As a result of the COVID-19 pandemic, the WHO has called for surface hygiene to be carried out more frequently. Experts are again warning of a new risk of pandemic proportions: the global spread of multidrug-resistant pathogens. Intensifying surface disinfection would also be necessary here in light of poor compliance.

The most important facts:

• With the COVID-19 pandemic, surfaces potentially being a source of transmission also became a focus of preventative measures.
• Contaminated surfaces play a particularly important role in the transmission of multi-resistant bacteria.
• Only one third of the necessary surfaces in inpatient and outpatient health institutions are disinfected properly.
• After surface disinfection has been carried out, re-contamination with pathogens can reach the initial level again after just 1.5 to 2.5 hours.

In May 2020, the WHO called for surface hygiene to be carried out more frequently in health institutions to combat the COVID-19 pandemic. The role of inanimate surfaces in the transmission of SARS-CoV-2 has not yet been conclusively investigated. The WHO recommendations for intensifying surface hygiene are based on studies addressing other coronaviruses such as SARS-CoV and MERS-CoV. Contact surfaces have been identified as important sources of transmission for both coronavirus species.

Resistant germs on surfaces

With its recommendation, the WHO draws attention to surface hygiene as an important measure to prevent pathogen transmission. Inanimate surfaces have long been known as a source of transmission of pathogenic germs. In outbreak situations, contamination of the patient’s immediate surroundings is often detected. The main focus is on (resistant) pathogens such as C. difficile, MRSA, VRE, A. baumannii and noroviruses. Contaminated surfaces are significantly involved in the spread of gram-negative bacteria. For example, the risk of becoming infected with carbapenem-resistant A. baumannii increases 2.77-fold if the surrounding surfaces are contaminated.

Compliance with surface disinfection is lacking

Disinfecting the surfaces close to the patient can significantly reduce the risk of transmission of pathogens. Ideally, ready-to-use disinfectants or appropriately pre-soaked disposable wipes are suitable for this purpose. However, despite useful application solutions, compliance with surface hygiene is lacking according to studies: An investigation into the disinfection rate on surfaces with frequent hand and skin contact showed a rate of only 35 percent. At the same time, further studies show that the contamination of surfaces in intensive care units, e.g. with MRSA, quickly returns to the initial level after disinfection.

Conclusion:

Surface disinfection demands increased attention, and not just within the context of the COVID-19 pandemic. Surfaces in patient rooms with frequent hand and skin contact are, as of now, not disinfected to a sufficient level. To protect patients from dangerous germs such as gram-negative bacteria, surface disinfection in patient rooms must be intensified.

TIP: When it comes to surface disinfection, frequently touched surfaces in hospitals are often overlooked. Graphical representations of the individual rooms and the correct sequence for disinfection help to increase compliance.

 

Sources:
World Health Organization (2020). Cleaning and disinfection of environmental surfaces in the context of COVID-19. Interim guidance
Interim guidance 15 May 2020Klöcker U. (2015) Reinigung und Desinfektion im Krankenhaus. HYSIST, Düsseldorf
Kampf G. (2013). Flächendesinfektion. Krankenhaushygiene up2date
Hubert HA et al. (2012). Intrinsic bacterial burden associated with intensive care unit hospital beds: Effects of disinfection on population recovery and mitigation of potential infection risk. American Journal of Infection Control

COVID-19 has increased the willingness of employees to practice hand hygiene in health institutions. Much remains to be done to ensure that this trend continues and also results in falling infection rates, even after we’ve moved past COVID-19.

The most important facts:

• The increase in hand hygiene compliance at the start of the pandemic was a temporary phenomenon. The high compliance rates dropped again over time.
• The highest rates are recorded AFTER contact with a patient and are mainly driven by the desire to protect oneself rather than to protect patients.
• Gloves and long-sleeved clothing are important barriers to achieving good hand hygiene.
• Intervention programs to intensify hand hygiene are more efficient and sustainable than the threat of COVID-19.

