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Vaccination is considered one of the most important achievements of modern medicine and has saved millions of lives. As a result, the age-old fear of severe or fatal infectious diseases has largely been forgotten in society; however, the pandemic triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) shows how quickly this fear can return. Also, many people have reservations about medical measures, especially if they are directed against vague dangers. Paradoxically, the success of vaccinations jeopardizes the acceptance. To counteract this development, this article provides information on basic vaccination principles, legal frameworks and components of vaccines. It explains the most important categories, goals, core elements of vaccination programs and the most important recommendations of the Standing Committee on Vaccination at the Robert Koch Institute (STIKO). It explains the current state of knowledge with respect to required resources, assessment of vaccine reactions, complication management and possible vaccine damage.

Angesichts der zunehmenden antimikrobiellen Resistenzentwicklung ist Antibiotic Stewardship (ABS) eine wichtige Masnahme gegen die Ausbreitung resistenter Erreger und die Entstehung von Multiresistenz. Fur Deutschland und Osterreich steht eine 2018 aktualisierte umfangreiche S3-Leitlinie zur Verfugung. Die Steuerung des Antibiotika‑/Antiinfektivaeinsatzes im Krankenhausbereich sollen ABS-Teams begleiten. ABS beinhaltet auf Krankenhausebene die fortlaufende Analyse lokaler Antibiotikaverbrauchs- und Resistenzdaten. Daraus sollen Empfehlungen fur lokal angepasste Therapieschemata abgeleitet werden. In regelmasigen Visiten diskutieren Mitglieder des ABS-Teams am Krankenbett Indikation, Dosierung, Applikationsweg und Dauer einer antimikrobiellen Therapie. Herausfordernd ist der „sparsame“ Umgang mit Antibiotika, ohne den Patienten zu gefahrden. Digitalisierung und kunstliche Intelligenz bieten neue Moglichkeiten fur ABS. Wichtig ist auch die Adaptierung stationarer Konzepte an die ambulante Versorgung.

Antibiotic stewardship (ABS) is an important measure to counteract the spread of resistant pathogens and multidrug resistance. The most important ABS tools include the implementation of local guidelines, the development of a house-related list of anti-infective agents, regular ABS visits and practice-oriented internal training events. Effective strategies for therapy optimization include indication testing and therapy evaluation, dose optimization as well as determining an appropriate duration of therapy. Oralization of anti-infectives (sequence therapy) should be supported by consistent clinical criteria in in-house guidelines. The incidence of Clostridioides difficile infections (CDI) can be more than halved by restricting the so-called "4C antibiotics". Point-of-care tests help to minimize the use of antibiotics in the outpatient setting. Vaccination reduces the need for antibiotic therapy.

Vaccination is considered one of the most important achievements of modern medicine and has saved millions of lives. As a result, the age-old fear of severe or fatal infectious diseases has largely been forgotten in society; however, the pandemic triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) shows how quickly this fear can return. Also, many people have reservations about medical measures, especially if they are directed against vague dangers. Paradoxically, the success of vaccinations jeopardizes the acceptance. To counteract this development, this article provides information on basic vaccination principles, legal frameworks and components of vaccines. It explains the most important categories, goals, core elements of vaccination programs and the most important recommendations of the Standing Committee on Vaccination at the Robert Koch Institute (STIKO). It explains the current state of knowledge with respect to required resources, assessment of vaccine reactions, complication management and possible vaccine damage.Impfungen gelten als eine der wichtigsten Errungenschaften der modernen Medizin und haben Millionen Menschenleben gerettet. Im Zuge dessen ist die Angst vor schweren Infektionskrankheiten in unserer Gesellschaft weitgehend in Vergessenheit geraten. Die SARS-CoV-2-Pandemie zeigt jedoch, wie schnell dieses Angstgefühl zurückkehren kann. Gleichzeitig hegen viele Menschen Vorbehalte gegenüber medizinischen Maßnahmen, insbesondere wenn sich diese gegen mehr oder weniger abstrakte Gefahren richten. Paradoxerweise gefährdet der Erfolg von Impfungen somit deren Akzeptanz. Um dem entgegenzuwirken, informiert dieser Beitrag über Impfprinzipien, rechtliche Rahmenbedingungen und Impfkomponenten. Er erklärt die wichtigsten Impfstoffkategorien, Ziele und Kernelemente von Impfprogrammen sowie die grundlegenden Empfehlungen der Ständigen Impfkommission und erläutert den Wissensstand zu erforderlichen Ressourcen, Einschätzung von Impfreaktionen, Komplikationsmanagement und möglichen Impfschäden.

