Epidemiology of multidrug resistant bacterial organisms and Clostridium difficile in German hospitals in 2014: Results from a nationwide one-day point prevalence of 329 German hospitals
Huebner et al. BMC Infectious Diseases
Epidemiology of multidrug resistant bacterial organisms and Clostridium difficile in German hospitals in 2014: Results from a nationwide one-day point prevalence of 329 German hospitals
Nils-Olaf Huebner 0 1
Kathleen Dittmann 1
Vivien Henck 1
Christian Wegner 1
Axel Kramer 1
for the Action Group Infection Prevention (AGIP)
0 IMD laboratory network, MVZ Greifswald GmbH , 17489 Greifswald , Germany
1 Institute of Hygiene and Environmental Medicine, University Medicine Greifswald , Walther-Rathenau-Str. 49a, 17475 Greifswald , Germany
Background: One important aspect in combatting resistance to antibiotics is to increase the awareness and knowledge by epidemiological studies. We therefore conducted a German-wide point-prevalence survey for multidrug resistant bacterial organisms (MDROs) and Clostridium difficile (CD) to assess the epidemiology and structure quality of infection control in German hospitals. Method: 1550 hospitals were asked to participate and to report surveillance data on the prevalence of Methicillinresistant and Vancomycin resistant Staphylococcus aureus (MRSA, VRSA/GRSA), Vancomycin resistant Enterococcus faecalis/faecium (VRE), multiresistant strains of Escherichia coli (EC), Klebsiella spp. (KS), Enterobacter spp. (ES), Acinetobacter spp. (AB) and Pseudomonas spp. (PS). as well as CD infections. Results: Surveys from 73,983 patients from 329 hospitals were eligible for analysis. MRSA was the most often reported pathogen (prevalence: 1.64 % [CI95: 1.46-1.82]), followed by 3 multidrug resistant EC (3MRGN-EC) (0.75 % [CI95: 0.60-0.89]), CD (0.74 % [CI95: 0.60-0.88]), VRE (0.25 % [CI95: 0.13-0.37]) und 3MRGN-KS (0.22 % [CI95: [0.15-0.29]). The majority of hospitals met the German recommendations for staffing with infection control personnel. Conclusion: The continuing increase in participating hospitals in this third survey in a row indicates a growing awareness to MDROs and our pragmatic approach. Our results confirm that MRSA, 3MRGN-EC, VRE and 3MRGN-KS remain the most prevalent MDROs in German hospitals.
Point prevalence; MDROs; HICARE-network; MRSA; CD; ESBL; VRE; Infection control staff; Type of screening
Antibiotic resistance of bacterial pathogens is an
emerging problem worldwide [
]. While no longer limited to
in-patient care, hospitals are still a focal point for
transmissions and infections with multidrug resistant
organisms (MDRO). While for decades Methicillin-resistant S.
aureus (MRSA) strains was the leading MDRO, the raise
in antibiotic resistance in Gram-negative bacteria and of
other nosocomial pathogens like Clostridium difficile
(CD) have aggravated the problem of antibiotic
resistance and let to increased efforts to control MDROs [
One important aspect in combatting MDROs is to
increase awareness to as well as knowledge on the
epidemiology of MDROs. For Germany, a number of
regional surveys have been conducted by so called
regional MDRO-networks of care providers the last years.
These networks have now been established in all states
in Germany based on a resolution of the Conference of
Ministers of Health ("Gesundheitsministerkonferenz") in
]. Most of these surveys were based on an
admission screening and covered MRSA only [
In a complementary approach, the German Society of
Hospital Hygiene conducted a first German-wide
pointprevalence survey for MDROs to assess the in-house
epidemiology in German hospitals in 2010. This survey
assessed the epidemiology of MRSA and other MDROs
by gathering routine data by a questionnaire [
years later, the survey was repeated as collaboration
between the then newly founded Action Group Infection
Prevention, an interdisciplinary expert group, with the
“HICARE-Health Region Baltic Sea Coast”, a project
supported by the Federal Ministry of Education and
Research as part of the German strategy against bacterial
resistances (Deutsche Antibiotika-Resistenzstrategie,
]. While the fist survey included only 3,411
patients from nine hospitals, the second survey had a
much higher response rate and included 13,000 patients
from 56 hospitals distributed overall Germany. Here, we
report the results of the third survey that was, encouraged
by positive response, conducted in 2014 [
We conducted a voluntary, anonymous,
pointprevalence survey gathering routine data of structure
quality in infection control and microbiological
surveillance data that has to be present in hospitals in
Germany by law in February 2014 [
]. The survey
relied on aggregated routine data only, no informed
consent from individual patients was needed [
method used was approved by the Ethics Committee of
the Board of Physicians Mecklenburg-West Pomerania
at the University of Greifswald.
