[Hygienic aspects of emergency care: principles, requirements and reality]. / Hygiene im Rettungsdienst: Grundlagen, Anspruch und Wirklichkeit.

In preclinical emergency and rescue medicine, on-target and often improvised and smooth work is essential. Thus, some reductions of clinical standards must be accepted but cannot excuse fundamental mistakes. Hygienic protection of patients and medical staff are both equally important; however, preserving the vital functions of patients deserves top priority. In Germany, official guidelines govern the hygienic equipment of ambulance cars and hygienic management during and after transport both in routine and special cases. Disinfection of skin, hands and surfaces and hygienic protection of the medical staff predominate in daily work. Standard hygienic procedures during application of venous leads, intubation and artificial ventilation and correct handling of sterile materials should also be considered. The main goal of teaching is routine establishment of basic hygienic procedures, and, in addition, creation of sufficient hygienic basic knowledge for assessment and control of unusual situations.

[Tuberculosis and atypical mycobacterioses in HIV infection. Results from the Bonn Center 1985 to 1989]. / Tuberkulose und atypische Mykobakteriosen bei HIV-Infektion. Ergebnisse des Zentrums Bonn 1985 bis 1989.

485 HIV-positive patients have been treated at our institution in Bonn during 1985 to 1989. Mycobacterial infections occurred in twelve (2.5%) HIV-positive patients. Of 166 AIDS-manifestations according to CDC, eleven (6.6%) were mycobacterial infections. There occurred one case of miliary tuberculosis, six cases of extrapulmonary, one of disseminated tuberculosis and four cases of atypical mycobacteriosis. Mycobacteriosis other than tuberculosis (MOTT) were caused three times by Mycobacterium kansasii and once by Mycobacterium scrofulaceum. Tuberculosis was seen less often in haemophiliacs. Disseminated tuberculosis and atypical mycobacteriosis developed in late stages of HIV-infection with underlying severe immunodeficiency. The lung was the main target organ of tuberculosis. MOTT most often affected the gastrointestinal tract additionally. Noninvasive materials, first of all sputum and gastric acid, were reliably diagnostic but available with delay in particular cases. In those cases histologic studies proved helpful. Application of five-fold regimen (INH, RMP, EMB, PZA and SM) always succeeded in negative cultures in a mean of 15 days in all cases of tuberculosis. Two cases of atypical mycobacteriosis with Mycobacterium kansasii were treated with a five-fold regimen (one case with ciprofloxacin additionally) and culture-negative after six resp. 28 weeks of therapy.

[Serum and cerebrospinal fluid kinetics of ceftazidime]. / Serum- und Liquorkinetik von Ceftazidim.

Ceftazidime serum concentrations and cerebrospinal fluid (CSF) penetration across non-inflamed meninges were evaluated in 10 patients after intravenous application of 2 g ceftazidime over a period of 30 min. After a continuous increase during infusion the highest level of ceftazidime in serum with 172.27 micrograms/ml (+/- 60.43 micrograms/ml) was ascertained at the end of the infusion. The further development demonstrated a continuous decrease of serum concentrations. Concentrations in serum followed a two-compartment open kinetic model. Mean distribution volume was 17.6 l, the total clearance was 142.97 ml/min, half-life was 1.8 h and the determined area under the curve was 139.89 micrograms x min/ml. Penetration of ceftazidime into CSF could only be pointed out in 5 patients. The highest level with 5.11 micrograms/ml (+/- 1.2 micrograms/ml) was observed 32 min after starting the infusion. A steady state with CSF-concentrations over 2 micrograms/ml could be ascertained during the following 4 hours in these patients. Obviously high statistic significance (p less than or equal to 0.01) was present when penetration into CSF was correlated to body surface area (BSA) using the exact Fisher test with Yates correction. Penetration of ceftazidime into CSF across non-inflamed meninges with therapeutic concentrations over a period of 4 hours could only be achieved when BSA was less than 1.95 m2. Further investigations in more patients are necessary to evaluate if BSA is the only parameter which affects distribution of ceftazidime into CSF.

Clinical evaluation of diagnostic hemoperfusion for in vivo enrichment of bacteria and fungi in comparison with a conventional blood culture technique.

The hemoperfusion module, a newly developed technique for recovering pathogenic microorganisms from patients suffering from septicemia, was compared with conventional blood cultures. The module was interconnected with the extracorporeal circulation of 92 predominantly hemodialyzed patients. Nearly 12 liters of flowing blood (up to 200 ml min-1; mean running time, 60 min) came in contact with the coated charcoal. Of 99 modules examined, 44 (44.7%) yielded positive cultures and contained 54 potentially pathogenic bacteria or fungi (22 species). Only 32 of 190 (16.8%) conventional blood cultures were positive and contained 37 microorganisms (10 species). Even when patients were receiving antibiotic treatment, the frequency of isolation was significantly higher in hemoperfusion (21 of 44 modules positive, 47.7%) than in conventional blood cultures (10 of 88 cultures positive, 11.4%). In contrast, 23 of 55 modules (41.8%) and 22 of 102 conventional blood cultures (21.6%) were positive when patients were not treated with antibiotics prior to blood sampling. Altogether, hemoperfusion modules appeared to be superior to and more sensitive than the conventional blood cultures used and seemed to be a valuable tool for detecting septicemia.

