Hygienemaßnahmen bei Clostridioides difficile-Infektion (CDI): Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut

Hygiene requirements for cleaning and disinfection of surfaces: recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

This recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) addresses not only hospitals, but also outpatient health care facilities and compiles current evidence. The following criteria are the basis for the indications for cleaning and disinfection: Infectious bioburden and tenacity of potential pathogens on surfaces and their transmission routes, influence of disinfecting surface cleaning on the rate of nosocomial infections, interruption of cross infections due to multidrug-resistant organisms, and outbreak control by disinfecting cleaning within bundles. The criteria for the selection of disinfectants are determined by the requirements for effectiveness, the efficacy spectrum, the compatibility for humans and the environment, as well as the risk potential for the development of tolerance and resistance. Detailed instructions on the organization and implementation of cleaning and disinfection measures, including structural and equipment requirements, serve as the basis for their implementation. Since the agents for surface disinfection and disinfecting surface cleaning have been classified as biocides in Europe since 2013, the regulatory consequences are explained. As possible addition to surface disinfection, probiotic cleaning, is pointed out. In an informative appendix (only in German), the pathogen characteristics for their acquisition of surfaces, such as tenacity, infectious dose and biofilm formation, and the toxicological and ecotoxicological characteristics of microbicidal agents as the basis for their selection are explained, and methods for the evaluation of the resulting quality of cleaning or disinfecting surface cleaning are presented.

Suitable Disinfectants with Proven Efficacy for Genetically Modified Viruses and Viral Vectors

Viral disinfection is important for medical facilities, the food industry, and the veterinary field, especially in terms of controlling virus outbreaks. Therefore, standardized methods and activity levels are available for these areas. Usually, disinfectants used in these areas are characterized by their activity against test organisms (i.e., viruses, bacteria, and/or yeasts). This activity is usually determined using a suspension test in which the test organism is incubated with the respective disinfectant in solution to assess its bactericidal, yeasticidal, or virucidal activity. In addition, carrier methods that more closely reflect real-world applications have been developed, in which microorganisms are applied to the surface of a carrier (e.g., stainless steel frosted glass, or polyvinyl chloride (PVC)) and then dried. However, to date, no standardized methods have become available for addressing genetically modified vectors or disinfection-resistant oncolytic viruses such as the H1-parvovirus. Particularly, such non-enveloped viruses, which are highly resistant to disinfectants, are not taken into account in European standards. This article proposes a new activity claim known as "virucidal activity PLUS", summarizes the available methods for evaluating the virucidal activity of chemical disinfectants against genetically modified organisms (GMOs) using current European standards, including the activity against highly resistant parvoviridae such as the adeno-associated virus (AAV), and provides guidance on the selection of disinfectants for pharmaceutical manufacturers, laboratories, and clinical users.

Environmental Contamination and Persistence of Clostridioides difficile in Hospital Wastewater Systems

Clostridioides difficile produces an environmentally resistant dormant spore morphotype that infected patients shed to the hospital environment. C. difficile spores persist in clinical reservoirs that are not targeted by hospital routine cleaning protocols. Transmissions and infections from these reservoirs present a hazard to patient safety. This study aimed to assess the impact of patients acutely suffering from C. difficile-associated diarrhea (CDAD) on C. difficile environmental contamination to identify potential reservoirs. Twenty-three hospital rooms accommodating CDAD inpatients with corresponding soiled workrooms of 14 different wards were studied in a German maximum-care hospital. Additionally, four rooms that never accommodated CDAD patients were examined as negative controls. Stagnant water and biofilms from sinks, toilets, and washer disinfector (WD) traps as well as swabs from cleaned bedpans and high-touch surfaces (HTSs) were sampled. For detection, a culture method was used with selective medium. A latex agglutination assay and a Tox A/B enzyme-linked immunosorbent assay were performed with suspect colonies. Stagnant water and biofilms in hospital traps (29%), WDs (34%), and HTSs (37%) were found to be reservoirs for large amounts of C. difficile during the stay of CDAD inpatients that decreased but could persist 13 ± 6 days after their discharge (13%, 14%, and 9.5%, respectively). Control rooms showed none or only slight contamination restricted to WDs. A short-term cleaning strategy was implemented that reduced C. difficile in stagnant water almost entirely. IMPORTANCE Wastewater pipes are microbial ecosystems. The potential risk of infection emanating from the wastewater for individuals is often neglected, since it is perceived to remain in the pipes. However, sewage systems start with siphons and are thus naturally connected to the outside world. Wastewater pathogens do not only flow unidirectionally to wastewater treatment plants but also retrogradely, e.g., through splashing water from siphons to the hospital environment. This study focused on the pathogen C. difficile, which can cause severe and sometimes fatal diarrheas. This study shows how patients suffering from such diarrheas contaminate the hospital environment with C. difficile and that contamination persists in siphon habitats after patient discharge. This might pose a health risk for hospitalized patients afterward. Since this pathogen's spore morphotype is very environmentally resistant and difficult to disinfect, we show a cleaning measure that can almost entirely eliminate C. difficile from siphons.

