Authors:Julia Münch, Ralf Matthias Hagen, Martin Müller, Viktor Kellert, Dorothea Franziska Wiemer, Rebecca Hinz, Norbert Georg Schwarz and Hagen Frickmann
The effectiveness of a disinfectant-based decolonization strategy for multidrug-resistant bacteria like extended spectrum β-lactamase (ESBL)-positive Gram-negative bacteria with or without additional fluoroquinolon and carbapenem resistance as well as vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus was assessed.
Between 2011 and 2015, 25 patients from Libya, Syria, and the Ukraine with war traumata were treated at the Bundeswehr hospital Hamburg. The patients were heavily colonized and infected with multidrug-resistant bacteria, altogether comprising 371 distinct combinations of pathogens and isolation sites. Local disinfection was assessed for effectiveness regarding successful decolonization of multidrug-resistant bacteria.
Altogether, 170 cases of successful decolonization were observed, comprising 95 (55.8%) such events at sampling sites that were accessible to disinfecting procedures. The remaining 75 (44.2%) decolonization events had to be considered as spontaneous. In contrast, 95 out of 172 (55.2%) colonized isolation sites that were accessible to disinfection procedures were successfully decolonized. Patient compliance with the enforced hygiene procedures was associated with decolonization success. Systemic antibiotic therapy did not relevantly affect isolation time.
Disinfecting washing moderately supports local decolonization of multidrug-resistant pathogens in comparison with spontaneous decolonization rates if the patients’ compliance with the applied hygiene procedures is ensured.
Authors:Heike Granzer, Ralf Matthias Hagen, Philipp Warnke, Wolfgang Bock, Tobias Baumann, Norbert Georg Schwarz, Andreas Podbielski, Hagen Frickmann and Thomas Koeller
This study addressed carbapenem-resistant Acinetobacter baumannii complex (ABC) isolates from patients that were injured during the military conflict in the Eastern Ukraine and treated at German Armed Forces Hospitals in 2014 and 2015. Clonal diversity of the strains and potential ways of transmission were analyzed.
Patients with one or several isolation events of carbapenem-resistant ABC were included. Isolates were characterized by VITEK II-based identification and resistance testing, molecular screening for frequent carbapenemase genes, and DiversiLab rep-PCRbased typing. Available clinical information of the patients was assessed.
From 21 young male Ukrainian patients with battle injuries, 32 carbapenem- and fluoroquinolone-resistant ABC strains were isolated. Four major clonal clusters were detected. From four patients (19%), ABC isolates from more than one clonal cluster were isolated. The composition of the clusters suggested transmission events prior to the admission to the German hospitals.
The infection and colonization pressure in the conflict regions of the Eastern Ukraine with ABC of low clonal diversity is considerable. Respective infection risks have to be considered in case of battle-related injuries in these regions. The low number of local clones makes any molecular exclusion of transmission events difficult.
Authors:Carina Gottwald, Norbert Georg Schwarz and Hagen Frickmann
Introduction: The study was performed to estimate the prevalence and determinants of occurrence of sexually transmitted infections (STIs) in paratroopers and navy soldiers by anonymously analyzing medical records from the medical departments of two large German barracks in order to assess the need for medical STI prevention.
Methods: Medical records from 80 paratroopers and 80 navy soldiers were screened for records of STI. Results were anonymously collected next to information on risk factors, as well as diagnostic and therapeutic management, and comparatively assessed.
Results: Proportions of suspected STIs were 17.5% and 20%, and proportions of diagnosed STIs were 13.9% and 11.3% for paratroopers and navy soldiers, respectively. Chlamydia trachomatis, human papillomavirus, and genital scabies were observed in paratroopers and navy soldiers, while Gardnerella vaginalis, herpes simplex virus, Molluscum contagiosum virus, Neisseria gonorrhoeae, and Trichomonas vaginalis were additionally identified in navy soldiers.
Conclusions: Although clinical hints for STIs were frequently observed, clinical management was usually restricted to syndrome-based antibiotic treatment without detailed diagnostic workup, leaving room for procedural improvement. Ongoing need for medical STI prevention in the military could be confirmed.
