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Vaccines were originally developed to prevent potentially deadly childhood diseases, but during the 21st century attention broadened to include prevention of infection in all stages of life. Prevention and treatment of bacterial infections are two of the biggest public health challenges of the 21st century. A crisis threatens to arise as the ageing of the population and the associated increase in cases of life-threatening bacteraemia and healthcare-associated infection coincides with an increase in antimicrobial resistance.

Dutch healthcare institutions are relatively successful in preventing outbreaks of antibiotic-resistant pathogens, thus protecting vulnerable patients. However, measures taken to prevent the introduction and spread of MDROs can be burdensome for asymptomatic carriers of such bacteria or for people who may have been exposed to them. This leads to ethical dilemmas. On the basis of a study of the impact of being a carrier and precautionary measures on carrier well-being, we present an ethical framework for responsible care for carriers. We argue that solidarity requires that the burden of prevention and control of resistance is to be shouldered by society as a whole. It is not right to see this problem primarily as a conflict between the protection of vulnerable patients on the one hand and carriers on the other.

Isolating a methicillin-resistant Staphylococcus aureus (MRSA) from a client receiving home care can be a reason for source and contact investigation in the home setting. However, the management of MRSA in a home care setting differs from one during a hospital admission. We describe a case of a patient with MRSA in a home care situation where both the microbiologist from the regional hospital and the communicable disease control physician from the municipal health services were involved. This case illustrates the different perspectives and points of view from both specialties, and the multidisciplinary approach that led to a strategic plan. In this article we discuss a strategy for conducting a contact investigation in public health.

The 2017/2018 influenza season was severe and lasted twice as long as usual. Hospitals struggled to meet the demand for care. In addition to a high number of patients with flu and its complications, other factors played a role. These included absenteeism of informal caretakers and professional home care staff due to having flu themselves, and added strain on hospital capacity due to flu-related sick leave of hospital staff. A minority of the latter group is vaccinated annually against influenza. The authors of this article argue that all healthcare providers should take the yearly influenza vaccination. This will prove beneficial to the employer and employees, since non-attendance among employees will be reduced during peak demand and thus ensure continuity of care capacity. It will also have a positive impact in terms of patient safety and professionalism through improved protection of vulnerable patients against nosocomial influenza infection.

The increasing resistance to antibiotics and the aging of the population of patients who visit the dental practice can lead to more frequent infections with (resistant) microorganisms. The prevention of cross contamination by the implementation of effective measures in the area of hygiene and procedures of infection control is therefore important. The furnishing of a dental practice can play an important part in prevention. What are the important issues in furnishing a practice? A distinction is made between 'critical' and 'non-critical' rooms. Patients are only treated and instruments are only prepared for reuse in critical rooms. In these rooms, a strict separation is maintained between clean and contaminated, in both place and time. Only furniture that is strictly necessary for the treatment of patients is present in the critical rooms. Materials and equipment that are kept within the splatter area must be stored as much as possible in drawers and closed cabinets. Water taps can be controlled in a touch-free manner and are located within the present walking routes of the practice.Toenemende antibioticaresistentie en vergrijzing van de patiënten­populatie die de tandartspraktijk bezoekt, kan leiden tot meer infecties met (resistente) micro-organismen. Het voorkomen van kruisbesmetting door het toepassen van doelmatige maatregelen op het gebied van hygiëne en infectiepreventie zijn daarom belangrijk. De inrichting van een tandartspraktijk kan bij deze preventie een grote rol spelen. Wat zijn belangrijke punten bij de praktijkinrichting? Er wordt onderscheid gemaakt tussen kritische en niet-kritische ruimten. Alleen in de kritische ruimten worden patiënten behandeld en wordt instrumentarium klaargemaakt voor hergebruik. Hier vindt een strikte indeling plaats tussen schoon en gecontamineerd, zowel in plaats als in tijd. Er is alleen meubilair te vinden dat strikt noodzakelijk is voor de patiëntenbehandeling. Materiaal en apparatuur dat binnen de spatzone wordt bewaard, moet zoveel mogelijk worden opgeborgen in lades en achter kastdeuren. Kranen zijn zonder handcontact te bedienen en worden geplaatst binnen de bestaande looproutes.