100% hand hygiene compliance. What experts around the world hardly think possible has become reality at the National University Hospital in Singapore: Influenced by COVID-19, the staff’s willingness to disinfect their hands, which was already very good at 85%, rose to 100%. The largest hospital in the country, with 1,800 beds, evaluated the data both by measuring how much disinfectant was used and also by directly observing all “5 Moments for Hand Hygiene.” Several studies report increased hand disinfection rates among hospital staff in the early stage of the pandemic.

From a standard procedure to a daily habit?

Could hand hygiene, a standard procedure, have become a daily habit that people do without thinking thanks to the COVID-19 pandemic? According to the studies, the picture is rather mixed. In some studies, hand hygiene increased significantly at the start of the pandemic, but then decreased again and often even settled at a rather low level. It’s also worth comparing the moments when hand disinfection is carried out. From September 2019 to November 2020, Huang et. al investigated hand hygiene compliance in an infectious disease ward with 25 single rooms using an electronic monitoring system with a sensor. Time points for observing compliance were when entering the room, when providing care at the patient’s bedside and when leaving the room.

Patient protection was not the main focus

The authors found that the rate of hand hygiene upon entering the room, interpreted as the “before patient contact” moment, decreased over time. Compliance when leaving the room, interpreted as the “after patient contact” moment, increased by 13.73% during the first wave of COVID-19, decreased by 9.87% during the post-lockdown period, and then increased again by 2.82% during the second wave of the pandemic. The authors believe that the most important factor in the increase in hand hygiene was the employees’ desire to protect themselves from infections. Marie Stangerup’s team found out that the compliance rate is falling again despite the fact that the pandemic has not been declared over: A research team from Denmark conducted an observational study on a surgical ward between January 2019 and December 2020. One phase of the study consisted of an intervention program with employee meetings and presentations and discussions of anonymous hand hygiene compliance data. The analyses showed that hand hygiene compliance was at 58% during the intervention program that was run prior to the pandemic but dropped to 34% during the pandemic.

Conclusion:

Interventions and feedback remain indispensable tools to ensure that improvements in hand hygiene do not drop again. Employees quickly fall back into old routines as soon as intervention programs are stopped. On top of this, to ensure a high level of hand hygiene compliance, the management teams must remain committed to the issue of hand hygiene.

TIP: To achieve good hand hygiene, the basic conditions must also be right: Studies show that there is still room for improvement when it comes to placing dispensers at the point of care.

Checklists: Proper placement of dispensers at the point of care

1.) Dispenser placement in the OR

2.) Dispenser placement in the ER

3.) Dispenser placement in ICU

4.) Dispenser placement in General Wards

Sources:
Huang F et al. (2021) Journal of Hospital Infection 111: 27.-34
Moore LD et al. (2021) American Journal of Infection Control 49: 30−33
Stangerup M et al. (2021American Journal of Infection Control 49: 1118-1122
Thomas BW et al. (2009). JAOA; 109 (5): 263-267
Azim S et al. (2016). American Journal of Infection Control; 44 (7):772-776

Measures implemented to protect against the coronavirus in hospitals also reduce other nosocomial agents. One study shows that MRSA rates can even be halved.

Surveillance data from the largest hospital in Singapore, with 1,800 beds, show that infection protection measures implemented to prevent COVID-19 can also prevent other nosocomial infections.

The most important findings at a glance:

• High compliance rates in hand hygiene, upping surface hygiene and handling personal protective equipment correctly significantly reduce MRSA and catheter-associated bloodstream infections in particular.
   
• This study shows that compulsory social distancing and mask-wearing reduces nosocomial viral respiratory infections, which are responsible for severe courses of illness and intensive care.
   
• Other multidrug-resistant agents such as carbapenemase-forming/carbapenem-resistant Enterobacteriaceae and Clostridioides difficile can be kept stable despite high levels caused by the pandemic.

Success formula: Surveillance and reinforced infection control

We are not yet certain if upping our infection protection measures in the context of the coronavirus pandemic also reduces other hospital infections. This is due to a particular lack of comparative data before and during the pandemic. Now we have new evidence to suggest the coronavirus measures have a positive influence in reducing other hospital germs, provided by data from the largest hospital in Singapore. The 1,800-bed clinic established stringent infection protection measures from February to August 2020. The hospital maintained surveillance of important hospital agents and infections during this period.

