Bacterial Urinary Tract Infections (Utis)

Bacterial infections can urethra infected prostate, bladder or kidney. Symptoms may entirely absent or present themselves as frequent urination, urgency, dysuria and lower abdominal pain or flank pain. Systemic symptoms or even sepsis may occur with kidney infections. The diagnosis is based on urinalysis and culture. Treatment consists of antibiotics and removal of all obstructions Harntraktkatheter and-

Bacterial infections can urethra infected prostate, bladder or kidney. Symptoms may entirely absent or present themselves as frequent urination, urgency, dysuria and lower abdominal pain or flank pain. Systemic symptoms or even sepsis may occur with kidney infections. The diagnosis is based on urinalysis and culture. Treatment consists of antibiotics and removal of all obstructions Harntraktkatheter and-

(. Introduction (in the urinary tract UTIs) 173 Gram-negative rods; prostatitis; urinary tract infection (UTI) in children.) Bacterial infections can urethra infected prostate, bladder or kidney. Symptoms may entirely absent or present themselves as frequent urination, urgency, dysuria and lower abdominal pain or flank pain. Systemic symptoms or even sepsis may occur with kidney infections. The diagnosis is based on urinalysis and culture. Treatment consists of antibiotics and removal of all Harntraktkatheter and- obstructions in adults aged 20-50 years HWI come from women before 50 times more likely. Among women in this age group, most UTIs cystitis or pyelonephritis are in men the same age, most UTIs urethritis or prostatitis. The incidence of UTI increases> 50 years in patients, the ratio wife, but man decreases because prostate enlargement and instrumentation become more frequent in men. Pathophysiology The urinary tract – from the kidney to the urinary meatus – despite frequent contamination of the anterior urethra with intestinal bacteria resistant normally sterile and against bacterial colonization. The main defense against UTI is a complete emptying of the bladder during urination. Other mechanisms that keep the urinary tract sterile, the acidic pH of urine and various immunologic and mucosal barriers. About 95% of UTI occur by the rising of bacteria from the urethra into the bladder and – in the case of pyelonephritis – through upgrade via the ureter into the kidney. The other urinary tract infections are caused by hematogenous. A systemic infection can be caused by a UTI, especially in the elderly. About 6.5% of cases of nosocomial bacteremia attributable to a UTI. As uncomplicated UTI is usually a bladder or kidney infection is looked upon that occurs in premenopausal adult women without structural or functional abnormalities of the urinary tract, and who are not pregnant and do not have significant comorbidities that could lead to serious consequences. Some experts consider UTIs for uncomplicated, even when involving postmenopausal women or patients with well-controlled diabetes. In men, the most UTIs in children or the elderly occur and arise because of anatomical abnormalities or instrumentation, and are considered complicated. The rare UTIs that occur in men aged from 15 to 50 years, are usually in men who have unprotected anal intercourse or in those who have an uncircumcised penis and are generally considered uncomplicated. Urinary tract infections in men of this age, which have no unprotected anal intercourse or have no uncircumcised penis, are very rare and, even if they are considered to be straightforward, need to be examined to urological abnormalities. Complicated UTIs can affect any sex at any age. It is usually regarded as pyelonephritis or cystitis, which do not meet criteria to be considered as uncomplicated. A UTI is considered complicated if the patient is a child who is pregnant, or has any of the following: a structural or functional abnormalities of the urinary tract and obstruction of urine flow. A co-morbidity, which increases the risk of acquiring infections or resistance to treatment, such as poorly controlled diabetes, chronic kidney disease or immune deficiency. Recent instrumentation or surgery of the urinary tract. Risk Factors Risk factors for the development of UTIs in women include the following: sexual intercourse use of a diaphragm with spermicide the use of antibiotics new sexual partner within the last year history of UTI in female 1st degree history of recurrent UTIs first UTI at an early age self the use of condoms with spermicides coated increases the UTI risk in women. The increased UTI risk in women who use antibiotics or spermicides is likely due to a change in the vaginal flora, allowing an overgrowth of Escherichia coli. In older women, the pollution of the perineum increased by