One-day point prevalence of emerging bacterial pathogens in four secondary and five tertiary care German hospitals – results from a pilot study of the German Society for Hospital Hygiene (Deutsche Gesellschaft für Krankenhaushygiene, DGKH)

dgkh000177 10.3205/dgkh000177 urn:nbn:de:0183-dgkh0001774 Research Article One-day point prevalence of emerging bacterial pathogens in four secondary and five tertiary care German hospitals – results from a pilot study of the German Society for Hospital Hygiene (Deutsche Gesellschaft für Krankenhaushygiene, DGKH) Eintagesprävalenz wichtiger bakterieller Problemerreger in vier Krankenhäusern der Regelversorgung und fünf Krankenhäusern der Maximalversorgung in Deutschland – Ergebnisse einer Pilotstudie der Deutschen Gesellschaft für Krankenhaushygiene (DGKH) Kramer Kramer Axel A

Institute of Hygiene and Environmental Medicine Greifswald, University Medicine, Greifswald, Germany

author Ryll Ryll Sylvia S

Institute of Hygiene and Environmental Medicine Greifswald, University Medicine, Greifswald, Germany

author Wegner Wegner Christian C

Institute of Hygiene and Environmental Medicine Greifswald, University Medicine, Greifswald, Germany

author Jatzwauk Jatzwauk Lutz L

Department of Hospital Hygiene and Environmental Protection, University Medical Center, Dresden, Germany

author Popp Popp Walter W

Hospital Hygiene, University Medical Center, Essen, Germany

author Hübner Hübner Nils-Olaf NO Dr. med.

Institute of Hygiene and Environmental Medicine Greifswald, University Medicine, Walther-Rathenau-Str. 49a, D-17489 Greifswald, Germany, Phone: +49(0)3843-515546, Fax: +49(0)3843-515541Institute of Hygiene and Environmental Medicine Greifswald, University Medicine, Greifswald, Germany

