Die Aspergillose ist eine relativ seltene, aber häufig letal verlaufende Pilzinfektion, die überwiegend bei immunsupprimierten Patienten auftritt. Krankenhaushygienische Schutzmaßnahmen können die Risiken einer Exposition und somit das Erkrankungsrisiko minimieren. Die zentralen Maßnahmen zur Kontrolle und Prävention von aerogen übertragbaren Infektionen sind Gegenstand dieses Kapitels.

Isolierungsmaßnahmen

Die Kenntnis des infektionsspezifischen Übertragungsweges einer Erkrankung ist die entscheidende Voraussetzung zur Festlegung sinnvoller, d. h. effektiver Präventionsmaßnahmen, zu denen auch heute noch die räumliche Isolierung von Patienten gehört. Die in der Vergangenheit empfohlenen pauschalen Maßnahmen, die weder den Übertragungsweg noch die Virulenz eines Infektionserregers angemessen berücksichtigten, führten oftmals zu erkennbarer Überisolierung, mit der Folge, dass in der täglichen Praxis notwendige Isolierungsmaßnahmen eher nachlässig gehandhabt wurden. Die Konsequenzen waren vermeidbare Kontaktinfektionen in Kliniken. Andererseits birgt die Unterbringung in einem Isolierzimmer die Gefahr einer schlechteren medizinischen wie pflegerischen Versorgung und damit einer Gefährdung des Patienten. Erreger- und maßnahmenbezogene Isolierkriterien mit disziplinierter Befolgung erforderlicher Verhaltensregeln seitens aller Beschäftigten, der isolierten Patienten und ihrer Besucher sind die Voraussetzung einer erfolgreichen Vermeidung von Infektionsübertragungen. Die Vermeidung unnötiger Isolierungsmaßnahmen spart erhebliche Kosten, reduziert die Belastung von Ärzten wie Pflegekräften und damit die Gefahr der Noncompliance bei essenziellen Präventionsmaßnahmen wie Händedesinfektion und andere Maßnahmen der Basishygiene.

Primary prophylaxis of invasive fungal infections in patients with haematological malignancies: 2017 update of the recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society for Haematology and Medical Oncology (DGHO)

Immunocompromised patients are at high risk of invasive fungal infections (IFI), in particular those with haematological malignancies undergoing remission-induction chemotherapy for acute myeloid leukaemia (AML) or myelodysplastic syndrome (MDS) and recipients of allogeneic haematopoietic stem cell transplants (HSCT). Despite the development of new treatment options in the past decades, IFI remains a concern due to substantial morbidity and mortality in these patient populations. In addition, the increasing use of new immune modulating drugs in cancer therapy has opened an entirely new spectrum of at risk periods. Since the last edition of antifungal prophylaxis recommendations of the German Society for Haematology and Medical Oncology in 2014, seven clinical trials regarding antifungal prophylaxis in patients with haematological malignancies have been published, comprising 1227 patients. This update assesses the impact of this additional evidence and effective revisions. Our key recommendations are the following: prophylaxis should be performed with posaconazole delayed release tablets during remission induction chemotherapy for AML and MDS (AI). Posaconazole iv can be used when the oral route is contraindicated or not feasible. Intravenous liposomal amphotericin B did not significantly decrease IFI rates in acute lymphoblastic leukaemia (ALL) patients during induction chemotherapy, and there is poor evidence to recommend it for prophylaxis in these patients (CI). Despite substantial risk of IFI, we cannot provide a stronger recommendation for these patients. There is poor evidence regarding voriconazole prophylaxis in patients with neutropenia (CII). Therapeutic drug monitoring TDM should be performed within 2 to 5 days of initiating voriconazole prophylaxis and should be repeated in case of suspicious adverse events or of dose changes of interacting drugs (BIItu). General TDM during posaconazole prophylaxis is not recommended (CIItu), but may be helpful in cases of clinical failure such as breakthrough IFI for verification of compliance or absorption.

