Increase in acute mastoiditis at the end of the COVID-19 pandemic.

PURPOSE: Common respiratory infections were significantly reduced during the COVID-19 pandemic due to general protective and hygiene measures. The gradual withdrawal of these non-pharmaceutical interventions (NPI) was associated with a notable increase in these infections, particularly in pediatric and adult otorhinolaryngology. The aim of this retrospective monocentric study was to evaluate the impact of NPI during the COVID-19 pandemic on the incidence and severity of acute mastoiditis (AM). METHODS: Pre-pandemic clinical data of AM cases from 2011 to 2019 were compared with infection counts from January 2020 to June 2023 for seasonal periodicity, age-specific differences, pathogens, and complication rates in a German third-level hospital. RESULTS: Out of 196 patients with AM 133 were children, the majority between 1 and 5 years of age. Complications of AM, such as meningitis, brain abscess, and sinus vein thrombosis, were more common in adults (87%) than in children (17%). Morbidity and mortality rates were similar before, during and after the pandemic. Pneumococci were the most common pathogen in both age groups, with a post-pandemic cumulation of Streptococcus pyogenes infections in children. While pre-pandemic cases clustered in spring, seasonality was absent in all age groups during the main phase of the pandemic. The cessation of NPI caused a steep rise in AM cases in both age groups starting from December 2022. CONCLUSION: NPI during the COVID-19 pandemic reduced the incidence of AM. Their reversal led to a substantial increase in the incidence of AM during the post-pandemic period, which may be due to a general increase in viral respiratory infections and an insufficiently trained immune system.

[Aerosols and SARS-CoV-2: Statement of the "Expert Group Aerosols" on the development, infectivity, spread and reduction of airborne, virus-containing particles in the air]. / Stellungnahme des "Expertenkreises Aerosole": Aerosole und SARS-CoV-2 ­ Entstehung, Infektiosität, Ausbreitung und Minderung luftgetragener, virenhaltiger Teilchen in der Atemluft.

Aerosols are currently seen as one of the main transmission routes for SARS-CoV-2, but a comprehensive understanding of the processes and appropriate action/adaptation of protection concepts requires the exchange of information across interdisciplinary boundaries. Against this background, the Baden-Württemberg state government launched in October 2020 a multidisciplinary "Expert Group Aerosols" comprising engineers, natural scientists and medical professionals. In its statement, the group has compiled the current state of knowledge in all relevant disciplines in the context of airborne SARS-CoV-2 infection. In addition to the well-known hygiene and social distancing rules, the importance of the correct use of effective masks is emphasized. Furthermore, the necessity for dynamic and correct ventilation is pointed out and illustrated with ventilation intervals and periods for different scenarios as examples. The effectiveness of stationary or mobile cabin air filters as an important component in the protection concept is discussed. The first opinion of the expert group makes it clear that the existing hygiene and social distancing rules offer the best possible protection against SARS-CoV-2 infection only when correctly applied in combination.

Remote Intestinal Injury Early After Experimental Polytrauma and Hemorrhagic Shock.

Dysfunction of the gut-blood barrier plays an important role in many diseases, such as inflammatory bowel disease, hemorrhagic shock (HS), or burn injury. However, little is known about gut barrier dysfunction after hemodynamically instable polytrauma (PT). Therefore, we aimed to evaluate the effects of PT and HS on remote intestinal damage and barrier dysfunction, especially regarding the role of zonula occludens protein 1 (ZO-1) as an important tight junction protein.Male C57BL/6 mice were subjected to either PT (thorax trauma, closed head injury, soft tissue injury, and distal femoral fracture), 60 min of pressure-controlled HS (30 ±â€Š5 mmHg), or PT+HS, or sham procedures.Animals of all trauma groups showed an increase in abdominal girth and dilation of the intestine during the experimental period, which was largest in the PT+HS group. Increased blood-tissue permeability to albumin (assessed by Evans blue dye) was found in the HS group. Experimental groups showed a slight increase in plasma concentration of intestinal fatty acid binding protein and some intestinal damage was histologically detectable. Of note, PT+HS animals revealed significantly reduced expression of ZO-1 in intestinal epithelial cells. In an in-vitro model, stimulation of human colon epithelial cells with peptidoglycan, but not with lipopolysaccharide, resulted in elevated secretion of pro-inflammatory cytokines, reflecting inflammatory activity of the intestinal epithelium.Taken together, PT and HS lead to increased permeability of the gut-blood barrier. Bacterial components may lead to production of inflammatory and chemotactic mediators by gut epithelial cells, underlining the role of the gut as an immunologically active organ.