[Pathogen spectrum in suppurative meningitis with special reference to a patient sample]. / Keimspektrum der eitrigen Meningitis unter besonderer Berücksichtigung des Patientengutes.

In a five years period (1982 till 1986) the spectrum of pathogenic bacteria and fungi in acute meningitis was analysed. The appearance, spreading and suspected spectrum of pathogens have to be followed by special aspects considering effective therapeutic proceedings. 361 out of 392 positive cerebrospinal fluids (92.1%) were derived from only 3 (neurosurgical, neurological and pediatric department) out of 14 possible departments. Whereas in the pediatric department the classical pathogens of acute meningitis predominated, the patients in the neurosurgical department mainly showed nosocomial infections. There has to be considered the accidental infection, especially in the severely ill patients of the neurosurgical intensive care unit, which favours highly resistant pathogens. Furthermore, to initiate an infection, the pathogenicity of nosocomial microorganisms is not required to be high. The correlation of clinical signs and the proof of pathogens showed that often so called contaminants could be of higher value to be the infectious agent as assumed. Nevertheless, there seemed to be a regression of acute meningitis due to better diagnostic and therapeutic proceedings.

Establishment of a typing system for group D streptococci.

Group D streptococci (n = 971, 4037 samples, 139 patients) were isolated from two intensive care units. Differentiation and typing revealed 6 species, 25 phage types, and 85 enterococcinotypes. Distribution of species showed strong differences especially concerning Enterococcus faecium which was rarely isolated from extraintestinal sites (5.9%). Phage typing was species specific and discriminated Enterococcus faecalis (n = 703 typable isolates, 19 phage types) and the other group D streptococci (n = 63 typable isolates, 6 phage types). Based on the production of enterococcines (15 indicator strains used) the isolates could be classified into 6 groups, one of which was further subdivided into 3 subgroups. Enterococcus faecalis ssp. liquefaciens (n = 618), phage type V6b (n = 596), and enterococcine group IVc (n = 568) were most common. The combined use of markers resulted in 187 combinations, which demonstrated the valuable properties of the system.

Penetration of fosfomycin into cerebrospinal fluid across non-inflamed and inflamed meninges.

Serum and cerebrospinal fluid (CSF) concentrations of fosfomycin were evaluated in 45 patients. Mean serum concentration was 260.1 mg/l at 15 min postinfusion in 35 patients receiving a 5 g bolus dose, and 440 mg/l in five patients receiving a 10 g bolus dose. Mean distribution volume was 18.5 l (5 g dose), the total clearance was 118.8 ml/min, half-life was nearly 2 h, and the determined AUC were 420.95 mg/l.h (5 g dose) and 423.57 mg/l.h (10 g dose). The average peaks at 360 min in CSF reached 11.6 mg/l (5 g dose) and 17.7 mg/l (10 g dose). The CSF/serum ratio was 9.24% (5 g dose), and 13.81% (10 g dose). The CSF levels were not below 30 mg/l from the second day on in patients receiving 3 X 5 g fosfomycin per day. Meningeal inflammation increased the CSF concentrations from 30 mg/l at 6 h up to 150 mg/l at 120 h in the saturation phase, e. g., up to 300% more in comparison to non-inflamed meninges.

Combined use of phage typing, enterococcinotyping and species differentiation of group D streptococci as an effective epidemiological tool.

Ninety-five group D streptococcal isolates from the feces of 95 healthy persons were compared with 157 group D streptococcal isolates from 38 patients of the surgical intensive care unit (sICU). The typing systems consisted of phage typing, enterococcinotyping and species differentiation. Strains isolated from fecal specimens showed high individuality (66 combination types) whereas strains from the sICU revealed strongly uniform types (32 combination types, three types comprised 83 isolates, i.e. 52.8%). Endogenous colonization was demonstrated by isolation of strains from different locations (throat, trachea, wounds, blood, urine, drains, catheters, and vaginal swabs) from the same patient, and routes of transmission of the same strains to several patients were traced. The combination of three systems revealed a good discrimination between isolates of fecal and extrafecal specimens. The investigation detected highly preferred types in strains of extrafecal origin which were rarely isolated from fecal specimens. This may indicate that only strains with special characters preferably were able to colonize extraintestinal sites.

[Aspergillosis following liver transplantation as a hospital infection]. / Aspergillose nach Lebertransplantation als Hospitalismusinfektion.

