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There is growing evidence that bed occupancy (BO) rates, overcrowding and understaffing influence the spread of hospital-acquired infections (HAIs). In this article, a systematic review of the literature is presented, summarizing the evidence on the adverse effects of high BO rates and overcrowding in hospitals on the incidence of HAIs. A Pubmed database search identified 179 references, of which 44 were considered to be potentially relevant for full-text review. The majority (62.9%) focused on methicillin-resistant Staphylococcus aureus-associated infection or colonization. Only 12 studies were found that provided a statistical analysis of the impact of BO on HAI rates. The median BO rate of the analysed studies was 81.2%. The majority of studies (75%) indicated that BO rates and understaffing directly influence the incidence of HAIs. Only three studies showed no significant association between BO rates and the incidence of HAIs. Interestingly, only one of the included studies detected a seasonal trend in the BO rate. The present review shows an association between BO rates and the spread of HAIs in various settings. Because the evidence on this topic is limited, we conclude that further research is needed in order to analyse the rationale of a threshold BO rate, because keeping beds empty is comparatively costly.

Healthcare-associated infections are common adverse events in acute-care medicine, causing significant morbidity and mortality. There has been a significant increase in the commitment to infection prevention and control (IPC) among European countries in recent years. However, there is still heterogeneity in training opportunities and IPC qualifications. The European Union promotes the harmonization of IPC strategies among member states. The European Centre for Disease Prevention and Control (ECDC)-commissioned Training in Infection Control in Europe project sets the stage for harmonization of IPC activities in Europe by issuing a list of core competencies for IPC professionals. European certification of IPC training and professionals would be the next logical step, which must be achieved by close collaboration between different stakeholders in Europe such as the ECDC, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the European Union of Medical Specialities, and the national IPC societies. Therefore, the ESCMID has launched the new European Committee on Infection Control to take the lead in the implementation of a European (board) certificate for IPC professionals. Clinical Microbiology and Infection (C) 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

a b s t r a c t Background: As a major zoonotic pathogen, characterization of the infectivity and pathogenicity of Coxiella burnetii is essential to understand Q-fever epidemiology. Objectives: We want to extend a recently published human dose response model based on experimental challenge of young adult males to include other age groups and both genders. Additionally, we can estimate the spatial distribution of exposure based on observed outbreak data. Methods: Dose response assessment based on human challenge, is extended by including outbreak data, using location of cases as a proxy for exposure. This allows estimation of the influence of age and gender on the probability of developing symptoms of acute respiratory illness. Results: In an outbreak in Switzerland, in 1983, exposure to C. burnetii was shown to depend strongly on distance from the source. The susceptibility of males to develop Q-fever decreases with age, while in females, middle-aged women appear to have the lowest risk. Conclusions: The published dose response model for Q-fever, based on experimental challenge of a small group of human volunteers, has been updated with data from a well studied outbreak. Infectivity esti- mates remain high, and even low doses (of 10 or fewer organisms) cause a high risk of illness. © 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Recent age-projection showed that the number of elderly is expected to rise significantly over the next decades worldwide. Accordingly, the prevalence of chronic and degenerative diseases will increase, among them osteoarthritis, resulting in more and older patients undergoing total joint arthroplasty and thereby also being at risk for associated complications. Among those, prosthetic joint infections are feared as threatening complication with a mortality approaching 8 % and causing long-term antibiotic therapy, immobilization and often account for operative revision. This review summarizes epidemiological, microbiological, and therapeutic aspects of prosthetic joint infection in the elderly population. Considering the increase in the number of PJIs in the forthcoming years in most countries, a common action to reduce the associated morbidity and mortality is strongly encouraged in Europe.

Complicated infections caused by vancomycin-resistant enterococci (VRE) represent a therapeutic challenge, since adequate treatment options are limited and antibiotic resistance to the available agents has already been described. The most frequently used antibiotic in VRE treatment is linezolid. Tigecycline is an alternative to linezolid, however, clinical data for severe infections such as sepsis or endocarditis are scarce. Daptomycin on the one hand is an option but has not yet been approved for the treatment of enterococcal infections in Germany on the other hand. The present review critically evaluates the clinical significance of the antibiotics in question for VRE therapy based on existing data.