The survey consisted of three parts: one part assessed
the prevalence of MDRO (calculated as proportion of
the in-patients with a certain MDRO to all in-patients),
one part assessed basic structure of the hospitals (e.g.
data on the level of care, number of beds) and one part
assessed structure quality data of infection control in the
hospitals (e.g. staffing with infection control personnel,
presence of admission screening for MDROs). Finally,
we asked by whom and by which method the
epidemiological data were provided.
To allow comparisons to the former surveys as well as
to the former distinction between primary, secondary
and tertiary care hospitals, only data from intensive care
units, surgical and medical wards were collected.
Based on the survey forms used in 2010 [
] and 2012
], an updated version of former surveys was
generated and converted in an active PDF-form (Adobe
Acrobat X). In contrast to the former surveys that asked
the epidemiology of extended-spectrum beta lactamase
(ESBL) positive strains, the updated version in this
survey used the “multidrug resistant Gram-negative”
(MRGN)-classification of the German Commission on
hospital hygiene and infection protection (KRINKO) at
the Robert Koch Institute (RKI) for multi-resistance in
Gram-negative bacteria [
]. This classification is meant
to highlight the clinical impact of resistance of
Enterobacteriaceae, Pseudomonas spp. and Acinetobacter spp.
and is based on the sensitivity against four important
classes of antimicrobials: acylureidopenicillins, 3rd and
4th generation cephalosporins, quinolones and
carbapenems. According to this classification a multidrug
resistant strain is classified as either 3MRGN (resistant to
three out of four classes) or 4MRGN (resistant to four
out of four classes) [
The following bacterial pathogens were included in
the survey: Methicillin-resistant Staphylococcus aureus
(MRSA), Vancomycin resistant S. aureus (VRSA/GRSA),
Vancomycin resistant Enterococcus faecalis/ E. faecium
(VRE), 3MRGN and 4MRGN Escherichia (E.) coli
(3MRGN-EC; 4MRGN-EC), 3MRGN and 4MRGN
Klebsiella spp. (3MRGN-KS; 4MRGN-KS), 3MRGN and
4MRGN Enterobacter spp. (3MRGN-EB; 4MRGN-EB),
3MRGN and 4MRGN Acinetobacter spp. (3MRGN-AB;
4MRGN-AB), 3MRGN and 4MRGN Pseudomonas spp.
(3MRGN-PA; 4MRGN-PA) as well as Clostridium
difficile (CD) infections with infections in intensive care unit
(ICU)-patients or requiring ICU-treatment as sub-group.
We asked for Clostridium difficile colonisations, because
we knew, that CDI patients, who were no longer
suffering from diarrhoea but still in isolation were not well
reported under “infections” to assess this group too.
Hospitals were asked whether an outbreak with these
pathogens was ongoing at the day of the survey to
control for this possible confounder.
The participants were asked to report the prevalence
rates as known by health care workers and infection
control personnel in the hospitals. We therefore
deliberately gave no generic definition for cases or to
distinguish between infections/colonisations and nosocomial
and hospital acquired cases, respectively. Instead, we
aimed to collect the routine data exactly as used for
clinical and infection control decisions (e.g. isolation
measures), for reimbursement and for continuous recording
of the occurrence of MDROs that has is required in all
hospitals in Germany by law (IFSG). Case definitions
were therefore based on microbiological results as well
as information from case histories and so called “transfer
sheets” (German “Überleitbögen”), which are required to
share information on a present MDRO – carrier status
between medical facilities.
The form was sent by E-mail to 1,550 hospitals by the
last week of January 2014. Hospitals were asked to
perform the survey in February 2014. Returned surveys
were collected and consolidated using build-in functions
of Adobe Acrobat and exported to Microsoft Excel.
