dgkh000410 10.3205/dgkh000410 urn:nbn:de:0183-dgkh0004105 Guideline Anforderungen an die Infektionsprävention bei der medizinischen Versorgung von immunsupprimierten Patienten: Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut Commission for Hospital Hygiene and Infection Prevention (KRINKO) Commission for Hospital Hygiene and Infection Prevention (KRINKO)

Office of the Commission for Hospital Hygiene and Infection Prevention (KRINKO), Robert Koch Institute, Unit 14: Hospital Hygiene, Infection Prevention and Control, Nordufer 20, 13353 Berlin, Germany, Phone: +49 30 18754-2293, Fax: +49 30 1810754-3419Robert Koch Institute, Berlin, Germany

SekretariatFG14@rki.de author German Medical Science GMS Publishing House

Düsseldorf

610 immunocompromised iInfection prevention and control guideline health care Immunsupprierte Empfehlung Krankenhaushygiene Infektionsprävention 20220413 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2196-5226 17 GMS Hygiene and Infection Control GMS Hyg Infect Control 07 In Deutschland werden die Anforderungen an die Hygiene im Gesundheitswesen in Form von Empfehlungen von der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) veröffentlicht. Die KRINKO und ihre ehrenamtliche Arbeit legitimieren sich aus dem Auftrag nach §23 des Infektionsschutzgesetzes (IfSG).Die deutsche Originalfassung dieses Dokuments wurde im Februar 2021 veröffentlicht und nun auf Englisch der internationalen Fachöffentlichkeit zur Verfügung gestellt. Das Dokument enthält Empfehlungen zur Infektionsprävention und -kontrolle bei der Versorgung von immungeschwächten Personen in Gesundheitseinrichtungen. Diese Empfehlung befasst sich nicht nur mit Maßnahmen, die die direkte medizinische Versorgung immungeschwächter Patienten betreffen, sondern auch mit Managementaspekten z.B. Überwachung, Screening, Antibiotic Stewardship, sowie mit technisch/strukturellen Aspekten z.B. Patientenzimmer, Luftqualität und besonderen Maßnahmen bei Renovierungsarbeiten. In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, “KRINKO”). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, “IfSG”).The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations. Legal noticeThis translation is intended solely as a convenience to the non-German-reading public. Any discrepancies or differences that may arise in translation of the official German version of the recommendation of the Commission for Hospital Hygiene “Anforderungen an die Infektions-prävention bei der medizinischen Versorgung von immunsupprimierten Patienten” (Bundesgesundheitsbl. 2021;64(2):232–64, https://doi.org/10.1007/s00103-020-03265-x) are not binding and have no legal effect.Legal notice in GermanRechtlicher HinweisRechtlich bindend ist die deutsche Originalfassung dieser Empfehlung „Anforderungen an die Infektionsprävention bei der medizinischen Versorgung von immunsupprimierten Patienten“ (Bundesgesundheitsbl 2021; 64:232–264, https://doi.org/10.1007/s00103-020-03265-x). Die e</PlainText></TextGroup>nglische Fassung dient der Information der internationalen Fach&#246;ffentlichkeit.</Pgraph></TextBlock> <TextBlock linked="yes" name="List of abbreviations"> <MainHeadline>List of abbreviations</MainHeadline><Pgraph><UnorderedList><ListItem level="1">ABS: Antibiotic stewardship</ListItem><ListItem level="1">ADV: Adenovirus</ListItem><ListItem level="1">AFS: Antifungal stewardship</ListItem><ListItem level="1">AML: Acute myeloid leukaemia</ListItem><ListItem level="1">ART: Commission on Anti-infectives, Resistance and Therapy</ListItem><ListItem level="1">AWMF: Association of Scientific Medical Societies in Germany</ListItem><ListItem level="1">BMT: Bone marrow transplantation</ListItem><ListItem level="1">BSI: Bloodstream infection (infection with evidence of a pathogen in the blood culture, manifesting clinically as bacteraemia, fungaemia or sepsis) <TextLink reference="1"></TextLink></ListItem><ListItem level="1">CDI: <Mark2>Clostridioides difficile</Mark2> infection</ListItem><ListItem level="1">CHX: Chlorhexidine</ListItem><ListItem level="1">CMV: Cytomegalovirus</ListItem><ListItem level="1">CoNS: Coagulase-negative staphylococci</ListItem><ListItem level="1">CVAD: Central venous access device (an implanted central venous catheter providing long-term access, such as a Broviac or Hickman catheter or port)</ListItem><ListItem level="1">CVC: Central venous catheter</ListItem><ListItem level="1">Device: Medical device, the use of which is associated with an increased risk of infection (e.g. intravascular catheter, gastric tube, percutaneous endoscopic gastrostomy, tracheostomy, urethral catheter, bone implant materials, etc.)</ListItem><ListItem level="1">DIN: German Institute for Standardization</ListItem><ListItem level="1">ESBL: Extended-spectrum beta-lactamase</ListItem><ListItem level="1">FFP: Filtering face piece; respirator mask</ListItem><ListItem level="1">GVHD: Graft-versus-host disease</ListItem><ListItem level="1">HACCP: Hazard analysis and critical control points</ListItem><ListItem level="1">HD: Hygienic hand disinfection</ListItem><ListItem level="1">HEPA filter: High-efficiency particulate air&#47;arrestance filter</ListItem><ListItem level="1">HHV: Human herpes virus</ListItem><ListItem level="1">HMPV: Human metapneumovirus</ListItem><ListItem level="1">HS dispenser: Hand sanitiser dispenser </ListItem><ListItem level="1">HSV: Herpes simplex virus</ListItem><ListItem level="1">IfSG: <Mark2>Infektionsschutzgesetz</Mark2>, German Infection Protection Act</ListItem><ListItem level="1">KISS: German Nosocomial Infection Surveillance System</ListItem><ListItem level="1">KRINKO: Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute</ListItem><ListItem level="1">MRGN: Multidrug-resistant Gram-negative pathogens </ListItem><ListItem level="1">MRP: Multidrug-resistant pathogens</ListItem><ListItem level="1">MRSA: Methicillin (oxacillin)-resistant <Mark2>S. aureus</Mark2></ListItem><ListItem level="1">NI: Nosocomial infections</ListItem><ListItem level="1">NRC: National reference centre</ListItem><ListItem level="1">NTM: Nontuberculous mycobacteria</ListItem><ListItem level="1">PBSCT: Peripheral blood stem cell transplantation</ListItem><ListItem level="1">PCR: Polymerase chain reaction </ListItem><ListItem level="1">PJP: <Mark2>Pneumocystis jirovecii</Mark2> pneumonia</ListItem><ListItem level="1">RKI: Robert Koch Institute</ListItem><ListItem level="1">RSV: Respiratory syncytial virus</ListItem><ListItem level="1">SCT: Stem cell transplantation (usually stem cells separated from peripheral blood)</ListItem><ListItem level="1">SM: Surgical mask</ListItem><ListItem level="1">STIKO: German Standing Committee on Vaccination </ListItem><ListItem level="1">TrinkwV: German Drinking Water Ordinance</ListItem><ListItem level="1">VDI: Association of German Engineers</ListItem><ListItem level="1">VRE: Vancomycin-resistant enterococci</ListItem><ListItem level="1">VZV: Varicella zoster virus</ListItem><ListItem level="1">WHO: World Health Organization</ListItem></UnorderedList></Pgraph></TextBlock> <TextBlock linked="yes" name="Glossary of terms (as used in this document)"> <MainHeadline>Glossary of terms (as used in this document)</MainHeadline><SubHeadline>Allogeneic stem cell transplantation</SubHeadline><Pgraph>Transplantation of blood stem cells from another person, either a family member or an unrelated donor. </Pgraph><SubHeadline>Autologous stem cell transplantation</SubHeadline><Pgraph>Transplantation of the patient&#8217;s own blood stem cells, which are harvested from peripheral blood or bone marrow and processed, then frozen and transfused back into the patient at a later date.</Pgraph><SubHeadline>Bacteraemia</SubHeadline><Pgraph>The presence of viable bacteria in blood; evidence of infectious bacteria in a properly collected blood culture.</Pgraph><SubHeadline>Basic hygiene measures</SubHeadline><Pgraph>Measures taken in contact with all patients (or by patients themselves) to prevent transmission of infectious agents to patients and staff and to reduce the risk of nosocomial spread of pathogens. These include, in particular, hygienic hand disinfection (HD) and situational use of specific barrier measures: </Pgraph><Pgraph><UnorderedList><ListItem level="1">Disposable gloves if contamination of the hands with blood, respiratory secretions or other patient excretions is a possibility</ListItem><ListItem level="1">Protective clothing (patient-specific aprons or gowns) for tasks involving considerable contamination (e.g. caring for a patient with diarrhoea or vomiting) </ListItem><ListItem level="1">A respirator (e.g. FFP2 or FFP3) in the presence of patients with infections transmitted by aerosols</ListItem><ListItem level="1">A surgical mask (SM) for close contact with a patient who has an infection transmitted by droplets.</ListItem></UnorderedList></Pgraph><Pgraph>Other basic hygiene measures include the disinfection of contaminated surfaces and objects and the correct preparation of medical devices. Further information can be found in the KRINKO recommendations entitled &#8220;Infection Prevention in the Care and Treatment of Patients with Communicable Diseases <TextLink reference="2"></TextLink>&#8221;. </Pgraph><SubHeadline>Bloodstream infection</SubHeadline><Pgraph>Evidence of an infectious agent in the properly collected blood culture of a patient with signs of infection, such as fever, and any other clinical or laboratory manifestations of systemic inflammatory response syndrome. The use of this term does not depend on the severity of the clinical picture.</Pgraph><SubHeadline>Facultative pathogens</SubHeadline><Pgraph>Pathogens that require specific conditions to cause infectious diseases, such as access to parts of the body that are normally sterile, e.g. via catheter systems or foreign bodies, and can also cause infectious diseases in people who are not immunosuppressed.</Pgraph><SubHeadline>Graft-versus-host disease</SubHeadline><Pgraph>Cells from the donor&#8217;s immune system recognise the recipient&#8217;s own antigens as foreign and cause an immune reaction that harms the recipient. The skin, mucous membranes and liver of the recipient (and the lungs in chronic GVHD) are most often affected. Intensification of treatment with immunosuppressants may be necessary to control GVHD, which has been assigned four grades of severity by the WHO.</Pgraph><SubHeadline>Severe graft-versus-host disease</SubHeadline><Pgraph>In cases of severe GVHD, immunosuppression must be intensified, which substantially increases the risk of serious infections <TextLink reference="3"></TextLink>. GVHD that meets one of the clinical international consensus criteria for grade 3 or 4 is considered to be severe <TextLink reference="4"></TextLink>.</Pgraph><SubHeadline>Induction therapy</SubHeadline><Pgraph>In acute leukaemia, malignant cells crowd out healthy cells in the bone marrow, which can lead to infections and a tendency to bleed. In this situation, the primary goal of treatment is to destroy the diseased cells, enabling the displaced healthy cells to recover. To achieve this, several cycles of intensive chemotherapy are usually necessary. Chemotherapy administered to induce remission is called induction therapy, whereas chemotherapy given in remission is usually called consolidation therapy. Patients undergoing solid organ transplantation also require more intensive immunosuppression (e.g. with antithymocyte globulin or basiliximab) at the time of the transplant. This treatment is also called induction therapy and very important in terms of the level of immunosuppression in the individual patient.</Pgraph><SubHeadline>Isolation room</SubHeadline><Pgraph>A room that can be used as a single room with ensuite sanitary facilities (shower and toilet), HS dispensers and an entrance area large enough for gowns, gloves and SM to be put on and disposed of before leaving the room <TextLink reference="2"></TextLink>.</Pgraph><SubHeadline>Neutropenia</SubHeadline><Pgraph>A neutrophil count in peripheral blood of &#60;0.5x10<Superscript>9</Superscript>&#47;L or a white blood cell count that is &#60;1x10<Superscript>9</Superscript>&#47;L and falling if a differential blood count is not available. Severe (prolonged) neutropenia: neutropenia lasting longer than 10 days.</Pgraph><SubHeadline>Neutropenic diet</SubHeadline><Pgraph>Explicitly avoiding any foods that can cause infections in immunosuppressed patients through contamination with and transmission of facultative or opportunistic microorganisms <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>.</Pgraph><SubHeadline>Obligate pathogens</SubHeadline><Pgraph>Pathogens which, in the absence of specific immunity, can cause infectious diseases in healthy people.</Pgraph><SubHeadline>Opportunistic pathogens</SubHeadline><Pgraph>Pathogens which usually only cause infectious diseases if the immune system is compromised.</Pgraph><SubHeadline>Sepsis</SubHeadline><Pgraph>Life-threatening organ dysfunction due to an inadequate host response to infections <TextLink reference="1"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>, <TextLink reference="10"></TextLink>.</Pgraph><SubHeadline>Severe immunosuppression</SubHeadline><Pgraph>Severe immunosuppression equivalent or comparable to risk groups 2 and 3 (see Table 1 <ImgLink imgNo="1" imgType="table"/>).</Pgraph><SubHeadline>Authors&#8217; note on the English translation of some specific professional desig- nations in this document</SubHeadline><Pgraph>This document uses professional terms for the hygiene team that are established in the German healthcare system. Since there may be no direct equivalents for these professional designations in other countries, we would like to explain the terms used in this document in more detail:</Pgraph><Pgraph><UnorderedList><ListItem level="1"><Mark2>Infection control specialist</Mark2> (&#8220;Krankenhaushygieniker&#8221;): In Germany, infection prevention and control is a certified medical specialty (&#8220;Facharzt f&#252;r Krankenhaushygiene und Umweltmedizin&#8221;). As in other medical specialties, a 60-month postgraduate training must be completed after medical school to become an IPC specialist. This training includes 12 months spent in clinical wards (i.e., internal medicine, surgery, pediatrics) and at least 48 months in a certified and authorized IPC department <TextLink reference="11"></TextLink>.