nhuebner@uni-greifswald.de author German Medical Science GMS Publishing House

Düsseldorf

610 one-day point prevalence MRSA ESBL E. coli Klebsiella multiresistance Pseudomonas spp. Acinetobacter spp. VRE Clostridium difficile infection prevention personnel DGKH Eintagesprävalenz MRSA ESBL E. coli ESBL Klebsiella spp. multiresistente Pseudomonas spp. multiresistente Acinetobacter spp. VRE toxinbildende C. difficile Hygienefachpersonal DGKH 20111215 engl 1863-5245 6 1 GMS Krankenhaushygiene Interdisziplinär GMS Krankenhaushyg Interdiszip Prevention and therapy of nosocomial infections 20 Zielsetzung: In 5 Krankenhäusern der Maximalversorgung und 4 Kra</PlainText></TextGroup>nkenhäusern der Regelversorgung wurde am 10.2.2010 eine Eintagesprävalenzstudie zum Vorkommen bakterieller Problemerreger durchgeführt, um Prävalenzdaten für unterschiedliche Regionen zu generieren, da insbesondere für ESBL, multiresistente <Mark2>Pseudomonas </Mark2>spp. und <Mark2>Acinetobacter </Mark2>spp. sowie <Mark2>Clostridium difficile</Mark2> spp. kaum Daten für Deutschland vorliegen.</Pgraph><Pgraph><Mark1>Methode:</Mark1> Mittels Fragenbogen wurden der Versorgungstyp der Einrichtung, die Ausstattung mit Hygienefachpersonal, die Durchführung eines MRSA Screenings und die mikrobiologische Versorgung sowie die Prävalenz fünf bakterieller Problemerreger in den Bereichen Intensivtherapie, Chirurgie und Innere Medizin erfasst.</Pgraph><Pgraph><Mark1>Ergebnisse:</Mark1> Insgesamt wurden 3411 Patienten analysiert. In den Krankenhäusern der Maximalversorgung wurden folgende Prävalenzen ermittelt: MRSA 1,8%, ESBL <Mark2>E. coli</Mark2> 0,45%, ESBL <Mark2>Klebsiella</Mark2> spp. 0,41%, multiresistente Pseudomonaden 0,53%, multiresistente <Mark2>Acinetobacter</Mark2> spp. 0,15%, VRE 0,49% und toxinbildende <Mark2>C. difficile</Mark2> 1,01%. In den Krankenhäusern der Regelversorgung ergaben sich folgende Prävalenzen: MRSA 3,48%, ESBL <Mark2>E. coli</Mark2> 0,4%, ESBL <Mark2>Klebsiella</Mark2> spp. 0,4%, multiresistente <Mark2>Pseudomonas</Mark2> spp. 0%, multiresistente <Mark2>Acinetobacter</Mark2> spp. 0%, VRE 0,13% und toxinbildende <Mark2>C. difficile</Mark2> 1,34%.</Pgraph><Pgraph><Mark1>Diskussion:</Mark1> Die MRSA Prävalenz liegt in der Größenordnung anderer in den letzten Jahren veröffentlichter Prävalenzerhebungen, aber deutlich über den Prävalenzdaten des Krankenhaus-Infektions-Surveillance-Systems. Da für die anderen Problemerreger für Deutschland keine Prävalenzdaten recherchiert werden konnten, stehen zum Vergleich nur die ITS KISS Daten für den Zeitraum 2010 zur Verfügung, auch hier sind die in der vorliegenden Studie erhobenen Prävalenzen für MRSA, VRE und ESBL deutlich höher. Ob das ein zufälliger Effekt ist oder auf einem systematischen Fehler im KISS beruht, kann aus diesen Daten nicht geschlossen werden.</Pgraph><Pgraph><Mark1>Schlussfolgerung:</Mark1> Die Ergebnisse der Eintagesprävalenzstudie zeigen, dass sich die Prävalenz bakterieller Problemerreger zwischen verschiedenen Einrichtungen deutlich unterscheidet. Das kann durch regionale Faktoren, den Versorgungsauftrag des Krankenhauses sowie methodisch bedingt sein. Trotzdem sind die Prävalenzen vergleichbar mit anderen Punktprävalenzdaten, aber deutlich höher als aus den Daten des KISS zu erwarten gewesen wäre. </Pgraph><Pgraph>Da die Erhebung einer Eintages-Punkt-Prävalenz ohne großen Aufwand realisierbar ist, erscheint es sinnvoll, derartige Erhebungen jeweils auf denselben Stichtag bezogen, auszuweiten, um repräsentative Daten für Deutschland zu generieren. Durch solche Initiativen können Medizinische Fachgesellschaften wie die DGKH einen einfachen aber wichtigen Beitrag zur Beschreibung der Epidemiologie wichtiger Pathogene leisten.</Pgraph></Abstract> <Abstract language="en" linked="yes"><Pgraph><Mark1>Objective:</Mark1> Data on the prevalence of emerging bacterial pathogens like extended-spectrum-lactamase-building (ESBL) Gram negative organisms, multiresistant <Mark2>Pseudomonas</Mark2> and <Mark2>Acinetobacter</Mark2> species or toxin-building <Mark2>Clostridium difficile</Mark2> in German hospitals are sparse. To provide data for different regions in Germany, a one-day point prevalence study with five tertiary care hospitals and four secondary care hospitals was conducted on the 10<Superscript>th</Superscript> of February 2010.</Pgraph><Pgraph><Mark1>Method:</Mark1> For participating hospitals, the level of care (primary/secondary/tertiary), staffing with infection prevention personnel, availability of a MRSA-screening, microbiological support and the prevalence of five emerging bacterial pathogens in intensive care, surgical and medical wards was assessed by questionnaire.