Nosocomial legionellosis and invasive aspergillosis in a child with T-lymphoblastic leukemia

Invasive aspergillosis of the lungs and the central nervous system and Legionella pneumophilia serotype 1 infection of the lungs were diagnosed in a 22-month old child during inpatient induction treatment for T-lymphoblastic leukemia. Environmental investigations i.e. samples from the hospital water system did not reveal any Legionella. The patient may have been exposed to waterborne pathogens despite terminal water filtration due to a technical device to release residual tap water from the hose after showering. A sodium chloride nose spray was found to be contaminated with the A. fumigatus isolate of the patient.

Abridged version of the AWMF guideline for the medical clinical diagnostics of indoor mould exposure: S2K Guideline of the German Society of Hygiene, Environmental Medicine and Preventive Medicine (GHUP) in collaboration with the German Association of Allergists (AeDA), the German Society of Dermatology (DDG), the German Society for Allergology and Clinical Immunology (DGAKI), the German Society for Occupational and Environmental Medicine (DGAUM), the German Society for Hospital Hygiene (DGKH), the German Society for Pneumology and Respiratory Medicine (DGP), the German Mycological Society (DMykG), the Society for Pediatric Allergology and Environmental Medicine (GPA), the German Federal Association of Pediatric Pneumology (BAPP), and the Austrian Society for Medical Mycology (ÖGMM)

This article is an abridged version of the AWMF mould guideline "Medical clinical diagnostics of indoor mould exposure" presented in April 2016 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with the above-mentioned scientific medical societies, German and Austrian societies, medical associations and experts. Indoor mould growth is a potential health risk, even if a quantitative and/or causal relationship between the occurrence of individual mould species and health problems has yet to be established. Apart from allergic bronchopulmonary aspergillosis (ABPA) and mould-caused mycoses, only sufficient evidence for an association between moisture/mould damage and the following health effects has been established: allergic respiratory disease, asthma (manifestation, progression and exacerbation), allergic rhinitis, hypersensitivity pneumonitis (extrinsic allergic alveolitis), and increased likelihood of respiratory infections/bronchitis. In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitizing prevalence of 3-10% in the general population across Europe. Limited or suspected evidence for an association exist with respect to mucous membrane irritation and atopic eczema (manifestation, progression and exacerbation). Inadequate or insufficient evidence for an association exist for chronic obstructive pulmonary disease, acute idiopathic pulmonary hemorrhage in children, rheumatism/arthritis, sarcoidosis and cancer. The risk of infection posed by moulds regularly occurring indoors is low for healthy persons; most species are in risk group 1 and a few in risk group 2 (Aspergillus fumigatus, A. flavus) of the German Biological Agents Act (Biostoffverordnung). Only moulds that are potentially able to form toxins can be triggers of toxic reactions. Whether or not toxin formation occurs in individual cases is determined by environmental and growth conditions, above all the substrate. In the case of indoor moisture/mould damage, everyone can be affected by odour effects and/or mood disorders. However, this is not a health hazard. Predisposing factors for odour effects can include genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for mood disorders may include environmental concerns, anxiety, condition, and attribution, as well as various diseases. Risk groups to be protected particularly with regard to an infection risk are persons on immunosuppression according to the classification of the German Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, KRINKO) at the Robert Koch- Institute (RKI) and persons with cystic fibrosis (mucoviscidosis); with regard to an allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma should be protected. The rational diagnostics include the medical history, physical examination, and conventional allergy diagnostics including provocation tests if necessary; sometimes cellular test systems are indicated. In the case of mould infections the reader is referred to the AWMF guideline "Diagnosis and Therapy of Invasive Aspergillus Infections". With regard to mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medicine standpoint it is important that indoor mould infestation in relevant dimension cannot be tolerated for precautionary reasons. With regard to evaluating the extent of damage and selecting a remedial procedure, the reader is referred to the revised version of the mould guideline issued by the German Federal Environment Agency (Umweltbundesamt, UBA).