Three patients were recently transferred to two Intensive Care Units (ICUs) in the Netherlands from two different ICUs in Bucharest, Romania. The patients appeared to be colonised with several, partly identical, carbapenemase-producing bacteria (CPB) after a short hospitalisation in Romania. In this article, we show that it is important to be aware of the possibility that patients are colonised with CPB after a short hospitalisation abroad. This has consequences for infection prevention measurements, but probably also for the discontinuation of selective bowel decontamination in the ICU.

The increase in Highly Resistant Micro-Organisms (HRMO) in hospitals and nursing homes requires an intensification of infection prevention measures. This paper describes a new, standardised approach to infection prevention and monitoring of antibiotic use.Cross-sectional, observational study.The Infection RIsk Scan (IRIS) measures a number of objectifiable variables in the field of infection prevention, including the dissemination of HRMO, the use of antibiotics and indwelling medical devices, environmental contamination, hand hygiene and personal hygiene of healthcare workers, and various infection control preconditions. The scan converts the measurements into a risk profile and an improvement chart, a graphic presentation that is easy to understand for care professionals, managers and patients. Based on the results, targeted improvements can be made by a department or institution, and a quality cycle can be started in which the scans are repeated.The IRIS has been successfully applied in 5 hospital departments, a rehabilitation clinic and 19 nursing homes. In the hospital departments, 3 IRIS cycles resulted in a significant improvement in hand hygiene compliance (43% to 66%, p0.001) and a significant reduction in environmental contamination. In one nursing home, the IRIS resulted in a previously undetected outbreak of HRMO being discovered.The IRIS method makes it possible to compare departments and institutions and can therefore provide an impetus for standardization of measurements of risks and results in the field of infection prevention, antibiotic use and resistance.

Healthcare is becoming more complex and healthcare providers are often only involved in a small part of the process of patient care. Measuring the outcome of the process, in this case healthcare-related infections, with feedback to the professionals involved is indispensable for assessment and improvement of quality of care. Prevalence surveys are used frequently to determine the quality of the process. This method has important limitations that can lead to a biased result. This problem is discussed on the basis of a case and a recent publication on healthcare-related infections occurring after discharge.

To determine the number and duration of nosocomial outbreaks caused by highly resistant microorganisms (HRMO) posing a potential threat to public health, in order to undertake a risk assessment.Descriptive study.Data on nosocomial outbreaks were collected from April 2012 to June 2014. The following characteristics were recorded at the start and end of each outbreak: type of microorganism, reason for reporting, phase of outbreak, number of patients colonised and infected, and infection prevention measures implemented.47 medical institutions reported 87 outbreaks (mean: 3 outbreaks per month). 20 outbreaks were reported in 2012 (2.2/month), 39 in 2013 (3.3/month), and 28 in the first six months of 2014 (4.7/month). Outbreaks of vancomycin-resistant enterococci (n = 26), methicillin-resistant Staphylococcus aureus (MRSA; n = 23) and resistant or highly resistant Enterobacteriaceae (n = 17) were reported most frequently. 65 outbreaks (75%) were controlled within two months of reporting.Transparent reporting of HRMO outbreaks is important for correct public perceptions of the safety of hospitals and nursing homes in the Netherlands. Reports to the Hospital-acquired Infection and Antimicrobial Resistance Monitoring Group show that HRMO outbreaks are an almost daily occurrence in Dutch hospitals. However, most outbreaks are quickly controlled without posing a threat to public health.

In the Netherlands the quality of health care is supervised by the Health Care Inspectorate. Since 2013 the Health Care Inspectorate has been specifically checking hospital practices for reducing transmission of highly resistant microorganisms. Its mode of operation, using process indicators, has been criticised. Here, it is proposed that this quality control be based on relevant outcome parameters of infection prevention strategies. This would also maximise transparency regarding the occurrence of infections caused by highly resistant microorganisms in Dutch hospitals.