Background: Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF) provides fast and accurate identification of microorganisms. Several reports have speculated about its use in epidemiological typing. However, there is no systematic comparison with standard typing methods, such as pulsed-field gel electrophoresis (PFGE). This study evaluates the potential use of MALDI-TOF for the analysis of suspected outbreaks of vancomycin-resistant enterococci (VRE), compared to PFGE. Methods: During a suspected outbreak of VRE, including five patients, on an intensive care unit, all isolates were analyzed by PFGE as well as by MALDI-TOF. A series of 24 spectra for each extracted isolate were created. Obtained spectra were smoothed, baseline corrected and calibrated. Subsequently, main spectra (MSP) were created using a Microflex mass spectrometer (Bruker-Daltonik) and the MALDI Biotyper 3.0. Mass peaks were compared manually; a dendrogram was automatically generated. All isolates were tested in triplicate to assess measurement fluctuations. Results: Analysis of the MSP mass peaks and the dendrogram could clearly identify three different strains which were in agreement with the PFGE. Two clusters, reflecting four isolates and two occurred transmissions, were clearly identified. Measurement fluctuations did not affect the strain typing. Conclusions: MALDI-TOF provided results concordant to PFGE and that in a fraction of time and costs. However, Bruker's algorithm for automated dendrogram creation is partly consisting of identification log scores making its resolution too low for exact typing analysis. Hence, fully automated analysis is not possible. However, the obtained results show some potential for the use of MALDI-TOF as an epidemiological tool for future outbreak management.

Looking at the components and implementation of Infection Prevention and Control (IPC) measures in European hospitals, am osaic is thefirst picture you could easily use to describe it. Indeed a mosaic is ’a surface decoration made by inlaying small pieces of variously coloured material to form pictures’ [1]. To form such a picture the mosaic pieces need to be organized and arranged by artists following the set pattern that they have in their minds. Therefore those pieces are usually of standardized size and form, while their coatings vary greatly in colours creating an almost limitless variety of composition. Almost 100 years after the 1918 flu pandemic killed ~4% of the world’s population the world is still not very well prepared to face a similar event. Healthcare-associated infections (HAI) remain a leading cause of morbidity and mortality worldwide and increasing rates of antimicrobial resistance among common bacteria significantly add to the rate of inappropriate therapy and related mortality and long-term consequences. Multidrugresistant organisms have been implicated in severe invasive infections and their occurrence has increased steadily. Furthermore, well-known risk factors for HAI, such as international migration, travel and country-to-country transfer of patients, lead to a permanently increasing risk of spread. Introduction and establishment of multidrug-resistant organisms in previously unaffected regions is becoming more likely every day. Successful IPC can therefore no longer be established by one entity (hospital, country or region) alone but by international cooperation and coordination. To foster international collaboration and strengthen efforts to reduce HAI burden in Europe, many different initiatives have been running for years under the aegis of the European Centre for Diseases Prevention and Control, WHO and many national and international societies focused on infectious diseases, clinical microbiology and infection control with different degrees of success. Among them, the implementation of a European network for antimicrobial resistance and HAI surveillance (EARSS) played a pivotal role in reducing morbidity. The European Society for Clinical Microbiology and Infectious Diseases recently launched a new Committee for IPC, the European Committee on Infection Control. This committee aims to contribute to the harmonization of IPC and the stan

