title: Cross-border comparison of the Dutch and German guidelines on multidrug-resistant Gram-negative microorganisms.
abstract: BACKGROUND
  In all European countries, hospital-acquired infections caused by Gram-negative multidrug-resistant microorganisms (GN-MDRO) are a major health threat, as these pathogens cannot be adequately treated anymore, or the start of effective antibiotic treatment is delayed. The efforts to limit the selection and spread of GN-MDRO remains a problem in cross-border healthcare, as the national guidelines on hygiene standards applicable for patients colonized or infected with GN-MDRO in hospitals are not harmonized between European countries.
  
  
  METHODS
  In order to point out the similarities and differences in the national guidelines of Germany and The Netherlands regarding GN-MDRO, guidelines were compared and an expert workshop was organized by the INTERREG IVa project EurSafety Health-net.
  
  
  RESULTS
  Both guidelines divide the Gram-negative organisms into subgroups based on bacterial species and antibiotic susceptibility patterns in order to define multidrug-resistant variants of these bacteria. However, the Dutch guideline defines that GN-MDRO Enterobacteriaceae requires testing for certain mechanisms causing antibiotic resistance, whereas the German guideline makes use of a newly created classification scheme, based on phenotypic characterization. Besides diagnostic issues, the main difference between the Dutch and German guideline is the divergent evaluation of ESBL-producing Enterobacteriaceae. Special hygiene measures are required for all patients with ESBL-producing Enterobacteriaceae in The Netherlands, whereas the German guideline recommends special precautions only for those cases in which patients are colonized or infected with strains showing co-resistance to ciprofloxacin ("3MRGN").
  
  
  CONCLUSIONS
  The usage of consistent terminology and harmonized diagnostic procedures would improve the possibilities for infection prevention, treatment and patient safety. Prevention of severe non-treatable infections and outbreaks due to MDRO, caused by an increased population seeking medical treatment abroad together with an increased number of highly susceptible individuals demands gathering of regional data, and data comparable between the two sides of the Dutch-German border. The necessity to cooperate multidisciplinary and across borders is required to prevent a post-antibiotic era - in which common infections and minor injuries may lead to death.
authors.affiliation: Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, hpc EB80, 9713 GZ Groningen, The Netherlands.
authors.forename: Jan
authors.initials: J
authors.lastname: Müller
authors.affiliation: Department of Medical Microbiology, Canisius-Wilhelmina Hospital and Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Andreas
authors.initials: A
authors.lastname: Voss
authors.affiliation: Institute of Hygiene, University Hospital Münster, Münster, Germany.
authors.forename: Robin
authors.initials: R
authors.lastname: Köck
authors.affiliation: Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, hpc EB80, 9713 GZ Groningen, The Netherlands.
authors.forename: Bhanu
authors.initials: B
authors.lastname: Sinha
authors.affiliation: Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, hpc EB80, 9713 GZ Groningen, The Netherlands.
authors.forename: John W
authors.initials: JW
authors.lastname: Rossen
authors.affiliation: National Reference Laboratory for Multidrug Resistant Gram-negative Bacteria, Department of Medical Microbiology, Ruhr University Bochum, Bochum, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Kaase
authors.affiliation: Robert Koch-Institute, Berlin, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Mielke
authors.affiliation: Division of Health Protection, Health Promotion, NRW Centre for Health, Münster, Germany.
authors.forename: Inka
authors.initials: I
authors.lastname: Daniels-Haardt
authors.affiliation: Department of Infectiology and Hygiene, NRW Centre for Health, Münster, Germany.
authors.forename: Annette
authors.initials: A
authors.lastname: Jurke
authors.affiliation: Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, hpc EB80, 9713 GZ Groningen, The Netherlands.
authors.forename: Ron
authors.initials: R
authors.lastname: Hendrix
authors.affiliation: Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands.
authors.forename: Jan A
authors.initials: JA
authors.lastname: Kluytmans
authors.affiliation: Amphia Academy Infectious Disease Foundation, Amphia Hospital, Breda, The Netherlands.
authors.forename: Marjolein F
authors.initials: MF
authors.lastname: Kluytmans-van den Bergh
authors.affiliation: Governmental Institute of Public Health of Lower Saxony, Hannover, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Pulz
authors.affiliation: Institute for Hygiene, University Hospital Oldenburg, Oldenburg, Germany.
authors.forename: Jörg
authors.initials: J
authors.lastname: Herrmann
authors.affiliation: Center for Infectious Diseases and Travel Medicine, University Hospital Freiburg, Freiburg, Germany.
authors.forename: Winfried V
authors.initials: WV
authors.lastname: Kern
authors.affiliation: Hygiene-Institute, University of Heidelberg, Heidelberg, Germany.
authors.forename: Constanze
authors.initials: C
authors.lastname: Wendt
authors.affiliation: Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, hpc EB80, 9713 GZ Groningen, The Netherlands.
authors.forename: Alex W
authors.initials: AW
authors.lastname: Friedrich
keywords: Cross-border healthcare; Gram-negative organism; Infection prevention guidelines; MDRO