KPC-2 carbapenemase-producing Pseudomonas aeruginosa reaching Germany.

Background: Antimicrobial resistance due to carbapenemase expression poses a worldwide threat in healthcare. Inter-genus exchange of genetic information is of utmost importance in this context. Objectives: Here, to the best of our knowledge, we describe the first detection and characterization of a KPC-2-producing Pseudomonas aeruginosa in Germany. Methods: Characterization of the isolate was performed using MALDI-TOF MS, automated microdilution and MLST. Carbapenemase detection was performed using phenotypic and genotypic assays. The blaKPC-2-carrying plasmid was transformed into Escherichia coli NEB® 10-beta. The purified plasmid DNA was sequenced using the Illumina technique. Results: The isolate expressed ST235 and was resistant to carbapenems. Antimicrobial susceptibility testing revealed colistin to be the only antimicrobial agent active in vitro. The blaKPC-2 gene was located on a replicon type lncHI1 plasmid as part of Tn4401. Conclusions: The first detection (to the best of our knowledge) of plasmid-encoded KPC-2 in P. aeruginosa in Germany may point to a currently underestimated spread of carbapenemases among clinically relevant Gram-negative bacteria. Here, to the best of our knowledge, we also provide the first report of blaKPC-2 associated with the IncHI1 plasmid.

Community-acquired Haemophilus influenzae pneumonia--New insights from the CAPNETZ study.

OBJECTIVES: We aimed to identify clinical characteristics and to assess effectiveness of different initial antibiotic regimens in adult patients with community-acquired pneumonia (CAP) caused by Haemophilus influenzae. METHODS: Characteristics were compared between patients with H. influenzae monoinfection versus CAP of other and unknown aetiology enrolled by the German prospective cohort study CAPNETZ. Impact of initial antibiotic treatment on "early clinical response" according to FDA criteria and overall clinical cure were analysed. RESULTS: H. influenzae was found in 176 out of 2790 patients with pathogen detection (6.3%). Characteristics significantly associated with a H. influenzae CAP (p < 0.017) included purulent sputum, prior pneumococcal vaccination and respiratory co-morbidities. Early clinical response rates on day 4 did not differ between patients receiving any mono- versus combination therapy (85.9% versus 88%), but were numerically higher for regimens including any fluoroquinolone (96.7%) and lower under macrolide monotherapy (70%). Initial CURB-65 score and chronic liver disease were identified as negative predictors for "early clinical response". At day 14, overall clinical cure was 91.9%. CONCLUSIONS: H. influenzae was a common CAP pathogen, particularly in patients with previous pneumococcal vaccination and respiratory co-morbidities. Severity of illness and chronic liver disease were associated with a lower rate of "early clinical response".

Microbiological diagnosis and molecular typing of Legionella strains during an outbreak of legionellosis in Southern Germany.

