Low-threshold SARS-CoV-2 testing facility for hospital staff: Prevention of COVID-19 outbreaks?

BACKGROUND: The ongoing global SARS-CoV-2 pandemic has caused over 4.7 million infections greatly challenging healthcare workers (HCW) and medical institutions worldwide. The SARS-CoV-2 pandemic has shown to significantly impact mental and physical health of HCW. Thus, implementation of testing facilities supporting HCW are urgently needed. METHODS: A low-threshold SARS-CoV-2 testing facility was introduced at the University Hospital Bonn, Germany, in March 2020. Irrespective of clinical symptoms employees were offered a voluntary and free SARS-CoV-2 test. Furthermore, employees returning from SARS-CoV-2 risk regions and employees after risk contact with SARS-CoV-2 infected patients or employees were tested for SARS-CoV-2 infection. Pharyngeal swabs were taken and reverse transcription polymerase chain reaction for detection of SARS-CoV-2 was performed, test results being available within 24 h. Profession, symptoms and reason for SARS-CoV-2 testing of employees were recorded. RESULTS: Between 9th March and April 30, 2020, a total of 1510 employees were tested for SARS-CoV-2 infection. 1185 employees took advantage of the low-threshold testing facility. One percent (n = 11) were tested positive for SARS-CoV-2 infection, 18% being asymptomatic, 36% showing mild and 36% moderate/severe symptoms (missing 10%). Furthermore, of 56 employees returning from SARS-CoV-2 risk regions, 18% (10/56) were tested SARS-CoV-2 positive. After risk contact tracking by the hospital hygiene 6 patient-to-employee transmissions were identified in 163 employees with contact to 55 SARS-CoV-2 positive patients. CONCLUSION: In the absence of easily accessible public SARS-CoV-2 testing facilities low-threshold SARS-CoV-2 testing facilities in hospitals with rapid testing resources help to identify SARS-CoV-2 infected employees with absent or mild symptoms, thus stopping the spread of infection in vulnerable hospital environments. High levels of professional infection prevention training and implementation of specialized wards as well as a perfectly working hospital hygiene network identifying and tracking risk contacts are of great importance in a pandemic setting.

Association between antibiotic residues, antibiotic resistant bacteria and antibiotic resistance genes in anthropogenic wastewater - An evaluation of clinical influences.

The high use of antibiotics in human and veterinary medicine has led to a wide spread of antibiotics and antimicrobial resistance into the environment. In recent years, various studies have shown that antibiotic residues, resistant bacteria and resistance genes, occur in aquatic environments and that clinical wastewater seems to be a hot spot for the environmental spread of antibiotic resistance. Here a representative statistical analysis of various sampling points is presented, containing different proportions of clinically influenced wastewater. The statistical analysis contains the calculation of the odds ratios for any combination of antibiotics with resistant bacteria or resistance genes, respectively. The results were screened for an increased probability of detecting resistant bacteria, or resistance genes, with the simultaneous presence of antibiotic residues. Positive associated sets were then compared, with regards to the detected median concentration, at the investigated sampling points. All results show that the sampling points with the highest proportion of clinical wastewater always form a distinct cluster concerning resistance. The results shown in this study lead to the assumption that ciprofloxacin is a good indicator of the presence of multidrug resistant P. aeruginosa and extended spectrum ß-lactamase (ESBL)-producing Klebsiella spec., Enterobacter spec. and Citrobacter spec., as it positively relates with both parameters. Furthermore, a precise relationship between carbapenemase genes and meropenem, regarding the respective sampling sites, could be obtained. These results highlight the role of clinical wastewater for the dissemination and development of multidrug resistance.

Antibiotic resistant bacteria and resistance genes in biofilms in clinical wastewater networks.