Against the background of increasing antimicrobial resistance, antibiotic stewardship (ABS) is an important measure to counteract the spread of resistant pathogens and multidrug resistance. For Germany and Austria, a comprehensive S3 guideline is available, which was last updated in 2018. The control of antibiotic or anti-infective use in hospitals should be guided by specialized ABS teams. At the hospital level, ABS also includes a structured ongoing analysis of local antibiotic use and resistance data. Recommendations for locally adapted therapy regimens should be derived and implemented from this data analysis. ABS consists of regular ward rounds ("ABS visits"), during which members of the ABS team review the indication, dosage, route of administration and duration of antimicrobial therapy at the bedside. Here, the key challenge is to save antibiotics without compromising the individual patient. Digitalization and artificial intelligence offer new options for ABS, while the adaption of inpatient concepts to outpatient care is also important.

Antibiotic stewardship (ABS) is an important measure to counteract the spread of resistant pathogens and multidrug resistance. The most important ABS tools include the implementation of local guidelines, the development of a house-related list of anti-infective agents, regular ABS visits and practice-oriented internal training events. Effective strategies for therapy optimization include indication testing and therapy evaluation, dose optimization as well as determining an appropriate duration of therapy. Oralization of anti-infectives (sequence therapy) should be supported by consistent clinical criteria in in-house guidelines. The incidence of Clostridioides difficile infections (CDI) can be more than halved by restricting the so-called "4C antibiotics". Point-of-care tests help to minimize the use of antibiotics in the outpatient setting. Vaccination reduces the need for antibiotic therapy.

Die rasche Zunahme multiresistenter Gram-negativer Erreger (MRGN) ist ein drangendes und weitgehend ungelostes globales Problem. Die Behandlungsoptionen bei diesen Erregern sind sehr stark eingeschrankt. Nur wenige neue Substanzen sind zugelassen worden oder befinden sich aktuell in klinischen Phase-II/III-Studien. Ubersichtliche Vorstellung der bislang vorliegenden Daten zu den neuen β‑Laktam-Antibiotika und β‑Laktamase-Inhibitor-Kombinationen. Die neuen Makrolide, Ketolide und Aminoglykoside werden nicht adressiert. Selektive Literaturrecherche zu den Substanzen Ceftazidim/Avibactam, Ceftolozan/Tazobactam, Imipenem/Cilastatin + Relebactam, Meropenem/Vaborbactam, Aztreonam/Avibactam und Cefiderocol unter Einbeziehung aktuell registrierter Studien mit klinischer Auswertung und Datenanalyse. Die Entwicklung neuer Substanzen zur Therapie von Infektionen durch MRGN eroffnet neue Optionen bei Infektionen durch besonders schwierig zu behandelnde Erreger, insbesondere Erreger, die Carbapenemasen vom Klebsiella-pneumoniae-Carbapenemase (KPC) und OXA-48-Typ bilden. β‑Laktamase-Bildner werden durch die neuen Substanzen oder Kombinationen unterschiedlich stark gehemmt; allerdings fehlen noch immer ausreichende Therapieoptionen fur Metallo-β-Laktamase-Bildner sowie Infektionen durch multiresistente Pseudomonas-aeruginosa- und Acinetobacter-spp.-Stamme. Vielfach sind die klinischen Daten noch indifferent und stammen aus uneinheitlich definierten Patientenkollektiven. Direkte Vergleiche mit etablierten Behandlungsstrategien wie dem „Last-resort-Einsatz“ von Polymyxinen sind kaum moglich. Leider sind auch bereits Falle einer raschen Resistenzentwicklung beschrieben. Der Stellenwert der Toxizitat und optimalen Dosierung – auch bei Organversagen oder Organersatzverfahren wie Dialyse – ist vielfach noch unklar.

