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Headline Arial Bold Shit happens – feces in infection prevention and everybody´s life Kelsey Lecture, Birmingham, 7 April 2014 Walter Popp How important is the topic? 40 % of world population live without adequate sanitary conditions: 2.6 billion people Resulting in dead of 1.5 million children under 5 years per year, mainly because of diarrhea Defecation and urination are typical inquiries in any medical assessment – important symptoms. Most of multiresistant gramnegative bacteria are living in our guts. Folie 2 Titel 2 09.04.2014 | Autor Präsentationstitel 1 Extremely important: Life is starting and ending with problems re defecation Folie 3 Titel 3 09.04.2014 | Autor Präsentationstitel Folie 4 Titel 4 09.04.2014 | Autor Präsentationstitel 2 Folie 5 Titel 5 09.04.2014 | Autor Präsentationstitel Avoparcin Glycopeptide antibiotic, effective against Gram-positive bacteria. Used as an additive to livestock feed to promote growth in chickens, pigs, and cattle since around 1970 in Europe. Similarity with vancomycin selection of VRE transmission to humans´ gut by food. Forbidden in EU in 1997. Folie 6 Titel 6 09.04.2014 | Autor Präsentationstitel 6 3 Avoparcin in Taiwan Forbidden in 2000. VRE decreased from 2000 to 2003: E. faecalis: 13,7 % 3.7 % E. faecium: 3.4 % 0 % VRE found in chicken farms: 25 % 8.8 % Lauderdale, Environ Microbiol 2007, 9, 819 Folie 7 Titel 7 09.04.2014 | Autor Präsentationstitel 7 Multiresistente Erreger Geffers, Christine; Gastmeier, Petra Nosokomiale Folie 8 InfektionenTitel und multiresistente Erreger in Deutschland: Epidemiologische Daten aus dem Krankenhaus- Infektions8 -Surveillance09.04.2014 | -AutorSystem Präsentationstitel Dtsch Arztebl Int 2011; 108(6): 87-93; DOI: 10.3238/arztebl.2011.0087 4 FDA approval of new antimicrobial substances Folie 9 Titel 9 09.04.2014 | Autor Präsentationstitel Folie 10 Titel 10 09.04.2014 | Autor Präsentationstitel 5 Folie 11 Titel 11 09.04.2014 | Autor Präsentationstitel Folie 12 Titel 12 09.04.2014 | Autor Präsentationstitel 6 EHEC Enterohaemorrhagic Escherichia coli Gramnegative Production of Shigatoxine – STX (= shiga-like Toxin – SLT = Verotoxin – VT) Few bacteria needed for infection: < 10² bacteria Folie 13 Titel 13 09.04.2014 | Autor Präsentationstitel EHEC 2005 in Germany: 1,162 infections, 78 cases of HUS Incubation time 2-10 days Symptoms: - Diarrhea - 10 – 20 % haemorrhagic colitis - Complication: HUS (around 7 days after start of diarrhea) HUS: - Hemolytic anemia - Thrombopenia - Acute renal failure Folie 14 Titel 14 09.04.2014 | Autor Präsentationstitel 7 Folie 15 Titel 15 09.04.2014 | Autor Präsentationstitel HUS cases in Germany Folie 16 Titel 16 09.04.2014 | Autor Präsentationstitel Frank et al. NEJM 2011 8 EHEC at University Clinics Essen Adults Children EHEC 10 4 HUS 8 4 Plasmapherese 6 1 Dialysis 6 1 Eculizumab 3 1 Folie 17 Titel 17 09.04.2014 | Autor Präsentationstitel Number of patients with diarrhea coming daily to our hospital (18/5-29/6/2011) Folie 18 Titel 18 09.04.2014 | Autor Präsentationstitel 9 Measures Isolation ward (by chance available, renovation just finished) Gowns, gloves Hand disinfection No cap or mask Until 3 stool examinations were negative, 1-2 weeks between each Folie 19 Titel 19 09.04.2014 | Autor Präsentationstitel Folie 20 Titel 20 09.04.2014 | Autor Präsentationstitel 10 Folie 21 Titel 21 09.04.2014 | Autor Präsentationstitel Folie 22 Titel 22 09.04.2014 | Autor Präsentationstitel 11 Folie 23 Titel 23 09.04.2014 | Autor Präsentationstitel VRE outbreak at University Clinics Essen 05/2011 until 07/2011 25 patients with VRE VAN B, 21 of them with clonal identity Folie 24 Titel 24 09.04.2014 | Autor Präsentationstitel 12 VRE in patients swab blood culture 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Week 2011 Folie 25 Titel 25 09.04.2014 | Autor Präsentationstitel Measures . Outbreak management team . Isolation of patients . Personal protective clothing of staff, also for all contact persons . Isolation of all contact patients . Isolation of all patients who were longer than 2 days on that ward . Screening of all new patients . Isolation of all new patients on that ward until results of screening . Training of all staff, especially in hand hygiene . Additional dispensers for hand disinfectant . Daily observations by hygiene nurses . Final disinfection in 3 steps: cleaning with disinfectant in high concentration, fumigation of hydrogen peroxide, cleaning with disinfectant in usual concentration . Many environmental swabs: 4 out of 100 positive for VRE . Contact plates from staff hands: 1 positive for enterococci . Closing of ward for 3 days in July for basic cleaning and throwing away all single use items Folie 26 Titel 26 09.04.2014 | Autor Präsentationstitel 13 After week 30 no new cases. But: once found at a bascet for suction catheters. Folie 27 Titel 27 09.04.2014 | Autor Präsentationstitel Outbreak University Clinics Leipzig Klebsiella pneumoniae carbapenemase First case from Greece in 2010. 