Increasing isolation rates of resistant bacteria in the last years require identification of potential infection reservoirs in healthcare facilities. Especially the clinical wastewater network represents a potential source of antibiotic resistant bacteria. In this work, the siphons of the sanitary installations from 18 hospital rooms of two German hospitals were examined for antibiotic resistant bacteria and antibiotic residues including siphons of showers and washbasins and toilets in sanitary units of psychosomatic, haemato-oncological, and rehabilitation wards. In addition, in seven rooms of the haemato-oncological ward, the effect of 24 h of stagnation on the antibiotic concentrations and MDR (multi-drug-resistant) bacteria in biofilms was evaluated. Whereas no antibiotic residues were found in the psychosomatic ward, potential selective concentrations of piperacillin, meropenem and ciprofloxacin were detected at a rehabilitation ward and ciprofloxacin and trimethoprim were present at a haemato-oncology ward. Antibiotic resistant bacteria were isolated from the siphons of all wards, however in the psychosomatic ward, only one MDR strain with resistance to piperacillin, third generation cephalosporins and quinolones (3MRGN) was detected. In contrast, the other two wards yielded 11 carbapenemase producing MDR isolates and 15 3MRGN strains. The isolates from the haemato-oncological ward belonged mostly to two specific rare sequence types (ST) (P. aeruginosa ST823 and Enterobacter cloacae complex ST167). In conclusion, clinical wastewater systems represent a reservoir for multi-drug-resistant bacteria. Consequently, preventive and intervention measures should not start at the wastewater treatment in the treatment plant, but already in the immediate surroundings of the patient, in order to minimize the infection potential.

The occurrence of antimicrobial substances in toilet, sink and shower drainpipes of clinical units: A neglected source of antibiotic residues.

Antibiotics represent one of the most important drug groups used in the management of bacterial infections in humans and animals. Due to the increasing problem of antibiotic resistance, assurance of the antibacterial effectiveness of these substances has moved into the focus of public health. The reduction in antibiotic residues in wastewater and the environment may play a decisive role in the development of increasing rates of antibiotic resistance. The present study examines the wastewater of 31 patient rooms of various German clinics for possible residues of antibiotics, as well as the wastewater of five private households as a reference. To the best of our knowledge, this study shows for the first time that in hospitals with high antibiotic consumption rates, residues of these drugs can be regularly detected in toilets, sink siphons and shower drains at concentrations ranging from 0.02 µg·L-1 to a maximum of 79 mg·L-1. After complete flushing of the wastewater siphons, antibiotics are no longer detectable, but after temporal stagnation, the concentration of the active substances in the water phases of respective siphons increases again, suggesting that antibiotics persist through the washing process in biofilms. This study demonstrates that clinical wastewater systems offer further possibilities for the optimization of antibiotic resistance surveillance.

Rapid monitoring of vancomycin-resistant Enterococcus faecium in hospital departments by repetitive element palindromic polymerase chain reaction.

BACKGROUND: The current increase in nosocomial infections caused by vancomycin-resistant enterococci (VRE) warrants improvement of detection methods and hygiene measures. Knowledge of the local epidemiology is important for monitoring compliance of medical personnel with hygiene measures. AIM: To evaluate semi-automated repetitive element palindromic polymerase chain reaction (rep-PCR) for rapid molecular typing of VRE. METHODS: Primary VRE isolates were collected during an observation period of one year and retrospectively typed by rep-PCR. Molecular typing was performed on isolates from two departments with elevated VRE rates and patients with increased risk for systemic VRE infections. Typing results were correlated with temporal and spatial information on patient moves, VRE laboratory results and multi-locus sequence typing (MLST). FINDINGS: Approximately 70% of VRE isolates within a department could be assigned to similarity clusters. Spread of VRE was limited to the individual departments. There was no evidence for spread of endemic VRE strains within the geographical catchment area of the hospital. Our results demonstrate the utility of rep-PCR typing on a department level. However, a Diversilab® threshold of ≥98% had to be applied to claim similarity, and suspected transmissions needed to be confirmed by vanA/B genotyping and compiled information on spatial and temporal patient contact. MLST verified the findings. CONCLUSION: Spread of predominantly detected vancomycin-resistant Enterococcus faecium was limited to the department level with no evidence for wider dissemination within the hospital. Well-standardized and validated (semi-)automated rep-PCR systems are useful for rapid detection of possible VRE transmission. However, suspected transmissions need to be confirmed by clinical and microbiological parameters.