The following nosocomial agents were monitored, among others:

• Respiratory viral infections caused by agents such as human metapneumovirus (HMPV), respiratory syncytial virus (RSV), rhinovirus A/B/C, influenza virus A/B, human parainfluenza virus (HPIV), human coronavirus (hCoV)
   
• Methicillin-resistant Staphylococcus aureus (MRSA)
   
• Carbapenemase-forming, carbapenem-resistant Enterobacteriaceae (CP/CRE)
   
• Clostridioides difficile
   
• Device-associated infections (urinary tract infections, bloodstream infections, ventilator-associated pneumonia)

 

Multi-stage infection control program

With the occurrence of the first SARS-CoV-2 case in January 2020, the Singapore hospital established a multi-level prevention strategy:

• Isolation of patients with symptoms of respiratory disease and a minimum social distance of 1.5 m between beds
   
• Universal compulsory mask-wearing for personnel, initially ordinary face masks, later FFP2 masks
   
• Upping the surface disinfection in the environment surrounding the patient to 3 x daily
   
• Surveillance of surface disinfection with fluorescent markers
   
• Intensifying hand hygiene
   
• Personal protective equipment (gowns, gloves) for health workers; and cleaning staff including training on how to properly wear it

 

Positive effects for patient safety

• Viral respiratory diseases

The greatest positive effect was seen in the decrease in nosocomial viral respiratory infections. The incidence decreased from 9.69 cases per 10,000 patient stay-overs before the infection control program was introduced to 0.83 cases per 10,000 patient stay-overs. Viral respiratory diseases are often an underestimated cause of severe hospital-acquired pneumonia that eventually requires intensive care.

• MRSA

The MRSA rate also developed in a positive way. Before the pandemic, it was 11.7 cases per 10,000 patient stay-overs, compared to 6.4 cases per 10,000 patient stay-overs during the pandemic. Nosocomial bacteraemia caused by MRSA decreased from 0.36 cases per 10,000 patient stay-overs to 0.11 cases per 10,000 patient stay-overs.

• Catheter-associated bloodstream infections

For catheter-associated bloodstream infections, the authors of the study recorded a decrease from 0.83 cases per 1,000 days a catheter was used (95 incidents, 113,466 days a catheter was used) to 0.20 incidents per 1,000 days a catheter was used.

• CP-CRE and other nosocomial agents

Despite the interruptions to the daily running of the clinic caused by the pandemic, CP-CRE and C. difficile rates remained stable. The authors assume that upping alcohol-based hand disinfection was not successful to the same extent with C. difficile as it was with MRSA, since hands must be washed as well as sanitized. For CP-CRE, it’s mainly hospital sinks and drains that serve as reservoirs. Surface hygiene during the COVID-19 pandemic focused in particular on frequent disinfection of the environment surrounding the patient as well as frequently touched surfaces. A less frequent usage of sanitary areas could have led to CP-CRE persisting in sinks and drains.

Despite these limitations, the positive effects of the coronavirus prevention measures should not be underestimated and should not be taken for granted: for example, during the first SARS outbreak in 2003, there was an increase of MRSA in a Hong Kong hospital intensive care unit that cared for SARS patients. Resistant agents increased from 3.53% in the pre-SARS period to 25.30% during the SARS period and then decreased again to 2.21% in the post-SARS period. The rate of ventilator-associated pneumonia was also high at 36.5 episodes per 1,000 days on a ventilator.

 

Sources:

1. Liang En Ian Wee et al. Unintended consequences of infection prevention and control measures during COVID-19 pandemic. American Journal of Infection Control 2021; 49:469−477. 
https://www.ajicjournal.org/article/S0196-6553(20)30963-9/pdf
 (Letzter Zugriff 13.06.2021).

2. Yap FHY et al. Increase in Methicillin-Resistant Staphylococcus aureus Acquisition Rate and Change in Pathogen Pattern Associated with an Outbreak of Severe Acute Respiratory Syndrome. Clinical Infectious Diseases 2004; 39:511–6.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204093/ 
(Letzter Zugriff 13.06.2021).