Medical diagnostics for indoor mold exposure

In April 2016, the German Society of Hygiene, Environmental Medicine and Preventative Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin (GHUP)) together with other scientific medical societies, German and Austrian medical societies, physician unions and experts has provided an AWMF (Association of the Scientific Medical Societies) guideline 'Medical diagnostics for indoor mold exposure'. This guideline shall help physicians to advise and treat patients exposed indoors to mold. Indoor mold growth is a potential health risk, even without a quantitative and/or causal association between the occurrence of individual mold species and health effects. Apart from the allergic bronchopulmonary aspergillosis (ABPA) and the mycoses caused by mold, there is only sufficient evidence for the following associations between moisture/mold damages and different health effects: Allergic respiratory diseases, asthma (manifestation, progression, exacerbation), allergic rhinitis, exogenous allergic alveolitis and respiratory tract infections/bronchitis. In comparison to other environmental allergens, the sensitizing potential of molds is estimated to be low. Recent studies show a prevalence of sensitization of 3-10% in the total population of Europe. The evidence for associations to mucous membrane irritation and atopic eczema (manifestation, progression, exacerbation) is classified as limited or suspected. Inadequate or insufficient evidence for an association is given for COPD, acute idiopathic pulmonary hemorrhage in children, rheumatism/arthritis, sarcoidosis, and cancer. The risk of infections from indoor molds is low for healthy individuals. Only molds that are capable to form toxins can cause intoxications. The environmental and growth conditions and especially the substrate determine whether toxin formation occurs, but indoor air concentrations are always very low. In the case of indoor moisture/mold damages, everyone can be affected by odor effects and/or impairment of well-being. Predisposing factors for odor effects can be given by genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for impairment of well-being are environmental concerns, anxieties, conditioning and attributions as well as a variety of diseases. Risk groups that must be protected are patients with immunosuppression and with mucoviscidosis (cystic fibrosis) with regard to infections and individuals with mucoviscidosis and asthma with regard to allergies. If an association between mold exposure and health effects is suspected, the medical diagnosis includes medical history, physical examination, conventional allergy diagnosis, and if indicated, provocation tests. For the treatment of mold infections, it is referred to the AWMF guidelines for diagnosis and treatment of invasive Aspergillus infections. Regarding mycotoxins, there are currently no validated test methods that could be used in clinical diagnostics. From the perspective of preventive medicine, it is important that mold damages cannot be tolerated in indoor environments.

Lack of Effectiveness of Neutropenic Diet and Social Restrictions as Anti-Infective Measures in Children With Acute Myeloid Leukemia: An Analysis of the AML-BFM 2004 Trial

PURPOSE

Although nonpharmacologic anti-infective measures are widely used in children treated for acute myeloid leukemia (AML), there is little evidence of their effectiveness.

PATIENTS AND METHODS

We analyzed infectious complications in children during intensive treatment of AML according to the AML-BFM 2004 trial and surveyed sites on institutional standards regarding recommended restrictions of social contacts (six items), pets (five items), and food (eight items). A scoring system was developed with a restriction score for each item. Multivariable Poisson regression adjusted for sex, age, weight group, risk stratification, and prophylactic antibiotics was used to estimate the impact of the restrictions on the incidence ratios of fever of unknown origin, bacteremia, pneumonia, and gastroenteritis.

RESULTS

Data on recommendations of nonpharmacologic anti-infective measures and infectious complications were available in 339 patients treated in 37 institutions. Analyses did not demonstrate a significant benefit of any of the restrictions regarding food, social contacts, and pets on the risk of fever, bacteremia, pneumonia, and gastroenteritis. In contrast, age, weight group, risk stratification, and nonabsorbable antibiotics had some influence on infections complications.

CONCLUSION

The lack of effectiveness of dietary restrictions and restrictions regarding social contacts and pets should result in reconsideration of anti-infective policies.