PAH, PCB, TPH and mercury in surface sediments of the Delaware River Estuary and Delmarva Peninsula, USA.

Surface sediment concentrations of polycyclic aromatic hydrocarbons (PAH) and polychlorinated biphenyls (PCB), total petroleum hydrocarbons (TPH) and mercury, were compared from two areas with contrasting land use history, the industrial Delaware Estuary and the rural Delmarva Peninsula (USA). TPH in the Delaware (38-616mg/kg) and saturate/aromatic fractions suggested petroleum/industrial sources compared to biogenic sources in the Delmarva coastal control (<34-159mg/kg). Within the Delaware the ∑PAH18 ranged from 3749 to 22,324µg/kg with isomeric ratios indicative of petroleum combustion source/s, conversely, those in the Delmarva (5-2139µg/kg) also yielded relatively higher perylene that were consistent with natural background levels derived from vegetation/coal combustion source/s. ∑PCB(tri-hepta) concentrations in the Delmarva (0.6-6.5µg/kg) were less than the threshold effect concentration (TEC), whereas the Delaware had received much higher PCB loading (18.1-136.8µg/kg) as evidenced by a significantly higher amounts in some samples (>TEC).

[Hospital disinfection challenges due to multiresistant pathogens in surgery]. / Krankenhaushygienische Herausforderungen durch multiresistente Erreger in der Chirurgie.

The number of antibiotic-resistant pathogens is increasing continuously while the development of new, effective antibiotics cannot be expected in the near future. Postoperative infections represent most of the nosocomial infections by now. Based on this, hygienic strategies regain importance, since a sustainable control of nosocomial infections will not succeed without the implementation of such strategies. In this article, the most important preventive strategies for prevention of infections with MRSA and 3- and 4-fold resistant gram-negative bacteria on the basis of current recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) are presented.

[Farmer's lung antigens in Germany]. / Farmerlungen-Antigene in Deutschland.

Recent studies suggest that besides the long-known farmer's lung antigen sources Saccharopolyspora rectivirgula (Micropolyspora faeni), Thermoactinomyces vulgaris, and Aspergillus fumigatus, additionally the mold Absidia (Lichtheimia) corymbifera as well as the bacteria Erwinia herbicola (Pantoea agglomerans) and Streptomyces albus may cause farmer's lung in Germany. In this study the sera of 64 farmers with a suspicion of farmer's lung were examined for the following further antigens: Wallemia sebi, Cladosporium herbarum, Aspergillus versicolor, and Eurotium amstelodami. Our results indicate that these molds are not frequent causes of farmer's lung in Germany.

[Experience with prevention and control of legionellosis in Germany : plea for proactive risk management]. / Erfahrungen zur Prävention und Kontrolle von Legionellosen in Deutschland : Plädoyer für ein proaktives Risikomanagement.

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.

Successful management of an MRSA outbreak in a neonatal intensive care unit.

We report an MRSA outbreak in our 25-bed tertiary neonatal intensive care unit (NICU), which was successfully contained. Methods include a retrospective review of patient files, microbiology records and meeting protocols. During the seven months of outbreak, 27 patients and seven health care workers (HCWs) had positive cultures for MRSA. The outbreak was caused by the epidemic Rhine-Hessen strain; cultured isolates were monoclonal. After a sharp increase of the number of new MRSA-cases the installation of an outbreak management team (OMT) and implementation of comprehensive measures (extensive screening and decolonization strategy including orally applied vancomycin, isolation wards, intensive disinfection regimen) successfully terminated the outbreak within one month. Ten (53%) of 19 patients with completed follow-up and all of the HCWs were decolonized successfully. Gastrointestinal colonization was present in 15 of 27 (56%) neonates, and was associated with poor decolonization success (30% vs. 78% in absence of gastrointestinal colonization). A comprehensive outbreak management can terminate an outbreak in a NICU setting within a short time. Thorough screening of nares, throat and especially stool is necessary for correct cohorting. Gastrointestinal decolonization in neonates seems difficult.