</Pgraph><Pgraph><Mark1>Results:</Mark1> Overall, 3411 patients were included. In tertiary hospitals, the following prevalences were given: MRSA 1.8%, ESBL <Mark2>E. coli</Mark2> 0.45%, ESBL <Mark2>Klebsiella</Mark2> spp. 0.41%, multiresistant <Mark2>Pseudomonas</Mark2> 0.53%, multiresistant <Mark2>Acinetobacter</Mark2> species 0.15%, VRE 0.49% und <Mark2>Clostridium difficile</Mark2> 1.01%. In secondary hospitals, as prevalences resulted for MRSA 3.48%, ESBL <Mark2>E. coli</Mark2> 0.4%, ESBL <Mark2>Klebsiella</Mark2> spp. 0.4%, multiresistant <Mark2>Pseudomonas</Mark2> 0%, multiresistant <Mark2>Acinetobacter</Mark2> species 0%, VRE 0.13% und <Mark2>Clostridium difficile</Mark2> 1.34%.</Pgraph><Pgraph><Mark1>Discussion:</Mark1> The prevalence of MRSA found is comparable to other prevalence studies published in the last years, but remarkably higher than reported by the German National Surveillance System (KISS). As no prevalence data for other pathogens as MRSA could be found, only data from the ITS-KISS are available for comparison. Again, the preval<TextGroup><PlainText>ence</PlainText></TextGroup>s found in the present study are much higher than reported by the KISS. Whether this is by chance or indicates a systematic underreporting in the KISS remains unclear.</Pgraph><Pgraph><Mark1>Conclusion:</Mark1> The results from this one day point prevalence study show that prevalences of emerging bacterial pathogens differ markedly between regions, departments and hospitals. This can be explained by regional, methodical and other difference associated with the level of care provided by these hospitals. Still, the prevalences found fit well to other prevalence studies from the last years but are remarkably higher than to be expected by the KISS. </Pgraph><Pgraph>As questionnaire-based one-day prevalence studies have been shown to be inexpensive and feasible, such studies, using a fixed day and protocol, should be extendedly used in the future to collect represent<TextGroup><PlainText>ati</PlainText></TextGroup>ve data for Germany. By such initiatives, scientific societies as the DGKH can take part in collecting valuable epidemiological data of emerging bacterial pathogens.</Pgraph></Abstract> <TextBlock linked="yes" name="Introduction"> <MainHeadline>Introduction</MainHeadline><Pgraph>In 2010, the German Society for Hospital Hygiene (Deutsche Gesellschaft für Krankenhaushygiene, DGKH) launched a study to assess the prevalence of five emerging bacterial pathogens in volunteering hospitals to help to provide data on the epidemiology of carrier-ship and infections with these emerging nosocomial pathogens. The study was designed as a one-day point-prevalence study and conducted on the on the 10<Superscript>th</Superscript> of February 2010.</Pgraph></TextBlock> <TextBlock linked="yes" name="Method"> <MainHeadline>Method</MainHeadline><Pgraph>For participating hospitals, the level of care, staffing with infection prevention personnel, availability of a MRSA-screening and microbiological support was assessed by a basic questionnaire and the prevalence of the five emerging bacterial pathogens: Methicillin-resistant <Mark2>St</Mark2><TextGroup><Mark2>aphyl</Mark2></TextGroup><Mark2>ococcus aureus</Mark2> (MRSA), extended-spectrum-lactamase-building (ESBL) Gram negative organisms, multiresistant <Mark2>Pseudomonas</Mark2> (MRP) and <Mark2>Acinetobacter</Mark2> species (MAB), Vancomycin-resistant <Mark2>Entoerococcus</Mark2> species (VRE) and toxin-building <Mark2>Clostridium difficile</Mark2> (CD) in intensive care, surgical and medical wards by three identical questionnaires (Table 1 <ImgLink imgNo="1" imgType="table"/>).</Pgraph></TextBlock> <TextBlock linked="yes" name="Results"> <MainHeadline>Results</MainHeadline><SubHeadline>Participating hospitals</SubHeadline><Pgraph>Five tertiary and four secondary care hospitals particip<TextGroup><PlainText>ate</PlainText></TextGroup>d in the study (Table 2 <ImgLink imgNo="2" imgType="table"/>). Overall, 3411 patients were included. Questionnaires were mostly filled out by infection control nurses. None of the participating hospitals reported logistical problems.</Pgraph><SubHeadline>Infection prevention personnel</SubHeadline><Pgraph>Four tertiary care hospitals had an own infection control specialist and one was serviced by an external specialist. In contrast, one secondary care hospital had no infection control specialist and the other three had an external one. </Pgraph><Pgraph>All tertiary care hospitals had own infection control nurses: three hospitals had four, one three and one only one nurse. In secondary care hospitals, however, had only one, external, infection control nurse each (Table 2 <ImgLink imgNo="2" imgType="table"/>). With one exception, the microbiological service was reported as “sufficient”.