Surveillance of bloodstream infections in pediatric cancer centers - what have we learned and how do we move on?

Pediatric patients receiving conventional chemotherapy for malignant disease face an increased risk of bloodstream infection (BSI). Since BSI may represent an acute life-threatening event in patients with profound immunosuppression, and show further negative impact on quality of life and anticancer treatment, the prevention of BSI is of paramount importance to improve and guarantee patients' safety during intensive treatment. The great majority of all pediatric cancer patients (about 85%) have a long-term central venous access catheter in use (type Broviac or Port; CVAD). Referring to the current surveillance definitions a significant proportion of all BSI in pediatric patients with febrile neutropenia is categorized as CVAD-associated BSI. This state of the art review summarizes the epidemiology and the distinct pathogen profile of BSI in pediatric cancer patients from the perspective of infection surveillance. Problems in executing the current surveillance definition in this patient population are discussed and a new concept for the surveillance of BSI in pediatric cancer patients is outlined.

Hygiene guideline for the planning, installation, and operation of ventilation and air-conditioning systems in health-care settings - Guideline of the German Society for Hospital Hygiene (DGKH)

Since the publication of the first "Hospital Hygiene Guideline for the implementation and operation of air conditioning systems (HVAC systems) in hospitals" (http://www.krankenhaushygiene.de/informationen/fachinformationen/leitlinien/12) in 2002, it was necessary due to the increase in knowledge, new regulations, improved air-conditioning systems and advanced test methods to revise the guideline. Based on the description of the basic features of ventilation concepts, its hygienic test and the usage-based requirements for ventilation, the DGKH section "Ventilation and air conditioning technology" attempts to provide answers for the major air quality issues in the planning, design and the hygienically safe operation of HVAC systems in rooms of health care.

Hygiene auf der IMC-Station

Im Kapitel Hygiene auf der IMC-Station wird dargelegt, dass die Einhaltung von Hygienemaßnahmen nach den neuesten wissenschaftlichen Erkenntnissen zu den Basismaßnahmen einer jeden IMC-Station gehört. Neben den Standard-Hygienemaßnahmen einer IMC-Station werden die besonderen Aspekte der hygienischen Körperpflege beschrieben. Die erforderlichen Interventionen zur Vermeidung von Katheterinfektionen werden begründet. Die Vorbereitung, Anlage und Pflege der Katheter werden detailliert dargestellt, sodass jeder Lernende dies als Handlungsanweisung verwenden kann und dem Erfahrenen eine Detailprüfung ermöglicht wird. Wichtige Aspekte der Wund-, Drainagen- und Stomapflege werden besprochen und eine Kurzübersicht zur Pflege von Patienten mit MRE gegeben.

Anti-infective prophylaxis in pediatric patients with acute myeloid leukemia

Pediatric patients undergoing treatment for acute myeloid leukemia (AML) are at high risk for infectious complications, predominantly due to Gram-negative bacteria, viridans group streptococci and fungal pathogens. In order to prevent infections in these patients, most institutions have implemented a number of non-pharmacological approaches to supportive care. In addition, antibiotic prophylaxis reduces bacterial infection, but may increase the emergence of resistance. Antifungal prophylaxis is generally recommended for children with AML. Whereas the use of hematopoietic growth factors has not resulted in improved survival, the efficacy of prophylactic granulocyte transfusions has to be determined.

[Intra-articular punctures and injections]

Joint punctures and injections are a widely used approach to obtain a differential diagnostic assessment for the formation of a treatment concept for recurrent joint effusions, to exclude a periprosthetic infection in painful and loosened endoprostheses before a planned revision, to assign the origin of pain symptoms to a specific joint or to provide a treatment for arthritis of any kind. In all medical fields the standardization of processes has progressed. Therefore, for joint punctures there are standards relating to the implementation and hygiene of intra-articular punctures or injections in order to prevent the occurrence of complications, such as joint infections.