Regularly opening windows or an efficient ventilation system can significantly reduce airborne coronaviruses in hospitals and other facilities, according to the experts.

So-called aerosols are one of the main transmission routes of COVID-19. The solid or liquid particles in the air that we exhale provide the viruses with a convenient “means of transport”. These particles remain in the air for a long time and can spread throughout the entire room in a matter of minutes. At the same time, just the heat emitted by the human body is sufficient to keep the virus-containing particles suspended in the air.

Ventilation concepts to reduce the viral load

The “Aerosols Expert Group” carried out an investigation into which ventilation methods can reduce the concentration of coronaviruses in, for example, patient rooms and waiting areas. This group of scientists includes the Deputy Chair of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI), Prof. Dr. med. Heike von Baum.

In practice, it is not possible to actually measure the viral load in the air in a room. However, one way to track the virus-carrying aerosols is by measuring the air quality by means of the CO₂ concentration. Although the amount of carbon dioxide emitted does not provide a specific measure of the number of virus particles, a low CO₂ content is nevertheless indicative of a smaller aerosol load.

The expert panel of engineers, scientists and physicians recommends indoor air quality with a CO₂ concentration of less than 800 parts per million (> 800 ppm). According to the scientists, this technical guide value is currently the best means of assessing the amount of aerosols in a room.

The CO₂ level, and therefore the viral load, in the air can be reduced by:

• Opening windows
• Ventilation and air conditioning (VAC) systems
• Air purifiers (in addition)

This is how the experts of the Aerosols Working Group evaluate the various ventilation concepts:

5 facts about ventilation by opening windows 

1. Tilted windows only have a limited ventilation effect.
    
2. The required air flow can only be achieved by pulse ventilation (windows wide open for short periods) or cross-ventilation with windows/doors on opposite sides of the room.
    
3. Low outside temperatures reduce the ventilation time required. Example: a 20 m² room with an open window takes 3 minutes to ventilate at outside temperatures between 0°C and -10°C. At 15°C, it would take twice as long.
    
4. This type of natural ventilation is not appropriate everywhere, as it can cause a major temperature drop in the room, which affects the well-being of the occupants. Windows fitted with security restrictors are another factor.
    
5. If there are several people infected with SARS-CoV-2 in the room, ventilation has only a limited effect.

 

5 facts about ventilation and air conditioning systems (VAC)

1. VAC systems use fans to draw in outside air, then filter it and adjust its temperature before blowing the conditioned incoming air through openings into the room.
    
2. If the openings are placed appropriately, a large-volume, room-wide air flow is created, regardless of the outdoor temperature.
    
3. Aerosols are also removed from the room with the extracted air.
    
4. VAC units should be operated without recirculation and should be equipped with filters.
    
5. So-called HEPA (High Efficiency Particulate Air) filters with an efficiency of >99.95% or >99.995% are recommended. These have a H13 or H14 (outdated) rating, as well as classes ISO 35 H or ISO 45 H.

 

5 facts about air purifiers

1. Air purifiers have a fan that draws in the indoor air, passes it through filters and returns it to the room as purified air.
   
   
2. These portable devices can reduce or keep the viral load low over time.
   
   
3. But even air purifiers are not a substitute for the “hands, face, space” + ventilation rule. If two people come together in a room without wearing masks and social distancing, they will be exposed to aerosols even if an air purifier is used.
   
   
4. The device must be large enough and suitably equipped. The decisive factor is the clean air delivery rate (CADR) rather than the filtering efficiency.
   
   
5. Limiting factors for their use are power consumption, noise emission and maintenance costs.

 

Proper ventilation of patient rooms during the coronavirus pandemic at 20 m²

Download graphic

Proper ventilation of patient rooms during the coronavirus pandemic at 40 m²

Download graphic

 

Sources:

Dittler A et al. (12/2020). Stellungnahme: Aerosole&SARS CoV2 – Entstehung, Infektiosität, Ausbreitung & Minderung luftgetragener, virenhaltiger Teilchen in der Atemluft. (Letzter Zugriff 02.02.2021) https://www.baden-wuerttemberg.de/fileadmin/redaktion/m-mwk/intern/dateien/Anlagen_PM/20201204_Stellungnahme_Aerosole_SARS_CoV2.pdf