Antibiotic resistance is a worldwide threat to health care as it impairs the effective treatment of bacterial infections. Measures against the spread of resistance are mainly focused on individual health care institutions as these are viewed as the main source of resistance. However, health care institutions are not completely independent in their control of the prevalence of resistance, as movement of patients between hospitals and care institutions can induce movement of resistant micro-organisms. In other words, antibiotic resistance follows the flow of patients. Mapping this flow of patients results in a network that includes all health care institutions, and has a distinctive modular structure. Patients are moved primarily within regions, much less so between regions. We argue that the structure of this health care network should be used to design efficient and effective control strategies. To this end, we advocate (a) regional coordination of control measures, (b) differentiation of investment in infection prevention according to the network position of the institution, and

To gain insight into the prevalence of healthcare-associated (HAI) infections in hospital patients in the Netherlands, and their link with previous hospital admission.Cross-sectional study.This prevalence study was carried out in 36 hospitals at 42 locations in the Netherlands in March 2014. All inpatients at the time of the study were evaluated for the presence of an HAI, according to the standard protocol and in accordance with internationally determined definitions. It was subsequently determined whether the HAI had been acquired during the current admission or was linked to a previous recent admission. Readmission had to have taken place within a predetermined time period.A total of 9,420 patients were evaluated for the presence of an HAI; 470 (5.0%) HAI were reported, of which almost 36% was linked to a previous admission. Two-thirds of the HAI were post-operative surgical-site infections. Almost 88% of the patients with HAI were treated with antibiotics, versus 32% of the patients without HAI.Registration of HAI on admission to hospital provides insight into the frequency of HAI that become apparent after discharge. There is no insight into the treatment frequency of HAI by general practitioners. An inventory of the treatment frequency of HAI in primary care is advised, to evaluate infection-prevention policy in hospitals and to optimise primary care.

Antibiotic resistance is a worldwide threat to health care as it impairs the effective treatment of bacterial infections. Measures against the spread of resistance are mainly focused on individual health care institutions as these are viewed as the main source of resistance. However, health care institutions are not completely independent in their control of the prevalence of resistance, as movement of patients between hospitals and care institutions can induce movement of resistant micro-organisms. In other words, antibiotic resistance follows the flow of patients. Mapping this flow of patients results in a network that includes all health care institutions, and has a distinctive modular structure. Patients are moved primarily within regions, much less so between regions. We argue that the structure of this health care network should be used to design efficient and effective control strategies. To this end, we advocate (a) regional coordination of control measures, (b) differentiation of investment in infection prevention according to the network position of the institution, and

Antibiotic resistance is a worldwide threat to health care as it impairs the effective treatment of bacterial infections. Measures against the spread of resistance are mainly focused on individual health care institutions as these are viewed as the main source of resistance. However, health care institutions are not completely independent in their control of the prevalence of resistance, as movement of patients between hospitals and care institutions can induce movement of resistant micro-organisms. In other words, antibiotic resistance follows the flow of patients. Mapping this flow of patients results in a network that includes all health care institutions, and has a distinctive modular structure. Patients are moved primarily within regions, much less so between regions. We argue that the structure of this health care network should be used to design efficient and effective control strategies. To this end, we advocate (a) regional coordination of control measures, (b) differentiation of investment in infection prevention according to the network position of the institution, and

Healthcare is becoming more complex and healthcare providers are often only involved in a small part of the process of patient care. Measuring the outcome of the process, in this case healthcare-related infections, with feedback to the professionals involved is indispensable for assessment and improvement of quality of care. Prevalence surveys are used frequently to determine the quality of the process. This method has important limitations that can lead to a biased result. This problem is discussed on the basis of a case and a recent publication on healthcare-related infections occurring after discharge.

In the Netherlands the quality of health care is supervised by the Health Care Inspectorate. Since 2013 the Health Care Inspectorate has been specifically checking hospital practices for reducing transmission of highly resistant microorganisms. Its mode of operation, using process indicators, has been criticised. Here, it is proposed that this quality control be based on relevant outcome parameters of infection prevention strategies. This would also maximise transparency regarding the occurrence of infections caused by highly resistant microorganisms in Dutch hospitals.

In the Netherlands the quality of health care is supervised by the Health Care Inspectorate. Since 2013 the Health Care Inspectorate has been specifically checking hospital practices for reducing transmission of highly resistant microorganisms. Its mode of operation, using process indicators, has been criticised. Here, it is proposed that this quality control be based on relevant outcome parameters of infection prevention strategies. This would also maximise transparency regarding the occurrence of infections caused by highly resistant microorganisms in Dutch hospitals.