Hospital resource endowments and nosocomial infections: longitudinal evidence from the English National Health Service on Clostridioides difficile between 2011 and 2019

OBJECTIVES

To identify key factors associated with Clostridioides difficile infections (CDIs) in healthcare at the hospital organization level.

DESIGN

Longitudinal study covering the period 2011-2019. Hospital reports were analysed to determine the number of CDIs and several hospital-related environmental factors: financial resources (i.e., cleaning expenditure), spatial resources (i.e., number of single rooms with a private bathroom), human resources (i.e., number of physicians and nursing staff) and cultural resources (i.e., error reporting climate). The relationships between the environmental factors and CDIs were analysed in a hybrid within- and between-hospital random-effect model.

SETTING

A total of 129 general hospital Trusts operating in the English National Health Service (NHS).

PARTICIPANTS

All inpatients in 129 general hospital trusts of the NHS in the years 2011-2019, covering 120,629 cases of CDI.

MAIN OUTCOME MEASURE

Annual number of CDIs per hospital trust.

RESULTS

Single rooms were associated with fewer CDIs at the within-hospital level, but not at the between-hospital level. Similarly, more nursing staff was associated with fewer CDIs at the within-hospital level, but not at the between-hospital level. This effect was not observed for physician staffing. A different picture emerged for the protective effect of cultural resources, with a weakly significant effect of between-hospital differences, but no within-hospital effect. Financial resources were not associated with CDIs either between hospitals or within them over time.

CONCLUSIONS

The present study identified hospital resources with a beneficial influence on CDI rates. Healthcare organizations can use this knowledge for active CDI prevention.

Molecular Epidemiology, Clinical Course, and Implementation of Specific Hygiene Measures in Hospitalised Patients with Clostridioides difficile Infection in Brandenburg, Germany

(1) Background: Clostridioides difficile infections (CDI) have increased worldwide, and the disease is one of the most common healthcare-associated infections (HAI). This study aimed to evaluate the molecular epidemiology of C. difficile, the clinical outcome, and the time of initiation of specific hygiene measures in patients with CDI in a large tertiary-care hospital in Brandenburg. (2) Methods: Faecal samples and data from hospitalised patients diagnosed with CDI were analysed from October 2016 to October 2017. The pathogens were isolated, identified as toxigenic C. difficile, and subsequently subtyped using PCR ribotyping and whole genome sequencing (WGS). Data regarding specific hygiene measures for handling CDI patients were collected. (3) Results: 92.1% of cases could be classified as healthcare-associated (HA)-CDI. The recurrence rate within 30 and 90 days after CDI diagnosis was 15.7% and 18.6%, and the mortality rate was 21.4% and 41.4%, respectively. The most frequent ribotypes (RT) were RT027 (31.3%), RT014 (18.2%), and RT005 (14.1%). Analysis of WGS data using cgMLST showed that all RT027 isolates were closely related; they were assigned to two subclusters. Single-room isolation or barrier measures were implemented in 95.7% patients. (4) Conclusions: These data show that RT027 is regionally predominant, thus highlighting the importance of specific hygiene measures to prevent and control CDI and the need to improve molecular surveillance of C. difficile at the local and national level.

Frequency of Diarrhea, Stool Specimen Collection and Testing, and Detection of Clostridioides Difficile Infection Among Hospitalized Adults in the Muenster/Coesfeld Area, Germany

Clostridioides difficile infection (CDI) often manifests as diarrhea, particularly in adults of older age or with underlying comorbidities. However, only severe cases are notifiable in Germany. Moreover, failure to collect a stool specimen from inpatients with diarrhea or incomplete testing may lead to underdiagnosis and underreporting of CDI. We assessed the frequency of diarrhea, stool specimen collection, and CDI testing to estimate CDI underdiagnosis and underreporting among hospitalized adults. In a ten-day point-prevalence study (2019-2021) of nine hospitals in a defined area (Muenster/Coesfeld, North Rhine-Westphalia, Germany), all diarrhea cases (≥ 3 loose stools in 24 h) among adult inpatients were captured via medical record screening and nurse interviews. Patient characteristics, symptom onset, putative origin, antibiotic consumption, and diagnostic stool sampling were collected in a case report form (CRF). Diagnostic results were retrieved from the respective hospital laboratories. Among 6998 patients screened, 476 (7%) diarrhea patients were identified, yielding a hospital-based incidence of 201 cases per 10,000 patient-days. Of the diarrheal patients, 186 (39%) had a stool sample collected, of which 160 (86%) were tested for CDI, meaning that the overall CDI testing rate among diarrhea patients was 34%. Toxigenic C. difficile was detected in 18 (11%) of the tested samples. The frequency of stool specimen collection and CDI testing among hospitalized diarrhea patients was suboptimal. Thus, CDI incidence in Germany is likely underestimated. To assess the complete burden of CDI in German hospitals, further investigations are needed.