Linezolid is an antibiotic of last resort for the treatment of infections with vancomycin-resistant enterococci (VRE). Here we report the increasing prevalence of linezolid resistance among clinical Enterococcus faecium strains from German hospital patients. Linezolid minimum inhibitory concentrations (MICs) were determined for 4461 clinical E. faecium strains isolated between 2008 and 2014. Isolates originated from the network of diagnostic laboratories collaborating with the National Reference Centre (NRC) for Staphylococci and Enterococci covering all German federal states. All linezolid-resistant isolates were determined by broth microdilution and confirmed by Etest as well as by analysing the 23S rDNA for putative mutations. Marker genes were determined by PCR. Genotyping was performed by SmaI macrorestriction analysis in pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) for selected isolates. An increase in linezolid resistance was observed, from1% in 2008 to9% in 2014. Occasionally, outbreaks with linezolid-resistant VRE (ST117) were observed. In total, 232 (92.4%) of 251 linezolid-resistant E. faecium isolates (including 61 vanA and 29 vanB) contained the G2576T 23S rDNA mutation and showed a varying mixture of wild-type and mutated alleles per genome sufficient to confer linezolid resistance. In vitro growth experiments revealed a stable linezolid MIC. Of the 251 linezolid-resistant isolates, 5 were cfr-positive. In conclusion, these NRC data identified a country-wide ongoing trend of increasing linezolid resistance among clinical E. faecium isolates within the last 5 years.

The world is aging and the number of elderly multimorbid patients is steadily increasing. The limited numbers of acute care beds in hospitals, in addition to the need to reduce costs, has led to the introduction of efficient discharge policies, which in turn have increased demand for beds in nursing homes and long-term care facilities (LTCFs). As a consequence, the number of postacute LTCF residents is rising, as is the number of residents requiring complex medical care delivered by use of indwelling medical devices. These devices place patients at a heightened risk for infection. Furthermore, infection control resources in LTCFs are often limited. This article reviews the preventive measures that should be taken in LTCFs to reduce the risk of device-related infections.

SUMMARY Background: The spread of vancomycin-resistant enterococci (VRE), particularly E. faecium, in hospitals leads to many cases of colonization, but only sporadic infections. Detailed and valid risk assessment is needed so that patients at risk can be protected from VRE infection. The principal aims of risk assessment must include not only lowering VRE-associated morbidity and mortality in patients at risk, but also refraining from unnecessary anti-infective measures among those who are not at risk. Methods: We selectively searched the PubMed database for pertinent articles on the epidemiology and clinical relevance of VRE in order to derive a uniform and practical hygiene strategy from the available scientific evidence. Results: Only low-level evidence is available for the interventions studied to date, and most of the recommendations that have been issued can be characterized as expert opinion. As a rule, VRE are not highly pathogenic; they tend to have high rates of colonization, but low rates of infection. The risk factors for colonization with VRE include (among others) the administration of antibiotics and immunosuppressants, prior hospitalization, diarrhea, intubation, and other invasive treatments. The areas of highest risk are hematology/oncology wards, liver transplantation wards, dialysis units, and neonatology wards. Conclusion: The chain of infection can be broken by improved and consistently applied standard hygienic measures (hand and surface disinfection). Some patients are nonetheless at elevated risk of VRE infection. In specific clinical situations, the optimal protection of these patients against VRE infection demands the obligatory enforcement of stricter hygienic measures (contact isolation). ►Cite this as

Background: The recent outbreak of Q fever in the Netherlands between 2007 and 2009 is the largest recorded Q fever outbreak. Exposure to Coxiella burnetii may cause Q fever but the size of the population exposed during the outbreak remained uncertain as little is known of the infectivity of this pathogen. The quantification of the infectiousness and the corresponding response is necessary for assessing the risk to the population. Methods: A human challenge study was published in the 1950s but this study quantified the dose of C. burnetii in relative units. Data from a concurrent guinea pig challenge study were combined with a recent study in which guinea pigs were challenged with a similar aerosol route to quantify human exposure. Concentration estimates for C. burnetii are made jointly with estimates of the dose response parameters in a hierarchical Bayesian framework. Results: The dose for 50% infection (InfD50%) in human subjects is 1.18 bacteria (95% credible interval (CI) 0.76-40.2). The dose for 50% illness (IllD50) in challenged humans is 5.58 (95%CI 0.89-89.0) bacteria. The probability of a single viable C. burnetii causing infection in humans is 0.44 (95%CI 0.044-0.59) and for illness 0.12 (95%CI 0.0006-0.55). Conclusions: To our knowledge this is the first human dose–response model for C. burnetii. The estimated dose response relation demonstrates high infectivity in humans. In many published papers the proportion of infected individuals developing illness is reported to be 40%. Our model shows that the proportion of symptomatic infections may vary with the exposure dose. This implies that presence of these bacteria in the environment, even in small numbers, poses a serious health risk to the population.