Healthcare is becoming more complex and healthcare providers are often only involved in a small part of the process of patient care. Measuring the outcome of the process, in this case healthcare-related infections, with feedback to the professionals involved is indispensable for assessment and improvement of quality of care. Prevalence surveys are used frequently to determine the quality of the process. This method has important limitations that can lead to a biased result. This problem is discussed on the basis of a case and a recent publication on healthcare-related infections occurring after discharge.

In October 2013, the Municipal Health Service, Rotterdam, the Netherlands, was notified of an outbreak of Mycoplasma pneumoniae infections in an institution for mentally disabled persons.A total of 58 potential infections were identified, of which 12 were confirmed in the laboratory, 5 with PCR testing on throat swabs, 3 by an increased IgM value in the serum, 2 via IgM seroconversion and 2 with an increased IgG titer in consecutive serum samples. To combat the outbreak, measures were taken in collaboration with the municipal health service. Every patient who coughed with fever or malaise was considered to be potentially infected and immediately treated with antibiotics, with as much cohort nursing as possible. The staff made every effort to explain the more stringent hand and cough hygiene measures to the residents.An outbreak of Mycoplasma pneumonia in an institution for mentally disabled persons was controlled through active disease surveillance, treatment of potential cases and hygiene measures.

MERS-CoV is the sixth type of corona virus to cause disease in humans. This virus can cause severe respiratory infections, particularly in patients with underlying conditions. Although dromedary camels appear to be the most important source in primary cases, nosocomial transmission has proved to be a major cause of secondary infections. In accordance with the case definitions formulated by the Dutch National Institute for Public Health and the Environment (RIVM), in those patients who present with lower respiratory infections within 14 days of visiting the Arabian Peninsula, MERS-CoV should be considered.

The Dutch Health Care Inspectorate investigated the preparedness of Dutch hospitals for the emergence of antibiotic resistance, and concluded that hospitals are not well prepared and are insufficiently aware that infection prevention is a prerequisite for patient safety. These conclusions are based on observations of process indicators of current practice guidelines, without including the available outcome indicators that demonstrate the persistently low incidence of infections with antibiotic resistant bacteria in Dutch hospitals. The conclusions may have negative effects on the quality of infection prevention in Dutch hospitals. Therefore, it is advisable to use outcome indicators rather than process indicators to evaluate the quality of infection prevention.

The Dutch Health Care Inspectorate investigated the preparedness of Dutch hospitals for the emergence of antibiotic resistance, and concluded that hospitals are not well prepared and are insufficiently aware that infection prevention is a prerequisite for patient safety. These conclusions are based on observations of process indicators of current practice guidelines, without including the available outcome indicators that demonstrate the persistently low incidence of infections with antibiotic resistant bacteria in Dutch hospitals. The conclusions may have negative effects on the quality of infection prevention in Dutch hospitals. Therefore, it is advisable to use outcome indicators rather than process indicators to evaluate the quality of infection prevention.

The Dutch Health Care Inspectorate investigated the preparedness of Dutch hospitals for the emergence of antibiotic resistance, and concluded that hospitals are not well prepared and are insufficiently aware that infection prevention is a prerequisite for patient safety. These conclusions are based on observations of process indicators of current practice guidelines, without including the available outcome indicators that demonstrate the persistently low incidence of infections with antibiotic resistant bacteria in Dutch hospitals. The conclusions may have negative effects on the quality of infection prevention in Dutch hospitals. Therefore, it is advisable to use outcome indicators rather than process indicators to evaluate the quality of infection prevention.

There have recently been 12 outbreaks of infection caused by vancomycin-resistant enterococci (VRE) in Dutch hospitals. Although the first VRE outbreaks were reported almost 12 years ago, such outbreaks remained uncommon and the question is why they are occurring now. Based on molecular epidemiological studies we have learned that a subpopulation of Enterococcus faecium, resistant to amoxicillin but susceptible to vancomycin, has become highly endemic in Dutch hospitals in the past 12 years. Initial analyses suggest that several transposons containing vancomycin-resistance genes have been introduced into this population, followed by nosocomial spread. We recommend that hospitals without detected VRE outbreaks screen high-risk patients for the presence of VRE. If transmission has already occurred in many hospitals, it will be extremely difficult (and costly) to eradicate VRE.

