Introduction: Vancomycin-resistant Enterococcus faecium accounts for around 10–23% of nosocomial enterococcal infections and constitutes a relevant therapeutic problem due to its limited susceptibility to antibiotics. The resistance towards glycopeptide antibiotics is mediated by the so-called van genes. Currently, the most common resistance type in Germany is the vanB-type. Little data are available on the molecular epidemiology in Germany. Therefore, an epidemiological typing of Enterococcus faecium isolates with vanB-type resistance from two German hospitals in Essen and Nuremberg was performed. Two outbreaks and 104 sporadic cases were investigated. Methods: All 128 isolates with vanB-type resistance were collected between 2011–2012 and 2017–2018. They were characterized using multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE). Results: ST 117 was the most common sequence type (ST) in both hospitals, especially since 2017. PFGE divided the isolates of this study into 68 PFGE types and showed a broad genetic diversity. Two epidemiologically assumed in-hospital outbreaks were genetically confirmed. Apart from that, in-hospital transmissions were rare events. Conclusion: The results obtained by MLST confirmed the previously described allocation of STs in Germany. PFGE showed a broad genetic diversity of vanB VRE between the two hospitals and also within each hospital. In-hospital transmissions were rare, but outbreaks did occur. Our data supports the strategy to screen and isolate patients in transmission events in order to detect monoclonality indicating a common source or hygiene mismanagement.

SARS-CoV-2 is a worldwide challenge for the medical sector. Healthcare workers (HCW) are a cohort vulnerable to SARS-CoV-2 infection due to frequent and close contact with COVID-19 patients. However, they are also well trained and equipped with protective gear. The SARS-CoV-2 IgG antibody status was assessed at three different time points in 450 HCW of the University Hospital Essen in Germany. HCW were stratified according to contact frequencies with COVID-19 patients in (I) a high-risk group with daily contacts with known COVID-19 patients (n = 338), (II) an intermediate-risk group with daily contacts with non-COVID-19 patients (n = 78), and (III) a low-risk group without patient contacts (n = 34). The overall seroprevalence increased from 2.2% in March–May to 4.0% in June–July to 5.1% in October–December. The SARS-CoV-2 IgG detection rate was not significantly different between the high-risk group (1.8%; 3.8%; 5.5%), the intermediate-risk group (5.1%; 6.3%; 6.1%), and the low-risk group (0%, 0%, 0%). The overall SARS-CoV-2 seroprevalence remained low in HCW in western Germany one year after the outbreak of COVID-19 in Germany, and hygiene standards seemed to be effective in preventing patient-to-staff virus transmission.

•The average SARS-CoV-2 seroprevalence in healthcare workers of a a tertiary hospital, University Hospital Essen, Germany was 1.6 % in the period between March to April 2020.•The local hygiene standards seem to be effective to prevent patient-to-staff virus transmission at the designated COVID-19 units wards.•Awareness for COVID-19 infections is crucial even in non−COVID-19 wards.

Aim: In ENT (Ear, Nose and Throat) treatment units, medical devices for examination are commonly stored on open trays. The aim of this study is to investigate whether open storage is a relevant cause for microbiological contamination of ENT instruments during a working day. Methods: Qualitative and quantitative tests, such as imprints and swabs, were performed on the instruments and the surfaces of the treatment units in an ENT outpatient clinic at the beginning and at the end of consultation hours. The microbiological analysis of the samples focused on potential pathogens, e.g., Staphylococcus aureus or Pseudomonas aeruginosa, bacteria of skin and oral microbiota, as well as the number of colony forming units (CFU). The samples were collected at three distinct ENT treatment units over five working days. Results: The samples taken at the beginning of consultation hours showed a low number of CFU and no pathogens. Overall, 5% of the instruments were contaminated with bacteria of skin microbiota. At the end of a working day, this rate increased significantly to 17.5% (p<0.01). At the beginning of the working day, the mean number on the instrument trays was 4 CFU/25 cm(2), which increased to 34 CFU/25 cm(2) at the end of the working day. In some cases of the imprints taken at the end of the working day showed that a bacterial lawn had formed. In two cases, the pathogens Ralstonia picketii and Enterobacter cloacae were detected; in another case Bacillus spp. was identified. The contamination of ENT instruments and the ENT treatment unit increased significantly (p<0.01) over the duration of consultation hours. Conclusion: The results show that the current hygiene requirements for storage und reprocessing are not sufficient to conform to the mandatory guidelines of the German Commission on Hospital Hygiene and Infection Prevention. Although we could not find a pressing risk for the patients, we also cannot exclude it in the long term. Thus, new concepts are needed.