</ListItem><ListItem level="1">An <Mark2>IPC link doctor</Mark2> (&#8220;hygienebeauftragter Arzt&#8221;) is a physician working in the respective area who supports the implementation of the IPC measures in his or her area. </ListItem><ListItem level="1">An <Mark2>IPC nurse</Mark2> (&#8220;Hygienefachkraft&#8221;) is a nurse who has additional training in infection prevention and control.</ListItem></UnorderedList></Pgraph></TextBlock> <TextBlock linked="yes" name="1. Introduction and objectives"> <MainHeadline>1. Introduction and objectives</MainHeadline><SubHeadline>1.1. Background</SubHeadline><Pgraph>Congenital and acquired forms of immunodeficiency are independent risk factors for potentially life-threatening nosocomial infections (NI), which can be caused by a multitude of pathogens (some opportunistic) <TextLink reference="12"></TextLink>. The term immunosuppression is understood to mean the iatrogenic suppression of certain components of the immune system. The resulting immunodeficiency is either necessary for medical reasons (e.g. in certain autoimmune diseases or to prevent a rejection reaction after stem cell or organ transplantation) or a side effect of the medical treatment (e.g. cytostatic chemotherapy, radiotherapy or the use of biologicals in antineoplastic therapy). In this document, the term immunosuppression will also be used for patients (all references to professions or groups in this document include all genders) who are immunocompromised because of a congenital or acquired underlying disease and not medication <TextLink reference="13"></TextLink>.</Pgraph><Pgraph>Patients to whom these recommendations relate may be among those at risk of a complicated SARS-CoV-2 infection. Management of the pandemic caused by the new SARS-CoV-2 coronavirus is not covered by these recommendations. Please refer to relevant documents issued by the Robert Koch Institute (<Hyperlink href="http:&#47;&#47;www.rki.de&#47;covid-19">http:&#47;&#47;www.rki.de&#47;covid-19</Hyperlink>) and competent medical professional associations, which are updated regularly, and to local pandemic plans.</Pgraph><SubHeadline>1.2. Classification of risk groups</SubHeadline><Pgraph>In its 2010 recommendations entitled &#8220;Hygiene Requirements for the Medical Care of Immunosuppressed Patients&#8221;, the Commission for Hospital Hygiene and Infection Prevention (KRINKO) defined three risk groups of immunosuppressed patients <TextLink reference="14"></TextLink>. Infection prevention measures are based on the relevant risk group. This classification has been retained in this updated version (Table 1 <ImgLink imgNo="1" imgType="table"/>). </Pgraph><Pgraph>Further details of risk groups, infectious agents and transmission pathways can be found in Tab. 3 to Tab. 6 in Attachment 1 <AttachmentLink attachmentNo="1"/>. Tab. 3 contains information about infections that are occurring with greater frequency because of the increasing use of certain biologicals in recent years. As there are many possible patterns of findings, this table is inevitably incomplete. For instance, severe immunodeficiency can consist of immune cells which are numerically normal but dysfunctional. Important groups of patients with severe immunodeficiency include patients with certain congenital immunodeficiency syndromes, such as septic granulomatosis, and patients on immunosuppressive therapy (certain biologicals, long-term treatment with high doses of systemic corticosteroids or lifelong immunosuppression after organ transplantation). Acute treatment of rejection reactions after organ transplantation can be comparable with GVHD in terms of the resulting immunosuppression <TextLink reference="15"></TextLink>. Tab. 4 provides a guide to the spectrum of pathogens causing invasive infections in patients with weakened immune systems.</Pgraph><Pgraph><Mark1>The risk groups of immunosuppressed patients defined here are a dynamic (and to some extent pragmatic) guide introduced primarily for adaptation of the required hygiene measures. This allocation concept suggested by the KRINKO must not be confused with other clinical risk scores or stages of disease.</Mark1></Pgraph><Pgraph>The specific situation of individual patients and the corresponding risk of infection can change in the course of treatment. Individual patients can move between risk groups depending on their clinical treatment situation (e.g. induction vs. consolidation therapy, recurrence of leukaemia, preparation for and execution of stem cell transplantation after conventional treatment). This means that it may be necessary for doctors to amend the risk group in their risk analysis.</Pgraph><Pgraph>A <Mark1>&#8220;medical risk analysis&#8221;</Mark1> is a critical review of the patients&#8217; current situation (from an infection risk and prevention perspective) by the doctors treating them. It requires close on-site contact with the infection control specialist, the IPC link doctor and&#47;or IPC nurse in hygiene so that more complex issues can be discussed at any time (please also refer to the KRINKO recommendations on personnel and organisational requirements for the prevention of nosocomial infections <TextLink reference="16"></TextLink>).</Pgraph><Pgraph>As the attending physicians know from experience how long the neutropenia associated with certain underlying diseases and therapeutic interventions is likely to last, most patients can be assigned to the appropriate risk group in advance. Patients with solid tumours face additional risks because they usually require tumor surgery <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="20"></TextLink>, <TextLink reference="21"></TextLink>.</Pgraph><Pgraph>After allogeneic transplantation, the severity of graft-versus-host disease (GVHD) is also particularly crucial to the intensity of immunosuppressive therapy and corresponding risk group assignment. Patients with severe GVHD of the skin or gastrointestinal tract are at particularly high risk of severe exogenous and endogenous infections.</Pgraph><SubHeadline>1.3. Prevention aims of these recommendations</SubHeadline><Pgraph>The <Mark1>overall aim of these updated recommendations</Mark1> is to reduce the incidence of NI in immunosuppressed patients, if possible to unavoidable events <TextLink reference="22"></TextLink>, thereby increasing patient safety, improving their quality of life <TextLink reference="23"></TextLink> and reducing the morbidity and mortality associated with NI <TextLink reference="12"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="25"></TextLink>. It is also to counteract the selection and transmission of pathogens with specific and multidrug resistance, and NI caused by <Mark2>Clostridioides (C.) difficile</Mark2> (CDI) or viral pathogens, by taking appropriate measures.</Pgraph><SubHeadline>1.4. Target groups of these recommendations</SubHeadline><Pgraph>These recommendations are aimed at all professionals who are directly or indirectly involved in the medical care of immunosuppressed patients, particularly doctors and the relevant medical professional associations, nursing staff, hygiene professionals (infection control specialists, IPC link doctors, IPC nurses, physiotherapists, technical staff, public health services, hospital administrative staff, doctors working for health insurance companies, medical students and trainees &#91;e.g. in healthcare and nursing&#93;). They are also intended to provide a basic framework for infection prevention when drawing up plans for new wards and specialist outpatient clinics in which severely immunosuppressed patients will be treated.</Pgraph><SubHeadline>1.5. What is new in these recommendations&#63;</SubHeadline><Pgraph>These recommendations replace the 2010 recommendations entitled &#8220;Hygiene Requirements for the Medical Care of Immunosuppressed Patients&#8221;. To make them easier to follow, this revised version has a new structure. Instead of a detailed introductory analysis of the various causes and manifestations of immunodeficiency (or immunosuppression), reference is made to relevant specialist literature <TextLink reference="12"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>, <TextLink reference="30"></TextLink>, <TextLink reference="31"></TextLink>,<TextLink reference="32"></TextLink>. The KRINKO assumes that those responsible for the medical treatment of immunosuppressed patients have a sufficient knowledge in line with their training. Some recommendations are preceded by specific background information, which is intentionally brief so the document is easier to read.</Pgraph><Pgraph>This revised and updated document focuses on specific recommendations for NI prevention in healthcare facilities treating immunosuppressed patients <TextLink reference="30"></TextLink>. Section 5 of the 2010 recommendations, which contains guidance on infection prevention during periods of outpatient treatment, is to be transferred to the information booklet first produced in 2010 by the German Association of Self-Help Organisations for Patients with Leukaemia and internet-based resources for wider distribution and use <TextLink reference="33"></TextLink>.</Pgraph><Pgraph>The KRINKO evidence categories from 2010 <TextLink reference="34"></TextLink> are used in these recommendations (Table 2 <ImgLink imgNo="2" imgType="table"/>). As there is no scientific evidence from controlled studies for some of the recommendations, not every recommendation is assigned a category.</Pgraph><Pgraph>There are of course many direct references to the latest version of other KRINKO recommendations, which are listed in the references section. The primary purpose of these recommendations is to add to existing KRINKO recommendations by highlighting specific aspects of the medical treatment of this particular patient population. However, very important measures that also feature in other KRINKO recommendations will be repeated in places. </Pgraph></TextBlock> <TextBlock linked="yes" name="2. Recommendations"> <MainHeadline>2. Recommendations</MainHeadline><SubHeadline>2.1. Prevention</SubHeadline><SubHeadline2>2.1.1. Training for all staff</SubHeadline2><Pgraph><Mark1>The KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Regular training in nosocomial infection prevention and control <Mark1>in immunosuppressed patients</Mark1> for all members of the treatment team (no cat.). This involves the transfer of knowledge and specific practical skills in accordance with locally agreed standards.</ListItem><ListItem level="1">That critical activities, such as the care of intravascular catheters and other devices, only be performed independently by adequately trained staff <TextLink reference="35"></TextLink> (cat. IV).</ListItem><ListItem level="1">Combining training with practical exercises in small groups using examples from everyday clinical practice and involving hygiene professionals (no cat.).</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.2. Training for patients and their relatives</SubHeadline2><Pgraph>Many patients and those accompanying them want to be actively involved in infection prevention through general information, specific advice and practical guidance <TextLink reference="36"></TextLink>, <TextLink reference="37"></TextLink>, <TextLink reference="38"></TextLink>, <TextLink reference="39"></TextLink>. Severely immunosuppressed patients are often admitted to hospital, in some cases for long periods of time, or attend specialist outpatient clinics or day hospitals for their treatment. In such cases, there is a continuity of interaction with medical staff, which can be used to share basic hygiene strategies and repeatedly emphasise their importance. For example, without continuous active guidance, hygienic hand disinfection (HD) is performed too rarely by patients and visitors, but together with hand sanitiser dispensers (HS dispensers) (e.g. at the entrance to the hospital, ward or specialist outpatient clinic), it can increase the HD rate of patients and visitors <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>, <TextLink reference="43"></TextLink>. Experience shows that nursing staff are tremendously important in providing patients and their relatives with information and guidance about basic hygiene measures because of the intensive contact they have with them. Patients who are consistently asked to take these measures by medical staff are more likely to tell them about gaps in prevention (e.g. staff HD or three-way valve disinfection before manipulation of a central venous catheter) <TextLink reference="42"></TextLink>, <TextLink reference="44"></TextLink>, <TextLink reference="45"></TextLink>. Obstacles arising from language barriers or a lack of health knowledge can be anticipated and overcome by involving patients and providing practical guidance. A professional translation should be provided if possible. Precise and clear explanations and rules should be communicated in simple terms. Patients who already have neutropenia or are expected to develop it in the course of their treatment should be told what neutropenia is and why it increases the risk of infections. Patients must know how fever is defined, how to take their temperature and exactly what to do if they develop a fever. Specific information and rules (on all aspects of this section) are essential for appropriate behaviour during periods of outpatient treatment <TextLink reference="46"></TextLink>, <TextLink reference="47"></TextLink>, <TextLink reference="48"></TextLink>. Contradictory statements from different members of the treatment team should be avoided. Any existing differences of opinion within the team should not be shared with the patient; speak with one voice where possible <TextLink reference="30"></TextLink>, <TextLink reference="49"></TextLink>, <TextLink reference="50"></TextLink>.