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Medicine meets technology - Only through planning we can reach this goal With new concepts, cleanroom technology is returning to its roots - the fight against germs in hospitals.
Thanks to better hygiene and lower energy consumption, healthcare costs are reduced. How does a hospital become microbiologically and energy technologically optimized? As with all major projects, thorough planning is essential. When it comes to disease-causing germs, we fear the unknown, the distant and the foreign. Unhygienic conditions therefore do not prevail here, but elsewhere, for example in Asia. From there, threatening killer germs regularly seem to make their way to us. Since the year 2000 we have been afraid of the SARS coronavirus (Severe Acute Respiratory Syndrome), of the bird flu virus H5N1, of the swine flu virus A(H1N1) pdm09 and now of the Coronavirus SARS- CoV-2 (COVID-19). Global pandemics are a recurring horror scenario in the consciousness of the world.
But why wander into the distance when the evil is so near? From the common world germ to the antibiotic-resistant death bacterium, threatening microorganisms can be found in unacceptably large quantities here in Germany where weakened and wounded people are particularly susceptible to infections: in hospitals.
15.000 deaths from hospital infections
The topic does not receive attention in the sad rule case, but only in the scandalous exception case. The horror was great when in recent years premature babies and babies died in clinics in Berlin, Bremen, Mainz and Passau were exposed to intestinal bacteria such as Escherichia Hermannii, Enterobacter cloacae and Serratia marcescens. Their immune system was still too weak to defend itself against micro-organisms that should have been kept away from them. The causes are then searched for: In Mainz the nutrient solution was contaminated; what was in Bremen and Berlin? finally an outcry of the media and everything is forgotten again.
The tragic cases in neonatal wards are counted annually by around 15.000 deaths due to infections in hospitals. Every year between 400.000 and 600.000 patients are infected in hospitals, estimates the Federal Ministry of Health. So many people catch a disease with the hospital germs that they did not have when they were admitted (nosocomial infection). Statistically speaking, this means that about 3 percent of all patients treated in hospital are affected.
According to official statements, about 3 percent of these patients succumb to
the infection. approximately each bed in the 2.000 German hospitals is occupied
for four days a year by a patient who has become infected in the hospital.
There has been speculation about the level of these figures for a long time, as only estimates are circulating due to a lack of precise reporting obligations.
The dark figures range from 7.500 to 40.000 annual deaths. Current results of the
"Alerts Study" at the University Hospital Jena, which is funded by the Federal Ministry of Research, now suggest that the order of magnitude of 600.000 infected persons in Germany is quite realistic.
According to the study, around 4 percent of patients in Jena were infected with hospital germs in the first half of 2012.
1 Bundesministerium für Gesundheit, 2011, Zwischenbericht DART Deutsche Antibiotika- Resistenzstrategie, URL: http://www.bmbf.de/pubRD/Zwischenbericht_DART.pdf1 Bei einer durchschnittlichen Behandlungszeit pro Fall von 4 Tagen
(RKI, 2008, URL: http://www.gpk.de/downloadp/STIKO_2008_Bulletin34_080822_Aktion_Saubere_Haende.pdf) und502.00 Betten (Krankenhausstatistik 2011 des Statistischen Bundesamts)1 7.500: Bundesministerium für Gesundheit, 2011 Zwischenbericht DART Deutsche Antibiotika- Resistenzstrategie; 40.000: Deutsche Gesellschaft für Krankenhaushygiene, Sprecher Klaus-Dieter Zastrow.1 Uniklinikum Jena, 2012, URL: http://www.uniklinikum jena.de/Startseite/Aktuelles_Presse/Presse/Aktuelle+Pressenews/Krankenhausinfektionen_+Erstmals +klinikweite+Langzeitzahlen-pos-.html
The fear of pandemics - these are worldwide epidemics - keeps us in suspense again and again. In the last century there have been a number of such epidemics: since the Spanish flu of 1918/19 there has been Asian flu, Russian flu and twice Hong Kong flu. Every year the fear of influenza encourages many Germans to
vaccinate. However, what receives little attention after the respective wave of
fear has subsided is an assessment of how bad it really was. This shows that
the public's perception seems somewhat distorted.
Warnings of potential pandemic pathogens are certainly not harmful, especially if they leadto more protective measures. It would make even more sense if the dangers of infections were given similar attention in German hospitals. With around 600,000 infections, around 15.000 people fall victim to these infections - year after year (see text).