An explosive outbreak of Legionnaires' disease with 64 reported cases occurred in Ulm/Neu-Ulm in the South of Germany in December 2009/January 2010 caused by Legionella (L.) pneumophila serogroup 1, monoclonal (mAb) subtype Knoxville, sequence type (ST) 62. Here we present the clinical microbiological results from 51 patients who were diagnosed at the University hospital of Ulm, the results of the environmental investigations and of molecular typing of patients and environmental strains. All 50 patients from whom urine specimens were available were positive for L. pneumophila antigen when an enzyme-linked immunosorbent assay (EIA) was used following concentration of those urine samples that tested initially negative. The sensitivity of the BinaxNow rapid immunographic assay (ICA), after 15 min reading and after 60 min reading were 70% and 84%, respectively. Direct typing confirmed the monoclonal subtype Knoxville in 5 out of 8 concentrated urine samples. Real time PCR testing of respiratory tract specimens for L. pneumophila was positive in 15 out of 25 (60%) patients. Direct nested sequence based typing (nSBT) in some of these samples allowed partial confirmation of ST62. L. pneumophila serogroup 1, monoclonal subtype Knoxville ST62, defined as the epidemic strain was isolated from 8 out of 31 outbreak patients (26%) and from one cooling tower confirming it as the most likely source of the outbreak. While rapid detection of Legionella antigenuria was crucial for the recognition and management of the outbreak, culture and molecular typing of the strains from patients and environmental specimens was the clue for the rapid identification of the source of infection.

Poorly processed reusable surface disinfection tissue dispensers may be a source of infection.

BACKGROUND: Reusable surface disinfectant tissue dispensers are used in hospitals in many countries because they allow immediate access to pre-soaked tissues for targeted surface decontamination. On the other hand disinfectant solutions with some active ingredients may get contaminated and cause outbreaks. We determined the frequency of contaminated surface disinfectant solutions in reusable dispensers and the ability of isolates to multiply in different formulations. METHODS: Reusable tissue dispensers with different surface disinfectants were randomly collected from healthcare facilities. Solutions were investigated for bacterial contamination. The efficacy of two surface disinfectants was determined in suspension tests against two isolated species directly from a contaminated solution or after 5 passages without selection pressure in triplicate. Freshly prepared use solutions were contaminated to determine survival of isolates. RESULTS: 66 dispensers containing disinfectant solutions with surface-active ingredients were collected in 15 healthcare facilities. 28 dispensers from nine healthcare facilities were contaminated with approximately 107 cells per mL of Achromobacter species 3 (9 hospitals), Achromobacter xylosoxidans or Serratia marcescens (1 hospital each). In none of the hospitals dispenser processing had been adequately performed. Isolates regained susceptibility to the disinfectants after five passages without selection pressure but were still able to multiply in different formulations from different manufacturers at room temperature within 7 days. CONCLUSIONS: Neglecting adequate processing of surface disinfectant dispensers has contributed to frequent and heavy contamination of use-solutions based on surface active ingredients. Tissue dispenser processing should be taken seriously in clinical practice.

Adult patients with nosocomial pneumonia: epidemiology, diagnosis, and treatment.

BACKGROUND: Nosocomial pneumonia is among the most common types of infection in hospitalized patients. The increasing prevalence of multi-drug resistant organisms (MDROs) in recent years points to the need for an up-to-date clinical guideline. METHODS: An interdisciplinary S3 guideline was created on the basis of a systematic literature review in the PubMed and Cochrane Library databases, with assessment and grading of the evidence according to the GRADE system. RESULTS: 9097 abstracts and 808 articles were screened in full text, and 22 recommendations were issued. It is recommended that any antimicrobial treatment should be preceded by a microbiological diagnostic evaluation with cultures of blood and respiratory samples. The diagnosis of nosocomial pneumonia should be suspected in any patient with a new or worsened pulmonary infiltrate who meets any two of the following three criteria: leucocyte count above 10,000 or below 4000/µL, temperature above 38.3°C, and/or the presence of purulent respiratory secretions. The initially calculated antimicrobial treatment should be begun without delay; it should be oriented to the locally prevailing resistance pattern, and its intensity should be a function of the risk of infection with MDROs. The initial treatment should be combination therapy if there is a high risk of MDRO infection and/or if the patient is in septic shock. In the new guideline, emphasis is laid on a strict de-escalation concept. In particular, antimicrobial treatment usually should not be continued for longer than eight days. CONCLUSION: The new guideline's recommendations are intended to encourage rational use of antibiotics, so that antimicrobial treatment will be highly effective while the unnecessary selection of multi-drug-resistant organisms will be avoided.