Positionspapier der Gesellschaft für Aerosolforschung zum Verständnis der Rolle von Aerosolpartikeln beim SARS-CoV-2 Infektionsgeschehen vom 07.12.2020. Letzter Zugriff 02.02.2021. https://www.tropos.de/aktuelles/pressemitteilungen/positionspapier-der-gaef-zum-verstaendnis-der-rolle-von-aerosolpartikeln-bei-covid-19

Emergency departments are facing enormous challenges during the coronavirus pandemic. A new triage model at the Göttingen-Weende Hospital ensures early detection of COVID-19 as well as patient isolation. This efficient risk stratification also succeeds in protecting vulnerable groups in all areas of the hospital.

How can an emergency department (ED) with around 30,000 emergencies per year operate efficiently in the context of SARS-CoV-2 while ensuring protection against nosocomial spread of the pathogen? Marc Wieckenberg, Head Physician of the ED at the Evangelisches Krankenhaus Göttingen-Weende, and his colleagues answered this question with a model for risk stratification of suspected SARS-CoV-2 and COVID-19 cases [1]. Based on the epidemiological criteria of the Robert Koch Institute and internal case definitions, the emergency physicians defined five risk categories.

COVID-19 risk categories I-V:
RK I = Confirmed SARS-CoV-2 infection
RK II= COVID-19 Reasonable Suspicion
RK III=COVID-19 Differential diagnosis
RK IV= COVID-19 19 Low probability
RK V = COVID-19 No suspicion

Aim: Comprehensive protection against infection

A standardized treatment procedure for emergency diagnostics and therapy has been established for all emergency patients on the basis of the system of risk categories I-IV. This procedure is used to strictly separate COVID-19/non-COVID-19 emergencies, thereby protecting staff and patients against nosocomial infection. The focus is on particularly vulnerable groups, such as patients with risk factors including advanced age, immunodeficiency, lung, heart and kidney diseases and malignancies.

In order to establish risk stratification, considerable structural changes within the hospital building were necessary, for example to enable CT and conventional X-ray diagnostics for accident victims with an increased risk of COVID-19. The changes were implemented by measures such as

• Installing a walk-through tent to protect waiting patients from the weather
• Expanding the available space by means of movable partitions
• Integrating the trauma room CT into the isolation area
• Separating the isolation ED from the routine ED by means of a rolling grille and airlock system
• Relocating the main entrance and closure of all side entrances
• A Plexiglas-protected space for patient interviews and administration

Standardized procedure for all emergency patients

Risk stratification becomes the central means of controlling patient flows in the ED by linking the respective risk category to criteria such as

• Symptoms and/or occupational group
• Specific hygiene protection measures
• Specific treatment room within the ED
• Specifying the room used for further inpatient care

Treatment Procedure in the ED

Download infographic [PDF]

Treatment Procedure in the Emergency Department

1. Initial coronavirus screening by the doctor in charge and the ED nurse according to the dual-control principle.
2. Determining the COVID-19 risk status. 
3. Triage using the Manchester Triage System (MTS) to determine the urgency of treatment.
4. Allocation of the primary, appropriately labeled treatment and isolation site in the ED.
5. Determining hygiene protection measures according to risk category.
6. Emergency diagnostics (vital signs, laboratory diagnostics, nasopharyngeal swab/gargle test, thoracic ultrasound, low-dose CT in cases of reasonable suspicion).
7. Re-evaluation of the COVID-19 risk status if the patient is to be hospitalized.
8. Selection of the appropriate ward according to risk category:

RC I = COVID-19 ward NC/IMC/ICU
RC II and RC III = suspected COVID-19 ward NC/IMC/ICU
RC IV and RC V = Pre-isolation NC/IMC/ICU
(Barrier measures; no further functional diagnostics until test result)

Source:

Wieckenberg M, Meier V, Pfeiffer S, Blaschke S. Risikostratifizierung von Notfällen während der COVID-19-Pandemie in der Zentralen Notaufnahme. Med Klin Intensivmed Notfmed, Springer, https://doi.org/10.1007/s00063-020-00748-2. Eingegangen: 4. Juni 2020. Überarbeitet: 21. August 2020. Angenommen: 12. September 2020.