Microsoft Excel and IBM SPSS Statistics 22 were used
for statistical analysis.
Prevalence rates were calculated on hospital/ward
level and mean prevalence rates and confidence
intervals were calculated as average of the prevalence rates
of the former. For statistical comparisons, confidence
intervals were used as robust and conservative
alternative to p-values were ever possible due to the
explorative nature of the survey and to avoid problems
associated with multiple statistical testing explorative
nature of the survey and as robust and conservative
alternative to p-values [
]. Were confidence intervals
implied a true difference between two groups, a t-test
was performed to test for statistically significant
differences when appropriate.
To calculate the percentage of patients with nosocomial
infections due to MRSA, VRE, ESBL-E.coli and CD from
the point prevalence study of the ECDC , the following
formula was used [
prevalence of nosocomial infections due to a given MDRO
nosocomial infections with a given organism
percentage of resistant strains of that organism
number of patients in the survey
In total, 364 hospitals returned the questionnaire (return
rate: 23.5 %) of which 329 (90.4 %) representing 120,180
beds were finally eligible for analysis (Table 1). Of those
included, 45 (13.7 %) were tertiary care providers, 76
(23.1 %) were secondary and 208 (63.2 %) were primary
care hospitals. Overall, 73,983 patients were included.
The average number of beds in tertiary care, secondary
care and primary care providers was 800, 400 and 259,
Figure 1 shows the participation of hospitals divided
by federal German states. In the majority of states
between 15 – 25 % of hospitals could be included in the
study. Bremen, Mecklenburg-Western Pomerania,
Thuringia and Baden-Wuerttemberg showed the highest
participation, while Hesse was the only state with
participation below 10 %. In total, hospitals from
Level of care
(ICN = infection control nurse, ICC = infection control consultant)
Northrhine-Westphalia made up the larges fraction of
participating hospitals (21.3 %), followed by
BadenWuerttemberg (18.2 %) and Bavaria (17.3 %) and
Mecklenburg Western Pomerania (7.3 %).
Staffing with infection control personnel
The survey revealed that the German recommendations
by KRINKO for staffing with infection control personnel
were not fully met by the participating hospitals
regardless of the level of care (Table 1) [
]. In total, 279 of
329 (84.8 %) hospitals met the staffing needs for
infection control nurses and 246 (74.8 %) hospitals for
infection control consultants (Table 1).
In total, 89.1 % of included hospitals reported to have
some kind of MRSA-admission screening, with
marginal differences between levels of care (tertiary
91.1 %, secondary 88.2 %, primary 88.9 %) (Table 2).
Most screening regimes (79.3 %) followed the
recommendation of KRINKO to screen defined groups of
risk patients [
]. Another 6.7 % reported to have a
universal admission screening and 3.0 % did only
screen admissions to critical wards like ICUs or
transplant units (Table 2).
Screening for other MDROs was much less common.
Only 38.3 % of hospitals reported to screen for 4MRGN,
21.9 for ESBL (as proxy for 3MRGN) and 21 % for VRE.
There was a marked difference in the policy to screen
for MDRO other than MRSA between levels of care.
Hospitals with a higher level of care were more likely to
screen for MDROs other than MRSA (Table 2). The
association between the screening policies for certain
MDROs and the reported prevalence rates are show in
Table 3 and discussed below.
Responsibility of data collection
In total, data were collected directly at the wards
(50.8 %) or using electronic systems in most hospitals
(45.0 %), whereas the infection control nurse was
responsible for collecting data in the majority of hospitals
(82.4 %) (Table 4).