fecal incontinence risk. Anatomical, structural and functional abnormalities are risk factors for UTI. A frequent consequence of anatomical anomalies consists vesicoureteral reflux (VUR), which is present at 30-45% of the Kleinkindermit symptomatic UTI. VUR is usually caused by birth defect, which leads to the incompetence of the ureterovesical valve. A VUR may also arise in patients with flaccid bladder due to spinal cord injury or after surgery of the urinary tract. Other anatomical abnormalities that predispose to a HWI, urethral valves are (a congenital obstructive abnormality), delayed maturation bladder neck, bladder diverticulum and Doppelurethra. Structural and functional Harnwegsanomalien that predispose usually for a HWI include obstruction of urinary flow and poor bladder emptying. The urine flow can be obstructed by stones and tumors. The voiding is difficult in neurogenic dysfunction (neurogenic bladder dysfunction), pregnancy, uterine prolapse, cystocele, and prostate enlargement. UTIs caused by congenital factors manifests itself most often during childhood. Most other risk factors are more common in older people. Other risk factors for UTI include instrumentation (eg. As urinary catheterization, stenting, cystoscopy) and recent surgery. Etiology Baktereien, most cause cystitis and pyelonephritis, are as follows: Enteral, gram negative usually aerobic bacteria (most). Gram-positive bacteria (less often) IWhen largely normal Harntrakten are strains of Escherichia coli with specific adhesion factors for the transitional epithelium of the bladder and of the ureters in 75 to 95% of cases, the cause. The remaining Gram-negative pathogenic Harnkeime are usually other enterobacteria, especially Klebsiella or Proteus mirabilis and sometimes Pseudomonas aeruginosa. In gram-positive bacteria, Staphylococcus saprophyticus is isolated in 5 to 10% of the bacterial urinary tract infection. Less common gram-positive bacterial isolates are Enterococcus faecalis (Group D streptococci) and Streptococcus agalactiae (Group B Streptococcus), which may be contaminated, especially when they were with uncomplicated cystitis isolated from patients. In hospitalized patients E. coli accounts for about 50% of cases. The gram-negative bacteria Klebsiella, Proteus, Enterobacter, Pseudomonas, and Serratia account for about 40% and the gram-positive bacterial cocci E. faecalis, S. saprophyticus and Staphylococcus aureus of the rest. Classification urethritis An infection of the urethra caused by bacteria (or by protozoa, viruses or fungi) occurs when organisms gain access and acute or chronic numerous periurethral glands of the pars bulbosa or colonize pendulans the male urethra or the entire female urethra. Sexually transmitted pathogens such as Chlamydia trachomatis (chlamydia, mycoplasma and ureaplasma mucosal infections), Neisseria gonorrhoeae (gonorrhea), Trichomonas vaginalis (trichomoniasis) and herpes simplex viruses come in both sexes vor.Zystitis cystitis is an infection of the bladder. It is common in women who have preceded cases of uncomplicated cystitis usually intercourse (honeymoon cystitis). In men, the bacterial infection of the bladder is usually complicated and generally arises as ascending infection from the urethra or prostate, or is a consequence of urethral instrumentation. The most common cause of recurrent cystitis in men is a chronic bacterial Prostatitis.Akutes urethral syndrome Acute urethral syndrome that occurs in women, is a syndrome, dysuria, frequent urination and pyuria (dysuria-pyuria syndrome) includes, reflecting a cystitis , In an acute urethral syndrome (in contrast to cystitis), routine urine cultures are negative, or show colony numbers that are lower than the traditional criterion for a bacterial UTIs. Urethritis is a possible cause because pathogens Chlamydia trachomatis and Ureaplasma urealyticum included that are not detected on routine urine culture. Non-infectious causes have been suggested, but supporting evidence is not conclusive, and most non-infectious causes usually cause little or no pyuria. Possible non-nfektiösen causes include anatomical abnormalities (eg. As urethral stenosis), physiological abnormalities (eg. As dysfunction of the pelvic floor muscles), endocrine disorders (eg. As atrophic urethritis), localized trauma, GI symptoms and bacteriuria Asymptomatic Entzündungen.Asymptomatische bacteriuria is the absence of UTI symptoms in a patient whose urine culture meets the criteria for UTI. There may be a pyuria or not. Because it is asymptomatic, such bacteriuria v. a. found when patients are screened at high risk or when a urine culture is performed for other reasons. Screening patients for asymptomatic bacteriuria is indicated for those