The incidence of clostridium difficile infections (CDI) remains on a high level globally. In Germany, the number of severe or even lethal cases continues to increase. The main risk factor for the development of CDI is exposure to broad spectrum antibiotics, which disturb the physiological microbiome and therefore enable colonization with C. difficile. According to the updated US and European guidelines, orally administered vancomycin is the treatment of choice. Fidaxomicin is as effective as vancomycin but has the advantage of a lower rate of recurrence. Furthermore, recent clinical studies were able to demonstrate that significantly fewer recurrences occurred in patients who additionally received the monoclonal antibody bezlotoxumab. In recent years, several new antibiotics with narrow-spectrum acitivity and low intestinal resorption have been developed for the treatment of CDI, including surotomycin, cadazolid, and ridinilazol. Novel toxoid vaccines are expected to become an efficacious tool in the prevention of CDI; however, pivotal clinical trials have so far not been completed.

Das humane intestinale Mikrobiom hat wichtige metabolische und immunologische Funktionen fur den Wirt und ist Bestandteil der Abwehr von pathogenen Erregern im Gastrointestinaltrakt. Antibiotika, Probiotika, diatetische Masnahmen wie Prabiotika sowie als relativ neu etablierte Methode der fakale Mikrobiomtransfer (FMT) konnen die Zusammensetzung des intestinalen Mikrobioms beeinflussen. Als FMT wird die Ubertragung von Stuhlmikroorganismen, vornehmlich Bakterien, aber auch von Bakteriophagen, Pilzen und Viren, eines gesunden humanen Spenders in den Gastrointestinaltrakt eines Patienten bezeichnet. Diese Masnahme soll der Wiederherstellung eines normalen Darmmikrobioms bei Patienten mit einer dysbioseassoziierten Erkrankung dienen. Die bislang einzige Indikation fur einen FMT ist die multipel rezidivierende Clostridium-difficile-Infektion. Uber 85 % der betroffenen Patienten konnen in dieser Situation durch eine „Stuhltransplantation“ erfolgreich und dauerhaft geheilt werden, dagegen nur etwa 30 % durch eine konventionelle antibiotische Behandlung mit Vancomycin. Als weitere Anwendungsgebiete werden unter anderem chronisch-entzundliche und funktionelle Darmerkrankungen, Insulinresistenz oder morbide Adipositas diskutiert. Die Evaluation in klinischen Studien steht aus. Das Wissen uber den optimalen Spender, die beste Dosierung und den geeignetsten Applikationsweg ist noch beschrankt. Notwendig ist eine sorgfaltige Spenderselektion. Der FMT unterliegt in Deutschland dem Arzneimittelgesetz – er gilt als individuelle Heilmittelzubereitung, an deren Herstellung und Durchfuhrung der behandelnde Arzt personlich beteiligt sein muss. Durch Dokumentation in einem zentralen Register sollen langfristig Wirkungen und Nebenwirkungen auswertbar werden.

The incidence of clostridium difficile infections (CDI) remains on a high level globally. In Germany, the number of severe or even lethal cases continues to increase. The main risk factor for the development of CDI is exposure to broad spectrum antibiotics, which disturb the physiological microbiome and therefore enable colonization with C. difficile. According to the updated US and European guidelines, orally administered vancomycin is the treatment of choice. Fidaxomicin is as effective as vancomycin but has the advantage of a lower rate of recurrence. Furthermore, recent clinical studies were able to demonstrate that significantly fewer recurrences occurred in patients who additionally received the monoclonal antibody bezlotoxumab. In recent years, several new antibiotics with narrow-spectrum acitivity and low intestinal resorption have been developed for the treatment of CDI, including surotomycin, cadazolid, and ridinilazol. Novel toxoid vaccines are expected to become an efficacious tool in the prevention of CDI; however, pivotal clinical trials have so far not been completed.

