Prevention and Control of Multidrug-Resistant Bacteria in The Netherlands and Germany—The Impact of Healthcare Structures
Abstract
:1. Introduction
2. Multidrug-Resistant Microorganisms, Antibiotic Use and Healthcare-Associated Infections in The Netherlands and Germany
2.1. Data about the Occurrence of MDRO
2.2. Data about HAI
2.3. Data about Antibiotic Use
3. Data about Healthcare Structures in The Netherlands and Germany
4. Discussion
- Hospitalization (number of cases, length of stay) per se increases the risk of MDRO transmission (from patient-to-patient, via healthcare workers or via surfaces). Moreover, due to the higher number of hospitals in Germany, many hospitals are less specialized. Consequently, there is more patient traffic between different hospitals (as patients are sent from basic care to more specialized hospitals). In this setting, each admission bears the possibility of inter-institutional transmission, facilitating regional dissemination of MRDO. Some studies have demonstrated that this led to a clonal expansion of some MDRO [13,14].
- Hand hygiene must be performed more rigorously in German hospitals. Due to fewer personnel and more patients, there are more contacts per individual healthcare worker. In addition, one healthcare worker has contact with more patients. If it is assumed that the compliance level with hand hygiene is similar in The Netherlands and Germany, these underlying structures might facilitate the transmission of MDRO. Moreover, a high awareness about the AMR problem among healthcare workers has been recently shown for both countries [15].
- Although the density of hospital beds is higher in Germany, the bed occupancy rate is also higher than in The Netherlands. While in German hospitals occupancy rates are regularly above 80%, they are usually around 60%-70% in Dutch hospitals (Table 3). This has an impact on the availability of single rooms for isolation. Besides the rather low scientific evidence for the isolation of patients with MDRO and the lack of randomized trials regarding this issue [16], as well as the potential disadvantages of “isolated care” in single-rooms (e.g., stigmatization and less awareness), many clinicians and hospital administrations in Germany refer to a lack of isolation beds and financial penalties due to blocked beds, when arguing against single-room isolation. In The Netherlands, due to the structural difference, single-room isolation is easier to organize and rather undisputed for most MDROs including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, multidrug-resistant Gram-negative bacteria (including even extended-spectrum betalactamase-producing, carbapenem-susceptible Enterbacteriaceae). For risk patients, the concept of pre-emptive isolation at admission as long as screening results are pending, is also a key component of Dutch IPC recommendations. In Germany, pre-emptive isolation is performed for patients with a high risk of carriage of carbapenem-resistant Enterobacteriaceae or Acinetobacter baumannii or for patients with a very high risk of MRSA carriage (e.g., known carriage from previous hospitalizations). However, for MRSA, the fact that >30% of patients at admission are risk patients in Germany, prevents the ability to use pre-emptive isolation for all patients at risk [17].
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Pathogen * | Germany | The Netherlands | ||
---|---|---|---|---|
Cases (Incidence) | Deaths (Mortality) | Cases (Incidence) | Deaths (Mortality) | |
CRAB | 278 (0.34) | 24 (0.03) | 14 (0.08) | 1 (0.01) |
VRE | 3089 (3.80) | 206 (0.25) | 63 (0.37) | 4 (0.02) |
CRKP | 125 (0.15) | 3 (0) | 0 (0) | 0 (0) |
MRSA | 13,684 (16.85) | 653 (0.80) | 249 (1.47) | 12 (0.07) |
3rd generation-cephalosporin-res. E. coli | 28,392 (34.97) | 868 (1.07) | 3503 (20.73) | 107 (0.63) |
all assessed MDROs | 54,509 (67.13) | 2363 (2.91) | 4982 (29.48) | 206 (1.22) |
Type of Antibiotic | EU-Mean | Germany | The Netherlands |
---|---|---|---|
Total use | 21.8 | 13.7 | 10.1 |
Penicillins | 11.5 | 5.0 | 4.0 |
Other betalactams | 2.0 | 2.8 | 0 |
Sulfonamide/trimethoprim | 0.6 | 0.5 | 0.4 |
Macrolides | 2.9 | 2.1 | 1.4 |
Tetracyclines | 2.2 | 1.8 | 2.0 |
Quinolones | 1.6 | 1.1 | 0.7 |
Other antibiotics | 1.1 | 0.5 | 1.5 |
Indicator | The Netherlands | Germany | |
---|---|---|---|
Population | 16,979,140 | 82,175,684 | |
Health expenditures in Mio. € | 72,788.63 | 351,701.00 | |
Pro inhabitant in € | 3,885 | 4,160 | |
Life expectancy at birth (years) | 81.7 | 81.0 | |
Length of hospital stay (curative care) in days | 5.0 | 7.5 | |
Hospital days per year | 8,268165 | 146,048,193 | |
per 1,000 inhabitants | 486.96 | 1777.27 | |
Hospital beds total (curative, rehabilitative, long-term care) | 61,767 | 663,941 | |
Curative | 51,176 | 498,718 | |
rehabilitative | 1946 | 165,223 | |
per 1000 inhabitants | 3.64 | 8.08 | |
Hospital beds/100,000 inhabitants curative care | 301 | 606 | |
Bed occupancy rate (curative care) | 66% | 80% | |
Hospital discharges | 1,649,905 | 19,480,503 | |
Per 1000 inhabitants | 97.17 | 237.06 | |
Hospital personnel (full-time equivalents) | 198,670 | 988,000 | |
per 100 patient-days | 2.40 | 0.68 | |
Physicians | 21,808 | 166,000 | |
per 100 patient-days | 0.26 | 0.11 | |
Qualified nurses/midwives | 58,489 | 341,000 | |
per 100 patient-days | 0.71 | 0.23 | |
Nursing associates | 11,563 | 34,000 | |
per 100 patient-days | 0.14 | 0.02 | |
Antibiotic Stewardship Teams | |||
1 team * per hospital mandatorily | 1 FTE per 500 beds recommended * | ||
Selected interventions per 100,000 inhabitants | |||
cataract-surgery | 1014 | 1041 | |
appendectomies | 96 | 155 | |
Transluminal coronary angioplasty (PTCA) | 234 | 406 | |
% of 1-day interventions (day-patients, outpatients) | |||
cataract-surgery | 99.6% | 82.5% | |
tonsillectomies | 68.4% | 4.0% | |
Inguinal hernia | 80.2% | 0.3% |
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Köck, R.; Becker, K.; Idelevich, E.A.; Jurke, A.; Glasner, C.; Hendrix, R.; Friedrich, A.W. Prevention and Control of Multidrug-Resistant Bacteria in The Netherlands and Germany—The Impact of Healthcare Structures. Int. J. Environ. Res. Public Health 2020, 17, 2337. https://doi.org/10.3390/ijerph17072337
Köck R, Becker K, Idelevich EA, Jurke A, Glasner C, Hendrix R, Friedrich AW. Prevention and Control of Multidrug-Resistant Bacteria in The Netherlands and Germany—The Impact of Healthcare Structures. International Journal of Environmental Research and Public Health. 2020; 17(7):2337. https://doi.org/10.3390/ijerph17072337
Chicago/Turabian StyleKöck, Robin, Karsten Becker, Evgeny A. Idelevich, Annette Jurke, Corinna Glasner, Ron Hendrix, and Alexander W. Friedrich. 2020. "Prevention and Control of Multidrug-Resistant Bacteria in The Netherlands and Germany—The Impact of Healthcare Structures" International Journal of Environmental Research and Public Health 17, no. 7: 2337. https://doi.org/10.3390/ijerph17072337