Low prevalence of fluoroquinolone resistant strains and resistance precursor strains in Streptococcus pneumoniae from patients with community-acquired pneumonia despite high fluoroquinolone usage.

We investigated the usage of fluoroquinolones and the prevalence of fluoroquinolone resistant pneumococci and their precursors (first step mutants and efflux expressing isolates) in patients with community-acquired pneumonia, who were enroled into the German CAPNETZ surveillance study from 2002 to 2006 before the introduction of the pneumococcal conjugate vaccine (n=5780). Thirty-eight percent of all outpatients received fluoroquinolones. Moxifloxacin accounted for 70%, levofloxacin for 19% and ciprofloxacin for 9% of all fluoroquinolone prescriptions. One hundred and sixty-three pneumococcal isolates from 556 patients with pneumococcal pneumonia were analyzed for fluoroquinolone resistance, efflux phenotype, prevalence of mutations within the quinolone-resistance determining regions and clonality. None of the isolates exhibited fluoroquinolone resistance, 1.2% of the isolates contained a first step mutation and 6.7% exhibited an efflux phenotype. There was no clonal relationship among these strains at increased risk for fluoroquinolone resistance. The absence of fluoroquinolone resistance in the context of high fluoroquinolone usage might be explained by the high proportion of third-generation fluoroquinolones with enhanced activity against pneumococci.

Inflammatory parameters predict etiologic patterns but do not allow for individual prediction of etiology in patients with CAP: results from the German competence network CAPNETZ.

BACKGROUND: Aim of this study was to evaluate the correlation of inflammatory markers procalcitonin (PCT), C-reactive protein (CRP) and leukocyte count (WBC) with microbiological etiology of CAP. METHODS: We enrolled 1337 patients (62 +/- 18 y, 45% f) with proven CAP. Extensive microbiological workup was performed. In all patients PCT, CRP, WBC and CRB-65 score were determined. Patients were classified according to microbial diagnosis and CRB-65 score. RESULTS: In patients with typical bacterial CAP, levels of PCT, CRP and WBC were significantly higher compared to CAP of atypical or viral etiology. There were no significant differences in PCT, CRP and WBC in patients with atypical or viral etiology of CAP. In contrast to CRP and WBC, PCT markedly increased with severity of CAP as measured by CRB-65 score (p < 0.0001). In ROC analysis for discrimination of patients with CRB-65 scores > 1, AUC for PCT was 0.69 (95% CI 0.66 to 0.71), which was higher compared to CRP and WBC (p < 0.0001). CRB-65, PCT, CRP and WBC were higher (p < 0.0001) in hospitalised patients in comparison to outpatients. CONCLUSION: PCT, CRP and WBC are highest in typical bacterial etiology in CAP but do not allow individual prediction of etiology. In contrast to CRP and WBC, PCT is useful in severity assessment of CAP.

Mycoplasma pneumoniae pneumonia revisited within the German Competence Network for Community-acquired pneumonia (CAPNETZ).