Contributing and Terminating Factors of a Large RSV Outbreak in an Adult Hematology and Transplant Unit

BACKGROUND

In January 2012, an increase of respiratory syncytial virus (RSV) infections on an adult hematology and transplant unit in a German university hospital was detected. We investigated the outbreak to assess its timing and extent and to identify risk factors for transmission.

METHODS

We tested and typed patient samples pro- and retrospectively for RSV. We conducted a cohort and a case-control study. A confirmed outbreak case had laboratory-diagnosed, nosocomially-acquired RSV infection. Possible outbreak cases had pneumonia but were not laboratory-confirmed.

RESULTS

Of 53 outbreak cases, 36 (68%) were confirmed and 17 (32%) possible. Retrospective testing and chart review dated the beginning of the outbreak to November 2011. Patients with community-acquired RSV infection were identified when the community epidemic began in January 2012. In multivariable analysis (controlling for contact with medical personnel, hygiene behaviour and age) patients with active social behaviour were more at risk for RSV infection (odds ratio 23.8, 95% confidence interval, 1.3 to 434.9; p-value, 0.03). Confirmed outbreak cases were more likely than controls to have been accomodated together with a confirmed or possible case before their onset of illness (OR 9.3, 95%CI: 2.1-85.1; p<0.001). Control measures, including isolation of every patient in the unit, initiated until the end of January terminated the outbreak.

CONCLUSIONS

Epidemiological investigations revealed co-accomodation with a case-patient and active social behaviour as likely risk factors for RSV infection. Awareness of and vigorous testing for respiratory viruses in immunosuppressed hospitalised patients is necessary to timely detect cases with outbreak potential. Isolation of patients with respiratory infectious illnesses is crucial to prevent the continuation or occurrence of outbreaks.

Hygiene auf der IMC-Station

Laut Aussage des Bundesgesundheitsministeriums im Juli 2011 erkranken in Deutschland jährlich 400.000–600.000 Menschen an einer Krankenhausinfektion. Schätzungsweise zwischen 7.500 und 15.000 Menschen sterben jährlich an einer Krankenhausinfektion. 20–30% der Infektionen könnten durch die Einhaltung von Hygienemaßnahmen vermieden werden (BMG 2012).

Variations in non-pharmacological anti-infective measures in childhood leukemia--results of an international survey

BACKGROUND

Standardization in clinical practice may lead to improved outcomes. Unfortunately, little is known about the variability of non-pharmacological anti-infective measures in children with cancer.

DESIGN AND METHODS

A web-based survey assessed institutional recommendations regarding restrictions of social contacts, pets and food and instructions on wearing face masks in public for children with standard- risk acute lymphoblastic leukemia and acute myeloid leukemia during intensive chemotherapy.

RESULTS

A total of 336 institutions in 27 countries responded to the survey (range, 1-76 institutions per country; overall response rate 61%). Most institutions recommend that patients with acute myeloid leukemia avoid indoor public places and daycare, kindergarten and school, whereas recommendations for patients with acute lymphoblastic leukemia differ considerably by institution. In terms of restrictions related to pets, there was a wide variability between institutions for both acute lymphoblastic and acute myeloid leukemia patients. Most, but not all institutions do not allow children with either acute lymphoblastic or acute myeloid leukemia to eat raw meat, raw seafood or unpasteurized milk. Whereas most institutions do not routinely recommend that patients with acute lymphoblastic leukemia wear face masks in public, advice on this matter varies for patients with acute myeloid leukemia.

CONCLUSIONS

The survey demonstrates that there is a wide variation in recommendations on non-pharmacological anti-infective measures between different institutions, countries and continents. This information may be used to encourage harmonization of supportive care practices and future clinical trials.

Can the Hazard Assessment and Critical Control Points (HACCP) system be used to design process-based hygiene concepts?