Authors:Hagen Frickmann, Norbert G. Schwarz, Dorothea F. Wiemer, Marcellus Fischer, Egbert Tannich, Patrick L. Scheid, Martin Müller, Ulrich Schotte, Wolfgang Bock and Ralf M. Hagen
This report analyzes the occurrence of Cryptosporidium spp., E. histolytica, and G. intestinalis in stool of returnees from military deployments and the impact of hygiene precautions. Between 2007 and 2010, stool samples of 830 returnees that were obtained 8–12 weeks after military deployments in Afghanistan, Uzbekistan, the Balkans, Democratic Republic of the Congo/Gabonese Republic, and Sudan and 292 control samples from non-deployed soldiers were analyzed by PCR for Cryptosporidium spp., E. histolytica, G. intestinalis, and the commensal indicator of fecal contamination E. dispar. Data on hygiene precautions were available. The soldiers were questioned regarding gastrointestinal and general symptoms. Among 1122 stool samples, 18 were positive for G. intestinalis, 10 for E. dispar, and no-one for Cryptosporidium spp. and E. histolytica. An increased risk of acquiring chronic parasitic infections in comparison with non-deployed controls was demonstrated only for G. intestinalis in Sudan, where standardized food and drinking water hygiene precautions could not be implemented. Standard food and drinking water hygiene precautions in the context of screened military field camps proved to be highly reliable in preventing food-borne and water-borne chronic infections and colonization by intestinal protozoa, leading to detection proportions similar to those in non-deployed controls.
Authors:Hagen Frickmann, Andreas Hahn, Norbert Georg Schwarz, Ralf Matthias Hagen, Denise Dekker, Rebecca Hinz, Volker Micheel, Benedikt Hogan, Jürgen May and Raphael Rakotozandrindrainy
Direct growth on blood and screening agar for methicillin-resistant Staphylococcus aureus (MRSA) at a tropical surveillance site was compared with broth enrichment and subsequent growth on selective MRSA agar after international sample transport.
In Madagascar, 1548 swabs from an MRSA surveillance study were assessed for growth on Columbia blood agar enriched with 5% sheep blood and MRSA screening agar at the surveillance site with subsequent cold storage of the samples and shipment to Germany. In Germany, 1541 shipped samples were analyzed by non-selective broth enrichment with subsequent culture on MRSA selective agar.
A total of 28 MRSA isolates were detected. Of these, 20 strains were isolated from direct culture on blood and MRSA screening agars at the surveillance site, 24 MRSA strains were isolated using the broth enrichment method in Germany, and 16 MRSA strains were identified by both approaches.
In spite of the observed die-off of individual strains due to long-term storage and transport, broth enrichment with subsequent screening on MRSA selective agar after international sample shipment led to comparable sensitivity of MRSA detection like streaking on blood and MRSA agar at the tropical surveillance site.
Authors:Volker Micheel, Benedikt Hogan, Rivo Rakotoarivelo, Raphael Rakotozandrindrainy, Fetra Razafimanatsoa, Tsiriniaina Razafindrabe, Jean Rakotondrainiarivelo, Sabine Crusius, Sven Poppert, Norbert Schwarz, Jürgen May, Hagen Frickmann and Ralf Hagen
This study assesses the nasal occurrence of β-lactamase-producing Enterobacteriaceae both in patients in a hospital department of infectious diseases at admission and in healthy Madagascan students and health care workers.Nasal swabs from 681 students, 824 health care workers, and 169 patients were obtained in Antananarivo, Madagascar, and transferred to Germany. Screening for β-lactamase (ESBL, ampC) producing Enterobacteriaceae was performed by cultural and molecular approaches, comprising Brilliance ESBL agar, E-testing, ABCD-testing, and commercial hyplex ESBL and SuperBug ID PCR.Regarding ESBL-positive strains and strains with resistance against at least three out of the four tested bactericidal antibiotic drugs, 0.3% (five out of 1541) of the students and health care workers group showed nasal colonization, whereas colonization was observed in 7.1% (12 out of 169) of the hospitalized patients at admission. No appreciably reduced detection rates after sample storage and intercontinental transport were observed.A considerable proportion of nasal colonization with cephalosporin-resistant Enterobacteriaceae was demonstrated in Madagascan hospital patients at admission, posing a risk of developing future endogenous infections. The nasal colonization of healthy individuals was negligible. Good storage and transport stability of Enterobacteriaceae will allow for future studies even in areas difficult to access.
Authors:Andreas Hahn, Rebecca Hinz, Thomas Meyer, Ulrike Loderstädt, Ottmar Herchenröder, Christian G. Meyer, Norbert Georg Schwarz and Hagen Frickmann
Introduction: German sex workers have illegally established a prevention strategy, which consists of testing potential sexual partners with human immunodeficiency virus (HIV)-specific rapid diagnostic tests (RDTs) prior to engaging in unprotected sexual intercourse eventually performed in case of a negative test result. Based on a recently established modeling approach, the effectiveness of this strategy regarding the risk of HIV exposure was compared with protection provided by condom use.
Methods: Based on a literature search, the following assumptions were used for the calculations: an averaged 80% exposure risk reduction with a condom used during sexual intercourse, usage of a well-characterized 4th-generation HIV RDT, and a 10 day post-infection period without any measurable viral load in peripheral blood followed by a seroconversion period of about 3 weeks with 12.3% test sensitivity (antigen-specific) and only afterwards 97.3% (antibody-specific) test sensitivity.