[Repeated prevalence investigations of nursing home-associated infections as a tool to assess the hygienic quality of care]. / Wiederholte Prävalenzuntersuchungen Pflegeheim-assoziierter Infektionen als Instrument zur Erfassung der hygienischen Ergebnisqualität.

The rate of healthcare-associated infections can be regarded as an important outcome parameter of the hygienic quality of care in nursing homes. Our study aimed to evaluate the applicability of repeated prevalence investigations as a tool for surveillance of healthcare-associated infections in nursing homes. From December 2006 to September 2007 a total of five prevalence investigations were conducted in four nursing homes each (n=2,369 residents). Initially, defined structural and procedural parameters of the hygienic quality of the four nursing homes were evaluated based on a detailed inspection and a checklist including 40 parameters. The results showed a uniformly high level of the hygienic quality with only minor variation (mean 84%, range 75%-93% of parameters fulfilled). In total, the prevalence of healthcare-associated infections was 6.8%, with a marked increase with higher categories of dependency (3.5%, 4.0%, 8.5%, and 12.3%, respectively, in the categories 0, I, II, and III of the German grading of skilled nursing care). Respiratory tract (4.1%), skin/soft tissue (1.5%), and urinary tract infections were the most prevalent healthcare-associated infections. Respiratory tract infections showed a marked seasonal pattern. During the second prevalence investigation (February 2007), an outbreak of upper respiratory tract infections occurred in one of the nursing homes (attack rate, 17%). The crude prevalence rates showed considerable differences between the four nursing homes; however, after adjusting for the different categories of dependency, the standardized infection rates (SIR) were largely comparable (excluding the outbreak). After inclusion of the outbreak, the SIR of the specific nursing home was significantly higher compared to all other nursing homes. In conclusion, our study shows that repeated prevalence investigations can be an easy to use tool for surveillance of healthcare-associated infections as a surrogate parameter of the hygienic quality in nursing homes. This implies a knowledge of the seasonality of specific infections and a risk adjustment according to the categories of dependency. The primary intention of surveillance should be the identification of hygienic problems. However, the resources should preferentially be focused on hygienic structures and processes.

[Risk of infection in the home environment. Plea for a new risk assessment]. / Infektionsrisiken im häuslichen Umfeld. Plädoyer für eine neue Risikobewertung.

Within the last two decades risks posed by infectious diseases outside of hospitals and nursing homes had no high significance in the public perception. The home environment is regarded as a save shelter from infectious risks. In the mean time there have been dramatic socio-demographic, health policy and technological changes which have increased infectious risks outside medical facilities. In Germany up to 1.4 million people with multiple morbidities are nursed at home. Technological changes with the aim to protect the environment, like reduction of water temperature and water volumes in washing processes has lowered the efficacy to control pathogens. Thus it is time to revise the process of risk assessment in which not only aspects of environmental protection but also those of health protection must be taken into account. The article gives an overview of new risks and epidemiological changes and discusses the necessity of a new risk assessment and risk management approach which hopefully will lead to a changing paradigm.

The significance of mycotoxins in the framework of assessing workplace related risks.

Mycotoxins are fungal metabolite which may in some cases exhibit a high health hazard potential. Mycotoxins can show carcinogenic, mutagenic, toxic, teratogenic or immunotoxic effects. Mycotoxin exposure in the workplace may occur through inhalation and skin contact,e.g. during occupational handling of organic matter such as livestock feed, food products, or waste. Various studies suggest that both acute and chronic effects can occur, depending at least on the exposure level. The magnitude of the potential health risks associated with a respiratory or dermal intake of mycotoxins has largely remained unclear to date. However, according to the directive 2000/54/EC on biological agents and the corresponding German Biological Agents Ordinance, employers are also required to consider the potential hazards posed by toxic effects of biological agents when assessing workplace risks. The aim of this article, therefore, is to present some basis information that should facilitate an evaluation of the significance of mycotoxins in the context of assessing workplace risks. It also provides suggestions for occupational health and safety measures.