Objective design We describe a case series of patients colonized with KPC-producing Enterobacteriaceae related to dialysis drains at patient’s bedside. Setting The study was set at the intensive care unit (ICU) of a tertiary referral hospital. Patients In March 2016, we discovered four ICU patients to be colonized with KPC-producing Enterobacteriaceae in routine screening. All of these patients had already received contact isolation, and all of them were treated with continuous veno-venous dialysis. Environmental examinations showed KPC-producing Enterobacteriaceae in dialysis drains in different ICU rooms and even in rooms not hosting KPC-colonized patients. Interventions Based on our findings, we suspected the dialysis drains as a reservoir of KPC-producing Enterobacteriaceae with a potential risk for the patients. Therefore, we decided to change the dialysis waste management. Results As a result, no KCP-producing Enterobacteriaceae were detected during the following weekly screening of the patients. Conclusions Installation of dialysis connection units including a drain system at the patient’s bedside is a comfortable way to provide water supply. In many ICUs, such dialysis drains are installed near the patients’ head and directly besides the infusion systems. When the drains are not used properly, in our opinion, they pose a risk of transmission of pathogens from the drain to the patient. Our findings support the need of specific precautions.

BACKGROUND:Invasive aspergillosis (IA) in immunocompromised patients has been associated with demolition in or adjacent to hospitals. In recent years, azole-resistant clinical isolates of Aspergillus fumigatus, the most common agent of IA, have emerged in Western Europe and are spreading globally. AIM:To determine the potential risk of IA, including azole resistance, in patients caused by demolition of a hospital building. METHODS:Air sampling before, during and after demolition, screening for azole resistance, genotyping of non-susceptible isolates, and comparing those with strains from patients with azole-resistant IA during demolition. FINDINGS:Mean concentrations of A. fumigatus spores did not differ significantly between the three periods before [17.5 colony-forming units (cfu)/m³], during (20.8 cfu/m³) (P=0.26) and after (17.7 cfu/m³) demolition (P=0.33). No significant difference in IA cases documented by clinicians was found when comparing the timeframe of demolition with the previous year (44 vs 42 cases). Thirty of 200 A. fumigatus isolates (15%) showed azole resistance. Genotyping by microsatellite polymerase chain reaction of the azole-resistant environmental and clinical isolates showed a polyclonal distribution. CONCLUSIONS:The results suggest that with implemented preventive measures, there is no increased risk for IA, including azole resistance, in immunocompromised patients during outdoor demolition work. Further prospective studies are needed to confirm these findings.

INTRODUCTION:Outbreaks of scabies are common in community facilities, but rare in hospitals. We report the outbreak of scabies infestations in health care workers in a tertiary care hospital.DESCRIPTION OF THE OUTBREAK:Five staff members developed a scabies infestation, confirmed by a dermatologist. The scabies was acquired obviously while treating a severe ill ICU patient, no other source of the infection could be detected.THERAPY:All staff members were treated with Permethrine and Ivermectine.DISCUSSION:The immunocompromised index patient had undergone antiscabious treatment several months before she was admitted to the ICU, but due to the close physical contact with the staff in the ICU transmissions of mite occurred obviously.This case underlines that scabies may remain contagious over a long period even after an appropriate treatment of a well-known patient. Especially in the conditions of an ICU environment, appropriate personal protective measures are required for a long period of time.