In the first four weeks after a liver transplantation, there was an invasive aspergillosis with a lethal course in three out of five patients who were treated postoperatively in the same room. The clinical symptoms were very different. One patient was asymptomatic, and the diagnosis could only be made by autopsy. In another patient, pulmonary symptoms, and in the third patient, cerebral symptoms were the most prominent. In the two latter patients, the infection was demonstrated in the sputum and by bronchoalveolar lavage. The disease course was fulminant in all patients, and therapy was without success. Owing to this high incidence, mycological investigations were carried out on the ward. A flower bench in the hall beside the ward was probably the main focus of distribution. To avoid such nosocomial infections, foci of aspergillus distribution should if possible be removed from the surroundings of patients with weakened immune resistance.

[Pharyngeal flora as a reference spectrum for infection pathogens in intensive care patients]. / Rachenflora in der Funktion eines Referenzspektrums für Infektionserreger bei Intensivpatienten.

Differentiation according to species, phage type and enterocinogenotype shows that isolates of enterococci obtained from throat swabs and simultaneously from other localisations can mostly be considered as isotypical. However, it is also possible to demonstrate with other pathogens that there is an isotypicality between the spectra of other pathogens in the throat swab and in other pathological material including blood cultures, the agreement increasing with the severity of the disease. For example, in patients with multiple injuries 61% of the facultatively pathogenic opportunistic germs in the oropharynx correspond with the germs localised elsewhere; in septic patients, this agreement amounts to 96%. This means that especially with most severely ill patients the daily throat swab can yield early hints to the spectrum of pathogens responsible for an infection.

[Principles of the prevention of pneumonia by the intratracheal instillation of aminoglycoside antibiotics]. / Grundlagen der Pneumonieprophylaxe durch die intratracheale Instillation von Aminoglykosid-Antibiotika.

In long-term respiration the descension of the pharyngeal contents into the tracheobronchial system appears as unavoidable as the colonisation of the oropharynx with pathogens. On the other hand, elimination of the descended pathogens from the trachea and the bronchi by setting up an antibiotic barrier represented by the aminoglycoside antibiotics, can prevent colonisation of the lower respiratory passages. As a matter of fact, the aminoglycoside antibiotics exercise, first of all, rapid and bactericidal action, and secondly a spectrum of pathogens. Intratracheal application of 4 X 40 mg tobramycin daily, distributed over 24 hours, leads in the case of persons with healthy kidneys to serum levels between 0.4 and 0.7 micrograms/ml. Side effects are mainly seen in patients with restricted renal function in the form of cumulative serum concentrations. At present there are no alternative possibilities of prophylaxis against the sequels of descension.

Purification and properties of LIQ 4, an antibacterial substance produced by Streptococcus faecalis var. liquefaciens K4.

An antibacterial substance (LIQ 4) produced by Streptococcus faecalis var. liquefaciens K 4 was isolated in extracellular and cell associated form. It markedly inhibited the growth of Gram-positive bacteria, whereas only a few Gram-negative bacteria were susceptible. LIQ 4 was purified by hydrophobic chromatography (Servachrome XAD-2; octyl-Sepharose CL-4B; Sephadex LH 60) and Sephacryl S-200. TLC yielded a fluorescent spot as the active component and several inactive ninhydrin-positive substances. These contaminating peptides strongly adsorbed to LIQ 4 and could only be removed by repeated reversed phase HPLC. Furthermore, HPLC separated LIQ 4 into seven closely related substances. All showed strong fluorescence under UV light, stained yellow with ninhydrin, and contained aspartate and lysine after acid hydrolysis. The molecular weight was estimated by Amicon ultrafiltration to be less than 2000. LIQ 4 was stable at 80 degrees C (30 min) and pH 2, but considerably inactivated above pH 8. It was apparently affected by proteolytic enzymes, but the activity could be fully restored upon heating.

Species distribution of coagulase-negative staphylococci isolated from clinical sources.

The distribution of coagulase-negative staphylococcal species from clinical material was investigated in order to detect possible tropisms. 398 strains of staphylococci (336 coagulase-negative and 62 coagulase-positive strains) and 3 micrococcus strains were isolated. Differentiation between the two genera was achieved by testing sensitivity to lysostaphin and anaerobic growth in thioglycolate. Four S. hominis strains reacted like micrococci in these tests. Staphylococci were classified according to the Kloos and Schleifer biotyping scheme in a modified way on microtitre plates. Additionally coagulation and reduction of methylene blue milk were determined and the test proved to be useful. Identified coagulase-negative species included S. epidermidis (205 strains), S. hominis (64), S. haemolyticus (35), S. warneri (15), S. capitis (5), S. simulans (6), S. saprophyticus (5), and S. species (1). A high predominance of S. epidermidis was found among isolates from nasopharyngeal (91%) and tracheobronchial (80%) tracts and most other localizations. A different distribution of species was observed in urine and vaginal swabs where non-S. epidermidis species accounted for over 50% of identified strains. The majority of S. hominis and S. haemolyticus strains was isolated from these sources. S. simulans, like S. saprophyticus was found in urine specimens only and occurred predominantly in women of the sexually active age.