at risk for complications if the bacteriuria is untreated. These patients Pregnant women belong in the SSE 12 to 16 or at the first prenatal visit, if later (because of the risk of symptomatic UTI, including pyelonephritis during pregnancy, and adverse pregnancy outcomes, including newborns with low birth weight and premature birth) (See US ) patients who had a kidney transplant within the last 6 months Small children transurethral with pronounced VUR before certain invasive procedures of the genitourinary system, which can cause mucous membrane bleeding (eg. as resection of the prostate) certain patients (eg Preventive Services task Force Reaffirmation Recommendation statement. . B. post-menopausal women, patients with controlled diabetes, patients with persistent use of Harnwegsfremdkörpern such as stents, nephrostomy tubes and indwelling catheter) often have persistently e asymptomatic bacteriuria and pyuria sometimes. However, such patients should not be gesreent because they have and because of bacteriuria low risk for complicated urinary tract infections thus do not require treatment. However, in patients with indwelling catheters often the treatment to combat bacteriuria does not respond and only leads to the development of highly antibiotic-resistant Organismen.Akute pyelonephritis Pyelonephritis is a bacterial infection of the renal parenchyma. The term should not be used to describe a tubulointerstitiale nephropathy, unless an infection is present. About 20% of Alltagsbakteriämien in women stem from a pyelonephritis. In men with a healthy urinary tract pyelonephritis is rare. In 95% of cases of pyelonephritis, the cause is the rise of bacteria through the urinary tract. Although obstruction (stricture, stone, tumor, neurogenic bladder, VUR) predisposes to pyelonephritis, most women with pyelonephritis have no demonstrable functional or anatomical defects. In men, pyelonephritis always arises because of a functional or anatomical defect. A sole cystitis or anatomical defects can cause reflux. The risk of bacterial growth may increase significantly if the Ureterperistaltik is obstructed, such. B. during pregnancy due to obstruction or by endotoxins of gram negative bacteria. Pyelonephritis is common in young girls or pregnant women to urinary catheterization. Pyelonephritis, which is not caused by bacteria rise, caused by hematogenous spread, which is particularly characteristic of virulent organisms such as S. aureus, P. aeruginosa, Salmonella species and Candida species. The affected kidney is usually carried inflammatory PMN (polymorphonuclear leukocytes) and edema increased. The infection is focal and patchy, begins in the renal pelvis and medulla and spreads like to enlarging wedge into the cortex of. Cells that mediate the chronic inflammation that appear within a few days, and it can develop medullary and subcortical abscesses. Healthy tissue between the sites of infection is the rule. A papillary necrosis can for acute pyelonephritis with diabetes, obstruction, sickle cell anemia, pyelonephritis in kidney transplants, pyelonephritis occur due to candidiasis or analgesic nephropathy. Although in children acute pyelonephritis is often associated with renal scars, scars similar in adults are not found in the absence of reflux or obstruction. Symptoms and complaints in elderly patients and patients with neurogenic bladder or indwelling catheter sepsis and delirium may manifest, but no evidence of urinary tract infection. When symptoms arise, correlate these may not necessarily with an infection in the urinary tract, because a considerable overlap may exist. However, one should keep in mind. In urethritis, the main symptoms dysuria and, especially in men, in urethral discharges are made. The finish may be purulent, whitish or slimy. Features of disposal, such as the amount of purulence, can not be reliably distinguish gonococcal of non-gonococcal urethritis. The onset of cystitis is usually acute, typically with frequent urination, urgency, burning or pain during urination of small amounts of urine. A nocturia with suprapubic pain and often low back pain is common. The urine is often cloudy, and microscopic (or rarely gross) hematuria may occur. It may develop a mild fever. Pneumaturia (departure from air in the urine) or can occur at a caused by a vesikoenterale or vesicovaginal fistula infection by a emphysematous cystitis. In acute pyelonephritis, the findings of cystitis which may be similar. One third of patients have frequency and dysuria. However, it comes with pyelonephritis typically chills, fever, flank pain, colicky abdominal pain, nausea and vomiting. In the absence or weak Bauchdeckentonus a pressure-sensitive, enlarged kidney can occasionally keys. A