Background: Urinary tract infection is the most common complication after kidney transplantation. It can cause severe sepsis and transplant loss. Emergence of drug resistance among gram-negative urinary pathogens is the current challenge for urinary tract infection treatment after kidney transplantation.Methods: This study analyzes the antimicrobial susceptibility of gram-negative urinary pathogens after kidney transplantation from 2009 to 2012 at the Transplant Outpatient Clinic of the University Hospital Essen, Germany. Kidney transplant patients at the University Hospital Essen receive regular follow up examinations after transplantation. Midstream urines were examined for bacteriuria at each follow up visit.Results: From 2009 to 2012 15.741 urine samples were obtained from 859 patients. In 2985 (19%) samples bacterial growth was detected. The most frequently detected gram-negative bacteria were E. coli 1109 (37%), Klebsiella spp. 242 (8%) and Pseudomonas aeruginosa 136 (4.5%). Klebsiella spp. showed a significant increase of resistance to trimethoprim-sulfamethoxazole by 19% (p = 0.02), ciprofloxacin by 15% (p = 0.01) and ceftazidime by 17% (p = 0.004). E. coli and P. aeruginosa isolates presented no significant differences of antimicrobial susceptibility to the analyzed antibiotics.Conclusions: Antimicrobial resistance of Klebsiella spp. increased significant to trimethoprim-sulfamethoxazole, ciprofloxacin and ceftazidime from 2009 to 2012.

In the past years infections caused by multidrug-resistant Gram-negative bacteria have dramatically increased in all parts of the world. This consensus paper is based on presentations, subsequent discussions and an appraisal of current literature by a panel of international experts invited by the Rudolf Schülke Stiftung, Hamburg. It deals with the epidemiology and the inherent properties of Gram-negative bacteria, elucidating the patterns of the spread of antibiotic resistance, highlighting reservoirs as well as transmission pathways and risk factors for infection, mortality, treatment and prevention options as well as the consequences of their prevalence in livestock. Following a global, One Health approach and based on the evaluation of the existing knowledge about these pathogens, this paper gives recommendations for prevention and infection control measures as well as proposals for various target groups to tackle the threats posed by Gram-negative bacteria and prevent the spread and emergence of new antibiotic resistances.

It is a century-old tradition of furnishing Bibles in the bedside drawers of hospitalized patients. But since the books cannot be disinfected, it might be possible that bacterial pathogens survive on the bibles. The aim of this study was to determine whether Bibles in patient's rooms can act as a vehicle for the spread of nosocomial infections from one to the next patient. We took samples from 50 Bibles in various general wards of the hospital. During the same period, we took contact samples of 99 hymnals from the hospital chapel. The hospital chapel is visited by patients from all departments of the hospital. As expected, microorganisms were detected on all books. They were mainly apathogenic organisms. Molds (Aspergillus spp.) were identified on the surfaces of five books. Two Bibles showed pathogen bacteria in a low number. No invasive infections with those pathogens could be documented during the investigation period, retrospectively. In conclusion, our results do not support Bibles as a possible source of nosocomial infections.

Background: Prevalence of vancomycin-resistant enterococci has increased in Germany. Here, we report the cluster of linezolid-and vancomycin-resistant Enterococcus faecium (LVRE) in a German department for hematologic stem cell transplantation (HSCT).Methods: In this retrospective analysis we included all patients with LVRE in a university-based department for HSCT in 2014 and 2015. Patients chart reviews were used to investigate the epidemiology and clinical outcome. Available LVRE isolates underwent detailed microbiological characterization and genotyping by pulsed-field gel electrophoresis (PFGE).Results: In total, 20 patients with LVRE were identified within the observed time period. All except two patients underwent allogeneic HSCT. Surveillance culture results from incoming patients and chart review revealed that 10 of 20 patients were colonized at hospital admission. Eight of 10 patients with in-hospital acquired LVRE had previous linezolid treatment. Analysis of spatio-temporal patterns showed no evidence for LVRE patient-to-patient or environment-to-patient transmission within the HSCT department. In five cases (25 %) LVRE bloodstream infection occurred. Nine LVRE isolates could be saved for characterization. Eight isolates carried vanA, one isolate vanB. PFGE analysis showed that four different LVRE clones were responsible for the cluster. One single genotype was present in six LVRE isolates whereupon the corresponding patients were all referred from the same hospital to the HSCT department.Conclusions: This is the first report demonstrating the emergence of LVRE in a German HSCT department. (L) VRE screening at patients' admission and appropriate infection control strategies were sufficient to prevent any transmission. Further studies in this predisposed patient collective are warranted.