</Pgraph><SubHeadline>MRSA screening</SubHeadline><Pgraph>Quality of MRSA screening regimes differed markedly between hospitals. In three tertiary hospitals, patients were screened in accordance with the recommendations by the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO) <TextLink reference="1"></TextLink> if they had two or more risk factors. In two hospitals, patients with one or more risk factor and all patients admitted to intensive care wards were screened as established in the University Medicine Greifswald (“Greifswald model”) <TextLink reference="2"></TextLink>, <TextLink reference="3"></TextLink>. In one tertiary care hospital an ESBL-screening for urological patient is established, too. </Pgraph><SubHeadline>Prevalences</SubHeadline><Pgraph>MRSA was the most frequently reported pathogen in all participating hospitals (Table 3 <ImgLink imgNo="3" imgType="table"/>, Table 4 <ImgLink imgNo="4" imgType="table"/>, Table 5 <ImgLink imgNo="5" imgType="table"/>, Table 6 <ImgLink imgNo="6" imgType="table"/>, Table 7 <ImgLink imgNo="7" imgType="table"/>, Table 8 <ImgLink imgNo="8" imgType="table"/>, Table 9 <ImgLink imgNo="9" imgType="table"/>, Table 10 <ImgLink imgNo="10" imgType="table"/>, Table 11 <ImgLink imgNo="11" imgType="table"/>), followed by CD and ESBL. No patient with CD was reported to require intensive care. </Pgraph><Pgraph>Seen over all departments and hospitals, MRSA and CD had a higher prevalence in secondary care hospitals in comparison to tertiary care. ESBL prevalence was comparable for both groups and MRP and VRE were more frequently reported in tertiary care hospitals. MAB were reported in tertiary care hospitals only (Table 12 <ImgLink imgNo="12" imgType="table"/>, Table 13 <ImgLink imgNo="13" imgType="table"/>, Table 14 <ImgLink imgNo="14" imgType="table"/>, Table 15 <ImgLink imgNo="15" imgType="table"/>).</Pgraph><Pgraph>Some hospitals additionally provided refined data that allow to between infection and colonisation (Table 16 <ImgLink imgNo="16" imgType="table"/>).</Pgraph></TextBlock> <TextBlock linked="yes" name="Discussion"> <MainHeadline>Discussion</MainHeadline><Pgraph>Data on the epidemiology of emerging bacterial pathogens with significant impact on hospital epidemiology are still sparse in Germany. Voluntary prevalence studies as this one initiated by the DGKH are an attempt to improve the epidemiological knowledge in this field. While this type of study has several limitations, as it gives only a momentary image of the situation and the data can be compared to data gathered with the same method only, it still is an inexpensive, convenient and feasible way to generate valuable data and sensitize health care workers for the situation on their wards.</Pgraph><Pgraph>The overall prevalence of MRSA, the post frequently reported pathogen in this study, was 2.2%. While not directly comparable to other studies, this seems to be in the range of other surveys as from the county of Höxter in 2008 (3.4%) <TextLink reference="4"></TextLink>, the EUREGIO MRSA-net Twente/Münsterland in 2006 (1.6% for the German part) <TextLink reference="5"></TextLink>, the city of Essen in 2009 (2% in hospitals) <TextLink reference="6"></TextLink> and the Saarland 2010 (2.18%) <TextLink reference="7"></TextLink>.</Pgraph><Pgraph>In the four secondary care hospitals the MRSA prevalence was 3.7% and therefore much higher as in the tertiary care hospitals (1.74%), which was unexpected. </Pgraph><Pgraph>Remarkably, all five studies report much higher preval<TextGroup><PlainText>enc</PlainText></TextGroup>es than one would expect from the data provided by the German KISS (Krankenhaus-Infektions-Surveillance-System), that reported a mean prevalence of 0.98% for all participating hospitals (n=268) only, 0.96% for hospit<TextGroup><PlainText>al</PlainText></TextGroup>s >600 beds and 1.00% for hospitals <600 beds in 2010 (Figure 1 <ImgLink imgNo="1" imgType="figure"/>) <TextLink reference="8"></TextLink>.