BACKGROUND: Currently, broad empiric antimicrobial treatment including atypical coverage is recommended for patients with mild to moderate community-acquired pneumonia (CAP). Therefore, the relative impact of each atypical pathogen, particularly Mycoplasma pneumoniae deserves renewed attention. METHODS: Based on prospective data from 4532 patients with CAP included in the German CAP-Competence Network (CAPNETZ), we studied the incidence, clinical characteristics, and outcome of patients with Mycoplasma pneumoniae pneumonia (MPP). The diagnosis of MPP was based on a positive PCR from respiratory samples and/or a positive IgM-titer from an acute phase serum sample. RESULTS: 307 patients (6.8%) had definite MPP (148 with positive PCR, 204 with positive IgM, 46 with positive PCR and IgM). Compared to patients with other definite and unknown etiologies, patients with MPP were significantly younger (41 +/- 16 versus 62 +/- 17 and 61 +/- 18 years), had fewer co-morbidities, presented with a less severe disease, showed a lower inflammatory response in terms of leukocyte counts (median 8850 versus 13200 and 11000 microL) and CRP values (60 versus 173 and 73 mg/L), and had better outcomes, including a shorter length of hospitalization (9 +/- 5 versus 14 +/- 11 and 12 +/- 9 days), fewer patients requiring mechanical ventilation (0.3 versus 4.5 and 2.1%), and a minimal mortality (0.7 versus 8.7 and 6.5%). CONCLUSION: In this large series of patients with definite MPP according to very strict criteria, MPP appears as a condition with a high incidence, quite specific clinical presentation, and a largely benign course. In view of a widely favorable clinical outcome, recent recommendations including regular coverage of atypical pathogens in patients with mild to moderate CAP might be reconsidered for patients in Germany as well as in other countries with comparable epidemiological settings.

What healthcare workers want--the ideal hand disinfectant.

The results of an anonymised and voluntary survey asking for characteristics of an ideal hand disinfectant are presented. Participants were 475 healthcare workers from a German University Hospital.

Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia.

BACKGROUND: The Competence Network for Community Acquired Pneumonia (CAPNETZ) offers a unique opportunity to study the epidemiology of legionellosis throughout Germany, applying sophisticated diagnostic tools. METHODS: The incidence, clinical characteristics, and outcome of Legionella pneumonia in 2503 adult patients with community-acquired pneumonia, participating in the German Multicenter Study of the CAPNETZ, were studied. RESULTS: Legionella pneumonia was diagnosed in 94 patients (3.8%), thus identifying Legionella species as one of the most common pathogens to cause community-acquired pneumonia. It was equally common among ambulatory and hospitalized patients (3.7% and 3.8%, respectively). The predominant species causing community-acquired pneumonia was Legionella pneumophila; however, 10% of cases were caused by other species not detectable by the urinary antigen test. Patients whose disease was diagnosed by urinary antigen testing experienced a more severe clinical course. Compared with hospitalized patients, ambulatory patients with Legionella pneumonia showed an equal sex distribution, were younger, had fewer comorbidities, fewer cases of discordant initial antimicrobial treatment, and a milder clinical course without fatalities. Thirty percent of patients with Legionella pneumonia received discordant initial antimicrobial treatment without increased mortality. CONCLUSIONS: Legionella is a leading cause of community-acquired pneumonia in Germany. It needs to be considered equally in hospitalized and ambulatory patients. A positive result of a urine antigen test is associated with a more severe clinical course and leads to a potentially relevant underrecognition of species other than L. pneumophila. Legionella pneumonia in outpatients differs significantly from that in hospitalized patients in terms of clinical presentation and outcome. There was an unacceptably high rate of discordant initial antimicrobial treatment.

Pro-atrial natriuretic peptide and pro-vasopressin to predict severity and prognosis in community-acquired pneumonia: results from the German competence network CAPNETZ.