</Pgraph><Pgraph><Mark1>The KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Actively involving patients (and relatives, visitors and companions) as partners in infection prevention and control as much as possible (no cat.). This requires well-planned and sustained efforts by the entire treatment team <TextLink reference="27"></TextLink>, <TextLink reference="50"></TextLink>.</ListItem><ListItem level="1">Emphasising the importance of the hands in the transmission of pathogens on first contact after diagnosis <TextLink reference="51"></TextLink>, <TextLink reference="52"></TextLink>, <TextLink reference="53"></TextLink> (cat. IB).</ListItem><ListItem level="1">Explaining and demonstrating the most important indications and correct procedure for HD (and hand washing at home) <TextLink reference="54"></TextLink>, <TextLink reference="55"></TextLink>, <TextLink reference="56"></TextLink>, <TextLink reference="57"></TextLink> (see KRINKO recommendations entitled &#8220;Hand Hygiene in Healthcare Facilities&#8221; <TextLink reference="54"></TextLink>, <TextLink reference="55"></TextLink> &#91;no cat.&#93;).</ListItem><ListItem level="1">At a later stage of treatment, specifically addressing more complex aspects of infection prevention, e.g. strategies for preventing food-related infections <TextLink reference="58"></TextLink>, <TextLink reference="59"></TextLink>, <TextLink reference="60"></TextLink> or, if appropriate, infections transmitted through contact with pets or farm animals (case history) <TextLink reference="61"></TextLink>, <TextLink reference="62"></TextLink>, <TextLink reference="63"></TextLink>, and which vaccinations are recommended for relatives or close contacts <TextLink reference="64"></TextLink> (cat. II). </ListItem><ListItem level="1">Where they are used: explaining why certain measures that go beyond basic hygiene &#91;e.g. wearing a surgical mask (SM), contact isolation, protective isolation&#93; are required and what they consist of (see sections 2.1.9 and 2.1.13) (no cat.). Experience shows that this avoids conflict and improves adherence.</ListItem></UnorderedList></Pgraph><Pgraph>If patients or the relatives caring for them are involved in any aspect of their treatment, <Mark1>the KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Training them to the same standard as everyone else in the department, as happens with new members of the treatment team (no cat.).</ListItem><ListItem level="1">Documenting this training carefully (no cat.).</ListItem></UnorderedList></Pgraph><Pgraph>For example, this can include central venous catheter (implanted for long-term access) maintenance care during periods of outpatient treatment <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, <TextLink reference="67"></TextLink>, <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>. Patients (or their relatives) should be trained to carry out critical aspects of catheter care (such as dressing changes or flushing the catheter) independently <TextLink reference="70"></TextLink>, <TextLink reference="71"></TextLink>, <TextLink reference="72"></TextLink>. </Pgraph><Pgraph>These standards must never overwhelm patients or their relatives. Such training is not possible or wise for all patients (families).</Pgraph><Pgraph>To support the provision of information and active patient involvement, the KRINKO recommends:</Pgraph><Pgraph><UnorderedList><ListItem level="1">As a team (with hygiene professionals), discussing the most important issues and deciding exactly how to communicate them (no cat.).</ListItem><ListItem level="1">For example, providing brochures or simple handouts on basic hygiene and other subjects, in the patient&#8217;s language where possible, and using pictograms or visual aids <TextLink reference="43"></TextLink> (no cat.).</ListItem><ListItem level="1">Involving patient representatives in the development of new information materials where possible (no cat.).</ListItem><ListItem level="1">Referring to reliable (for example, provided or reviewed by medical professional associations) online resources for patients <TextLink reference="33"></TextLink>, <TextLink reference="73"></TextLink>, <TextLink reference="74"></TextLink>, <TextLink reference="75"></TextLink> (no cat.).</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.3. Visitor rule requirements</SubHeadline2><Pgraph>Even with immunosuppressed patients in an inpatient setting, it is in their interests to actively encourage and facilitate social contact with relatives and visitors in order to counteract social isolation, depression and a tendency to withdraw. However, visitors must not have a communicable infectious disease (or be in the incubation period after known exposure to such a disease) and should always take basic hygiene measures when in contact with patients. The more open the communication between the treatment team, patients and relatives about this, the more likely patients and relatives (e.g. parents) are to ask in advance whether or not a visit is appropriate in terms of a possible infection. Basic clinical screening of all children for signs of infection before they enter the ward can be included in visitor rules but has not been shown to help prevent infection. If relatives and patients have understood how to behave and learnt to ask the treatment team any outstanding questions, such screening is not absolutely necessary outside risk groups 2 and 3 (see Table 1 <ImgLink imgNo="1" imgType="table"/>). Infants who have received a live rotavirus vaccine should not have close contact with severely immunosuppressed patients for the following two weeks (if contact is unavoidable: disposable gloves during and HD after nappy changes).</Pgraph><Pgraph><Mark1>The KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Establishing binding rules for visitors, which can be consulted immediately in individual cases, in consultation with the most senior doctor and nurse in the ward or department (no cat.).</ListItem><ListItem level="1">Instructing visitors in HD and, if necessary, other aspects of basic hygiene and infection prevention (see KRINKO recommendations entitled &#8220;Hand Hygiene in Healthcare Facilities&#8221; <TextLink reference="54"></TextLink>, <TextLink reference="55"></TextLink>) (no cat.).</ListItem><ListItem level="1">Excluding visitors who have a potentially transmissible infection (cardinal symptoms include fever, heavy cold, cough, conjunctivitis, unexplained rash, diarrhoea or vomiting) (no cat.).</ListItem><ListItem level="1">That visitors with signs of a mild respiratory infection, such as rhinitis, or oral herpes wear a SM (in addition to strict HD) <TextLink reference="2"></TextLink>, <TextLink reference="76"></TextLink> (cat. II). </ListItem><ListItem level="1">Excluding visitors with only mild symptoms of a respiratory infection from visiting patients in risk groups 2 and 3 (see Table 1 <ImgLink imgNo="1" imgType="table"/>) (no cat.).</ListItem><ListItem level="1">Also instructing children in HD in a way that is appropriate to their age and stage of development. Direct supervision and manual assistance are usually required until they reach school age (no cat.).</ListItem></UnorderedList></Pgraph><Pgraph>For the following measures, there is no scientific evidence that they help to prevent infection. <Mark1>Therefore, the KRINKO does not recommend them (cat. III) in risk group 3 </Mark1><TextLink reference="77"></TextLink><Mark1> (except in appropriate treatment situations or for specific infection epidemiology reasons in the general population)</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Gowns for all visitors</ListItem><ListItem level="1">A SM for all visitors (exception: see 2.1.5.2; current prevention measures for the COVID-19 pandemic are of course unaffected by this)</ListItem><ListItem level="1">Disposable gloves for all visitors <TextLink reference="78"></TextLink>. </ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.4. Immunoprophylaxis</SubHeadline2><Pgraph>Active and passive immunisation of immunosuppressed patients is the subject of current recommendations by the German Standing Committee on Vaccination (STIKO) at the Robert Koch Institute, the body mandated by the IfSG to provide such recommendations <TextLink reference="64"></TextLink>, <TextLink reference="79"></TextLink>, <TextLink reference="80"></TextLink>, and medical professional associations <TextLink reference="81"></TextLink>. Employers in the health service are entitled to know the vaccination status of their employees and use this information <Mark2>&#8220;to make decisions about a new employment relationship or the nature of employment&#8221;</Mark2>. As some easily transmitted, vaccine-preventable illnesses can be life-threatening, especially in immunosuppressed or immunocompromised patients (e.g. measles, chickenpox, influenza), the most senior doctor and nurse, infection control specialist and the occupational medical service should work intensively together to ensure that, where possible, all non-immune members of the treatment team get vaccinated against these illnesses <TextLink reference="82"></TextLink>, <TextLink reference="83"></TextLink>, <TextLink reference="84"></TextLink>. This is an important task for the hospital administration <TextLink reference="85"></TextLink>. Irrespective of this, please read section 20 (8) of the IfSG (duty to demonstrate immunity to measles), which came into effect on 01.03.2020 <TextLink reference="84"></TextLink>. </Pgraph><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">That treating physicians play an active role in ensuring that patients (depending on their current treatment situation and degree of immunosuppression) and their relatives (close contacts) are fully vaccinated according to the appropiate STIKO recommendations (no cat.).</ListItem><ListItem level="1">That medical staff (all types) who work in close contact with immunosuppressed patients are fully vaccinated, particularly to prevent nosocomial infections (including the annual influenza vaccine) <TextLink reference="86"></TextLink>, <TextLink reference="87"></TextLink>, <TextLink reference="88"></TextLink>, <TextLink reference="89"></TextLink>, <TextLink reference="90"></TextLink>, <TextLink reference="91"></TextLink> (cat. IB).</ListItem></UnorderedList></Pgraph><Pgraph>If staff who have not been vaccinated against influenza have close patient contact (contact and droplet infection), the hygiene committee should review additional measures to minimise the risk of transmission (e.g. wearing a SM in addition to HD and other basic hygiene measures) (no cat.).</Pgraph><SubHeadline2>2.1.5. Basic hygiene measures</SubHeadline2><SubHeadline3>2.1.5.1 Hand hygiene</SubHeadline3><Pgraph>Hygienic hand disinfection (HD) is the most important measure in the prevention of NI. Without appropriate HD, staff hands have been shown to be contaminated with pathogenic microorganisms <TextLink reference="92"></TextLink>.</Pgraph><Pgraph>Adherence to HD is often relatively high on wards containing immunosuppressed patients <TextLink reference="93"></TextLink>, <TextLink reference="94"></TextLink>, <TextLink reference="95"></TextLink>. However, even on these wards, staff disinfect their hands more often after patient contact than before (e.g. before an aseptic activity <TextLink reference="95"></TextLink>). In a study of a stem cell transplantation unit, authorisation to disinfect gloved hands increased adherence, particularly before aseptic activities. The incidence density of severe infections (in this case: bloodstream infections &#91;healthcare-associated bloodstream infection; HABSI&#93; and pneumonia &#91;hospital-acquired pneumonia; HAP&#93;) decreased (from 6.0 to 2.5&#47;1,000 patient days, not statistically significant), and the transmission rate of multidrug-resistant pathogens (MRP) (MRSA, ESBL-producing Gram-negative pathogens, VRE) was unaffected <TextLink reference="96"></TextLink>. In order to maintain a high standard, participation in the <Mark2>&#8220;Aktion Saubere H&#228;nde&#8221;</Mark2> <Mark1>Clean Hands Campaign</Mark1> (or local implementation of a comparable concept) seems eminently reasonable <TextLink reference="56"></TextLink>. HS dispensers should also be installed in the entrances to the relevant wards and outpatient clinics so that the first HD can take place on arrival <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>.</Pgraph><Pgraph><Mark1>The KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Regular careful instruction, training and supervision of the entire treatment team in following the KRINKO recommendations on hand hygiene (cat. IA&#47;IB, see KRINKO recommendations entitled &#8220;Hand Hygiene in Healthcare Facilities&#8221; <TextLink reference="54"></TextLink>, <TextLink reference="55"></TextLink>).</ListItem><ListItem level="1">Installing an adequate number of patient-accessible HS dispensers in wards and specialist outpatient clinics for immunosuppressed patients (cat. IA&#47;IB, see KRINKO recommendations entitled &#8220;Hand Hygiene in Healthcare Facilities&#8221; <TextLink reference="54"></TextLink>, <TextLink reference="55"></TextLink>).</ListItem></UnorderedList></Pgraph><SubHeadline3>2.1.5.2 Patient-specific protective clothing and scrubs</SubHeadline3><Pgraph><Mark1>The KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">In order to contain certain transmissible infectious agents, wearing suitable, exclusively patient-specific protective clothing (e.g. aprons, gowns) for activities in which close patient contact could contaminate work clothing with blood, faeces, urine or secretions, and in general when caring for patients with diarrhoea, vomiting or extensive wounds (in this context, specific reference is made to the KRINKO recommendations entitled &#8220;Infection Prevention in the Care and Treatment of Patients with Communicable Diseases&#8221; <TextLink reference="2"></TextLink>, <TextLink reference="97"></TextLink>) (no cat.).</ListItem><ListItem level="1">That medical staff providing care wear work clothes (not their private clothes) that have been properly prepared by their employer <TextLink reference="2"></TextLink> (no cat.).