</Pgraph><Pgraph>Our initial consideration was, that this may be due to the fact that our prevalence study was conducted on surgical, medical and intensive care wards only, and that therefore intensive care (which has a relatively high MRSA-preval<TextGroup><PlainText>enc</PlainText></TextGroup>e) is overweighed in comparison to the KISS data that includes all wards. However, the MRSA prevalence on intensive care units in this study is also much higher than the one reported by the ITS-KISS with 8.39% versus 1.5%, respectively (Figure 2 <ImgLink imgNo="2" imgType="figure"/>) <TextLink reference="9"></TextLink>. </Pgraph><Pgraph>Unfortunately, the MRSA-KISS system does not support individual statistics for other medical specialities. Whether the obvious differences between the results from all five prevalence studies and the KISS is by chance or indicates a systematic underreporting in the KISS remains unclear. </Pgraph><Pgraph>As the tertiary care hospital number 5 provided the whole-year for MRSA-prevalence additionally, the point-preval<TextGroup><PlainText>enc</PlainText></TextGroup>e and the overall prevalence for 2010 can be compared for this hospital. With 2.23%, the point-prevalence was higher than the mean prevalence for 2010 (1.28%), which is, again, much higher than to be expected from the MRSA-KISS. Just as for the relation between the p<TextGroup><PlainText>revale</PlainText></TextGroup>nce studies and the KISS-data discussed above, this could be caused by overweighting intensive care units (see above). Still, the prevalence data from the intensive care units is also much higher (3.58%) than to be exp<TextGroup><PlainText>ecte</PlainText></TextGroup>d from ITS-KISS (1.5%), underlying the need to validate the KISS results by external studies <TextLink reference="9"></TextLink>, <TextLink reference="10"></TextLink>.</Pgraph><Pgraph>Compared to MRSA, the prevalence of the other included pathogens was much lower, but they were still frequently reported especially on ICUs. Table 17 <ImgLink imgNo="17" imgType="table"/> compares the p<TextGroup><PlainText>revalen</PlainText></TextGroup>ces found in participating ICUs between levels of care and data from the ITS-KISS, if available [9]. Again, prevalences for all levels of care and all pathogens were much higher as to be expected from the KISS. For CD, too, the prevalence found in our study was more than twice as high (1.08%) as expected based on the CDAD-KISS (0.46%) <TextLink reference="11"></TextLink>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusion"> <MainHeadline>Conclusion</MainHeadline><Pgraph>As previously reported by other authors, our study shows that prevalences of emerging bacterial pathogens differ markedly between regions, departments and hospitals. While one-day point-prevalences have to be interpreted with caution, the prevalences found fit well to other p<TextGroup><PlainText>revale</PlainText></TextGroup>nce studies from the last years. Remarkably, all of those studies have found much higher prevalences than to be expected from the data of the KISS. Further studies are needed to show whether this was by chance alone or indicates a systematic underreporting in the KISS. </Pgraph><Pgraph>Voluntary point-prevalence studies from routine data have been shown to be an inexpensive way to generate valuable data. By such initiatives, scientific societies as the DGKH can take part in collecting valuable epidemiological data. Future studies, using a fixed day and protocol, could be an interesting tool to describe the epidemiology of emerging bacterial pathogens and verify data from other sources. </Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Anonym</RefAuthor> <RefTitle>Empfehlung zur Prävention und Kontrolle von Methicillin-resistenten Staphylococcus aureus-Stämmen (MRSA) in Krankenhäusern und anderen medizinischen Einrichtungen Mitteilung der Kommission für Krankenhaushygiene und Infektionsprävention am RKI</RefTitle> <RefYear>1999</RefYear> <RefJournal>Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz</RefJournal> <RefPage>954-8</RefPage> <RefTotal>Empfehlung zur Prävention und Kontrolle von Methicillin-resistenten Staphylococcus aureus-Stämmen (MRSA) in Krankenhäusern und anderen medizinischen Einrichtungen Mitteilung der Kommission für Krankenhaushygiene und Infektionsprävention am RKI. 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Available from: http://www.nrz-hygiene.de/surveillance/kiss/its-kiss/</RefTotal> <RefLink>http://www.nrz-hygiene.de/surveillance/kiss/its-kiss/</RefLink> </Reference> <Reference refNo="10"> <RefAuthor>Geffers C</RefAuthor> <RefAuthor>Gastmeier P</RefAuthor> <RefTitle>Nosokomiale Infektionen und multiresistente Erreger in Deutschland: Epidemiologische Daten aus dem Krankenhaus-Infektions-Surveillance-System</RefTitle> <RefYear>2011</RefYear> <RefJournal>Dtsch Ärztebl Int</RefJournal> <RefPage>87-93</RefPage> <RefTotal>Geffers C, Gastmeier P. Nosokomiale Infektionen und multiresistente Erreger in Deutschland: Epidemiologische Daten aus dem Krankenhaus-Infektions-Surveillance-System [Nosocomial Infections and Multidrug-Resistant Organisms in Germany-Epidemiological Data From KISS (The Hospital Infection Surveillance System)]. Dtsch Ärztebl Int. 2011;108(6):87-93. 