To confirm previously risk factors for MRSA carriage in our geriatric patient population and to suggest a simplified risk score with a combination of these risk factors, to test the Novel Score and to check if a targeted MRSA screening on admission is possible to reduce the screening workload and cost.a prospective in-hospital cohort study.1125 geriatric patients were screened for MRSA carriage within 24 hours after admission to a geriatric hospital.Risk factors, based on recently published risk scores (Preop Score and Ger Score) were determined.Prevalence of MRSA carriage was 8.44%. In a multivariate analysis ageor = 87 year (OR 1,864; 95% CI 1,145-3,035), presence of a long-term catheter (OR 2,813; 95% CI 1,562-5,065) and prior carriage of MRSA (OR 13,25; 95% CI 8,007-21,926) remained predictors of MRSA carriage. The Novel Score (cut-offor = 1) had a sensitivity of 73.7%, a specificity of 64%, PPV 15.9%, NPV 96.3% and AUC of 0.688. The Novel Score allows reduction of the screening load by 57.2%, but misses 26% of positive cases. 16% of MRSA carriers develop an infection that needs to be treated with vancomycin.With targeted MRSA screening on admission based on a risk score a substantial reduction of workload and costs is possible compared to generalized screening for MRSA. Because MRSA carriers can be missed with a risk score, the epidemiological context and the risk of transmission and infection with MRSA must be taken in to account when introducing a targeted screening.

The methicillin-resistant Staphylococcus aureus (MRSA) infection rate in the Netherlands is low thanks to a nationwide 'search and destroy' MRSA policy. This policy is based on two factors: MRSA in the community was rare and all patients at risk for MRSA are isolated until culture results are negative. However, in 2005, livestock-associated MRSA emerged. This gave rise to an MRSA reservoir in the community. Yet the risk of livestock-associated MRSA being transmitted is low compared to that of other MRSA strains. Moreover, MRSA prevalence is lower in patients treated in a foreign hospital than had been assumed in the past. New tests (chromogenic media and PCR) have become available that allow rapid detection of MRSA carriage, resulting in a 48-60% decrease in isolation days. When rapid tests are performed, in addition to conventional cultures, patients at risk no longer need to be isolated and the closure of wards due to the risk of an outbreak is no longer necessary.

Antibiotic resistance poses a serious threat to the successful treatment of hospitalized patients. Micro-organisms that produce carbapenamases, such as Klebsiella pneumoniae carbapenamases (KPCs) represent the next step in the continuously emerging problem of antibiotic resistance. Restrictions on antibiotic use plus optimal adherence to infection control measures will be crucial to limit the spread of KPC in hospitals in the Netherlands in the coming years.

Expectations are that 25% of the Dutch population will be aged 65 years or older in 2050 whilst in 2008 this proportion was only 15%. As a consequence the annual absolute number of new cases of specific infectious diseases will increase. Elderly people often have less clear symptoms of infection, making it harder for clinicians to recognize the disease. Morbidity and mortality caused by infections increase with age. Ageing will possibly cause an increase in levels of antibiotic resistance. There will be more elderly people in hospitals and nursing homes, where more antibiotics are used. This development will come in addition to other developments in the field of antibiotic resistance. There will be more elderly people with chronic HIV and viral hepatitis B and C infection and their complications because patients who are presently infected with those pathogens are ageing. Policy makers should more often consider introducing vaccination of older age groups against certain infectious diseases.

Seven patients operated on in a period of two consecutive days in the Havenziekenhuis, Rotterdam, the Netherlands developed symptoms of sepsis following a relatively minor procedure. One patient developed fever and hypotension a few hours after surgery, and developed thrombocytopenia and leucopenia. Postoperative bleeding occurred as a result of the thrombocytopenia, necessitating further surgery. This patient developed serious multi-organ failure, and required prolonged intensive care treatment. The other six patients developed less serious infections, the main symptoms of which were fever, leucopenia, thrombocytopenia and impairment of liver- and kidney function. They recovered quickly. Bacteriological investigation revealed that the infection was caused by extrinsic contamination of the intravenous anaesthetic propofol with Klebsiella pneumoniae and Serratia marcescens. Due to the high risk of contamination of the lipid formulation of this preparation, the use of propofol requires the following measures: syringes should be used just once; vials should be punctured just once; and administration should take place within 12 h after opening the vial or the ampoule. Hygienic working methods are also of crucial importance.