Results: In most constellations, the HIV exposure risk in case of RDT-based prevention was lower than with condom use.
Conclusions: The RDT-based HIV exposure prevention as established by sex workers is effective in most situations. A notable weakness of the strategy is the RDTs' poor sensitivity in spite of a high transmission risk during the seroconversion stage.
Authors:Hagen Frickmann, Kerstin Köller, Irina Veil, Mirjam Weise, Alicja Ludyga, Norbert Georg Schwarz, Philipp Warnke and Andreas Podbielski
This study assesses the clinical relevance of vancomycin-susceptible enterococci in bacteremic patients and compares it with bacteremia due to Staphylococcus aureus and Escherichia coli.
During a 5-year-study interval, clinical and diagnostic features of patients with enterococcal bacteremia were compared to those of patients with E. coli or S. aureus bacteremia. Each patient was only counted once per hospital stay.
During the 5-year study interval, data from 267 patients with enterococcal bacteremia and from 661 patients with bacteremia due to E. coli or S. aureus were evaluated. In spite of a comparable risk of death, patients with enterococci more frequently needed catecholamines and invasive ventilation. Furthermore, enterococci were more frequently associated with a mixed bacterial flora in bloodstream infections. While fatal sepsis due to E. coli and S. aureus was associated with typical shock symptoms, this association was not confirmed for enterococci.
Although enterococcal bacteremia is associated with a risk of dying comparable to that with bacteremia due to E. coli and S. aureus, a lower pathogenic potential of enterococci in bloodstream has to be acknowledged. Enterococci in the bloodstream are more likely to be an epiphenomenon of impending death than its major cause.
Authors:Hagen Frickmann, Wibke Schmeja, Emil Reisinger, Thomas Mittlmeier, Karen Mitzner, Norbert Georg Schwarz, Philipp Warnke and Andreas Podbielski
This study assessed protective effects of a continuous introduction of safe instruments in terms of reduction of needle stick injuries. The retrospective study analyzed correlations between the increasing proportion of safe instruments and a reduction of the incidence of needle stick injuries linked to such instruments in a German university hospital over 5 years. Incidents declined about 17.6% from 80.3 incidents per 1000 employees to 66.2, associated with an increase in the proportions of injuries due to instruments without protective mechanisms such as scalpels or hypodermic needles by 12.2%. For injuries due to venipuncture cannulae in various surgical and internal medicine departments, there was a negative association between the proportion of safe instruments and the incidence of injuries. For injection needles, portacath needles, and lancets in selected internal medicine departments, the number of injuries also dropped during this study interval. However, there was no clear-cut association with the percentage of safe instruments. This observational study suggests a correlation between the implementation of use of safe instruments and the reduction of needle stick injuries in a case of a graduated implementation. However, the effects are much less pronounced than in previous interventional studies.
Authors:Hagen Frickmann, Thomas Köller, Ralf Matthias Hagen, Klaus-Peter Ebert, Martin Müller, Werner Wenzel, Renate Gatzer, Ulrich Schotte, Alfred Binder, Romy Skusa, Philipp Warnke, Andreas Podbielski, Christian Rückert and Bernd Kreikemeyer
Introduction: We assessed the molecular epidemiology of multidrug-resistant bacteria colonizing or infecting war-injured patients from Libya and Syria who were treated at the Bundeswehr hospitals Hamburg and Westerstede, Germany.
Methods: Enterobacteriaceae and Gram-negative rod-shaped nonfermentative bacteria with resistance against third-generation methoxyimino cephalosporins or carbapenems as well as methicillin-resistant Staphylococcus aureus (MRSA) from war-injured patients from Libya and Syria were assessed by molecular typing, i.e., spa typing for MRSA strains and rep-PCR and next-generation sequencing (NGS) for Gram-negative isolates.
Results: A total of 66 isolates were assessed – comprising 44 Enterobacteriaceae, 16 nonfermentative rod-shaped bacteria, and 6 MRSA from 22 patients – and 8 strains from an assessment of the patient environment comprising 5 Enterobacteriaceae and 3 nonfermentative rod-shaped bacteria. Although 24 out of 66 patient strains were isolated more than 3 days after hospital admission, molecular typing suggested only 7 likely transmission events in the hospitals. Identified clonal clusters primarily suggested transmission events in the country of origin or during the medical evacuation flights.
Conclusions: Nosocomial transmissions in hospital can be efficiently prevented by hygiene precautions in spite of heavy colonization. Transmission prior to hospital admission like on evacuation flights or in crises zones needs further assessment.