A recent study review indicates that SARS-CoV-2 can remain infectious on glass, e.g. mobile phone and tablet displays, for up to 28 days at 20°C. This means that there is a significant risk of transmission of the viruses to the hands of staff and from there to other surfaces or persons.

EThe risk of SARS-CoV-2 transmission comes principally from aerosols. Studies have shown that the viruses can remain infectious in tiny droplet particles for longer than 3 hours. The role of surfaces contaminated with SARS-CoV-2 in the spread of the virus is not yet fully understood, but there are many documented cases of cross-contamination with other viruses. The transmission rate of noroviruses from contaminated surfaces to the hands, for example, is put at 40% in one study [1]. Surfaces with frequent skin and hand contact, such as touchscreens of smartphones, buttons for operating vending machines or elevators, as well as surfaces in the proximity of patients, are often found to be contaminated with viruses and bacteria.

Risks from smartphones underestimated

Current studies by Ridell et al. on the survivability of SARS-CoV-2 on glass and plastic show that the viruses remained infectious for up to 28 days at 20°C [2]. Displays of digital devices thus pose a potential transmission risk. However, the risk of infection from mobile devices is underestimated by health workers. Only about 8% of doctors who use their smartphones frequently disinfect them regularly.

Therefore, it is essential that electronic devices are not neglected in the daily disinfection of surfaces in the proximity of patients.

As an element of patient care, these surfaces should be wipe-disinfected at least once a day with a suitable surface disinfectant:

Work surfaces	Treatment couches	Bed frames	Monitors	Displays	Keyboards	Control panels

Winter viruses and how they differ

In addition to SARS-CoV-2, other highly infectious viruses such as noroviruses and influenza viruses must also be increasingly expected in the winter months. While SARS-CoV-2 and influenza viruses, as enveloped viruses, are easily inactivated using disinfectants with “limited spectrum virucidal activity”, noroviruses require disinfection with products in the “limited virucidal activity PLUS” category. You can find out more about the differences between the viruses in our infographic “Viruses in comparison”.

Download infografic [PDF]

Sources:

1. Kampf G. Flächendesinfektion. Krankenhaushygiene up2date 8; 2013. DOI http://dx.doi.org/10.1055/s-0033-1359050
2. Riddell, S., Goldie, S., Hill, A. et al. The effect of temperature on persistence of SARS-CoV-2 on common surfaces. Virology Journal 17, 145 (2020).

Preparations for the first phase of the COVID-19 vaccination campaign via vaccination centers and mobile vaccination teams are in full swing. The vaccination process takes about an hour per person, according to estimates by organizers such as the Technisches Hilfswerk. A large part of that time is spent on registration and the necessary documentation plus the 30-minute waiting period under medical supervision. The actual vaccination requires systematic hygiene measures, especially for high-risk patients. Our chart shows what is important to remember.

Vaccinations such as the influenza or COVID-19 shot are aseptic procedures. Before, during and after vaccination, care must be taken to sterilize the skin at the spot where the vaccine is injected so as to prevent transfer or penetration of harmful germs into the body. Preventing such transfer of germs is particularly important in the planned first phase of COVID-19 vaccination, since the people first in line for vaccination will belong to the vulnerable risk groups.

The hygiene steps that need to be observed in connection with COVID-19 vaccination are shown in an easy-to-follow chart.

Download the chart

 

Sources::

Impfung gegen COVID-19: Erst Zentren – dann Praxen. Dtsch Arztebl 2020; 117(50): A-2449 / B-2065

Anforderungen an die Hygiene bei Punktionen und Injektionen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut (RKI). Bundesgesundheitsbl 2011 · 54:1135–1144.

Current studies from England are showing that the risk of being infected with SARS-CoV-2 is high in healthcare facilities. One of the studies shows that the mortality rate of COVID-19 patients who become infected in hospital is lower than in patients admitted to hospital who had already contracted COVID-19.