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Available from: http://www.nrz-hygiene.de/fileadmin/nrz/module/cdad/CDADReferenz2010_extern.pdf</RefTotal> <RefLink>http://www.nrz-hygiene.de/fileadmin/nrz/module/cdad/CDADReferenz2010_extern.pdf</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Table 1: Questionnaire for the assessment of the prevalence of five emerging bacterial pathogens in patients on the day of the point prevalence study</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Table 2: Selected indicators of structure quality and MRSA screening policy in the participating hospitals</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Table 3: Prevalence data for tertiary care hospital No. 1</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption><Pgraph><Mark1>Table 4: Prevalence for tertiary care hospital No. 2</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>5</MediaNo> <MediaID>5</MediaID> <Caption><Pgraph><Mark1>Table 5: Prevalence data for tertiary care hospital No. 3</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>6</MediaNo> <MediaID>6</MediaID> <Caption><Pgraph><Mark1>Table 6: Prevalence data for tertiary care hospital No. 4</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>7</MediaNo> <MediaID>7</MediaID> <Caption><Pgraph><Mark1>Table 7: Prevalence data for tertiary care hospital No. 5</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>8</MediaNo> <MediaID>8</MediaID> <Caption><Pgraph><Mark1>Table 8: Prevalence data for secondary care hospital No. 6</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>9</MediaNo> <MediaID>9</MediaID> <Caption><Pgraph><Mark1>Table 9: Prevalence data for secondary care hospital No. 7</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>10</MediaNo> <MediaID>10</MediaID> <Caption><Pgraph><Mark1>Table 10: Prevalence data for secondary care hospital No. 8</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>11</MediaNo> <MediaID>11</MediaID> <Caption><Pgraph><Mark1>Table 11: Prevalence data for secondary care hospital No. 9</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>12</MediaNo> <MediaID>12</MediaID> <Caption><Pgraph><Mark1>Table 12: Comparison of prevalences in secondary and tertiary hospitals for all included departments</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>13</MediaNo> <MediaID>13</MediaID> <Caption><Pgraph><Mark1>Table 13: Comparison of prevalences in intensive care, surgical and medical departments for all included hospitals</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>14</MediaNo> <MediaID>14</MediaID> <Caption><Pgraph><Mark1>Table 14: Comparison of prevalences in intensive care, surgical and medical departments for tertiary care hospitals</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>15</MediaNo> <MediaID>15</MediaID> <Caption><Pgraph><Mark1>Table 15: Comparison of prevalences in intensive care, surgical and medical departments for secondary care hospitals</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>16</MediaNo> <MediaID>16</MediaID> <Caption><Pgraph><Mark1>Table 16: Refined data for infected and colonised patients</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>17</MediaNo> <MediaID>17</MediaID> <Caption><Pgraph><Mark1>Table 17: Prevalences (%) of included pathogens on intensive care units participating in the prevalence study and from ITS-KISS (all types, 2010)</Mark1></Pgraph></Caption> </Table> <NoOfTables>17</NoOfTables> </Tables> <Figures> <Figure format="png" height="678" width="881"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: Prevalences of MRSA for all participating hospitals and departments (TCH = tertiary care hospitals, SCH = secondary care hospitals), means and 95% confidence intervals for all, tertiary and secondary care hospitals in comparison to MRSA-KISS</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="618" width="943"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: Prevalences of MRSA for intensive care units from all participating hospitals (TCH = tertiary care hospitals, SCH = secondary care hospitals), means and 95% confidence intervals for all, tertiary and secondary care hospitals in comparison to ITS-KISS</Mark1></Pgraph></Caption> </Figure> <NoOfPictures>2</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>