1 WHO, 2012, URL:
1 Robert-Koch-Institut, 2011, URL: http://www.rki.de/DE/Content/InfAZ/I/Influenza/IPV/faq_grippe_tab_ges.html
1 Robert-Koch-Institut, 2012, Bericht zur Epidemiologie der Influenza in
Deutschland Saison 2011/12, Berlin
It is by not always multi-resistant germs (MRSA - methicillin-resistant
Staphylococcus Aureus) that are responsible for the diseases. They are only
particularly dangerous because antibiotics are often no longer effective
against them. The failure of hygiene in hospitals is demonstrated by many
microbiological examples, such as noroviruses, salmonella enteritidis or
legionella pneumophilia. The latter can be transmitted through the air and
ventilation systems in aerosol droplets and thus reach the lungs. Other germs
get into the body through open wounds, others through food.
In most cases, individual elements of hospital operations are pilloried in their
search for the causes: employees have probably not washed their hands
regularly. There, a batch of medicine mixed in the hospital pharmacy had
failed. Sometimes the cold chain was interrupted, sometimes the ventilation was
not in order. And of course, it makes one think that, according to the Federal
Ministry of Health, only 65 certified hygienists are employed at the
approximately 2,000 hospitals in Germany. As varied as the causes may be, they
can be clearly determined for each case: The hospital's quality management is
always to blame.
This applies to buildings, building services, operating theatres, equipment,
medicines, nursing care, suppliers, personnel and visitor behaviour. None of
these building blocks that make up a hospital can serve as the sole explanation
if nosocomial infections occur. Only those who understand how the parts mesh
together can recognise faulty patterns that need to be corrected for the
benefit of patients and employees. It is a matter of viewing hospital work as a
plannable process - no more and no less.
"Preventive measures could prevent a significant proportion of infections and deaths," says the German Antibiotics Resistance Strategy of the Federal Ministry of Health.
The roots of cleanroom technology lie in medicine. Even the Hippocratic doctors of antiquity knew that cleanliness and tidiness were of fundamental importance in the fight against disease. However, the topic of sterility reached a scientific level in the 19th century.
The English surgeon Joseph Lister (1827-1912) introduced antisepsis. In order to prevent infections, he pursued the goal of rendering pathogens harmless at the site of the medical operation and therefore disinfected open wounds with carbolic acid dressings. It seemed illusory to him to keep the germs away from the surgical site beforehand. Like many others at the time, he started from the idea that the disturbing germs simply went everywhere anyway. The idea of asepsis went a step further, and the Austro-Hungarian gynecologist Ignaz Philipp Semmelweis (1818-1865) introduced hospital hygiene on the basis of it. The aim was to keep all pathogens away from the scene during medical work. He had recognized that the germs spread via the instruments used and the personnel involved. As a countermeasure, he prescribed cleaning, disinfecting and sterilizing procedures, as well as the steam and hot air sterilization processes still used today. Asepsis was a very important step forward; the successes could not be overlooked. Semmelweis was soon called the "mother's savior" because,
thanks to his disinfection measures, the cases of childbed fever caused by
bacteria were significantly reduced.
At that time, however, it was still unknown that impurities could also be transported through the air. Suspended particles with dimensions in the micro- and nanometer range, which practically follow the air movements, can transport bacteria, spores, viruses or other biological substances - in part, the suspended particles themselves are the pathogens. Robert Koch and Louis Pasteur, pioneers in the field of microbiology, found explanations for the transmission of pathogens. Pasteurisation" is based on the discovery that bacteria are killed by heating them up to 65°C to 80°C. The bacteria are then killed by the heat.
The effort for cleanliness in the service of health soon extended beyond the hospitals. Since the pharmaceutical industry has developed preparations that are injected directly into the body and therefore cannot be sterilized before use in
hospitals, the production environments have also been put to the test outside
hospitals. Such preparations, for example sera, vaccines and antibiotics, must
be processed under secure conditions throughout the entire production chain.
The production of pure active ingredients and drugs therefore required sterile
working conditions. This realization, accompanied by developments in
microbiology and physical measurement technology, led to advances in cleanroom technology. Since then, cleanroom specialists have been striving to
hermetically seal the cleanroom in order to protect the critical workplaces
from unwanted contamination from the environment. In pharmaceutical and medical technology production lines this is more successful today than in the operating theatres of hospitals. There is still a long way to go before any contamination can be ruled out - and today this is by no means consistently pursued to the end.
follow our next article that will describes how these preventive measures can be implemented in hospitals according to the current state of the art in science and technology.