The human intestinal microbiome has important metabolic and immunological functions for the host and is part of the defense against pathogens in the gastrointestinal tract. Antibiotics, probiotics, dietary measures, such as prebiotics, and the relatively newly established method of fecal microbiota transplantation (FMT, also known as fecal microbiome transfer) all influence the intestinal microbiome. The FMT procedure comprises the transmission of fecal microorganisms from a healthy donor into the gastrointestinal tract of a patient. The aim of this intervention is to restore a normal microbiome in patients with diseases associated with dysbiosis. The only indication for FMT is currently multiple recurrence of Clostridium difficile infections. Approximately 85% of affected patients can be successfully treated by FMT compared to only about 30% treated conventionally with vancomycin. Other possible therapeutic applications are chronic inflammatory and functional bowel diseases, insulin resistance and morbid obesity but these have to be evaluated further in clinical trials. Knowledge on the optimal donor, the best dosage and the most appropriate route of administration is still limited. A careful donor selection is necessary. The implementation of FMT in Germany is subject to the Medicines Act (Arzneimittelgesetz, AMG) with a duty of disclosure and personal implementation by the attending physician. By documentation in a central register long-term effects and side effects of FMT have to be evaluated.

Durchfallerkrankungen gehoren zu den haufigsten Erkrankungen uberhaupt. In dieser Ubersichtsarbeit wird der derzeitige Stand der Behandlungen der akuten infektiosen Diarrho (Teil 1) und der chronischen infektiosen Diarrho (Teil 2) aufgearbeitet und auf die wichtigsten Erreger eingegangen. Nach der Darstellung der allgemeinen Therapieprinzipien der Diarrho wird die gezielte antimikrobielle Behandlung der wichtigsten bakteriellen gastrointestinalen Infektionen beschrieben. Hierzu gehoren: Salmonellose, Shigellose, Campylobacter-Infektionen, Infektionen mit pathogenen Escherichia-coli-Stammen, Yersiniose und Cholera. Aufgrund der ansteigenden Inzidenz und Erkrankungsschwere sowie wichtigen Neuerungen in der Behandlung der C.-difficile-Infektionen (CDI) bzw. C.-difficile-assoziierten Diarrho (CDAD) wird besonders ausfuhrlich auf diese Erkrankung eingegangen. Die symptomatische Therapie steht bei der Behandlung der infektiosen Diarrho nach wie vor im Vordergrund. Bei schwer erkrankten Patienten mit hoher Stuhlfrequenz (> 8/Tag), Immundefizienz, hohem Alter oder signifikanter Komorbiditat kann eine empirische Antibiotikatherapie erwogen werden. Zunehmende Resistenzen, insbesondere gegenuber Fluorchinolonen, sind zu bedenken. Aufgrund des Risikos der ubermasigen Erregervermehrung bzw. Toxinanreicherung im Darm mit protrahiertem oder komplikationsreicherem Krankheitsverlauf wird eine Therapie mit Motilitatshemmern nicht empfohlen. Hinsichtlich der Behandlung von Clostridium-difficile-Infektionen gab es 2012 eine vielversprechende Neuerung. Das makrozyklische Antibiotikum Fidaxomicin kann bei gleicher Effektivitat wie Vancomycin die Rate an Erkrankungsrezidiven reduzieren. Daruber hinaus wird der Nutzen der allogenen Stuhltransplantation zunehmend belegt. Die Behandlung der akuten Diarrho ist weiterhin primar supportiv. Der Nutzen einer generellen empirischen Antibiotikatherapie bei akutem Durchfall ist nicht erwiesen.

Diarrheal diseases are among the most common diseases worldwide. In this review the current treatment recommendations for acute (Part 1) and chronic (Part 2) infectious diarrhea are summarized and typical enteropathogens are discussed. The second part of the article describes chronic diarrhea, its related pathogens and treatment. In contrast to acute diarrhea which is mainly caused by viral and typical bacterial pathogens, chronic diarrhea has mainly non-infectious origins. Protozoal pathogens, such as Giardia lamblia and Entamoeba histolytica in particular are found and more rarely bacterial pathogens, such as Tropheryma whipplei. Opportunistic pathogens cause diarrhea in immunocompromised patients, such as in HIV patients. In these patients cytomegalovirus (CMV) colitis or infections with Cryptosporidium spp., Cyclospora cayetanensis, Isospora belli or microsporidia have to be considered. Besides targeted specific antimicrobial therapy, anti-retroviral drugs improving the underlying immunosuppression and thus the reconstitution of the adaptive immune response remain a cornerstone of the treatment in HIV-positive patients.