OBJECTIVE: Community acquired pneumonia (CAP) is the most important clinical infection. Therefore, the CAP competence network CAPNETZ was instituted in Germany. The aim of this substudy was to evaluate the value of pro-atrial natriuretic peptide (MR-proANP) and pro-vasopressin (CT-proAVP) for severity assessment and outcome prediction in CAP. DESIGN: Prospective observational study. SETTING: German CAP competence network CAPNETZ. METHODS: We enrolled 589 patients (age 61+/-18 years, 46% female) with proven CAP. MR-proANP, CT-proAVP, C-reactive protein (CRP), procalcitonin (PCT) and CRB-65 score were determined on admission. RESULTS: MR-proANP, CT-proAVP and PCT levels, but not CRP, increased with increasing severity of CAP, classified according to the CRB-65 score. In patients who died during 28-day follow-up, median MR-proANP and CT-proAVP levels (respectively 237.0 vs. 93.5 pmol/l and 44.2 vs. 12.4 pmol/l, each p<0.0001) were significantly higher than in survivors. In receiver operating characteristic (ROC) analysis for survival, the area under the curve (AUC) values for CT-proAVP (0.86, 95% CI 0.83-0.89) and MR-proANP (0.76, 95% CI 0.72-0.80) were similar to the AUC of CRB-65 (0.73, 95% CI 0.70-0.77). In multivariable Cox proportional-hazards regression analyses including MR-proANP/CT-proAVP, coexisting illnesses and CRB-65, increased MR-proANP and CT-proAVP concentrations were the strongest predictors of mortality. CONCLUSIONS: MR-proANP and CT-proAVP are useful new biomarkers for the risk stratification of CAP patients. They are significantly lower in CAP survivors and correlate with the severity of the disease measured by CRB-65 score.

Household contacts were key factor for children's colonization with resistant Escherichia coli in community setting.

OBJECTIVE: In young children infections with resistant Escherichia coli (E. coli) can lead to life-threatening situations. Epidemiological data on the prevalence and major determinants of carriage of antibiotic resistant E. coli among children in the community setting are sparse. STUDY DESIGN AND SETTING: In a population-based study from Germany, stool samples were obtained from children aged 6 months to 4 years attending a pediatrician for a regular health screening (N=568) or an acute infection (N=316), as well as from their parents (N=1,594) and siblings (N=624). E. coli was cultured, and minimal inhibitory concentrations to various antibiotics were tested. We determined prevalences of E. coli resistance to commonly prescribed antibiotics and their association with potential risk factors. RESULTS: Prevalence of E. coli resistance was 16.6%, 8.7%, and 11.6% for ampicillin, cotrimoxazole, and doxycycline, respectively. Strong associations were found with antibiotic resistance among siblings (odds ratios [95% confidence intervals] for ampicillin, doxycycline, and cotrimoxazole resistance: 4.4 [1.8-10.8], 8.0 [3.0-21.2], and 10.8 [3.5-32.7], respectively). CONCLUSION: Resistance prevalences in this community-based study were much lower than those reported from the clinical sector. Household contacts seem to be the key factor for children;s colonization with resistant E. coli in the community setting.

Infection control in German nursing homes.

Infection control in German nursing homes has become an issue during the past 10 years. The changing demographics and the introduction of the diagnosis-related group reimbursement system, as well as the increasing number of residents who are colonized with methicillin-resistant Staphylococcus aureus, may worsen already-existing infection control problems. The publication of national infection control guidelines for nursing homes that should be implemented and supervised by infection control nurses may increase the standard. However, the lack of responsibility of the caring physicians for the whole population of a nursing home may hinder the process. This article discusses the state of infection control in German nursing homes.

Low prevalence of Chlamydia pneumoniae in adults with community-acquired pneumonia.

The incidence of community-acquired pneumonia (CAP) due to Chlamydia pneumoniae was determined in a prospective study of 546 adult patients with CAP included in the German CAP Competence Network (CAPNETZ) project. Three different PCR protocols for detection of C. pneumoniae in respiratory specimens were compared by a multicenter, inter-laboratory comparison involving three laboratories. A case was defined as a patient with a respiratory sample positive by PCR in at least two laboratories. CAP was caused by C. pneumoniae in 5/546 cases (0.9%). Antibody testing by microimmunofluorescence was done in 376 of 546 patients. All patients were negative for IgM antibodies. In the five PCR-positive patients, neither specific IgG nor IgA antibodies were found. Patients with CAP caused by C. pneumoniae had a lower median age (36 years) than the general study population (62 years). C. pneumoniae is currently a rare cause of CAP in adult patients in Germany. Analysis of a single serum sample is not useful for diagnosis of acute C. pneumoniae infection in CAP.