The spread of vancomycin-resistant enterococci (VRE), particularly E. faecium, in hospitals leads to many cases of colonization, but only sporadic infections. Detailed and valid risk assessment is needed so that patients at risk can be protected from VRE infection. The principal aims of risk assessment must include not only lowering VRE-associated morbidity and mortality in patients at risk, but also refraining from unnecessary anti-infective measures among those who are not at risk.We selectively searched the PubMed database for pertinent articles on the epidemiology and clinical relevance of VRE in order to derive a uniform and practical hygiene strategy from the available scientific evidence.Only low-level evidence is available for the interventions studied to date, and most of the recommendations that have been issued can be characterized as expert opinion. As a rule, VRE are not highly pathogenic; they tend to have high rates of colonization, but low rates of infection. The risk factors for colonization with VRE include (among others) the administration of antibiotics and immunosuppressants, prior hospitalization, diarrhea, intubation, and other invasive treatments. The areas of highest risk are hematology/oncology wards, liver transplantation wards, dialysis units, and neonatology wards.The chain of infection can be broken by improved and consistently applied standard hygienic measures (hand and surface disinfection). Some patients are nonetheless at elevated risk of VRE infection. In specific clinical situations, the optimal protection of these patients against VRE infection demands the obligatory enforcement of stricter hygienic measures (contact isolation).

Background Vancomycin-resistant enterococci (VRE) are primarily opportunistic pathogens with incalculable clinical significance. In addition, the effectiveness of isolation in VRE is often not easily assessed. The goals of this study were to estimate the transmissibility of VRE of patients with VRE bacteraemia to other hospitalized patients and to document reliable epidemiologic data on all VRE cases in a large health care center. Methods A prospective survey on in-patients colonized and/or systemically infected with VRE was conducted at a 2,000-bed tertiary care university hospital in Germany. All roommates of VRE bacteraemia patients were analyzed. Pulsed-field gel electrophoresis was performed to assess clonal relatedness. Results 16,507 Screening tests were performed on 9,258 patients, of which 560 tested positive for VRE (6.1%). Nineteen patients also suffered from VRE bacteraemia, an incidence of 3.4%. This cohort was multimorbid and had high rates of exposure to external risk factors (eg, previous hospital stay prior to admission, 78.9%). The transmission rate to contacts was low (3.5%). Contact time of negative contacts was significantly lower than that of VRE-positive contacts (19.3 hours vs 72.0 hours, respectively, P Conclusion VRE bacteraemia was found exclusively in multimorbid patients, transmission occurred seldom, and average contact time of positive contacts was very high. The risk of transmission of VRE from bacteraemic patients to hospitalized contacts is low.

Background: Microbiological laboratories seek technologically innovative solutions to cope with large numbers of samples and limited personnel and financial resources. One platform that has recently become available is the Kiestra Total Laboratory Automation (TLA) system (BD Kiestra B.V., the Netherlands). This fully automated sample processing system, equipped with digital imaging technology, allows superior detection of microbial growth. Combining this approach with matrix-assisted laser desorption ionization time-offlight mass spectrometry (MS) (Bruker Daltonik, Germany) is expected to enable more rapid identification of pathogens. Methods: Early growth detection by digital imaging using Kiestra TLA combined with MS was compared to conventional methods (CM) of detection. Accuracy and time taken for microbial identification were evaluated for the two methods in 219 clinical blood culture isolates. The possible clinical impact of earlier microbial identification was assessed according to antibiotic treatment prescription. Results: Pathogen identification using Kiestra TLA combined with MS resulted in a 30.6 hr time gain per isolate compared to CM. Pathogens were successfully identified in 98.4% (249/253) of all tested isolates. Early microbial identification without susceptibility testing led to an adjustment of antibiotic regimen in 12% (24/200) of patients. Conclusions: The requisite 24 hr incubation time for microbial pathogens to reach sufficient growth for susceptibility testing and identification would be shortened by the implementation of Kiestra TLA in combination with MS, compared to the use of CM. Not only can this method optimize workflow and reduce costs, but it can allow potentially life-saving switches in antibiotic regimen to be initiated sooner.