</ListItem><ListItem level="1">That staff and relatives also use patient-specific protective gowns for close contact with patients in risk group 3 (see Table 1 <ImgLink imgNo="1" imgType="table"/>) and therefore protective isolation <TextLink reference="77"></TextLink> (cat. II).</ListItem><ListItem level="1">Using SMs for protective isolation in risk group 3 (see Table 1 <ImgLink imgNo="1" imgType="table"/>) and for targeted prevention of droplet infections (no cat.).</ListItem></UnorderedList></Pgraph><Pgraph>Staff who have an acute infection should not work in close contact with immunosuppressed patients <TextLink reference="98"></TextLink>. It is important to remember that respiratory viruses, which are generally harmless and self-limiting in otherwise healthy people, can cause a potentially life-threatening infection in immunosuppressed patients <TextLink reference="99"></TextLink>, <TextLink reference="100"></TextLink>, <TextLink reference="101"></TextLink>. After infection with respiratory viral pathogens, immunosuppressed patients shed these pathogens for a much longer period without symptoms <TextLink reference="102"></TextLink>, <TextLink reference="103"></TextLink>, <TextLink reference="104"></TextLink>, and therefore measures to prevent transmission (contact and droplet) are sometimes required for several weeks.</Pgraph><Pgraph>When there is a clear seasonal increase in the incidence of respiratory infections in the general population (e.g. a recent increase in the rate of inpatient admissions for influenza or respiratory syncytial virus infection (RSV) <TextLink reference="105"></TextLink>, <TextLink reference="106"></TextLink>, <TextLink reference="107"></TextLink>, <TextLink reference="108"></TextLink>, <TextLink reference="109"></TextLink>) and during the acute phase after stem cell transplantation, it can be beneficial for the treatment team and visitors to wear SM (during all contact with the patient) <TextLink reference="104"></TextLink>, <TextLink reference="110"></TextLink>, <TextLink reference="111"></TextLink>. The same applies in the oncology outpatient clinic and waiting room <TextLink reference="112"></TextLink>. For a situationally appropriate and flexible approach to the treatment team and visitors wearing a SM for all close patient contact, close cooperation and coordination with hospital hygiene and the attending diagnostic laboratory (current number of confirmed cases of influenza or RSV in the hospital as a whole) is crucial. </Pgraph><SubHeadline2>2.1.6. Antiseptic full body washes</SubHeadline2><Pgraph>In recent years, a full body wash (&#8220;bathing&#8221;) with solutions containing chlorhexidine (CHX) or octenidine, or with pre-packaged washcloths, has been promoted as a basic infection prevention measure, particularly in intensive care units and before and after surgery <TextLink reference="113"></TextLink>. As well as to prevent NI (e.g. bloodstream infections and postoperative wound infections), the aim is to reduce the probability of transmitting certain multidrug-resistant pathogens <TextLink reference="114"></TextLink>, <TextLink reference="115"></TextLink>, <TextLink reference="116"></TextLink>. According to a recent survey by the European Society for Blood and Marrow Transplantation (EBMT), 31&#37; of the 109 participating stem cell transplantation centres do this systematically <TextLink reference="117"></TextLink>. Other than for MRSA decolonisation <TextLink reference="118"></TextLink>, the KRINKO has previously only recommended this measure for cases in which the treating doctors and infection control specialists consider other preventive measures to be insufficient <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, <TextLink reference="67"></TextLink>, <TextLink reference="119"></TextLink>, <TextLink reference="120"></TextLink>. Existing studies of the use of a full body wash in immunosuppressed patients are not sufficient for a clear recommendation <TextLink reference="113"></TextLink>, <TextLink reference="121"></TextLink>, <TextLink reference="122"></TextLink>. In the commonly cited study by Climo et al., only one stem cell transplantation department participated, and its results are not presented separately (only in F<TextGroup><PlainText>ig. 2</PlainText></TextGroup> with no statistical data) <TextLink reference="123"></TextLink>. This study is also the focus of criticism because of a possible conflict of interests <TextLink reference="124"></TextLink>. In the full body &#8220;wash&#8221; patient group, the incidence density of intravascular catheter-related infections caused by coagulase-negative staphylococci (CoNS), in particular, was reduced; this can also be achieved through consistent use of prevention bundles <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, <TextLink reference="67"></TextLink>, <TextLink reference="120"></TextLink>. During the study, the investigational product (CHX washcloths) was withdrawn from the market temporarily because it was contaminated with <Mark2>Burkholderia</Mark2> <Mark2>cepacia</Mark2>. The inefficacy of CHX against certain Gram-negative infectious agents can promote outbreaks of the corresponding infections <TextLink reference="125"></TextLink>. Octenidine, the antiseptic used in Germany as an alternative, also exhibits gaps in efficacy here <TextLink reference="126"></TextLink>, <TextLink reference="127"></TextLink>, <TextLink reference="128"></TextLink>. </Pgraph><Pgraph>In the ABATE study by Huang et al., 4,730 and 5,800 oncology patients (not including acute stem cell transplantation) were included in the control and CHX full body bathing groups, respectively. There were no significant differences in the primary endpoints (clinical cultures for MRSA or VRE and the incidence of bloodstream infections). Oncology patients with a central venous catheter were probably in the subgroup of patients with devices for whom the post-hoc analysis showed a benefit. However, it remains unclear whether restricting CHX &#8220;bathing&#8221; to oncology patients with a central venous catheter (CVC) has any advantage as alternative to the design of the ABATE study <TextLink reference="116"></TextLink>. Certain device-related infections such as bacteriuria and candiduria are less common in men with a urinary catheter <TextLink reference="129"></TextLink> and other patients who receive a CHX full body wash <TextLink reference="130"></TextLink>. This may be because CHX treatment included all skin defects and wounds as well as the first 15 cm of every catheter (e.g., the ABATE study instruction video <Hyperlink href="https:&#47;&#47;vimeo.com&#47;164608558">https:&#47;&#47;vimeo.com&#47;164608558</Hyperlink> <TextLink reference="116"></TextLink> and section 2.1.1). The use of CHX full body treatments can reduce the CHX susceptibility of Gram-positive infectious agents in the corresponding patient population <Mark2>in vitro</Mark2> <TextLink reference="131"></TextLink>, <TextLink reference="132"></TextLink>. The clinical significance of this observation remains unclear.</Pgraph><Pgraph>As there is still insufficient evidence for immunosuppressed patients, the KRINKO can neither recommend nor dismiss the use of an antiseptic full body wash (cat. III).</Pgraph><SubHeadline2>2.1.7. Cleaning and disinfection</SubHeadline2><Pgraph>Please refer to the current version of the KRINKO recommendations entitled &#8220;Hygiene Requirements for the Cleaning and Disinfection of Surfaces&#8221; <TextLink reference="133"></TextLink> and &#8220;Infection Prevention in the Care of Patients with Communicable Diseases&#8221; <TextLink reference="2"></TextLink>, <TextLink reference="97"></TextLink>, the pathogen-specific KRINKO recommendations entitled &#8220;Recommendations for the Prevention and Control of Methicillin-resistant Strains of <Mark2>Staphy</Mark2><TextGroup><Mark2>lococcus</Mark2></TextGroup><Mark2> aureus</Mark2> (MRSA) in Medical and Care Facilities&#8221;, &#8220;Hygiene Measures for the Prevention of Infections Caused by Enterococci with Specific Antibiotic Resistance&#8221;, &#8220;Hygiene Measures for Infections or Colonisation with Multidrug-resistant Gram-negative Bacteria&#8221; and &#8220;Hygiene Measures for <Mark2>Clostridioides difficile</Mark2> Infection (CDI)&#8221; <TextLink reference="118"></TextLink>, <TextLink reference="134"></TextLink>, <TextLink reference="135"></TextLink>, <TextLink reference="136"></TextLink> as well as recent secondary literature on this subject <TextLink reference="137"></TextLink>, <TextLink reference="138"></TextLink>, <TextLink reference="139"></TextLink>.</Pgraph><Pgraph><Mark1>The KRINKO recommends:</Mark1> </Pgraph><Pgraph><UnorderedList><ListItem level="1">incorporating the above requirements for the cleaning and disinfection of surfaces into an overarching quality management plan that has been reviewed and approved by the infection control specialist or member of staff responsible for hygiene standards <TextLink reference="140"></TextLink>, <TextLink reference="141"></TextLink> (no cat.).</ListItem><ListItem level="1">providing cleaning staff for an appropriate number of hours with evidence of specific training, who can understand and follow instructions from the treatment team immediately, (no cat.). This is necessary to meet the high and sometimes rapidly changing demands of such high-risk areas of inpatient care adequately.</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.8. Number and features of isolation rooms</SubHeadline2><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">in view of the overall significantly increased and increasing demand for isolation rooms on a ward containing severely immunosuppressed patients <TextLink reference="142"></TextLink>, <TextLink reference="143"></TextLink>, <TextLink reference="144"></TextLink>, <TextLink reference="145"></TextLink>, <TextLink reference="146"></TextLink>, <TextLink reference="147"></TextLink>, <TextLink reference="148"></TextLink>, <TextLink reference="149"></TextLink>, <TextLink reference="150"></TextLink>, <TextLink reference="151"></TextLink>, equipping at least 50&#37; of the rooms so they can be used for isolation: a room that can be used as a single room with ensuite sanitary facilities (shower and toilet), HS dispensers and an entrance area large enough for gowns, gloves and SM to be put on and disposed of before leaving the room <TextLink reference="2"></TextLink> (cat. II).</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.9. Protective isolation</SubHeadline2><Pgraph><Mark1>The KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">accommodating neutropenic patients in risk groups 1 and 2 (Table 1 <ImgLink imgNo="1" imgType="table"/>) in a single or twin room with ensuite sanitary facilities, but not larger units (three or more patients per room), and carefully observing basic hygiene measures (no cat.). As paediatric haemato-oncology patients are regularly admitted with a parent (companion caregiver), their rooms should be large enough for a folding bed to be set up next to the bed without excessively obstructing their care (particularly at night) or creating additional transmission risks.</ListItem><ListItem level="1">accommodating patients in risk group 3 (see Table 1 <ImgLink imgNo="1" imgType="table"/>) in a single room with ensuite sanitary facilities <TextLink reference="77"></TextLink> (for room air requirements, see section 2.1.13) (no cat.).</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.10. Isolation in the event of colonisation or infection with transmissible pathogens</SubHeadline2><Pgraph>The treatment team should take active steps to counteract the negative effects of single-room isolation on the quality of medical and psychosocial treatment by providing adequate staffing and, where appropriate, monitoring devices (central monitors, intercom systems), facilitating external psychosocial support and making electronic forms of entertainment and communication (internet, etc.) available at the bedside <TextLink reference="152"></TextLink>. No patient should receive lower-quality medical monitoring or treatment as a result of colonisation or infection or the need for protective isolation. For MRGN, VRE and MRSA, please refer to the KRINKO recommendations entitled &#8220;Hygiene Measures for Infections or Colonisation with Multidrug-resistant Gram-negative Bacteria&#8221;, &#8220;Hygiene Measures for the Prevention of Infections Caused by Enterococci with Specific Antibiotic Resistance&#8221; and &#8220;Recommendations for the Prevention and Control of Methicillin-resistant Strains of <Mark2>Staphylococcus aureus</Mark2> (MRSA) in Medical and Care Facilities&#8221; <TextLink reference="118"></TextLink>, <TextLink reference="134"></TextLink>, <TextLink reference="135"></TextLink>, <TextLink reference="153"></TextLink>.</Pgraph><Pgraph>Biehl et al. conducted a prospective study in the haemato-oncology departments of four German university hospitals <TextLink reference="93"></TextLink>. They investigated the prevalence of colonisation with 3MRGN (resistance to third-generation cephalosporins and (for 3MRGN) also to fluoroquinolones. &#91;Transl<TextGroup><PlainText>ator&#8217;s </PlainText></TextGroup>note: In the German MRGN classification system, an isolate is classified as 3MRGN if it is resistant to 3 of the 4 groups of antibiotics (piperacillin, third-generation cephalosporins, carbapenems and fluoroquinolones)&#93;) <Mark2>E. coli</Mark2> on admission and the nosocomial transmission and development of bacteraemia resulting from this colonisation. Two hospitals were compared in each case. Patients with 3MRGN <Mark2>E. coli</Mark2> colonisation were treated in a single room where possible in two of the hospitals but not in the other two. In this patient population, which generally had high previous antibiotic exposure, the prevalence of 3MRGN on admission was 7.7&#37; and 7.5&#37;, respectively. The proportion of patients with 3MRGN colonisation was therefore slightly higher in haemato-oncology than in studies that included all university hospital admissions <TextLink reference="93"></TextLink>, <TextLink reference="154"></TextLink>, <TextLink reference="155"></TextLink>. In this study, both nosocomial transmissions and bloodstream infections due to 3MRGN <Mark2>E. coli</Mark2> were extremely rare (overall 1.59&#37; without isolation and 1.01&#37; with isolation) and not significantly influenced by single-room isolation <TextLink reference="93"></TextLink>. In a systematic literature review, the same research team also found a low incidence of secondary bloodstream infections (BSI) after colonisation with ESBL-producing Enterobacteriaceae <TextLink reference="156"></TextLink>. However, an Italian multicentre study found higher BSI rates in colonised haemato-oncology patients (15.6&#37; for ESBL producers and 14.1&#37; for carbapenem-resistant Gram-negative pathogens <TextLink reference="157"></TextLink>).