An immunocompetent Nigerian developed a fulminant hemophagocytic lymphohistiocytosis due to Epstein-Barr virus reactivation. The patient initially presented with fever, hepatosplenomegaly and pancytopenia. The clinical status of our patient deteriorated quickly despite treatment with corticoids. Escalation of immunosuppressive treatment was not possible. He died of lung, liver and circulatory failure in our intensive care unit.Hemophagocytic lymphohistiocytosis is a rare disease characterized by inflammation due to prolonged and excessive activation of antigen-presenting cells. High plasma ferritin levels and phagocytosis of hematopoetic cells in bone marrow, spleen and liver lead to the diagnosis. Hemophagocytic lymphohistiocytosis should therefore be included in the differential diagnosis in patients with persistent fever, hepatosplenomegaly and cytopenia.

Eine Salmonellose durch Salmonella enteritidis ist eine akute und in den meisten Fallen zoonotische Erkrankung, aber es sind auch menschliche Ubertrager bekannt. Die meisten Erkrankten genesen ohne medizinische Behandlung, und schwere Verlaufe sind selten. Erstmals beschreiben wir hier den Fall einer invasiven, wahrscheinlich durch rohes Schweinefleisch ubertragenen Infektion mit Salmonella enteritidis und mit resultierendem septischem Schock bei einem nierentransplantierten Patienten unter Immunsuppression mit Tacrolimus, 13 Jahre nach der Transplantation.

Das Antiandrogen Flutamid ist ein in der Behandlung des fortgeschrittenen Prostatakarzinoms haufig eingesetztes Medikament. Eine klinisch relevante Hepatotoxizitat wird selten beobachtet, kann aber unter Umstanden todlich verlaufen. Wir berichten uber 2 Patienten mit Prostatakarzinom, bei denen es unter der Therapie mit Flutamid zu einem toxischen Leberparenchymschaden unterschiedlichen Ausmases gekommen war. Nach Absetzen der entsprechenden Medikation und Gabe von Kortikosteroiden kam es bei einem Patienten zur vollstandigen Ruckbildung der klinischen Symptome und der laborchemischen Veranderungen. Bei dem anderen Patienten zeigte sich auch nach Absetzen der Medikation ein schwerer Verlauf mit zunehmender Leberdysfunktion und Entwicklung eines hepatorenalen Syndromes, sodass der Patient schlieslich im Leberzerfallskoma verstarb. Es handelt sich hierbei um den unseres Wissens ersten flutamidassoziierten Todesfall in Deutschland. Die in der Literatur verfugbaren Daten zum Arzneimittelmetabolismus und die bisher publizierten Falle werden aufgefuhrt.

Diarrhea is one of the most commonly occurring diseases.This article gives a review of the current state of the treatment of acute infectious diarrhea (part 1) and chronic infectious diarrhea (part 2) as well as of the most important pathogens.Following a presentation of the general principles of the therapy of diarrhea, the targeted antimicrobial therapy of the most important bacterial gastrointestinal infections is described. This includes salmonellosis, shigellosis and Campylobacter infections, infections with pathogenic Escherichia coli strains, yersiniosis and cholera. Due to the increasing incidence and changes in the severity of the disease and important new aspects in the treatment of diarrhea caused by toxigenic Clostridium difficile strains, these disease entities will be described in detail.Symptomatic therapy is still the most important aspect of the treatment of infectious diarrhea. For severely ill patients with a high frequency of stools ( 8/day), immunodeficiency, advanced age or significant comorbidities, empirical antibiotic therapy should be considered. Increasing resistance, in particular against fluoroquinolones must also be taken into consideration. Due to the risk of excessive pathogen proliferation and concomitant intestinal toxin production with protracted or multiple complications during the disease, therapy with motility inhibitors is not recommended. With respect to the treatment of Clostridium difficile infections a promising novel aspect arose in 2012. The macrocyclic antibiotic fidaxomycin can reduce the rate of recurrent disease with the same effectiveness as vancomycin. Furthermore, evidence for the benefits of allogenic stool transplantation is increasing.The treatment of acute diarrhea is still primarily supportive. The benefits of general empirical antibiotic therapy for acute diarrhea are not evidence-based.