Hospitals that comply with the
requirements for staffing for ICN (n, %)
Hospitals that comply with the
requirements for staffing for ICC (n, %)
Table 2 MRDO-Screening strategy
Universal screening *
Tertiary (n = 45) 2 (4.4 %)
Secondary (n = 76) 6 (7.9 %)
Primary (n = 208) 14 (6.7 %)
total (n = 329) 22 (6.7 %)
* all admissions, ** according to KRINKO
35 (77.8 %)
58 (76.3 %)
168 (80.8 %)
261 (79.3 %)
Only admission to critical wards
4 (8.9 %)
3 (3.9 %)
3 (1.4 %)
10 (3.0 %)
4 (8.9 %)
9 (11.8 %)
23 (11.1 %)
36 (10.9 %)
30 (66.7 %) 19 (42.2 %)
34 (44.7 %) 18 (23.7 %)
62 (29.8 %) 32 (15.4 %)
126 (38.3 %) 69 (21.0 %)
15 (33.3 %)
19 (25.0 %)
38 (18.3 %)
72 (21.9 %)
0.60 [0.46 – 0.73]
Notwithstanding the level of care or type of ward, MRSA
was the most often reported pathogen with a prevalence of
1.64 % [CI95: 1.46-1.82] of all included patients, followed
by 3MRGN-EC (0.75 % [CI95: 0.60–0.89]), CD (0.74 %
[CI95: 0.60–0.88]), VRE (0.25 % [CI95: 0.13–0.37]) und
3MRGN-KS (0.22 % [CI95: [0.15–0.29]) (Tables 5 and 6).
Prevalence and origin of Gram-positive MDROs
Prevalence, clinical presentation (infection or
colonisation) and origin (nosocomial or non-nosocomial) of
most reported MDRO cases are shown in Fig. 2.
MRSA had a marked prevalence in all levels of care
and types of wards (Fig. 2a). Most MRSA cases were
(ICN = infection control nurse, ICC = infection control consultant, LPIC = link physician for infection control, QM = Quality management)
colonisations of non-nosocomial origin (65.0 %). While
the prevalence in surgical and medical wards was quite
comparable between levels of care (ranging between 1.18
(surgical, primary level) and 1.78 % (medical, second
level), ICUs had a much higher prevalence in all settings,
ranging between 2.05 % (second level) and 3.39 %
(primary level). While there was a trend to a higher
MRSAprevalence in hospitals that did screen for MRSA and
hospitals that reported to have a universal screening
policy reported the highest prevalence, confidence intervals
did broadly overlap (Table 3). VRSA was almost absent
in this survey. Only one case of nosocomial colonization
from a tertiary level ICU was reported.
For VRE in contrast, there was a marked difference in
the mean prevalence between levels of care with a trend
to a higher prevalence in second and third level hospitals
(Fig. 2a). Again, the prevalence in ICUs was much higher
(ranging between 0.81 % and 2.25) compared to the
other wards regardless of the level of care, making VRE
the fourth most prevalent pathogen in this survey. As
for MRSA, most cases were classified as colonisations
but, the epidemiology was strongly determined by
nosocomial origin. This became particularly evident for ICUs
were 53.33 % (primary level) to 65.85 % (tertiary level) of
cases were reported to be nosocomial. While there was a
trend for a higher prevalence in hospitals that did screen
for VRE, confidence intervals did overlap (Table 3).
Prevalence of Gram-negative MDROs
Prevalence, clinical presentation (infection or
colonisation) and origin (nosocomial or non-nosocomial) of the
most prevalent Gram-negative MDROs 3MRGN-EC and
3MRGN-KS are shown in Fig. 2b. Again, ICUs had the
highest prevalence. For 3MRGN-EC in particular there
was a trend to higher prevalence in higher level of care
The prevalence of 3MRGN-PS was only slightly lower
than that of 3MRGN-KS (0.21 % [CI95: 0.10-0.31])
followed by 3MRGN-EB (0.10 % [CI95: 0.05-0.15], other
not otherwise specified 3MRGN-organisms (0.10 %
[CI95:0.05-0.15] and 3MRGN-AB (0.02 %
Besides 3MRGN-MDROs, 4MRGN-MDROs were
reported as well. With a prevalence of 0.17 %
[CI95:0.060.29] 4MRGN-PS was the seventh most common
Gramnegative MDRO. Moreover, this organism was reported
from all levels of care in a frequency that was
[95 % CI]*
comparable to 3MRGN-PS. While the prevalence of 4
MRGN-KS was low (0.04 % [0.00-0.07]), at least one
case was reported from all levels of care and type of
ward. The prevalence of other 4MRGN ranged between
0.01 % and 0.04 %.