</Pgraph><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">After a medical risk analysis, isolating patients who are infected with infectious agents or shedding asymptomatically (colonised) in a room that can be used as a single room in accordance with written hygiene standards based on the transmission route of the relevant pathogen (please refer to the KRINKO recommendations entitled &#8220;Infection Prevention in the Care and Treatment of Patients with Communicable Diseases&#8221;, &#8220;Recommendations for the Prevention and Control of Methicillin-resistant Strains of <Mark2>Staphylococcus aureus</Mark2> (MRSA) in Medical and Care Facilities&#8221;, &#8220;Hygiene Measures for the Prevention of Infections Caused by Enterococci with Specific Antibiotic Resistance&#8221;, &#8220;Hygiene Measures for Infections or Colonisation with Multidrug-resistant Gram-negative Bacteria&#8221; and &#8220;Hygiene Measures for <Mark2>Clostridioides difficile</Mark2> Infection (CDI)&#8221;) <TextLink reference="2"></TextLink> <TextLink reference="97"></TextLink>, <TextLink reference="118"></TextLink>, <TextLink reference="134"></TextLink>, <TextLink reference="135"></TextLink>, <TextLink reference="136"></TextLink>.</ListItem><ListItem level="1">That single-room isolation is not always necessary for adult haemato-oncology patients who are colonised (or infected) with <Mark1>3MRGN </Mark1><Mark1><Mark2>E.coli</Mark2></Mark1> and able to follow basic hygiene measures consistently (for 3MRGN isolates of other species, there are no comparable studies and therefore contact isolation in high-risk areas is still recommended) <TextLink reference="93"></TextLink> (cat. II).</ListItem><ListItem level="1">That before cohorting risk group 2 patients (see Table 1 <ImgLink imgNo="1" imgType="table"/>) with the same pathogen, a medical risk analysis be performed to check whether other aspects of infection prevention rule out cohorting for individual patients (no cat.).</ListItem><ListItem level="1">That in departments specialising in the treatment of immunocompromised patients, there is at least one room that is separated from the rest of the ward by an anteroom (with two doors) and has a ventilation system (negative pressure in the anteroom with sufficient airflow) that enables patients with airborne infectious diseases (e.g. chickenpox, measles) to be isolated <TextLink reference="2"></TextLink> (no cat.). Such patients can also be accommodated in a designated isolation ward at the same hospital if this ward can provide the same quality of medical monitoring and treatment for the underlying disease (no cat.). </ListItem><ListItem level="1">Not giving patients (or their close contacts) who are isolated for a communicable disease or asymptomatic shedding of a transmissible pathogen (colonisation) free access to communal areas (e.g. the ward kitchen) (no cat.).</ListItem><ListItem level="1">That parents&#47;close contacts admitted with paediatric patients also isolate with the child <TextLink reference="158"></TextLink>. This is particularly important for patients with MRSA, VRE, 3MRGN or 4MRGN colonisation (no cat.).</ListItem></UnorderedList></Pgraph><Pgraph>Close contacts isolated with the patient should pay particular attention to basic hygiene measures within the isolation room (HD, protective gown when providing <Mark2>care</Mark2>, e.g. washing, and clean disposable gloves when changing nappies, etc.). Hands should be disinfected before leaving the room. In some hospitals, it has proven beneficial for these parents to wear a gown (and SM, depending on the pathogen) <Mark2>outside the isolation room</Mark2> if they are not leaving the ward immediately.</Pgraph><SubHeadline2>2.1.11. Prevention of infections transmitted by contaminated foods</SubHeadline2><Pgraph>There is a fundamental distinction between: </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">An outpatient care setting (patients eat at home or outside the healthcare facility), where basic food hygiene rules apply. Immunosuppressed patients are familiar with these rules, which should be strictly observed by patients and their relatives <TextLink reference="58"></TextLink>, <TextLink reference="59"></TextLink>, <TextLink reference="60"></TextLink>. Patients and their families require specific and structured advice here (see section 2.1.2 and see T<TextGroup><PlainText>ab. 5</PlainText></TextGroup> in Attachment 1 <AttachmentLink attachmentNo="1"/>).</ListItem><ListItem level="1" levelPosition="2" numString="2.">The hospital kitchen, which must meet special requirements (statutory regulations and controls) based on HACCP principles <TextLink reference="159"></TextLink>. Infection prevention measures during food production, storage and distribution by the hospital operator (&#8220;hospital food&#8221;) apply to all patient groups and are not included in these recommendations. </ListItem><ListItem level="1" levelPosition="3" numString="3.">Food storage and preparation in a <Mark1>ward kitchen that is accessible to patients and relatives</Mark1> (in paediatric haemato-oncology: &#8220;parents&#8217; kitchen&#8221;). During intensive treatment, it can be difficult to feed immunosuppressed patients adequately and thereby prevent cachexia and other complications <TextLink reference="160"></TextLink>, <TextLink reference="161"></TextLink>, <TextLink reference="162"></TextLink>, <TextLink reference="163"></TextLink> <TextLink reference="164"></TextLink>. In this context, for medical reasons, it may be necessary to give patients access to their own food in addition or as an alternative to hospital food during their inpatient stay. This is sometimes achieved by bringing in food or by preparing and storing food for individual patients in a ward kitchen.</ListItem><ListItem level="1" levelPosition="4" numString="4.">The storage and delivery of food administered via a tube (gastric tube, jejunal tube, percutaneous endoscopic gastrostomy), formula milk (infants) <TextLink reference="165"></TextLink>, <TextLink reference="166"></TextLink>, <TextLink reference="167"></TextLink>, <TextLink reference="168"></TextLink> and breast milk (if this is expressed and stored).</ListItem></OrderedList></Pgraph><Pgraph>Of course, ward kitchens used by patients and their relatives also require a hygiene plan that has been agreed with hygiene professionals and is binding for all users of the kitchen. </Pgraph><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">continuing to avoid certain foods with a high risk of pathogenic bacterial contamination after discharge from hospital (see Tab. 5 in Attachment 1 <AttachmentLink attachmentNo="1"/>) and paying particular attention to basic hygiene measures when buying, storing and preparing food (see Tab. 5 in Attachment 1 <AttachmentLink attachmentNo="1"/>) <TextLink reference="5"></TextLink> (no cat.).</ListItem></UnorderedList></Pgraph><Pgraph>The KRINKO is strongly opposed to a strict &#8220;neutropenic diet&#8221;, as the benefits are unproven and such a diet can significantly reduce the patient&#8217;s quality of life <TextLink reference="7"></TextLink>, <TextLink reference="77"></TextLink>, <TextLink reference="169"></TextLink>, <TextLink reference="170"></TextLink>, <TextLink reference="171"></TextLink>, <TextLink reference="172"></TextLink>, <TextLink reference="173"></TextLink>, <TextLink reference="174"></TextLink>, <TextLink reference="175"></TextLink>, <TextLink reference="176"></TextLink>, <TextLink reference="177"></TextLink>, <TextLink reference="178"></TextLink> (cat. II).</Pgraph><Pgraph>Certain probiotics (of which standardisation under the German Medicinal Products Act is a significant problem) may have a favourable effect on the microbiome of immunosuppressed patients (e.g. a decrease in the incidence of antibiotic-associated diarrhoea or CDI) <TextLink reference="179"></TextLink>, <TextLink reference="180"></TextLink>, <TextLink reference="181"></TextLink>, <TextLink reference="182"></TextLink>, <TextLink reference="183"></TextLink>, <TextLink reference="184"></TextLink>. In a study of microbiome analyses, no significant change after administration of probiotics was demonstrated <TextLink reference="185"></TextLink>. However, analyses of various patient populations, individual case reports and case series suggest that probiotic microorganisms very rarely cause systemic (bloodstream) infections <TextLink reference="185"></TextLink>, <TextLink reference="186"></TextLink>, <TextLink reference="187"></TextLink>, <TextLink reference="188"></TextLink>, <TextLink reference="189"></TextLink>, <TextLink reference="190"></TextLink>, <TextLink reference="191"></TextLink>, <TextLink reference="192"></TextLink>, <TextLink reference="193"></TextLink>, <TextLink reference="194"></TextLink>, <TextLink reference="195"></TextLink>, <TextLink reference="196"></TextLink>, <TextLink reference="197"></TextLink>, <TextLink reference="198"></TextLink>, <TextLink reference="199"></TextLink>, <TextLink reference="200"></TextLink>, <TextLink reference="201"></TextLink>, <TextLink reference="202"></TextLink>.</Pgraph><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">for immunosuppressed patients in risk groups 2 and 3, carefully weighing up the risk of using <Mark1>probiotics</Mark1> (or approving their use by declaring that probiotic supplements are safe) against the expected benefit <TextLink reference="203"></TextLink>, <TextLink reference="204"></TextLink> (cat. III).</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.12. Structural functional measures to ensure a protective environment</SubHeadline2><Pgraph><Mark1>The KRINKO recommends:</Mark1> </Pgraph><Pgraph><UnorderedList><ListItem level="1">That wards and specialist outpatient clinics treating patients in our risk categories 1&#8211;3 may not be a passage to reach other wards or outpatient clinics but instead form separate structural units (no cat.).</ListItem><ListItem level="1">That all surfaces, including the floor, be easy to clean and disinfect <TextLink reference="133"></TextLink> (no cat.). Upholstered furniture, carpets and potted plants are not suitable <TextLink reference="138"></TextLink>.</ListItem><ListItem level="1">That environmental contamination by water spray from washbasins be avoided with a splash guard where necessary. This is particularly important in intervention rooms and areas in which injections, infusions, medication and enteral feeding solutions are prepared <TextLink reference="205"></TextLink> (cat. II). </ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.13. Room air requirements</SubHeadline2><Pgraph><Mark1>The KRINKO recommends:</Mark1> </Pgraph><Pgraph><UnorderedList><ListItem level="1">That in order to avoid invasive aspergillosis&#47;filamentous fungal infections, patients undergoing induction therapy for AML (or relapsed AML) and patients in the acute phase after allogeneic stem cell transplantation or with severe GVHD stay in state-of-the-art rooms supplied with HEPA-filtered air (filter class H13) during their inpatient treatment <TextLink reference="77"></TextLink>, <TextLink reference="206"></TextLink>, <TextLink reference="207"></TextLink>, <TextLink reference="208"></TextLink> (cat. IB). After autologous stem cell transplantation (without additional immunosuppression to prevent GVHD, which does not occur) patients do not require an isolation room with HEPA-filtered air, as in most centres the incidence of invasive mould infections is under 5&#37; <TextLink reference="209"></TextLink>, <TextLink reference="210"></TextLink> and the use of rooms with HEPA-filtered air does not have a significant effect on the rate of nosocomial pneumonia <TextLink reference="211"></TextLink>. </ListItem></UnorderedList></Pgraph><Pgraph>That is why, in many centres, it has not been compulsory to treat autologous stem cell transplantation patients in isolation rooms with HEPA-filtered air for a number of years <TextLink reference="212"></TextLink>, <TextLink reference="213"></TextLink>, <TextLink reference="214"></TextLink>. It is important to remember that patients may already have asymptomatic fungal colonisation of the respiratory tract or paranasal sinuses on admission, which will not be affected by the provision of HEPA 13-filtered room air. In addition to the above measures, medication to prevent fungal infections caused by Aspergillus in high-risk patients is a crucial component of the overall prevention plan for invasive mycosis. However, this is not covered by these recommendations.</Pgraph><Pgraph><Mark1>The KRINKO also recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Providing suitable protective isolation rooms with an anteroom (air pressure in the patient room is positive to the anteroom, air pressure in the anteroom is negative to the patient room and corridor, mainly to maintain safe pressure differentials between the patient room and corridor, and to prevent positive pressure in the patient room carrying pathogens into the corridor via exhaust air) <TextLink reference="214"></TextLink>. However, there are no clinical studies that confirm the benefit of an anteroom for the endpoint of NI or NI transmission (no cat.).</ListItem><ListItem level="1">With new buildings or major renovations, giving consideration to providing HEPA-filtered air, not only in individual patient rooms but also entire wards or certain sections of wards (at least two-stage F9 filtration in corridors), so that even severely immunosuppressed patients can move around freely, thereby reducing their risk of social isolation (no cat.).