[Infection prevention in neonatal intensive care units]

In diesem Beitrag werden einige Besonderheiten der Infektionsprävention bei intensivmedizinisch behandelten Früh und Neugeborenen dargestellt. Ergänzend finden sich Hinweise zum krankenhaushygienischen Management der SARS-CoV-2(„severe acute respiratory syndrome coronavirus 2“)-Pandemie und zur Antibiotic Stewardship in der neonatologischen Intensivmedizin.

Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review

Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach whereby different strategies may be implemented together, next to targeted, risk-based approaches, in order to reduce the risk of HAIs for patients. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. This review focuses on routine environmental cleaning and disinfection including areas with a moderate risk of contamination, such as general wards. As scientific evidence has not yet resulted in universally accepted guidelines nor led to universally accepted practical recommendations pertaining to surface cleaning and disinfection, this review provides expert guidance for healthcare workers in their daily practice. It also covers outbreak situations and suggests practical guidance for clinically relevant pathogens. Key elements of environmental cleaning and disinfection, including a fundamental clinical risk assessment, choice of appropriate disinfectants and cleaning equipment, definitions for standardized cleaning processes and the relevance of structured training, are reviewed in detail with a focus on practical topics and implementation.

[Legal Obligation to Notify Severe Clostridiodes difficile Infections - Data from Frankfurt am Main, Germany. Overview and Discussion]

BACKGROUND

Clostridioides difficile (C. difficile) is the most frequently identified causative agent of antibiotic-associated diarrhea in industrialized countries. As early as 2007, severe C. difficile infections (CDI) were to be notified in Germany as a "threatening disease with an indication of grave danger to the general public". In 2016, the Notification Adjustment Ordinance put in force a duty to notify CDI with a clinically severe course. Here, the necessity and suitability of mandatory notification of severe CDI in Frankfurt am Main, Germany, 2014-2018 is examined.

MATERIAL/METHOD

Cases of CDI reported to the health department Frankfurt am Main were compared with the C. difficile-associated deaths in Frankfurt for 2014-2018. The results were compared with data from the literature, the national reporting data according to the Infection Protection Act (IfSG), the mortality statistics, the hospital treatment data as well as the hospital surveillance data of the German hospital infection surveillance system for C difficile-associated diarrhea (CDAD).

RESULTS

With the entry into force of the new Notification Adjustment Ordinance, the number of CDIs reported annually in Frankfurt am Main increased from 5-8 to 13-14; however, in all years (with the exception of 2016), the number of deaths (death-leading illness or previous cause) was -17-50 per year and thus well above the number of reported CDI-cases according to the German Infection Protection Act.

CONCLUSION

The notification data from Frankfurt am Main show an approx. 2-fold lower score compared to the CDI-associated deaths. From the data of the Hospital Surveillance System (CDAD-KISS), it can be estimated that the majority of the cases are not notified. While an increase in CDI notifications is reported nationwide, there is a decrease in data from nationwide death statistics, hospital treatment data and CDI prevalence, and an increase in incidence of severe CDI. Therefore, and taking into account legal requirements of the IfSG and the options for action of the health authorities according to § 23 (4) Infection prevention act (IfSG), and regarding European recommendations and available data on CDI surveillance, the obligation to notify CDI should be lifted.

The largely unnoticed spread of Clostridioides difficile PCR ribotype 027 in Germany after 2010

In recent decades, incidence and severity of Clostridioides difficile infection (CDI) has increased dramatically, coinciding with the emergence of hypervirulent strains such as PCR ribotype 027 (RT027). Data on prevalence of distinct C. difficile strains in random CDI cases in Germany are scarce. The aim of this review was to obtain an overview of prevalence and geographical distribution of RT027 among clinical C. difficile isolates from random cases in non-outbreak settings in hospitals in Germany. For this purpose, we performed a literature review on reported cases of C. difficile RT027 in Germany between 2007 and 2019 in three databases (PubMed, Embase and LIVIVO) and conference proceedings. Studies with selection bias for RT027 (e.g. clinical severity, outbreak reports) were excluded. A total of 304 records were screened, from which 21 were included in this analysis. The nationwide prevalence of RT027 in Germany was <1% prior to 2010 but increased continuously thereafter, reaching 21.7% in 2013. The regional prevalence varied markedly between federal states, higher prevalence was reported from North Rhine-Westphalia (37.4%) and Saxony (31.8%) in 2013-2015. However, data on C. difficile RT027 were not available from almost half of the federal states and were scarce at the national level. Our data suggest a remarkable spread of RT027 in Germany during the past decade, which has remained rather unnoticed so far. A national program for molecular surveillance of C. difficile is required to monitor the changing epidemiology of CDI and to adjust the prevention and control measures.