With a prevalence of 0.74 % [CI95: 0.60–0.88]
Clostridium difficile was the third most often reported
pathogen in this survey (Table 5). Nosocomial cases
made up a relevant proportion in all settings, as 31.17 %
(medical wards, secondary level) to 65.22 % (surgical
wards, primary level) of cases were of nosocomial origin
(Fig. 2c). Still, most cases occurred on normal wards and
did not require ICU-treatment. Less than 3 % (15 cases)
were reported as severe cases (prevalence 0.04 % [CI95:
Hospitals that reported to have an ESBL-screening
policy showed a significantly higher prevalence of
3MRGN-EC compared to hospitals that did not screen
(p < 0.001) and a trend to higher prevalence rates for
3MRGN-KS, 3MRGN-EB and 3MRGN-PA (Table 3).
Likewise, hospitals that screened for 4MRGN reported
trend to higher prevalence rates of 4MRGN-KS,
3MRGN-EB, 3MRGN-AB and 3MRGN-PS. While the
confidence intervals for 3MRGN-KS did not overlap, the
difference was not statistically significant (p = 0.068).
Bacterial resistance has become one of the major
challenges in the therapy and control of nosocomial
infections. Studies assessing the prevalence of MDROs can
help to improve the understanding of the epidemiology
of MDROs as well as increase the awareness to this
* 95 % confidence interval
problem and thus foster the development and
implementation of evidence based strategies to combat
Our study is the third survey in a row to assess the
emergence of MDROs and Clostridium difficile as well
as staffing with infection control personnel and MDRO
screening policy in German hospitals. As in the previous
surveys, we used a pragmatic, easily accessible approach
by collecting routine surveillance data that has to be
present in hospitals by law in Germany. By limiting the
prevalence survey to intensive care units, surgical and
medical wards, our data allows comparisons between
primary, secondary and tertiary level hospitals.
Furthermore, as this survey uses the same method as the
previous surveys, temporal comparisons are possible in
principle, too. When comparing the three surveys, the
most obvious result is the steep increase in participating
hospitals that grow from 9 hospitals in 2010 to 62
hospitals in 2012 and 364 hospitals in this survey. The
increase from the first to the second survey can be
explained by the support from the Action Group Infection
Prevention (“Initiative Infektionsschutz”) (AGIP) and
Ipse communication GmbH that provided an extensive
list of e-mail contacts of hospitals. The 4-fold increase in
the return rate from the former to this survey however
can be interpreted as an expression of the growing
awareness to MDROs and public acceptance of our
easily accessible approach that depicts the “true” clinical
situation as seen by health care workers and infection
control personnel in the hospitals.
With the amendment of the German Protection
against Infection Act in 2011, the recommendations
from the German national committee for infection
prevention Commission on Hospital Hygiene and Infection
Prevention (KRINKO), the German national committee
for infection prevention, became obligatory for hospitals
and other health care facilities. As a consequence,
staffing with infection control personnel became mandatory.
The recommendations for staffing by the KRINKO are
based on a risk assessment that take into account the
treatment range of the medical provider as well as the
individual risk profile of the treated patients [
However, a recent report of the federal government on
nosocomial infections and bacterial resistance saw great
variations in the compliance with this standard [
Due to the requirements for staffing with infection
control consultants and infection control nurses, 82.2 %
85.6 % (median: 84.8 %) and 69.7 % - 80.0 % (median:
74.8 %) of hospitals met the KRINIKO-recommendation,
]. While still not perfect, our survey
shows a good compliance with the recommendations as
84.8 % of hospitals met the staffing needs for infection
control nurses and 74.8 % for infection control
consultants. This again points to the assumption, that
appropriate staffing with infection control personnel fosters
hospital epidemiology and awareness and
countermeasures against bacterial resistance.
Our data implies that there is still a relevant number
of unknown MDRO cases, as the reported prevalence
rates of most MDROs tends to be higher in hospitals
that screen for particular MDROs than in hospitals that
do not. While this problem may be negligible for MRSA
as most hospitals reported to have some kind of
screening in place, it may be influential for VRE and
Gramnegative MDROs, as the majority of hospitals still
reported to have no active screening policy.