According to the National Health Service England (NHS), currently 17.6% of COVID-19 infections in England are most likely due to infection in healthcare facilities. In the North West of England the rate is up to 25% and it is rising further in other parts of the country. Healthcare-associated COVID-19 infection in hospitals is defined by the NHS as being present when the diagnosis is made 7 days after admission. [1]

These figures are supported by a study conducted by King’s College London. According to the survey, at least 12.5% of COVID-19 hospital patients became infected with the coronavirus during their stay in hospital. The majority of the affected patients had been in hospital for a long time already. In the study, an infection was defined as acquired in hospital if it occurred 15 days after patient was admitted. [2]

Importance of timely clinical treatment

The King’s College study also compared the treatment outcomes of COVID-19 patients infected outside of hospital with those who had contracted the infection in hospital. The result: Taking into account age, pre-existing health conditions and the severity of the infection, those who became infected in hospital were less likely to die than comparable patients who became infected outside of hospital. [2]

The researchers suspect that the better outcomes for patients infected with coronavirus in hospital can be attributed to closer monitoring, faster diagnosis and timely clinical treatment. According to experts, the results also suggested that patients who became infected in hospital recovered better than patients who had already been hospitalized with a COVID-19 infection due to the rapid clinical treatment they received. [2]

Sources:

1.Heneghan C, Howdon D, Oke J, Jefferson T The Ongoing Problem of UK Hospital Acquired Infections
October 30, 2020, https://www.cebm.net/covid-19/the-ongoing-problem-of-hospital-acquired-infections-across-the-uk/ (Letzter Zugriff am 03.11.2020).

2. Carter et al. (2020) Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial study (COVID in Older People). Journal of Hospital Infection. DOI: 10.1016/j.jhin.2020.07.013.

COVID-19 patients have an increased risk of contracting bacterial co-infections. Triggers of this may include oral bacteria that accumulate in the oral cavity. They can spread from there to other areas of the body and cause infections. Older people are particularly vulnerable. In order to guard against this, it is important to practice thorough oral hygiene.

Viral respiratory tract infections make patients more susceptible to bacterial co-infections. [1] The co-infections in turn lead to increased disease severity and mortality. A Chinese study demonstrates that during the coronavirus pandemic, 50% of deceased COVID-19 patients had concurrent, secondary bacterial infections. [2] Another Chinese study identified both bacterial and fungal co-infections. [3]

Oral bacteria as triggers of co-infections

The development of co-infections in COVID-19 patients is promoted by oral bacteria that spread throughout the body. Analyses of genomic material from patients with SARS-CoV-2 showed high values of cariogenic and periodontal pathogenic bacteria. This confirms the view that there is a link between the oral microbiome and COVID-19 complications. [4]

In addition, there is evidence that periodontal pathogenic bacteria are involved in the onset and development of respiratory diseases associated with COVID 19. Moreover, these bacteria are associated with chronic-inflammatory systemic diseases including type 2 diabetes, hypertension and cardiovascular diseases. These diseases are therefore often comorbidities, which increase the risk of severe complications and death in cases of COVID-19. [4]

Oral hygiene is particularly important for the elderly

In contrast, other studies demonstrate that the clinical outcomes considerably improve and the mortality decreases for patients suffering from pneumonia when they implement improved oral hygiene. [5] One in ten pneumonia-related deaths among elderly care home residents aged 65 years and older are deemed avoidable thanks to improved oral hygiene. [6]

Conclusion: These connections illustrate just how important thorough oral hygiene is for infection prevention. Good oral hygiene is particularly vital for older patients and residents in nursing facilities in order to reduce the germs in the oral cavity and to prevent the spread of oral bacteria to other parts of the body.

Sources:

1. Cox M J et al. Co-infections: potentially lethal and unexplored in COVID-19, Correspondence.
www.thelancet.com/microbe Vol 1 May 2020.

2. Zhou F. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054–62.

3. Chen N et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507–13.

4. Patel J / Sampson V The role of oral bacteria in COVID 19, Correspondence. www.thelancet.com/microbe Vol 1 July 2020.

5. Manger D et al. Evidence summary: the relationship between oral health and pulmonary disease. Br Dent J 2017; 222: 527–33.

6. Sjögren P et al. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56: 2124–30.