Since its introduction in 1984, selective decontamination of the digestive tract has had clear supporters and opponents. De Smet et al. conducted a large national study in 13 Dutch intensive care units, investigating the effects of the following 3 regimens on mortality: standard treatment, selective decontamination of the digestive tract and selective oropharyngeal decontamination. The results showed decontamination to have a clear benefit in terms of reducing mortality. Based on these results, decontamination should be used in all intensive care patients.

ix, 88 p. ill.

The Netherlands Health Care Inspectorate recently changed its approach to quality of care and patient safety from a reactive to a firmly proactive style. In two reports, the current perioperative processes in Dutch hospitals were scrutinised. Despite a highly-motivated workforce, the inspectorate detected a lack of standardisation, incomplete or inaccessible patient data, poor adherence to hygiene standards and gaps during transfer of care in both the preoperative and intraoperative stages ofsurgery. The inspectorate mandates rapid implementation of various new patient safety approaches, including the use of checklists, 'time-outs' before the start of surgery, double checking of intravenous drugs and improved compliance with hygiene standards, as well as a strict definition of roles and responsibilities of team members. Implementation will require major changes within the processes and culture of operating theatres in Dutch hospitals. Such a change is unlikely to be completed within the short timeframe allowed by the inspectorate.

A small outbreak of measles occurred after a 33-year-old female aircrew (cabin) member presented at an emergency room with fever. Three members of the hospital staff were infected: a 42-year-old man, a 33-year-old woman, and a 26-year-old woman. The first 2 patients had not been immunised, and the third had received 2 immunisations according to the Dutch National Immunisation Programme. Vaccination of the 2 sero-negative patients within 48 h after exposure with the measles-mumps-rubella vaccine (MMR) did not prevent the development of measles. Vaccination was deemed unnecessary in the third patient. No tertiary cases occurred. The same measles virus (genotype D5) was detected by PCR and sequencing in all 4 patients. Measles remains a risk for hospital staff members who have not acquired natural immunity. The current policy of immunising patients within 72 h after exposure to measles may not be sufficient. It also appears that immunisation through the Dutch National Immunisation Programme does not always protect against nosocomial infection. Providing MMR vaccination or boosters to hospital staff in certain departments might be beneficial.

v, 103 p. ill.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have been confined to healthcare centres for decades. However, MRSA infections are increasingly seen in young healthy individuals with no exposure to healthcare centres. These community-acquired MRSA (CA-MRSA) strains differ from healthcare-associated MRSA (HA-MRSA) strains in various ways. For example, CA-MRSA is strongly associated with the staphylococcal cassette chromosome mec (SCCmec) type IV and the toxin Panton-Valentine leukocidin. CA-MRSA spreads relatively easily but often remains susceptible to non-3-lactam antibiotics. Given the epidemic potential of CA-MRSA strains, there is a high probability that the number of CA-MRSA infections will increase in The Netherlands. In order to prevent and control CA-MRSA outbreaks in the community successfully, the restrictive Dutch antibiotic policy must be followed with strict infection prevention measures.

The current policy concerning methicillin-resistant Staphylococcus aureus (MRSA) in hospitals needs to be altered because there is no reliable proof that the isolation policy that is currently in force actually leads to any reduction in the prevalence of MRSA. Conversely, it has been proved that these isolation measures lead to poorer patient care, sometimes resulting in death.

The Dutch methicillin-resistant Staphylococcus aureus (MRSA) 'search and destroy' policy is effective. MRSA should be banned from hospitals: MRSA infections are associated with increased mortality and costs. In addition, widespread use of vancomycin for treating MRSA infections encourages the spread and development of vancomycin-resistant micro-organisms.

It was recently observed that pig breeders in The Netherlands often carry methicillin-resistant Staphylococus aureus (MRSA). These MRSA strains are related to MRSA strains found in pigs. A case-control study showed that not only pig breeders but also cattle breeders are at risk of carrying MRSA. It is advised to keep pig breeders, if they are admitted to a hospital, in isolation until surveillance cultures are proven negative. This also applies to veterinarians and slaughterhouse personnel. For cattle breeders screening without isolation on admission to a hospital is sufficient.