Direct comparisons between prevalence rates reported
in this survey and other surveys, including our former
studies, should be made with caution as the samples are
not identical and it is therefore unclear whether the same
hospitals have participated. Still, comparisons between
point prevalence studies have been made regardless of
these problems [
]. Assured by the large number of
participating hospitals in our study we will therefore
discuss some general comparisons between our study and
other studies to give an impression how our data fits to
other surveys. The German part of the European point
prevalence study of the European Centers for Disease
Control (ECDC-PPS) from 2011 has been published as
public report by the National Reference Center for
Surveillance of Nosocomial Infections [
]. While the
European point prevalence study dates back from 2011,
the prevalence of nosocomial infections due to MRSA
(ECDC-PPS (Germany): 0.17 %, our survey: 0.17 %), CD
(ECDC-PPS (Germany): 0.30 %, our survey: 0.26 % and
3MRGN-EC (ECDC-PPS (Germany): 0.15 %, our survey:
0.12 %) fit well to our data, while the prevalence of
nosocomial infections due to VRE is much higher in our survey
(0.12 %) compared to the data from the German
ECDCPPS (0.02 %). This would fit to the increase in the VRE
prevalence as recently reported by the National Reference
Center for Surveillance of Nosocomial Infections [
A direct comparison to prevalence rates reported by
the German Surveillance System of Nosocomial
Infections in Hospitals (KISS) on the other hand is not
possible, as this system reports incidences and prevalence
rates of particular of some MDROs but uses an entirely
different way of data collection and statistics [
For example, MRSA-KISS reports MRSA prevalence
rates and incidences on a yearly base, but does not
separate by medical specialties, infections and colonizations.
Moreover, prevalence rates and incidences are not
calculated per hospital but pooled over all participating
hospitals and over the whole time . Other KISS modules
(ITS/Stations-KISS) on the other hand does report
prevalence rates and incidences divided by medical
specialties, infections and colonizations but not on a yearly
base but pooled from 2013 [
Our results underlay that prevalence data reported by
KISS cannot be used as valid indicators for the daily
prevalence of MDRO patients in hospitals. This further
explains why the situation felt by health care workers
and infection control personnel in the hospitals does
not fit well to the reported prevalence data, as the
perceived epidemiological situation is mainly determinated
Compared towards our former survey from 2012,
MRSA, VRE, 3MRGN-EC, 3MRGN-KS and CD
remain the most prevalent pathogens in all levels of
care and types of wards (Table 7) [
prevalence of MRSA and VRE almost matches the ones
from the former survey. Therefore MRSA still
remains the most prevalent and most prominent
MDRO in German hospitals. The prevalence of
3MRGN-EC and 3MRGN-KS are both somewhat
lower compared to the prevalence of ESBL-EC and
ESBL-KS reported in 2012, but confidence intervals
broadly overlap. The trend to a lower prevalence can
be explained by the stricter definition for 3MRGN is
than for ESBL. Only CD infections had an obviously
lower prevalence in comparison to 2012. An in depth
comparison showed that especially the prevalence on
surgical and internal ward was lower compared to
2012 (with confidence intervals non overlapping),
while the confidence intervals did broadly overlap for
ICUs. Whether this indicates a true reduction in CD
cases (e.g. caused by better antibiotic stewardship),
shorter duration of stay of CD cases (reducing the
chance to be detected in a point prevalence study) or
other factors, remains unclear. Either way, CD still
remains one of the most prevalent pathogens.
Our study has several limitations that should be
acknowledged when interpreting the data. First, as we used
routine data, our results have the typical constrains
associated with this type of data. We deliberately gave no
extra definition for cases, or to distinguish between
infections/colonisations, nosocomial and hospital acquired
cases. This is a complementary approach to other
epidemiological studies on the same topic that use generic
definitions (e.g. CDC-definitions) to classify cases.
The obvious drawback of our method is that there may
be some differences in the definitions between hospitals
or even wards. However, our approach has the advantage
that our results depict the “true” clinical situation as seen
by health care workers and infection control personnel in
the hospitals. Moreover, this data are used for calculating
of reimbursement by health insurances, too.