Zusammenfassung Vorgeschichte: Anfang des Jahres 2013 wurden innerhalb kurzer Zeit 5 Patienten einer Intensivstation mit dem Nachweis von Ralstonia pickettii in der Blutkultur auffällig. Da alle Patienten eine intravenöse Therapie erhielten, wurde zunächst ein unsachgemäßer Umgang mit Infusionen angenommen. Einige Tage später wurde ein 6.  Patient mit einer positiven Blutkultur für Ralstonia pickettii in einer anderen Abteilung des Krankenhauses entdeckt. Untersuchungen: Hygienische Untersuchungen und Beobachtungen der Abläufe ergaben keine Hinweise auf Fehler in der Vorbereitung und Verabreichung der intravenösen Therapie. Alle Patienten hatten verschiedene i. v. Medikamente erhalten, bei allen war 5 % Glucose und Magnesium infundiert worden. Daher wurden im Folgenden einzelne Medikamente beprobt sowie umfangreiche Umgebungsuntersuchungen durchgeführt. Ergebnisse und weiteres Vorgehen: Die Proben wurden mittels Membranfiltermethode untersucht. In Magnesium-Ampullen wurde dabei Ralstonia pickettii gefunden. Wir schlossen daraus, dass die Kontamination von Magnesium-Ampullen ursächlich für die Bakteriämie der Patienten sein könnte. Apotheker und Behörden wurden informiert. Alle Ampullen wurden gesammelt und durch Präparate eines anderen Herstellers ersetzt. Zu einem späteren Zeitpunkt wurde das Präparat bundesweit durch den Hersteller zurückgerufen. Nach diesen Maßnahmen waren keine weiteren Ralstonia pickettii in Blutkulturen bei den Patienten unserer Klinik nachweisbar. Folgerung: Bei Nachweis ungewöhnlicher Keime ist immer auch an selten Ursachen wie verunreinigte Medikamente zu denken.

Background/Aims: The incidence of hepatocellular carcinoma (HCC) in Mongolia is growing at an alarming rate. Traditional dried food was suggested as the major reason for high HCC numbers, due to possible aflatoxin contamination during manufacturing. We thus aimed to measure aflatoxin concentrations in Mongolian food samples. Methods: Samples of traditional Mongolian food (‘aaruul', dried meat, and dried noodles; in total 11 samples) were collected and shipped to Germany. The food samples were analyzed for aflatoxins by extraction, immunoaffinity purification, and subsequent HPLC with fluorescence detection. Results: The traditional Mongolian food samples did not contain any detectable amounts of aflatoxin. Conclusion: Since Mongolian food does not contain aflatoxins, the cause for the increasing HCC incidence in Mongolia is probably due to a high prevalence of viral hepatitides. Further studies to identify the reason for this development are warranted.

An overview is given about waste handling in hospitals in Mongolia. Basically, handling of waste is regulated according to international standards. But in reality there are several problems, specially outside of the capital Ulaanbaatar. The situation is described, examples of problems are given and also some proposals are made how to improve the situation.

Disposal of healthcare waste may pose complex problems because of the broad range of its composition. Household waste has to be managed as well as infectious and hazardous materials, parts of human origin from pathologies or operating theatres and recyclable waste. Occupational safety, legal and economic aspects have to be considered. German good practice guidelines to define, classify and treat medical waste are presented.

Environmental cleaning and disinfection is well known as an essential part of preventing hospital-acquired infections. We describe the observation of two outbreaks of nosocomial infections with different pathogens in a tertiary care teaching hospital in Germany. Cleaning and disinfection procedures were essential measures to stop the outbreaks. We used a standardised procedure for dealing with the outbreaks. One of the most important measures was a change in the cleaning and disinfection process which was conducted by staff with special training in disinfection. After disposal of all single-use materials, a scrub-wipe disinfection processwith high concentrations (3%) of an oxygen radical-producing substance was performed in the affected rooms, followed by nebulisation with the same product (3%). Finally, the room was cleaned again with another scrub-wipe process at routine concentration (0.5%). After changing the routine cleaning and disinfection procedure (twice daily with a 0.5% concentration of a radical-producing substance performed by housekeeping) to a 3-step cleaning process using a higher concentration (3%) of the substance performed by workers specially trained in disinfection, the outbreaks stopped. In combination with a multidisciplinary coordination team and training, the cleaning and disinfection process was one of the most important steps in stopping outbreaks of nosocomial infections.