[Water as a reservoir for nosocomial infections in health care facilities, prevention and control]. / 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.

Extrinsic allergic alveolitis (hypersensitivity pneumonitis) caused by Sphingobacterium spiritivorum from the water reservoir of a steam iron.

A case of extrinsic allergic alveolitis (EAA) caused by Sphingobacterium spiritivorum is described. The symptoms were associated with the use of a steam iron. The water reservoir was heavily contaminated with S. spiritivorum (10(6) CFU ml(-1)). This is the first report of S. spiritivorum as a causative agent of EAA.

Prevention and control of health care-associated waterborne infections in health care facilities.

The current article is a review of the public health risks attributable to waterborne pathogens in health care. The consequences of health care-associated infections (HAIs) are discussed. Not only are Legionella spp involved in HAIs, but also Pseudomonas aeruginosa, other gram-negative microorganisms, fungi, and amoeba-associated bacteria. This is particularly noteworthy among immunocompromised patients. New prevention strategies and control measures brought about through advanced planning, facility remodelling and reconstruction, disinfection, and filtration have resulted in a significant reduction of the incidence of waterborne HAIs. The positive consequences of a comprehensive multibarrier approach including prevention and control programs in health care facilities are discussed. Environmental cultures are now integrated within the infection control program of some European countries. In high-risk areas, the application of disposable sterile point-of-use filters for faucets and shower heads appears to be the practice of choice to efficiently control waterborne pathogens and to prevent infections.

Prospective surveillance for healthcare-associated infections in German nursing home residents.

We undertook a prospective surveillance study in order to determine the incidence of healthcare-associated infections (HCAIs) in German nursing home residents. All people residing for more than one day in a 103-bed nursing home for the elderly in Bonn, Germany between December 1998 and November 1999 were included. Active surveillance was based on previously published consensus definitions. Rates for HCAIs and urinary tract infections (UTIs) were calculated based on resident-days and device-utilization days, respectively. The overall incidence of HCAIs was 6.0 per 1000 resident-days, with respiratory tract infections, gastroenteritis, skin/soft tissue infections and UTIs representing 94% of all HCAIs (2.2, 1.2, 1.2 and 1.0 infections per 1000 resident-days, respectively). Residents with pneumonia were more likely to die than residents with other HCAIs (RR=5.09; 95%CI 1.87-13.89; P=0.011). We conclude that HCAIs are a serious health problem in German nursing home residents. Standardized surveillance in nursing homes is important to assess the effectiveness of infection control standards, and should be based on consensus definitions in order to allow for meaningful interfacility comparisons. In Germany, the implementation of a hospital reimbursement system based on diagnosis-related groups is likely further to increase the proportion of vulnerable populations in long-term-care facilities.

[1974-2004: the Commission for Hospital Hygiene has been working for 30 years. From the "old" to the "new" guideline]. / 1974-2004: 30 Jahre Kommission für Krankenhaushygiene. Von der "alten" zur "neuen" Richtlinie.

After 2 years of preparation, the Commission for Hospital Hygiene, founded in 1974 by the former German Public Health Service, published the "Guideline for Assessment,Prevention, and Controlling of Nosocomial Infections," which represented an exemplarily complete standard for hospital hygiene. In 1997 within the framework of planning the amendment to the Federal Epidemic Law, a new Commission for Hygiene and Infectious Disease Prevention started work and adapted the guideline to meet today's standards of systematic risk analysis and risk management. The amended Infection Protection Act (Infektionsschutzgesetz, IfSG), which came into force in January 2001, installed the Commission for Hospital Hygiene and Infectious Disease Prevention legally and required it to formulate a guideline to decrease the rate of nosocomial infections, the number of outbreaks, and the dissemination of antibiotic-resistant pathogens in healthcare facilities by establishing standards of modern prevention. This article describes the political importance of nosocomial infections for public health as well as the working basis, the methods, and the latest guidelines of the Commission.