</ListItem><ListItem level="1">With new buildings or major rebuilding work, not installing laminar air flow&#47;low-turbulence displacement flow in isolation rooms, as there is no scientific evidence that this helps to prevent infection <TextLink reference="77"></TextLink> (no cat.).</ListItem><ListItem level="1">Ensuring that all ventilation systems are regularly inspected and maintained in accordance with technical specifications (DIN 1946-4) and submitting the results of the hygiene acceptance test and regular state-of-the-art hygiene tests to the infection control specialist <TextLink reference="215"></TextLink> (no cat.).</ListItem><ListItem level="1">That after an individual risk assessment, patients in risk group 2 or 3 wear a tight-fitting particle-filtering respirator (FFP2) when they leave their room <TextLink reference="216"></TextLink>, <TextLink reference="217"></TextLink> (cat. II).</ListItem><ListItem level="1">Not using humidifiers or other technical equipment that emits potentially contaminated aerosols or raises dust (fans; justified exception: relieving dyspnoea during palliative treatment) (no cat.).</ListItem><ListItem level="1">If there is a ventilation system, not opening the windows where possible. It should not be possible for patients or staff to open patient room windows, except in a fire emergency. This requires appropriate state-of-the-art climate control and ventilation (see DIN 194<TextGroup><PlainText>6-4</PlainText></TextGroup> and VDI 6022) <TextLink reference="215"></TextLink>, <TextLink reference="218"></TextLink> (no cat.).</ListItem><ListItem level="1">Not setting up composting or waste processing units near departments in which severely immunosuppressed patients are treated, as they can emit large quantities of fungal spores <TextLink reference="219"></TextLink> (cat. II).</ListItem><ListItem level="1">Not using leaf blowers to clear leaves in the immediate vicinity of departments in which severely immunosuppressed patients are treated; a safety zone should be defined here (no cat.).</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.14. Requirements relating to the water supply and sanitary facilities</SubHeadline2><Pgraph>This section provides a number of basic recommendations for the prevention and control of water-related infections, which are particularly important for immunosuppressed patients <TextLink reference="220"></TextLink>, <TextLink reference="221"></TextLink>, <TextLink reference="222"></TextLink>, <TextLink reference="223"></TextLink>, <TextLink reference="224"></TextLink>. Please refer specifically to the recommendations in &#8220;Hygiene Requirements for Wastewater Systems in Medical Facilities&#8221; for more information on this subject. In particular, the measures described in the appendix for areas with a higher risk of infection should be considered for risk groups 2 and 3.</Pgraph><SubHeadline3>2.1.14.1 Hygienic construction and use of washbasins, showers and toilets in medical areas</SubHeadline3><Pgraph>These include <TextLink reference="225"></TextLink>: </Pgraph><Pgraph><UnorderedList><ListItem level="1">considering the use of thermic siphon disinfection devices in high-risk areas containing group 2 and 3 patients provided the risk of retrograde contamination or aerosol formation cannot be controlled by other technical means <TextLink reference="222"></TextLink>,</ListItem><ListItem level="1">in the area surrounding the washbasin, providing an area (or storage space) that is protected from water spray, where patients can store personal care items (toothbrushes, creams, etc. and dressings) of relevance for transmission, </ListItem><ListItem level="1">every room having ensuite sanitary facilities with a washbasin, shower and toilet (sanitary facilities shared by no more than two patients in risk groups 1 and 2, one sanitary area per patient in risk group 3),</ListItem><ListItem level="1">washbasin taps that can be operated without using the hands. As taps with an electronic sensor may increase the risk of water contamination, their use is only justifiable with careful microbiological monitoring <TextLink reference="226"></TextLink>,</ListItem><ListItem level="1">not directing the water jet into the drain or having an overflow <TextLink reference="55"></TextLink>, <TextLink reference="227"></TextLink>,</ListItem><ListItem level="1">adequate ventilation of sanitary facilities so they do not become a reservoir for moulds and other pathogens <TextLink reference="228"></TextLink>,</ListItem><ListItem level="1">choosing materials that can be cleaned using suitable disinfection methods (per-compounds, chlorine compounds) for the drains of washbasins, showers and toilets,</ListItem><ListItem level="1">specifying how often shower tubes should be replaced (e.g. every six months),</ListItem><ListItem level="1">not using shower curtains because these are laborious to disinfect <TextLink reference="229"></TextLink>, <TextLink reference="230"></TextLink>, <TextLink reference="231"></TextLink>, <TextLink reference="232"></TextLink>,</ListItem><ListItem level="1">closing the toilet lid before flushing in order to avoid contaminating the surrounding area and user with spray and aerosols. The toilet should always be flushed with the lid closed before use.</ListItem><ListItem level="1">rimless toilets <TextLink reference="222"></TextLink>.</ListItem></UnorderedList></Pgraph><SubHeadline3>2.1.14.2 Supply of drinking water (or mineral water from unopened bottles) </SubHeadline3><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">If the microbiological quality of the water is not guaranteed by other means <TextLink reference="233"></TextLink>, using terminal bacterial filters in haemato-oncology wards and other wards treating severely immunosuppressed patients, particularly in patient rooms <TextLink reference="224"></TextLink>, <TextLink reference="227"></TextLink>, <TextLink reference="234"></TextLink>, <TextLink reference="235"></TextLink>, <TextLink reference="236"></TextLink>, <TextLink reference="237"></TextLink>, <TextLink reference="238"></TextLink> (cat. II). It is important to ensure that external contamination of the filters does not result in transmission of the pathogens that its use is intended to prevent <TextLink reference="239"></TextLink> (cat. II).</ListItem><ListItem level="1"><Mark1>Not</Mark1> <Mark1>giving patients in risk groups 2 and 3</Mark1> (see Table 1 <ImgLink imgNo="1" imgType="table"/>) <Mark1>still mineral water</Mark1> in hospital (even for oral hygiene), as still mineral water can be contaminated with bacteria <TextLink reference="240"></TextLink>. Instead, carbonated, sterile-filtered or boiled drinking water, or alternatively a drinking fountain with a sterile filter, is recommended (no cat.).</ListItem><ListItem level="1">When making tea (for drinking or oral hygiene), not simply bringing water to a boil but instead leaving it on a rapid boil for several minutes <TextLink reference="241"></TextLink>, as tea leaves can be contaminated with pathogenic bacteria and fungi (cat. II). A critical analysis of the medical use of tea in patient care should be undertaken for this reason.</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.15. Hygiene requirements for demolition and reconstruction work</SubHeadline2><Pgraph>Building work in hospitals responsible for the inpatient care of severely immunosuppressed patients, or nearby construction or demolition work, can increase patient exposure to infectious agents <TextLink reference="242"></TextLink>. This exposure can cause life-threatening infections (e.g. invasive aspergillosis of the respiratory tract) <TextLink reference="243"></TextLink>. However, it is possible to avoid this kind of critical exposure through strict implementation of a suitably adapted bundle of measures ensuring close cooperation between clinicians, hospital hygiene, building designers and the companies carrying out the work <TextLink reference="244"></TextLink>, <TextLink reference="245"></TextLink>. Antifungal prophylaxis to prevent invasive fungal infection does not provide adequate protection for severely immunosuppressed patients on its own <TextLink reference="243"></TextLink>. Before any major building work takes place, the treating doctors should consider reviewing the indications in the guidelines for medication to prevent invasive fungal infections <TextLink reference="246"></TextLink>, <TextLink reference="247"></TextLink>, <TextLink reference="248"></TextLink>, <TextLink reference="249"></TextLink>, <TextLink reference="250"></TextLink> in their own patient populations (<Mark2>not within the responsibility of KRINKO</Mark2>).</Pgraph><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">Without exception, agreeing all building, renovation and demolition work in the vicinity of severely immunosuppressed patients with the appropriate hygiene professional (infection control specialist) and the most senior nurse and doctor in the relevant department as early as the planning phase and otherwise immediately <TextLink reference="251"></TextLink>, <TextLink reference="252"></TextLink>, <TextLink reference="253"></TextLink>, <TextLink reference="254"></TextLink> (cat. II). Hospital administration, or a subunit of hospital administration in charge of building work, is responsible for informing hospital hygiene staff about such work, giving a reasonable period of advance notice, and involving infection prevention personnel in the process.</ListItem><ListItem level="1">In contracts with the planners and companies doing the work, explicitly agreeing that the prevention guidelines of the hospital will be strictly followed by their employees and that these guidelines are a non-negotiable part of the building contract (no cat.).</ListItem><ListItem level="1">For larger projects that are likely to mean greater exposure for immunosuppressed patients, forming a multidisciplinary prevention group coordinated by infection prevention personnel well in advance of the work starting. This group makes specific recommendations on the protective measures that are required and monitors the building work from a hospital hygiene perspective on behalf of the medical and administrative director (no cat.).</ListItem><ListItem level="1">If necessary to protect patients, completely or temporarily transferring the relevant ward from the area of risk into another building <TextLink reference="254"></TextLink>, <TextLink reference="255"></TextLink> until the work has been completed (cat. II).</ListItem><ListItem level="1">If there is no central ventilation system with terminal HEPA filtration, and mainly to avoid temporarily high exposure caused by building and renovation work, considering the use of decentralised mobile HEPA filtration units in patient rooms <TextLink reference="256"></TextLink>, <TextLink reference="257"></TextLink>, <TextLink reference="258"></TextLink> (cat. II).</ListItem><ListItem level="1">Informing patients during building work and before major building or renovation work of a potentially increased risk of invasive fungal infections <TextLink reference="242"></TextLink>, <TextLink reference="251"></TextLink>, <TextLink reference="252"></TextLink>, <TextLink reference="254"></TextLink>, <TextLink reference="259"></TextLink>, <TextLink reference="260"></TextLink>, <TextLink reference="261"></TextLink> in a suitable way (no cat.).</ListItem><ListItem level="1">That, where possible, immunosuppressed patients avoid areas where building work is taking place, and wear an FFP2 respirator with an exhalation valve during transport through such areas (where this is unavoidable) <TextLink reference="27"></TextLink>, <TextLink reference="48"></TextLink> (cat. II).</ListItem><ListItem level="1">Safely shielding the ward from building work and preventing secondary entry of dust and dirt with a predetermined route. Where conditions allow, an impermeable dust barrier can often be created using drywall. To check for perfect sealing, a visual inspection should be performed (e.g. with gas detector&#47;air flow test tubes) and the results documented <TextLink reference="261"></TextLink> (no cat.).</ListItem><ListItem level="1">The removal of building rubble, the exhaust air system and disposal methods must be specified. Sealed containers should be used where necessary (no cat.).</ListItem><ListItem level="1">Cleaning patient care areas that are exposed to large amounts of construction dust with a wet disinfectant at least every working day and when dust is visible (no cat.).</ListItem><ListItem level="1">On wards and in outpatient clinics in the immediate vicinity of activities that generate dust, not opening windows while work is ongoing and protecting sterile materials and consumables from contamination (no cat.).</ListItem><ListItem level="1">After any work on the drinking water system with the potential to cause stagnation or contamination, or if it has not been used for a long time, checking the water <Mark1>for compliance with</Mark1> <Mark1>TrinkwV</Mark1> and for <Mark2>Legionella</Mark2> and <Mark2>P. aeruginosa</Mark2> before patients are exposed to it (cat. IV).</ListItem><ListItem level="1">Carrying out targeted surveillance of invasive mould infections while construction work is ongoing <TextLink reference="242"></TextLink>, <TextLink reference="245"></TextLink>, <TextLink reference="261"></TextLink> (no cat.). </ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.16. Prevention of nosocomial urinary tract infections</SubHeadline2><Pgraph>Please refer to the KRINKO recommendations entitled &#8220;Prevention and Control of Catheter-related Urinary Tract Infections&#8221; <TextLink reference="262"></TextLink>.</Pgraph><SubHeadline2>2.1.17. Prevention of postoperative wound infections </SubHeadline2><Pgraph>As there is nothing specific to consider in terms of prevention strategy, please refer to the KRINKO recommendations entitled &#8220;Prevention of Postoperative Wound Infections&#8221; <TextLink reference="263"></TextLink> and the secondary literature <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="20"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="264"></TextLink>.