Recently, the HACCP (Hazard Analysis and Critical Control Points) concept was proposed as possible way to implement process-based hygiene concepts in clinical practice, but the extent to which this food safety concept can be transferred into the health care setting is unclear. We therefore discuss possible ways for a translation of the principles of the HACCP for health care settings. While a direct implementation of food processing concepts into health care is not very likely to be feasible and will probably not readily yield the intended results, the underlying principles of process-orientation, in-process safety control and hazard analysis based counter measures are transferable to clinical settings. In model projects the proposed concepts should be implemented, monitored, and evaluated under real world conditions.

[Experience with prevention and control of legionellosis in Germany : plea for proactive risk management]

Legionellosis is meanwhile the most important specific water-associated infectious disease in developed countries, which is completely preventable, if water distribution systems are correctly planned and operated. This assumes clear criteria for risk regulation and for verification, including microbiological monitoring for Legionella. There are different reactive and proactive strategies in the USA and in Europe. The common premises for prevention and control of legionellosis in Germany, relevant facts for risk regulation, experience in Germany toward proactive risk regulation, and the current approach of the amended drinking water ordinance are discussed. The article concludes with a short discussion of the controversial approaches for the prevention of legionellosis in Germany.

Vaccination coverage in immunosuppressed patients: results of a regional health services research study

BACKGROUND

Patients with chronic inflammatory diseases are at elevated risk of infections that can be prevented by vaccination. This elevated risk is due not just to these patients' primary illnesses, but also to the immunosuppressive treatment that they often receive. We studied the vaccination rate in a random sample of patients with two types of inflammatory bowel disease (IBD), namely, Crohn's disease and ulcerative colitis. In particular, we asked unvaccinated patients why they had re-fused the vaccine.

METHODS

From April to September 2009, we gave a 38-item questionnaire to 203 consecutive patients with IBD (57% with Crohn's disease, 63% female, median age 36 years) who had not received vaccination counseling for at least one year, and inspected the patients' vaccination cards. We compared the findings to the current recommendations of the German Federal Standing Committee on Vaccination (Ständige Impfkommission).

RESULTS

83% of the patients had a vaccination card. Substantial deficiencies in vaccination were found. Only 67% of the patients had been immunized against tetanus in the previous 10 years, and only 21% against pertussis. Only 28% were vaccinated against seasonal influenza in 2008, and only 9% had ever received anti-pneumococcal vaccine. A subgroup analysis in which we compared 39 patients taking TNF-blockers to 67 patients who never had any type of immunosuppressive treatment revealed no difference in vaccination rates. 80% of all patients said they were willing to receive all of the officially recommended vaccinations. 22% of all patients said they avoided vaccinations for fear of side effects, while 15% said they did so because their immune system was supposedly "not intact", and 9% because they feared vaccination would worsen their IBD.

CONCLUSION

In this random sample, the vaccination rate fell far behind the recommendations. In particular, there was a marked discrepancy between patients' willingness to be vaccinated and the actual provision of vaccination. These findings imply that physicians need to be more aware of the possibly inadequate vaccination state of their immunosuppressed patients.

Unusual infections: Femoral abscess due to Nocardia abscessus in a patient suffering from metastatic peripheral bronchial carcinoma and hygienic consequences

During the course of a peripheral bronchial carcinoma with pulmonary and cerebral metastases a femoral abscess developed in a 49 year-old patient after radio- and chemotherapy. A bacterial strain, which was isolated four times from a deep wound of the left thigh was tentatively identified as a member of the genus Nocardia on the basis of selected phenotypic and chemotaxonomic characteristics. The isolate was confirmed to belong to Nocardia abscessus by 16S rRNA gene sequencing. This species had previously been described as the causative agent of soft tissue infections. Although rare, nocardia soft tissue infections as complication of systemic nocardiosis are typical air born infections of immuncompromised patients and need specific attention. Infection prevention can be realized by restriction of soil and aerosol (builder's dust) together with antibiotic intervention (oral administration of trimethoprim/sulfamethoxazole).