kostovertebraler percussion pain is usually found on the infected side of the body. At a urinary tract infection in children, the symptoms are often less severe and uncharacteristic. Diagnostic urinalysis Sometimes urine culture diagnosis of culture is not always necessary. Diagnosis requires the detection of a significant bacteriuria in the culture of a clean urine taken. Urine collection is suspected a sexually transmitted disease, a urethral swab should be obtained to diagnose before urination. The urine collection is then performed in a clean Depressurize container or by catheterization. To win a clean means sample the urethra opening is to be cleaned with a mild, non-foaming disinfectant and then air dried. The contact of the urine stream with the mucous membrane should be minimized by the labia are spread among women and not men zirkumzidierten the foreskin is stripped back. The first 5 ml of the urine are not used and collected the next 5-10 ml in a sterile container. In older women, who typically have difficulty sterile collection, and in women with vaginal bleeding or discharge catheter urine is preferred (n. D. Talk .: Basically should be obtained in all women because of the risk of contamination by contact with the vaginal mucosa catheter urine). Many doctors also use catheter urine during a pelvic examination. Diagnosis in patients with indwelling catheters is discussed elsewhere (catheter-associated urinary tract infections (CA-UTI): Diagnosis). Tests, in particular the cultivation should be performed within 2 h of sampling; if not, the sample should be cooled werden.Urinuntersuchung Microscopic examination of urine is helpful but not mandatory. As leucocyturia a concentration of ? 8 leukocytes / ul of a nichtzentrifugierten urine is defined. This corresponds to 2-5 leukocytes in high definition field rate of the centrifugal sediment. Most truly infected patients> 10 leukocytes / ul. The presence of bacteria without leucocyturia, especially if multiple strains are found, usually speaks for contamination during collection. Microscopic hematuria occurs in up to 50% of patients, however, a gross hematuria is uncommon. Leukozytenzylinder which may require special staining for the differentiation of renal tubular cylinders, speak only to an inflammatory process. They occur in pyelonephritis, glomerulonephritis and non-infectious tubulointerstitial nephritis. Pyuriie without bacteriuria and UTI is possible for. Example, if the patient nephrolithiasis, uroepithelial have a tumor, appendicitis or inflammatory bowel disease, or if the sample is contaminated by vaginal leukocytes. Women who dysuria and pyuria have, but without significant bacteriuria, have the urethral or dysuria-pyuria syndrome. Frequently test strips are Related. A positive nitrite test in a freshly collected sample (bacterial growth in the container leads to unreliable results if the investigation is not immediate) is highly specific for UTIs, but the test is not very sensitive. The Leukozytenesterasetest is very specific for the presence of> 10 leukocytes / ul and sensitive. In adult women with uncomplicated UTI with typical symptoms most clinicians consider a positive microscope and test strips finding sufficient. Assuming that common bacteria present cultures would in these cases, treatment probably will not change, but probably significantly increase the cost (n. D. Talk .: But since you do not know this, always have a culture to be created). Cultures are recommended in patients indicate their characteristics and symptoms in a complicated UTI or give an indication for the treatment of bacteriuria. Common examples are: Pregnant women after menopause Men Pre-pubertal children patients with Harnwegsanomalien or recent instrumentation patients with immunosuppression or significant comorbidities patients whose symptoms dauf pyelonephritis or sepsis suggest patients with recurrent UTIs (? 3 / year) samples with a large number of epithelial cells contaminated and barely helpful. A non-contaminated sample must be obtained for culture. Culture of a morning urine is most likely to detect a UTI. Samples left at room temperature for> 2 h, false high colony counts may be due to the persistent bacterial growth. Criteria for the culture positivity include isolation of a single species of bacteria from the center beam, cleaner or catching catheterized urine sample. In asymptomatic bacteriuria, the Kritereien based on the guidelines of the “Infectious Diseases Society of America” ??