An outbreak of scabies in a teaching hospital, two nursing homes and six health-care institutions for the elderly, occurred in the Nijmegen area in the Netherlands, between September 2004 and April 2005. In November 2004 the diagnosis of scabies crustosa (scabies norvegica) was made in the index patient - a 78-year-old woman. An atypical presentation, without much itching, as is not infrequently seen in elderly patients, resulted in there being a considerable delay before the diagnosis was made. This resulted in a total of 51 people, both in and outside the hospital, becoming infected. Based on article 7 of the Dutch Infectious Diseases Act, the Municipal Health Service (GGD) advised institutions on the policy and carried out both source and contact tracing. According to this Act notification and cooperation between hospital, care institutions and the GGD are of importance for the effective handling of epidemics. Systemic treatment with ivermectin is the main alternative to local treatment in outbreaks in institutions.

Health-care-associated infections caused by antibiotic-resistant pathogens have become a menace in hospitals worldwide and infection control measures have lead to vastly different outcomes in different countries. During the past 6 years, a theoretical framework based on mathematical models has emerged that provides solid and testable hypotheses and opens the road to a quantitative assessment of the main obstructions that undermine current efforts to control the spread of health-care-associated infections in hospitals and communities. We aim to explain to a broader audience of professionals in health care, infection control, and health systems administration some of these models that can improve the understanding of the hidden dynamics of health-care-associated infections. We also appraise their usefulness and limitations as an innovative research and decision tool for control purposes.

To determine the prevalence of carriers of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and gentamicin-resistant Gram-negative bacilli (GGNB) in patients repatriated from foreign hospitals to The Netherlands.Determination of prevalence.In the period May 1998-August 2001, 1167 patients were repatriated. Swab specimens, demographic data and clinical data were obtained during the transfer.The prevalence of carriers of resistant microorganisms was 18.2%. MRSA was carried by 2.7% of the total repatriated group and by 4.7% of patients transferred to a Dutch hospital. Risk factors were antimicrobial treatment (odds ratio (OR): 3.4; 95% CI: 1.2-9.7), length of stay in a foreign hospitalor = 14 days (OR: 5.4; 95% CI: 2.3-12) and artificial ventilation (OR: 8.5; 95% CI: 1.8-41). VRE and GGNB were isolated from 2.7% and 14.1% of patients, respectively. Transfer from Asia or southern, south-eastern and eastern Europe were risk factors for carrying GGNB.Carriership of resistant microorganisms was high among repatriated patients. The highest risk of GGNB was more closely associated with the country from which the patient was transferred than the antimicrobial treatment received in the foreign hospital.

In the period July-September 2003, a multi-resistant Escherichia coli strain caused an outbreak on a surgical ward in the Deventer Hospital, the Netherlands. This strain produced a beta-lactamase with an extended spectrum, making it resistant to third generation cephalosporins. Furthermore, the strain was resistant to trimethoprim-sulphamethoxazole (co-trimoxazole), gentamicin and quinolones, so that only treatment with carbapenems was possible. 8 patients were colonised. Genotyping of the strains by means of amplified fragment length polymorphism indicated the spread of a single strain. A multidisciplinary crisis team coordinated the infection control measures and the communication to involved persons and the press. Control measures consisted of contact isolation of colonised patients and extra attention to hand hygiene. After this proved to be ineffective, all patients on the ward were screened and the ward was closed for several days. The outbreak was stopped by strict cohorting ofthe colonised patients. There were no indications for transmission of resistance genes by plasmids. Several months later, on visiting the outpatient clinic, 3 other patients appeared to have been colonised by the epidemic E. coli strain during their admission. They had not been screened because they had already been discharged when all patients on the ward were screened for colonisation. In a follow-up study 9 months after the outbreak, 3 of the 6 investigated patients, who had in the meantime returned home, were still found to be colonised. Such patients constitute a risk for the re-introduction of multi-resistant bacteria into the hospital and should be preventively screened and isolated on admission.