Second, as the survey was voluntary and anonymous,
we have no means to validate the results and our sample
may not be representative. Still, with almost 74,000
patients from 329 hospitals, our survey uses data from
more than 16 % of German hospitals. It is therefore the
largest study of its kind in Germany with more than
twice as many participating hospitals as the in the
German part of the ECDC point prevalence study from
]. This underlies that pragmatic surveys to
collect routine surveillance data are an attractive and
replicable way to gather epidemiological data with
limited resources. Voluntariness and self-reporting are
an issue for other surveys, like the German hospital
infection surveillance system (KISS), too. As in the
previous surveys, data was collected directly at the wards or
using electronic systems by trained personnel in most
hospitals. Therefore, we are quite confident that our results
give a good estimate of the situation in German hospitals.
Our results should be used by infection control
personal to raise awareness towards bacterial resistance and
foster infection control measures. Further studies should
follow up our results and expand to other health care
settings as rehabilitation and nursing homes.
Point prevalence surveys that use a straight forward
approach allow making routine data available for
epidemiological research and can help to raise awareness
about bacterial multi-resistance. Our study indicates that
MRSA, 3MRGN-EC, CD, VRE and 3MRGN-KS remain
the most prevalent pathogens in all levels of care and
types of wards in Germany. While most cases are
reported to be non-nosocomial, nosocomial transmission
and infection plays a significant role especially on ICUs
that also show the highest prevalence rates of MDROs.
AB, Acinetobacter spp. ; AGIP, Action Group Infection Prevention; CD,
Clostridium difficile; EC, Escherichia coli; ECDC, European Centers for Disease
Control; ES, Enterobacter spp.; ESBL, extended-spectrum beta lactamase;
HICARE, Health, Innovative Care and Regional Economy; ICC, infection control
consultant; ICN, infection control nurse; ICU, intensive care unit; KISS, German
hospital infection surveillance system; KRINKO, German national committee
for infection prevention; KS, Klebsiella spp.; LPIC, link physician for infection
control; MDROs, multidrug resistant bacterial organisms; MRGN, multidrug
resistant Gram-negative; MRSA , Methicillin-resistant Staphylococcus aureus;
PPS, point prevalence study; PS, Pseudomonas spp.; QM, quality management;
spp., species pluralis; VRE, Vancomycin resistant Enterococcus faecalis/faecium;
VRSA/GRSA, Vancomycin resistant Staphylococcus aureus
In addition to the authors, the following experts are part of the Action
Group Infection Prevention: Prof. Ojan Assadian, MD, DTMH (University of
Huddersfield; UK), Dr. med. Dipl. oec. C.M. Krüger, MBA (Klinik für Visceral-und
Gefäßchirurgie, Vivantes Humboldt-Klinikum, Berlin, Germany), Ingo Pfenning
(Techniker Krankenkasse, Germany), Sylvia Ryll (Institute of Hygiene and
Environmental Medicine, University Medicine Greifswald, Greifswald, Germany).
We like to thank all participating hospitals and infection control units for
providing the data, Ipse communication GmbH for providing an extensive
list with e-Mail contacts of German hospitals and the members of the
“Action Group Infection Prevention” for their support.
This study was supported by the German Ministry for Education and
Research (BMBF), HICARE-Gesundheitsregion Ostseeküste, Grant D301KQ1001
and by the Ministry for Education, Science, and Culture of the State of
Mecklenburg-Western Pomerania, Grant UG 12001.
N-OH and: designed, implemented and analyzed the study and drafted the
manuscript. KD implemented the study, analyzed the data and drafted the
manuscript. VH analyzed the data and helped to draft the manuscript. CW,
implemented and designed the study and provided statistical support and
data management. AK: designed, implemented and analyzed the study. All
authors revised and approved the manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
The survey relied on aggregated routine data only, no informed consent
from individual patients was needed. The method used was approved by
the Ethics Committee of the Board of Physicians Mecklenburg-West Pomerania
at the University of Greifswald.
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27. Protokoll: Surveillance von Patienten mit multiresistenten Erregern (MRE) und/ oder Clostridium difficile assoziierter Diarrhö (CDAD) auf Intensivstationen und Normalpflegestationen [http://www.nrz-hygiene.de/fileadmin/nrz/module/its/ ITS_ STATIONS-KISS-Erreger-Surveillance-Protokoll_v201219.pdf] • We accept pre-submission inquiries Our selector tool helps you to find the most relevant journal