Managing Healthcare-associated Infections (HAI) and multidrug-resistant Microorganisms (MDRO) is a daily challenge in hospitals. Universal decolonization by daily bathing with impregnated cloths can result in a reduction of HAIs.

Treatment options for multidrug-resistant Gram-negative infections are scarce and therefore alternatives with a narrow spectrum or new agents are sought. Antimicrobial susceptibility to temocillin, mecillinam, ceftazidime, and ceftazidime/avibactam was determined using Etest and disk diffusion according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) methodology. A total of 77 carbapenem-nonsusceptible Enterobacteriaceae were studied, including Klebsiella pneumoniae (26%), Escherichia coli (26%), Enterobacter cloacae (26%), and Enterobacter aerogenes (22%). Several phenotypic tests, PCRs followed by sequencing and a microbiological bioassay excluded carbapenemase production in all isolates. Antimicrobial susceptibility rates were low for temocillin (15.6%, minimum inhibitory concentration [MIC] range 2 to >1,024 μg/ml), moderate for mecillinam (59.7%, MIC range 0.25 to >256 μg/ml), and excellent for ceftazidime/avibactam (100%, zone diameter range 19 to 32 mm, median 25 mm). 5.2% of the isolates were susceptible to ceftazidime alone (zone diameter range 6 to 32 mm). In this study, mecillinam exhibited moderate and ceftazidime/avibactam excellent in vitro antimicrobial activity against carbapenem-nonsusceptible Enterobacteriaceae without carbapenemase production. Ceftazidime/avibactam was able to restore previously reduced susceptibility to ceftazidime in all isolates, thus potentiating its activity. Temocillin only exhibited low in vitro antimicrobial activity against the isolates. Further evaluation of mecillinam and ceftazidime/avibactam with regard to the potential clinical utility against infections caused by these pathogens has to be performed.

Multidrug-resistant organisms (MDROs) are an economic burden, and infection control (IC) measures are cost- and labour-intensive. A two-tier IC management strategy was developed, including active screening, in order to achieve effective use of limited resources. Briefly, high-risk patients were differentiated from other patients, distinguished according to type of MDRO, and IC measures were implemented accordingly.To evaluate costs and benefits of this IC management strategy.The study period comprised 2.5 years. All high-risk patients underwent microbiological screening. Gram-negative bacteria (GNB) were classified as multidrug-resistant (MDR) and extensively drug-resistant (XDR). Expenses consisted of costs for staff, materials, laboratory, increased workload and occupational costs.In total, 39,551 patients were screened, accounting for 24.5% of all admissions. Of all screened patients, 7.8% (N=3,104) were MDRO positive; these patients were mainly colonized with vancomycin-resistant enterococci (37.3%), followed by meticillin-resistant Staphylococcus aureus (30.3%) and MDR-GNB (28.3%). The median length of stay (LOS) for all patients was 10 days (interquartile range 3-20); LOS was twice as long in colonized patients (P0.001). Screening costs totalled 255,093.82€, IC measures cost 97,701.36€, and opportunity costs were 599,225.52€. The savings of this IC management strategy totalled 500,941.84€. Possible transmissions by undetected carriers would have caused additional costs of 613,648.90-4,974,939.26€ (i.e. approximately 600,000-5 million €).Although the costs of a two-tier IC management strategy including active microbiological screening are not trivial, these data indicate that the approach is cost-effective when prevented transmissions are included in the cost estimate.