(see Guidelines for the Diagnosis and Treatment of Asymptomatic bacteriuria in Adults “): In women with suspected asymptomatic bacteriuria two consecutive clean gained urine samples (in men, a sample) from which the same bacterial strain in colony counts> 105 / is isolated ml in women or men is out of the catheter obtained urine, a single species of bacteria in colony counts> 102 / ml isolated For symptomatic patients, culture criteria are uncomplicated cystitis in women :> 103 / ml uncomplicated cystitis in women:> 102ml (This quantification appears to improve the sensitivity to E. coli.) Acute, uncomplicated pyelonephritis in women:> 104 / ml Complicated UTI:> 105 / ml in women; or> 104 / ml in men or by a catheter-derived sample in women Acute urethral syndrome:> 102 / ml of a single bacterial species Each positive culture result, regardless of number of colonies, which was obtained in a sample via suprapubic bladder puncture should be considered as a real positive. In a midstream urine E. coliin mixed flora can be a true exciter (1). Occasionally there is a UTI before despite a smaller number of colonies, possibly because of prior antibiotic therapy, high dilution of the urine (spec. Weight <1.003) or obstruction of the urine flow of heavy infected urine. Repeating the culture improves the diagnostic accuracy of a positive result, d. h., it can be between a contaminated and distinguish a really positive result werden.Lokalisation infection A clinical distinction between a UTI of the upper or lower urinary tract is not possible in many patients, and verification that is generally not recommended. If the patient has a high fever, flank pain on pressure, severe pyuria with cylinders, a pyelonephritis is highly likely. The best non-invasive technique for differentiating bladder and kidney infection seems to be the response to a short-term administration of antibiotics. If the urine after 3 days of treatment is not clear again, should be looking for a pyelonephritis. Cystitis and urethritis-like symptoms can occur with vaginitis in patients since the passage of urine through the inflamed labia can cause dysuria. A vaginitis vaginal foetor and dyspareunia can often by the presence of vaginal discharge, werden.Weitere closed testing procedures Seriously ill patients require testing for sepsis, typically with large blood count, electrolytes, lactate, urea, creatinine and blood cultures. Patients with abdominal pain or tenderness are examined for other causes of acute abdomen. Patients who have / pyuria dysuria, but no bacteriuria should perform tests on a sexually transmitted disease, usually using nucleic acid-based tests of smears from the urethra and cervix (chlamydial, mycoplasma and ureaplasma mucosal infections: Diagnosis) , Most adults do not require the review of structural abnormalities, unless in the following cases: The patient has ? 2 episodes of pyelonephritis. Infections are complicated. suspected nephrolithiasis we. There is a painless hematuria or new renal failure. The fever keeps ? 72 h at. Options for imaging of the urinary tract are sonography, CT and IVU. Occasionally voiding cystourethrography, retrograde Urethrography or cystoscopy can be considered. Urological tests are not necessary in women with symptomatic or asymptomatic cystitis recurrent cystitis because the findings would not affect the therapy. In children with UTI imaging techniques for diagnosis erforderlich.Hinweis Hooton TM, Roberts PL, ME Cox, Stapleton AE are. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 369 (20): 1883-1891, 2013. Antibiotics Occasionally surgery (let eg abscesses, correct structural abnormalities drain, or to relieve obstruction.) All forms of symptomatic bacterial UTIs require antibiotics. In patients with troublesome dysuria, Phenazopyridine can help to control the symptoms, to do this the antibiotics (usually within 48 hours). The choice of antibiotic should be on allergy and medical history of the patient, local resistance patterns (if known), availability and cost of antibiotic and risk of treatment failure of the patient and provider based. Propensity to induce antibiotic resistance should also be considered. If a urine culture is carried out, should be the choice of antibiotic when culture and sensitivity results are available, fall on the drug with the narrowest spectrum of activity against the identified pathogen. Surgical correction is usually in obstructive uropathy, anatomical abnormalities and neuropathic lesions in the urinary tract such. As a spinal cord compression, requiring typically required The catheter drainage of an obstructed urinary tract helps in the immediate command of a UTI. Occasionally a Nierenrindenabszess or perinephric abscess requires surgical relief (n. D. Talk .: The treatment of choice here is usually the percutaneous insertion of a drainage and no open surgery). An instrumentation in the lower urinary tract in the presence of an infected urine should be avoided. The sterilization