Dr. Reinhard Böhmer / Dr. Tiller Medical Laboratories

Dr. Böhmer is a leading medical microbiologist and medical director in one of the biggest German laboratories. Formerly he was attached to the Munich Bogenhausen hospital and also in South Africa. Dr. Böhmer was invited to the R-Biopharm Distributor meeting in Starnberg 2008 to conduct a training on hospital acquired infectious diseases, laboratory diagnostic requirements and hospital-related cost analysis.

Introduction
By definition, nosocomial Infections (NIs) occur in patients after admission to a hospital or healthcare service unit. NIs are considered as such if they first appear 48 hours or more after hospital admission or within 30 days after discharge (Nosocomial infections = synonym: Healthcareassociated infections).

The problem occurs worldwide in any large sized hospital. The prevalence is much lower in community hospitals. Differences in rates appear to be due to greater severity of diseases in patients (e.g. weakened immune status) in academic hospitals and everywhere where antibiotics are given in larger volumes.

Basically, NIs are of increased public awareness because they may even be more alarming as antibiotic resistance spreads. The most common NIs are related to the

1. urinary tract
2. lower respiratory tract
3. postoperative wounds/infections
4. primary septicaemia

Incidence and cost
Healthcare costs related to the NIs are incredibly high. Germany has approx. 75000 sepsis cases annually at costs of 1.7 billion €, at a third of the budget of the total intensive care (ICU) medicine. 128.000 post-operative wound infections cause 1 million additional hospital days annually.

In the USA it has been estimated that as many as one in ten hospitalized patients acquires a Nosocomial infection (~2 million patients a year). Annual costs range from $ 4.5-11 billion or contributed to 88000 deaths (data from 1999).

France has a prevalence of NIs up to 7.5%. An estimated 5-19% of hospitalized patients are infected and up to 3% in ICUs. Patients with a NI remain in hospital for an average of 4-5 days additional days. Italy: 6.7% of hospitalized patients are infected (up to 700000 patients annually).

Extrapolations assume that 70000 hospitalized patients are affected in Switzerland.

Australia reported out of 6 million hospital admissions per year a rate of 5% NIs. From a total of 7000 Staphylococcus aureus bacteremias,4500 are healthcare related. The average mortality rate is of 25%.

Preventive actions
As many as 92 percent of deaths from hospital infections could be prevented. Main actions in hospital settings are

1. Microbiological rapid diagnostics
2. Screening of patients
3. Surveillance of nosocomial infections
4. Availability of regional epidemiological data
5. Antibiotic audits in combination with reduction of antibiotic use
6. Thorough hand washing and use of alcohol rubs by all medical personnel before patient contact.

Emerging infectious diseases and causative pathogens
According to the NIH (National Institutes of Health, USA) statistics, infectious diseases remain among the leading causes of death worldwide because of emergence of new diseases, re-emerge of "old" infection disease and persistence (see Fig.). Many important infection diseases are not adequately controlled.

Even new common drugs such as TNF-alpha blockers raise the risk of infections due to decreased T-cell activity. Tuberculosis, Chikungunya and influenza are emerging not locally but spreading worldwide. For Norovirus, Germany reported week 1 – 20, 2008 148923 cases (Robert-Koch-Institute, www.rki.de).

The epidemiology of Clostridium difficile (C.diff.) associated disease is changing, with evidence of increased incidence and severity particularly in ICU settings. Superinfection with C. diff is a consequence of alteration of bowel flora by antimicrobial therapy. A number of countries do have guidelines for implementation of interventions to control in healthcare facilities. 3 – 7 % of diarrhoea cases in hospitals are related to Clostridium difficile.

During the past 2 decades, Giardia lamblia infection became recognized as one of the most common cause of waterborne disease worldwide. This might result from human actions such as improper disposal of sewage wastes or be due to weather and climate events, temperature affects their growth and survival.

50 million cases of amoebiasis annually with estimated 40 to 50000 deaths are caused by Entamoeba histolytica.

Prognosis
Many of the factors promoting infections in hospital have been identified and measures of control have been developed. Infections disease specialists and medical microbiologists are worldwide hunting for the determination of infectious disease epidemiology.
Rapid near-patient diagnostics and influencing hospital personnel to carry out control measures and restraint in the use of antibiotics remains a major challenge.

* Lit.: www3.niaid.nih.gov/topics/emerging/list.htm