Diarrheal diseases are among the most common diseases worldwide. In this review the current treatment recommendations for acute (Part 1) and chronic (Part 2) infectious diarrhea are summarized and typical enteropathogens are discussed. The second part of the article describes chronic diarrhea, its related pathogens and treatment. In contrast to acute diarrhea which is mainly caused by viral and typical bacterial pathogens, chronic diarrhea has mainly non-infectious origins. Protozoal pathogens, such as Giardia lamblia and Entamoeba histolytica in particular are found and more rarely bacterial pathogens, such as Tropheryma whipplei. Opportunistic pathogens cause diarrhea in immunocompromised patients, such as in HIV patients. In these patients cytomegalovirus (CMV) colitis or infections with Cryptosporidium spp., Cyclospora cayetanensis, Isospora belli or microsporidia have to be considered. Besides targeted specific antimicrobial therapy, anti-retroviral drugs improving the underlying immunosuppression and thus the reconstitution of the adaptive immune response remain a cornerstone of the treatment in HIV-positive patients.

An immunocompetent Nigerian developed a fulminant hemophagocytic lymphohistiocytosis due to Epstein-Barr virus reactivation. The patient initially presented with fever, hepatosplenomegaly and pancytopenia. The clinical status of our patient deteriorated quickly despite treatment with corticoids. Escalation of immunosuppressive treatment was not possible. He died of lung, liver and circulatory failure in our intensive care unit.Hemophagocytic lymphohistiocytosis is a rare disease characterized by inflammation due to prolonged and excessive activation of antigen-presenting cells. High plasma ferritin levels and phagocytosis of hematopoetic cells in bone marrow, spleen and liver lead to the diagnosis. Hemophagocytic lymphohistiocytosis should therefore be included in the differential diagnosis in patients with persistent fever, hepatosplenomegaly and cytopenia.

Salmonellosis caused by Salmonella enteritidis is an acute and in most cases zoonotic disease, but chronic human carriers are also known. Mostly, affected persons recover without treatment, but severe complications occur occasionally. For the first time we report a case of probably food-borne invasive Salmonella enteritidis infection with septic shock in a patient with Tacrolimus treatment, 13 years after renal transplantation, probably acquired by uncooked ground pork meat.

A 37-year-old homosexual man was admitted because of oropharyngeal pain, fever, diarrhea, loss of weight and lymphadenopathy since one week. Acute retroviral syndrome (ARS) in primary HIV type 1 infection was diagnosed, associated with Giardia lamblia infection. Antiinfective and combined antiretroviral treatment was established, and the general condition of the patient rapidly improved. The presented report demonstrates that in case of acute HIV-infection with diarrhea other infections should be considered, particularly with regard to enteropathogens like Giardia lamblia.

Flutamide is an antiandrogen and frequently used for the treatment of prostatic cancer. Severe hepatotoxicity occurs in few patients but may be fatal. We report on two patients with prostatic cancer who received a therapy with flutamide. They showed different degrees of liver damage. One patient recovered completely after withdrawal of Flutamide under medication with steroids. Clinical symptoms and laboratory findings returned to normal within four weeks. Despite immediate withdrawal of Flutamide, the other patient showed a severe course with progressive liver dysfunction and hepatorenal syndrome. He finally died under the clinical picture of fulminant hepatic coma. This case represents the first death associated with flutamide in Germany. The literature concerning the metabolism of flutamide and the published cases of hepatotoxicity of this drug are reviewed.