Three men, aged 39, 73, and 66 years, respectively, developed an infection with a new strain ofClostridium difficile, ribotype 027.C.difficile-associated diarrhoea (CDAD) occurred in two patients after multiple abdominal surgery and in the third patient one week after autologous haematopoietic cell transplantation. Within a few days, despite antibiotic therapy, all three patients developed severe (pseudomembranous) colitis with sepsis for which admission to the Intensive Care Unit was required. Two patients underwent (sub)total colectomy and received an intensive course of oral and/or rectal vancomycin. In all patients who develop diarrhoea in hospital, especially during or after treatment with antibiotics or chemotherapeutic agents, an infection with C. difficile ribotype 027 should be suspected. Recent outbreaks of this hypervirulent strain of C. difficile have been reported in Canada, the United States, United Kingdom, and The Netherlands. Demonstration of C. difficile toxin in faeces confirms the clinical suspicion of CDAD and ribotyping of the strain may reveal whether the 027 strain is present. For treatment of these 027 infections, vancomycin is preferred to metronidazole. After a severe course of colitis or in case of recurrence a 'tapering and pulse' course ofvancomycin can be prescribed; alternatively, treatment with bovine antibody-enriched whey may be considered. The introduction of this hypervirulent strain has led to reinforcement of the hygienic measures in accordance with the recommendations of the Dutch Working Party on Infection Prevention and a policy to deter the use of fluoroquinolones.

Recently, two Dutch hospitals reported outbreaks of Clostridium difficile ribotype 027, toxinotype III. This strain, which was seen earlier in the United States, Canada and the United Kingdom, produces large amounts of toxins due to a defect in the toxin-regulating gene and causes severe diarrhoea. Antibiotic use, especially use of fluoroquinolones, is a risk factor. Control of outbreaks is hampered by the fact that Clostridium forms spores that can survive for a very long time in the environment and are resistant to the usual surface disinfectants. Protocols for diagnostic investigations, prevention and control of outbreaks are available.

Isolation of patients is used to control the spread of certain microorganisms in the hospital, e.g. meticillin-resistant Staphylococcus aureus (MRSA). Recent investigations have shown that the quality of care for patients in isolation is affected significantly. However, this is not accompanied by an effect on the morbidity or mortality. The successful Dutch policy on MRSA is based largely on strict isolation of patients colonised with MRSA. If MRSA becomes endemic, this is accompanied by increases in morbidity and mortality as well as costs. The disadvantages of isolation are recognised and should be prevented as far as possible. New diagnostic and therapeutic developments can shorten the duration of isolation significantly, which will further improve the quality of care.

Four employees working on an Internal Medicine ward complained of itch after contact with an HIV-positive woman with crusted scabies.

EPIDEMIC: The annual number of new MRSA isolates in the Netherlands tripled in 2002 compared with previous years. This increase was in part due to a MRSA outbreak in the Rijnmond region. The outbreak occurred in two merged hospitals and is the largest ever to occur in the Netherlands. From November 2001 till June 2003 MRSA was isolated from 381 patients and 113 hospital employees. The worst affected departments were Surgery and Internal Medicine. One MRSA strain (pulsed-field gel electroforesis (PFGE) type 16) remained initially unrecognised and was therefore able to spread unnoticed. Soon two additional epidemic MRSA strains (types 37 and 38) were discovered.Multiple factors played a role in the extent and duration of the outbreak. Because of the delayed detection and rapid spread of MRSA type 16, the outbreak grew too large once recognised to be resolved within the available infrastructure. Investments were needed at various fields, including the infection-control service and the microbiology laboratory. Employees had to be informed and motivated, and a separate MRSA ward and OPD were provided. New MRSA outbreaks occurred, despite extensive MRSA (contact) screening among patients and employees. The numbers of isolates began falling as from the beginning of 2003.

Sebald Justinus Brugmans, Professor at Leyden University and from 1795 on Director of the 'Geneeskundig Bureau der Bataafsche Republiek', organized all necessary facilities in the Leyden Military Hospital. His appointment, 1811, as inspector-general of the French Imperial Military Health-Service, seemed to be the next step in a brilliant career of more than 25 years. He became a leading expert in the fight against hospital-gangrene and its prevention, not in the least because of the enthusiastic reception of his treatise on gangrene (1814) in which he meticulously analyzed and explained the causes of this dreadful disease. He completed his entry with a thorough evaluation of all possible and well experienced sanitary regulations. He was convinced of the contagious character of the disease. Quite unusual at the time, he used the terms "miasma" and "contagium" interchangeably. Maybe partly for that reason, his work was instrumental in convincing most later authors that gangrene was a contagious disease. Brugmans' fame was established forever after tha Battle of Waterloo (June 1815).