103 patients, over 40 dying. Ending 2013. Carpapenemase producing bacteria University Clinics Leipzig Since October 2012 (screening) Folie 28 Titel 28 09.04.2014 | Autor Präsentationstitel 28 14 Folie 29 Titel 29 09.04.2014 | Autor Präsentationstitel Definition: Nonsusceptible to one of the following carbapenems: doripenem, meropenem, or imipenem AND Resistant to all of the following third-generation cephalosporins that were tested: ceftriaxone, cefotaxime, and ceftazidine. Folie 30 Titel 30 09.04.2014 | Autor Präsentationstitel 15 Core measures for acute and long-term care facilities . Hand hygiene . Contact precautions . Patient and staff cohorting . Minimize use of invasive devices . Promote antimicrobial stewardship . Screening In case of transmission, additionally: . Conduct active surveillance testing . Chlorhexidine bathing Folie 31 Titel 31 09.04.2014 | Autor Präsentationstitel 31 Folie 32 Titel 32 09.04.2014 | Autor Präsentationstitel 16 MRGN 4 MRGN: always isolation 3 MRGN: isolation on „risk“ wards (ICU, hematology- oncology), not on „normal“ wards But: what about common use of toilets? nasal-pharyngeal carriers? Contact patients with immune deficiancy? ESBL not longer looked for Folie 33 Titel 33 09.04.2014 | Autor Präsentationstitel ESBL in nursing homes in Frankfurt 880 residents, 8 nursing homes, Frankfurt/Main 9 % MRSA 27 % ESBL enterobacteriaceae 3 % VRE Heudorf, Bundesgesundheitsbl 2014, 57, 414 Folie 34 Titel 34 09.04.2014 | Autor Präsentationstitel 17 1014 = 100,000,000,000,000 Folie 35 Titel 35 09.04.2014 | Autor Präsentationstitel Enterococci in food production Ripening of cheese, probably through proteolysis, lipolysis and citrate breakdown. Contributing to typical taste and flavour. Also in other fermented foods, like sausages and olives. Used as probiotics. Folie 36 Titel 36 09.04.2014 | Autor Präsentationstitel 36 18 Mongolia 36 Mio livestock Folie 37 Titel 37 09.04.2014 | Autor Präsentationstitel 3 mio people Folie 38 Titel 38 09.04.2014 | Autor Präsentationstitel 19 Folie 39 Titel 39 09.04.2014 | Autor Präsentationstitel Feces used as fertilizer Folie 40 Titel 40 09.04.2014 | Autor Präsentationstitel 40 20 Guano Ecrement of seabirds or birds, generally. Highly effective fertilizer with high content of nitrogen, phosphate and potassium, but few nitrates. Boom in 19th century with imports from Peru, Caribbean islands, Namibia, Oman, Patagonia. Boom ending after 1909 when Fritz Haber developed Haber-Bosch process of industrial nitrogen fixation. Right: Guanay Cormoran, historically most important producer of guano Folie 41 Titel 41 09.04.2014 | Autor Präsentationstitel Uguisu no fun („Geisha facial“) Uguisu no fun = nightingale feces Produced by a particular nightingale called the Japanese bush warbler. Used in facials since ancient Japanese times – around 800-1,100. The facial is said to whiten the skin and balance skin tone. High concentration of urea and guanine. Victoria Beckham is proven used, David has been said to be… Folie 42 Titel 42 09.04.2014 | Autor Präsentationstitel 42 21 Kopi Luwak (civet coffee) Beans of coffee berries once they have been eaten and excreted by the Asian palm civet. Indonesia and Philippines. Prices around 550 € per kilogramme. Folie 43 Titel 43 09.04.2014 | Autor Präsentationstitel 43 Stool transplantation Faecal transplantation in patients with fulminant or refractory Clostricium difficile infections. Review of 22 studies, 239 patients: effective in 87 % (Landy, Aliment Pharmacol Ther 2011, 34, 409) Review of 27 case series and reports, 317 patients: higly effecitve, disease resolution in 92 % (Gough, CID 2011, 53, 994) Review of 7 studies, 124 patients: safe and effective procedure, symptoms improved immediately in 83 %, some stayed diarrhoea free for months or years (Guo, Aliment Pharmacol Ther 2012, 35, 865) Review of 36 reports, 583 patients: overall success rate 80 – 98 % (Dodin, Int J Clin Pract 2013) Folie 44 Titel 44 09.04.2014 | Autor Präsentationstitel 22 Diseases by gut bacteria … diarrhoea Folie 45 Titel 45 09.04.2014 | Autor Präsentationstitel Obstipation In medieval times, obstipation was seen as biggest threat for health: intoxication from inside. In old sight, body fluids can intoxicate the person. Spitting may clean the body. Also flatulating. Medicine: Bloodletting, purging, clysterizing. One hour tobacco clyster. Folie 46 Titel 46 09.04.2014 | Autor Präsentationstitel 23 Typhoid Mary „The most harmless and most dangerous woman of America“ (title of a newspaper in US, 1909) New York, 1906: Banker family Warren 6 cases of typhus. Until then young Irish cook Mary
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