</Pgraph><SubHeadline2>2.1.18. Prevention of infections originating in intravascular catheters</SubHeadline2><Pgraph>In addition to the KRINKO recommendations entitled &#8220;Prevention of Infections Originating in Intravascular Catheters&#8221; <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, <TextLink reference="67"></TextLink>, <TextLink reference="120"></TextLink>, please refer to the detailed recommendations on preventing catheter-related BSI published by professional associations in the fields of general medicine and paediatric haemato-oncology <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>. </Pgraph><Pgraph>A significant proportion of BSI in patients with mucositis and&#47;or severe GVHD after intensive chemotherapy do not originate in intravascular catheters <TextLink reference="265"></TextLink>, <TextLink reference="266"></TextLink>. Nevertheless, severely immunosuppressed patients who require a central venous catheter for their treatment belong to the risk groups <TextLink reference="265"></TextLink>, <TextLink reference="267"></TextLink>, <TextLink reference="268"></TextLink>, <TextLink reference="269"></TextLink>, <TextLink reference="270"></TextLink>, <TextLink reference="271"></TextLink>, <TextLink reference="272"></TextLink> for which the use of specific aids (e.g. CHX-releasing dressings, disinfection caps) can be considered after a medical risk analysis <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, <TextLink reference="67"></TextLink>, <TextLink reference="120"></TextLink>, <TextLink reference="273"></TextLink>, <TextLink reference="274"></TextLink>, <TextLink reference="275"></TextLink>, <TextLink reference="276"></TextLink>, <TextLink reference="277"></TextLink>.</Pgraph><SubHeadline2>2.1.19. Prevention of oral infections</SubHeadline2><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">That a dental consultation be arranged for all newly admitted patients and, depending on the clinical situation, starting any dental treatment that may be required in order to minimise the risk of local inflammation and systemic infections <TextLink reference="278"></TextLink>, <TextLink reference="279"></TextLink>, <TextLink reference="280"></TextLink> (cat. II).</ListItem><ListItem level="1">Instructing patients in regular oral and dental hygiene in accordance with an in-house standard agreed by an interdisciplinary team, which can be continued during phases of oral (pharyngeal) mucositis <TextLink reference="281"></TextLink>, <TextLink reference="282"></TextLink>, <TextLink reference="283"></TextLink>, <TextLink reference="284"></TextLink> (cat. IB).</ListItem><ListItem level="1">General (non-targeted) use of mouthwash solutions containing CHX is not recommended in this context <TextLink reference="285"></TextLink> (cat. IB).</ListItem></UnorderedList></Pgraph><SubHeadline2>2.1.20. Prevention of nosocomial infections of the gastrointestinal tract</SubHeadline2><Pgraph>Immunosuppressed patients can develop intestinal infections caused by opportunistic pathogens and shed these pathogens for a relatively long period of time, even after the acute symptoms have passed <TextLink reference="286"></TextLink>, <TextLink reference="287"></TextLink>, <TextLink reference="288"></TextLink>. On the other hand, only a third of all episodes of diarrhoea in immunosuppressed patients after stem cell or organ transplantation are caused by a gastrointestinal infection <TextLink reference="136"></TextLink>, <TextLink reference="289"></TextLink>, <TextLink reference="290"></TextLink>. In this context, targeted and rational pathogen diagnostics are important, including for hospital hygiene reasons <TextLink reference="291"></TextLink>. </Pgraph><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">To rule out nosocomial infections in immunosuppressed patients with diarrhoea, considering prompt advanced pathogen diagnostics, the specifics of which should be established with the relevant microbiologists, virologists and hygiene professional (no cat.).</ListItem><ListItem level="1">Depending on the pathogen (and on patient adherence to targeted prevention measures), follow-up tests to confirm the duration of isolation after symptoms of infectious diarrhoea have subsided because immunosuppressed patients may continue shedding the pathogen for much longer <TextLink reference="292"></TextLink>, <TextLink reference="293"></TextLink>, <TextLink reference="294"></TextLink>, <TextLink reference="295"></TextLink>, <TextLink reference="296"></TextLink>, <TextLink reference="297"></TextLink> (cat. II). This does not include <Mark2>C. difficile</Mark2>-associated infections (a follow-up test is not required for asymptomatic patients) <TextLink reference="136"></TextLink>, <TextLink reference="295"></TextLink>, <TextLink reference="298"></TextLink>, <TextLink reference="299"></TextLink>, <TextLink reference="300"></TextLink>, <TextLink reference="301"></TextLink>.</ListItem></UnorderedList></Pgraph><Pgraph>Patients undergoing intensive chemotherapy or who have had a stem cell transplant are among those with the highest incidence density of CDI <TextLink reference="299"></TextLink>, <TextLink reference="302"></TextLink>, <TextLink reference="303"></TextLink>, <TextLink reference="304"></TextLink>, <TextLink reference="305"></TextLink>, <TextLink reference="306"></TextLink>. For information on prevention, please refer to the latest KRINKO recommendations entitled &#8220;Hygiene Measures for <Mark2>Clostridioides</Mark2> <Mark2>difficile</Mark2> Infection (CDI)&#8221; <TextLink reference="136"></TextLink>.</Pgraph><SubHeadline2>2.1.21. Prevention of zoonotic diseases</SubHeadline2><Pgraph><Mark1>The KRINKO recommends: </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">That risk group 2 and 3 patients (see Table 1 <ImgLink imgNo="1" imgType="table"/>) in protective isolation have no contact with animals in hospital <TextLink reference="61"></TextLink>, <TextLink reference="62"></TextLink>, <TextLink reference="63"></TextLink>, <TextLink reference="307"></TextLink> (cat. II).</ListItem></UnorderedList></Pgraph><Pgraph>A less restrictive approach may of course be taken with palliative care patients <TextLink reference="308"></TextLink>, <TextLink reference="309"></TextLink>, whereby contact with animals is restricted to these patients. Outside the hospital, simple rules of basic hygiene (e.g. washing hands with soap, HD) should be followed, as these can significantly reduce the risk of zoonotic diseases when handling pets and farm animals <TextLink reference="61"></TextLink>, <TextLink reference="62"></TextLink>, <TextLink reference="63"></TextLink>, <TextLink reference="310"></TextLink>, <TextLink reference="311"></TextLink>, <TextLink reference="312"></TextLink>, <TextLink reference="313"></TextLink>, <TextLink reference="314"></TextLink>, <TextLink reference="315"></TextLink>, <TextLink reference="316"></TextLink> (see Tab. 6 and Compilation 1 in Attachment 1 <AttachmentLink attachmentNo="1"/>).</Pgraph><SubHeadline>2.2. Surveillance</SubHeadline><Pgraph>Please refer to the latest version of the KRINKO recommendations entitled &#8220;Nosocomial Infection Surveillance&#8221; <TextLink reference="317"></TextLink>. First and foremost, surveillance data should be used in house to reduce the NI incidence rate on a long-term basis, or keep it as low as possible, in the interests of patient safety <TextLink reference="317"></TextLink>, <TextLink reference="318"></TextLink>, <TextLink reference="319"></TextLink>, <TextLink reference="320"></TextLink>. External communication of particularly low infection rates is not the aim of NI surveillance <TextLink reference="318"></TextLink>, <TextLink reference="321"></TextLink>, <TextLink reference="322"></TextLink>. There has not yet been a conclusive study depicting the definite proportion of avoidable NI in immunosuppressed patients <TextLink reference="22"></TextLink>, <TextLink reference="318"></TextLink>. In a survey of 109 European Society for Blood and Marrow Transplantation (EBMT) centres published in 2015, only 21&#37; carried out prospective surveillance of catheter-related bloodstream infections (CRBSI) <TextLink reference="117"></TextLink>. KRINKO encourages the relevant medical professional associations to work with the National Reference Centre for the Surveillance of Nosocomial Infections on the continuous development of existing data acquisition modules for NI in immunosuppressed patients, increasing active participation among centres and including the use of anti-infectives <TextLink reference="93"></TextLink>.</Pgraph><Pgraph><Mark1>The KRINKO recommends:</Mark1> </Pgraph><Pgraph><UnorderedList><ListItem level="1">That haemato-oncology treatment centres carry out prospective surveillance of nosocomial infections (particularly bloodstream infections; the RKI currently only recommends such surveillance in association with the use of intravascular catheters. For severely immunosuppressed patients, however, surveillance includes other BSI (see definition B3 in ONKO-KISS &#91;haemato-oncology component of the nosocomial infection surveillance system&#93;).) as set out in the German Infection Protection Act (Infektionschutzgesetz, IfSG) <TextLink reference="323"></TextLink> and corresponding comments by the RKI <TextLink reference="324"></TextLink>, <TextLink reference="325"></TextLink>, <TextLink reference="326"></TextLink>, <TextLink reference="327"></TextLink>, <TextLink reference="328"></TextLink>, <TextLink reference="329"></TextLink>, <TextLink reference="330"></TextLink> (cat. IB). Without surveillance, it is impossible to confirm whether prevention measures taken in the department are effective and have a beneficial effect on certain indicator infections in the long term (e.g. prevention bundles for bloodstream infections and CDI).</ListItem><ListItem level="1">Regularly reporting NI surveillance results along with pathogen and resistance statistics for invasive infections back to the treatment team, discussing these results with them and, if necessary, specifying further infection prevention measures (cat. IV).</ListItem><ListItem level="1">Carrying out NI surveillance using definitions that have been adapted to the characteristics of the immunocompromised patient population <TextLink reference="330"></TextLink>, <TextLink reference="331"></TextLink>, <TextLink reference="332"></TextLink> (cat. II). </ListItem></UnorderedList></Pgraph><Pgraph>This includes consideration of neutropenia (incidence and duration) as the most established risk factor <TextLink reference="327"></TextLink>. During cytostatic chemotherapy, however, a substantial proportion of all NI occur when the patient is not neutropenic. It is therefore sensible to include data on BSI and CDI, for example, when patients are not neutropenic <TextLink reference="330"></TextLink>. In these patient groups, the ONKO-KISS module (patient-based surveillance after stem cell transplantation; <Hyperlink href="https:&#47;&#47;www.nrz-hygiene.de&#47;surveillance&#47;kiss&#47;onko-kiss&#47;">https:&#47;&#47;www.nrz-hygiene.de&#47;surveillance&#47;kiss&#47;onko-kiss&#47;</Hyperlink>) and the STATIONS-KISS module (ward- or department-based surveillance of device-related infections; <Hyperlink href="https:&#47;&#47;www.nrz-hygiene.de&#47;surveillance&#47;kiss&#47;stations-kiss&#47;">https:&#47;&#47;www.nrz-hygiene.de&#47;surveillance&#47;kiss&#47;stations-kiss&#47;</Hyperlink>; category: haemato-oncology) developed by the NRC are particularly suitable for NI surveillance. In general, the aim should be for hygiene professionals and haemato-oncologists to reach agreement <TextLink reference="333"></TextLink>, <TextLink reference="334"></TextLink>, <TextLink reference="335"></TextLink> about whether a BSI is a secondary event (after translocation from the gastrointestinal tract in cases of severe mucositis or GVHD, for example) <TextLink reference="265"></TextLink>, <TextLink reference="267"></TextLink>, <TextLink reference="268"></TextLink>, <TextLink reference="269"></TextLink>, <TextLink reference="270"></TextLink>, <TextLink reference="271"></TextLink>, <TextLink reference="272"></TextLink>, <TextLink reference="336"></TextLink>, <TextLink reference="337"></TextLink>.</Pgraph><Pgraph><Mark1>The KRINKO recommends:</Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">That NI caused by <Mark2>Legionella</Mark2> <Mark2>pneumophila</Mark2> or <Mark2>Clostridioides</Mark2> <Mark2>difficile</Mark2> and probable&#47;confirmed invasive fungal infections (and NI caused by pathogens with specific or multidrug resistance) also be recorded for patients who are not neutropenic <TextLink reference="338"></TextLink> (cat. IV, multidrug-resistant pathogens must be recorded pursuant to section 23 of the IfSG <TextLink reference="339"></TextLink>).</ListItem><ListItem level="1">That haemato-oncology treatment centres are allocated an appropriate number of hours for surveillance by hygiene professionals <TextLink reference="16"></TextLink> (no cat.).</ListItem></UnorderedList></Pgraph><SubHeadline>2.3. Microbiological screening of immunosuppressed patients</SubHeadline><Pgraph>Immunosuppressed patients often have comorbidities, a history of intensive contact with the healthcare system and in some cases extensive cumulative exposure to antibiotics (including certain reserve antibiotics <TextLink reference="93"></TextLink>). However, the prevalence of colonisation with multidrug-resistant bacteria (e.g. MRSA, VRE, MRGN) can vary considerably in the different subgroups of immunosuppressed patients <TextLink reference="340"></TextLink>, <TextLink reference="341"></TextLink>, <TextLink reference="342"></TextLink>, <TextLink reference="343"></TextLink>, <TextLink reference="344"></TextLink>, and the consequences of such colonisation for individual patients cannot be summarised in a common risk algorithm <TextLink reference="345"></TextLink>. In this respect, medical risk analysis and local epidemiology of infections caused by the relevant pathogens are particularly useful when deciding whether screening for certain MRP on admission helps to prevent infections <TextLink reference="118"></TextLink>, <TextLink reference="134"></TextLink>, <TextLink reference="135"></TextLink>, <TextLink reference="142"></TextLink>, <TextLink reference="143"></TextLink>, <TextLink reference="144"></TextLink>, <TextLink reference="148"></TextLink>, <TextLink reference="346"></TextLink>, <TextLink reference="347"></TextLink>, <TextLink reference="348"></TextLink>, <TextLink reference="349"></TextLink>, <TextLink reference="350"></TextLink>, <TextLink reference="351"></TextLink>, <TextLink reference="352"></TextLink>, <TextLink reference="353"></TextLink>, <TextLink reference="354"></TextLink>, <TextLink reference="355"></TextLink>. For patients who come from countries with an increased incidence of tuberculosis or have stayed in these countries in the last year, tuberculosis should be included in the differential diagnosis of cough, fever and enlarged mediastinal lymph nodes for infection prevention reasons <TextLink reference="356"></TextLink>, <TextLink reference="357"></TextLink>.