of the urine before instrumentation and antibiotic therapy 3-7 days after the instrumentation can prevent a life-threatening Urosepsis. Urethritis Sexually active patients with symptoms are usually treated with test results pending on suspicion of sexually transmitted diseases. A typical treatment regimen is ceftriaxone 250 mg i.m. excl. azithromycin either 1 g p.o. 1 times or doxycycline 100 mg p.o. 2 times daily for 7 days. All sexual partners should be investigated within 60 days. Men, in which a urethritis was diagnosed, should be tested for HIV and syphilis, in accordance with the guidelines for the treatment of sexually transmitted diseases in the Centers for Disease Control and Prevention of 2015Zystitis first-line treatment of uncomplicated cystitis is nitrofurantoin 100 mg po 2 times daily for 5 days (it is contraindicated if creatinine clearance is <60 ml / min), trimethoprim / sulfamethoxazole (TMP / SMX) 160/800 mg p.o. for 3 days, 3 g fosfomycin po 2 times a day once. A less desirable choices include a fluoroquinolone or a beta-lactam antibiotic. If cystitis return within a week or two, a broader spectrum antibiotics (eg. As a fluoroquinolone) can be used, and the urine should be cultured. Complex cystitis should be treated with empirical broad-spectrum antibiotics, adapted based on local pathogens and resistance patterns, and on culture results. Urinary tract abnormalities have also treated werden.Akutes urethral syndrome The therapy depends on clinical findings and cultural detection of the pathogen. Women with dysuria, pyuria and colony growth> 102 / ml of a single bacterial species in urine culture, can be treated as in uncomplicated cystitis. Women who have dysuria and pyuria without bacteriuria should (be including investigated N. gonorrhoeae and C. trachomatis) to an STD. Women who dysuria, pyuria but neither yet have bacteriuria, have not the true urethral syndrome. They should be tested for non-infectious causes of dysuria. may value therapy attempts for. B. behavioral therapies (eg. As biofeedback and relaxation of the pelvic muscles), operation include (with urethral stenosis) and medication (eg. As hormone replacement in cases of suspected atrophic urethritis, anesthetics, antispasmodics). Asymptomatic bacteriuria Usually should asymptomatic bacteriuria in patients with diabetes, the elderly and those with chronic indwelling not be treated. But in patients at risk for complications of asymptomatic bacteriuria (asymptomatic bacteriuria) should all treatable causes be addressed and antibiotics are given as cystitis. In pregnant women, a few antibiotics can be used safely. Orally administered beta-lactams, sulfonamides and nitrofurantoin are in early pregnancy as safe; Trimethoprim should be avoided during the first trimester and sulfamethoxazole should be avoided during the third trimester, especially near the birth date. Patients with untreatable obstructive problems (eg. B., stones, reflux) can have a long-term therapy suppresive erfordern.Akute pyelonephritis antibiotics are required. Ambulante Behandlung mit oralen Antibiotika ist möglich, wenn alle der folgenden Kriterien erfüllt sind: Die Patienten werden voraussichtlich willens sein Die Patienten sind immunkompetent Patienten haben keine Übelkeit oder Erbrechen oder Nachweis eines Volumenmangels oder Septikämie Die Patienten haben keine Faktoren, die auf eine komplizierte HWI hindeuten Ciprofloxacin 500 mg p.o. 2-mal täglich für 7 Tage und Levofloxacin 750 mg p.o. 1-mal täglich für 5 Tage sind First-Line-Antibiotika, wenn < 10% der Uropathogene in der Gemeinschaft resistent sind. Eine zweite Option ist in der Regel Trimethoprim/Sulfamethoxazol (TMP/SMX) 160/800 mg p.o. 2-mal täglich für 14 Tage. Allerdings sollten lokale Empfindlichkeitsmuster, berücksichtigt werden, da in einigen Teilen der USA, > 20% der E. coli als resistent gegen Sulfonamide gelten. Patienten, die für eine ambulante Behandlung nicht geeignet sind, sollten stationär aufgenommen werden und eine parenterale Therapie erhalten, die auf der Basis der Empfindlichkeitsprüfung ausgewählt wird. First-Line-Antibiotika sind in der Regel Fluorchinolone wie Ciprofloxacin und Levofloxacin, die über die Nieren ausgeschieden werden. Andere Möglichkeiten wie Ampicillin plus Gentamicin, Breitspektrum-Cephalosporine (z. B. Ceftriaxon, Cefotaxime, Cefepim), Aztreonam, Kombinationen aus einem Beta-Lactam und Beta-Lactaminhibitor (Ampicillin/Sulbactam, Ticarcillin/Clavulansäure, Piperacillin/Tazobactam) und Imipenem/Cilastatin sind im Allgemeinen Patienten mit komplizierter Pyelonephritis (z. B. mit Obstruktion, Steine, resistente Bakterien, oder eine nosokomiale Infektion) oder aber Fällen nach H

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