</Pgraph><Pgraph><Mark1>The KRINKO recommends:</Mark1> </Pgraph><Pgraph><UnorderedList><ListItem level="1">Instead of general and undifferentiated MRP screening in immunosuppressed patients, preparing a local screening plan for colonisation with certain multidrug-resistant pathogens in consultation with hygiene professionals and the attending microbiology laboratory (cat. II). The KRINKO recommendations entitled &#8220;Recommendations for the Prevention and Control of Methicillin-resistant Strains of <Mark2>Staphylococcus aureus</Mark2> (MRSA) in Medical and Care Facilities&#8221; <TextLink reference="118"></TextLink>, &#8220;Hygiene Measures for the Prevention of Infections Caused by Enterococci with Specific Antibiotic Resistance&#8221; <TextLink reference="134"></TextLink> and &#8220;Hygiene Measures for Infections or Colonisation with Multidrug-resistant Gram-negative Bacteria&#8221; <TextLink reference="135"></TextLink>, <TextLink reference="358"></TextLink>, the medical risk analysis (patient population) and local multidrug-resistant pathogen epidemiology are the starting point for this.</ListItem><ListItem level="1">When interpreting pathogen and resistance statistics, paying special attention to infectious agents that show resistance to the antibiotics or antifungals used to prevent infection in the department <TextLink reference="246"></TextLink>, <TextLink reference="359"></TextLink>, <TextLink reference="360"></TextLink>, <TextLink reference="361"></TextLink>, <TextLink reference="362"></TextLink>, <TextLink reference="363"></TextLink>, <TextLink reference="364"></TextLink>, <TextLink reference="365"></TextLink>, <TextLink reference="366"></TextLink>, <TextLink reference="367"></TextLink>, <TextLink reference="368"></TextLink> (cat. II).</ListItem><ListItem level="1">Outside the agreed screening indications, refraining from routine microbiological cultures of patients and the environment if there is no suspicion of an infection or outbreak because random environmental controls do not have any measurable benefit <TextLink reference="369"></TextLink>, <TextLink reference="370"></TextLink>, <TextLink reference="371"></TextLink>, <TextLink reference="372"></TextLink>, <TextLink reference="373"></TextLink> (cat. IB); this excludes those prescribed by quality assurance laws and ordinances. </ListItem><ListItem level="1">Particularly in the winter months (November to April; influenza and RSV season), in addition to prompt diagnostic tests for symptomatic patients, considering screening patients in risk group 3 (see Table 1 <ImgLink imgNo="1" imgType="table"/>) for influenza and RSV on admission, for example with (R<TextGroup><PlainText>T-)</PlainText></TextGroup>PCR tests, because this makes it easier to identify immunocompromised patients who are already infectious but not (yet) symptomatic and has many implications for individual patients and hospital hygiene <TextLink reference="100"></TextLink>, <TextLink reference="101"></TextLink>, <TextLink reference="102"></TextLink>, <TextLink reference="103"></TextLink>, <TextLink reference="104"></TextLink>, <TextLink reference="112"></TextLink>, <TextLink reference="374"></TextLink>, <TextLink reference="375"></TextLink>, <TextLink reference="376"></TextLink>, <TextLink reference="377"></TextLink>, <TextLink reference="378"></TextLink>, <TextLink reference="379"></TextLink> (cat. II).</ListItem><ListItem level="1">In immunosuppressed patients with signs of atypical pneumonia, regular testing for <Mark2>Legionella</Mark2> (e.g. PCR testing of respiratory secretions in addition to the urinary antigen test) and, in the event of a positive result, informing hospital hygiene immediately, as even one nosocomial <Mark2>Legionella</Mark2> infection can indicate a nosocomial source of infection <TextLink reference="234"></TextLink>, <TextLink reference="380"></TextLink> (cat. II). </ListItem></UnorderedList></Pgraph><SubHeadline>2.4. Antimicrobial stewardship in immunosuppressed patients</SubHeadline><Pgraph>This falls within the responsibilities of the Commission on Anti-infectives, Resistance and Therapy (ART) afilliated with the Robert Koch Institute and medical professional associations <TextLink reference="381"></TextLink>, <TextLink reference="382"></TextLink>. The general information given here has been agreed with the ART. </Pgraph><Pgraph>Fundamentally, the hospital hygiene, infection prevention and <Mark1>antimicrobial stewardship (ABS)</Mark1> programmes followed in clinical practice have common goals that focus on patient protection (safety) and a continuous improvement in the quality of treatment <TextLink reference="142"></TextLink>, <TextLink reference="143"></TextLink>, <TextLink reference="144"></TextLink>, <TextLink reference="383"></TextLink>, <TextLink reference="384"></TextLink>, <TextLink reference="385"></TextLink>, <TextLink reference="386"></TextLink>, <TextLink reference="387"></TextLink>, <TextLink reference="388"></TextLink>. This is particularly true for the prevention, control and clinical management of infections caused by pathogens with specific or multidrug resistance. In immunosuppressed patients, such pathogens are particularly important when they cause clinically severe infections (e.g. sepsis). In such cases, it can be crucial for the spectrum of efficacy of empirical antibiotic treatment to include pathogens with specific resistance <TextLink reference="142"></TextLink>, <TextLink reference="143"></TextLink>, <TextLink reference="144"></TextLink>, <TextLink reference="148"></TextLink>, <TextLink reference="342"></TextLink>, <TextLink reference="346"></TextLink>, <TextLink reference="347"></TextLink>, <TextLink reference="348"></TextLink>, <TextLink reference="349"></TextLink>, <TextLink reference="350"></TextLink>, <TextLink reference="351"></TextLink>, <TextLink reference="361"></TextLink>, <TextLink reference="362"></TextLink>, <TextLink reference="388"></TextLink>, <TextLink reference="389"></TextLink>, <TextLink reference="390"></TextLink>, <TextLink reference="391"></TextLink>, <TextLink reference="392"></TextLink>, <TextLink reference="393"></TextLink>, <TextLink reference="394"></TextLink>, <TextLink reference="395"></TextLink>, <TextLink reference="396"></TextLink>, <TextLink reference="397"></TextLink>, <TextLink reference="398"></TextLink>, <TextLink reference="399"></TextLink>, <TextLink reference="400"></TextLink>, <TextLink reference="401"></TextLink>, <TextLink reference="402"></TextLink>, <TextLink reference="403"></TextLink>, <TextLink reference="404"></TextLink>, <TextLink reference="405"></TextLink>, <TextLink reference="406"></TextLink>, <TextLink reference="407"></TextLink>, <TextLink reference="408"></TextLink>, <TextLink reference="409"></TextLink>, <TextLink reference="410"></TextLink>, <TextLink reference="411"></TextLink>, <TextLink reference="412"></TextLink>, <TextLink reference="413"></TextLink>, <TextLink reference="414"></TextLink>. On the other hand, this must not lead to prolonged uncritical use of reserve antibiotics <TextLink reference="156"></TextLink>, <TextLink reference="415"></TextLink>, <TextLink reference="416"></TextLink>, <TextLink reference="417"></TextLink>, <TextLink reference="418"></TextLink>, <TextLink reference="419"></TextLink>, <TextLink reference="420"></TextLink>, <TextLink reference="421"></TextLink>. In haemato-oncology, professional associations have already developed comprehensive evidence-based guidelines for diagnosis and treatment in certain clinical situations involving infectious diseases, on which a local interdisciplinary ABS programme can be based. Immunosuppressed patients with a history indicating penicillin intolerance (but not clear immediate anaphylactic reactions) must undergo further evaluation to rule out a (very rare) penicillin allergy of the immediate type so as not to be unjustifiably denied the most effective treatment with penicillins or other beta-lactam antibiotics for their indication <TextLink reference="422"></TextLink>, <TextLink reference="423"></TextLink>, <TextLink reference="424"></TextLink>, <TextLink reference="425"></TextLink>, <TextLink reference="426"></TextLink>, <TextLink reference="427"></TextLink>, <TextLink reference="428"></TextLink>.</Pgraph><Pgraph>The prevention and treatment of invasive fungal infections in certain high-risk patients is another broad area in which enhanced <Mark1>antifungal</Mark1> <Mark1>stewardship</Mark1> <Mark1>(AFS)</Mark1> initiatives are now being developed with the help of national and international professional association guidelines <TextLink reference="429"></TextLink>, <TextLink reference="430"></TextLink>, <TextLink reference="431"></TextLink>, <TextLink reference="432"></TextLink>, <TextLink reference="433"></TextLink>, <TextLink reference="434"></TextLink>, <TextLink reference="435"></TextLink>, <TextLink reference="436"></TextLink>, <TextLink reference="437"></TextLink>, <TextLink reference="438"></TextLink>, <TextLink reference="439"></TextLink>, <TextLink reference="440"></TextLink>, <TextLink reference="441"></TextLink>, <TextLink reference="442"></TextLink>, <TextLink reference="443"></TextLink>, <TextLink reference="444"></TextLink>, <TextLink reference="445"></TextLink>. </Pgraph><Pgraph>Furthermore, staff specialising in hospital hygiene and infection prevention (and doctors with responsibility for hygiene) are increasingly taking advantage of ABS training opportunities <TextLink reference="446"></TextLink>, and therefore synergies exist in the personalisation of corresponding programmes (see Compilation 2 in Attachment 1 <AttachmentLink attachmentNo="1"/>).</Pgraph><Pgraph><Mark1>The KRINKO recommends (with the agreement of the Commission on ART): </Mark1></Pgraph><Pgraph><UnorderedList><ListItem level="1">That the medical professional associations in the <TextGroup><PlainText>AWMF</PlainText></TextGroup> continue with the progressive development and detailed formulation of existing guidelines on antimicrobial stewardship <TextLink reference="381"></TextLink>, <TextLink reference="382"></TextLink> for the different clinical areas in which immunosuppressed patients are treated so that the characteristics of this patient population are given proper consideration <TextLink reference="148"></TextLink>, <TextLink reference="270"></TextLink>, <TextLink reference="351"></TextLink>, <TextLink reference="408"></TextLink>, <TextLink reference="447"></TextLink>, <TextLink reference="448"></TextLink>, <TextLink reference="449"></TextLink>, <TextLink reference="450"></TextLink>, <TextLink reference="451"></TextLink>, <TextLink reference="452"></TextLink>, <TextLink reference="453"></TextLink>, <TextLink reference="454"></TextLink>, <TextLink reference="455"></TextLink>, <TextLink reference="456"></TextLink>, <TextLink reference="457"></TextLink>, <TextLink reference="458"></TextLink>, <TextLink reference="459"></TextLink>, <TextLink reference="460"></TextLink>, <TextLink reference="461"></TextLink>, <TextLink reference="462"></TextLink>, <TextLink reference="463"></TextLink>, <TextLink reference="464"></TextLink>, <TextLink reference="465"></TextLink>, <TextLink reference="466"></TextLink> (cat. II). The challenge is to identify distinct targets of ABS and AFS that are as specific as possible <TextLink reference="467"></TextLink> (see Compilatio<TextGroup><PlainText>n 2</PlainText></TextGroup> in Attachment 1 <AttachmentLink attachmentNo="1"/>) and implement sustainable ABS&#47;AFS strategies in clinical practice <TextLink reference="468"></TextLink>.</ListItem><ListItem level="1">When updating guidelines on the diagnosis and treatment of certain infections in immunosuppressed patients, focusing on aspects of ABS and AFS from a critical perspective and including them (no cat.).</ListItem><ListItem level="1">Developing common indicators for the quality of hospital hygiene and infection prevention structures, processes and results and for ABS&#47;AFS programmes in immunosuppressed patients <TextLink reference="469"></TextLink>, <TextLink reference="470"></TextLink>, <TextLink reference="471"></TextLink>, <TextLink reference="472"></TextLink>, <TextLink reference="473"></TextLink> (cat. II).</ListItem><ListItem level="1">Particularly in hospitals treating risk group 2 and 3 patients (see Table 1 <ImgLink imgNo="1" imgType="table"/>), setting up ABS programmes that meet medical professional association standards (AWMF guidelines) <TextLink reference="382"></TextLink> (cat. II). This also applies to paediatric haemato-oncology treatment centres and paediatric organ transplantation centres <TextLink reference="381"></TextLink> (cat. II).</ListItem></UnorderedList></Pgraph><Pgraph>These recommendations were produced on behalf of the Commission for Hospital Hygiene and Infection Prevention by Prof. Heike von Baum, Dr. Peter Bischoff, Prof. Dr. Maximilian Christopeit, Prof. Steffen Engelhart, Prof. Martin Exner, Prof. Thomas Lehrnbecher and Prof. Arne Simon (Head of the Working Party) on a voluntary basis and without influence from commercial groups. From the Robert Koch Institute, Dr. Eva Feuerhahn and Dr. Melanie Brunke were involved. 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