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Multiple studies have demonstrated the presence of microorganisms commonly associated with surgical site infections (SSIs), in the air within the operating theatre (OT). In some countries such Italy, the limit of microbial concentration in the air for OT with turbulent airflows is 35 CFU/m 3 for an empty OT and 180 CFU/m 3 during activity. This study aims to hypothesize new benchmarks for the airborne microbial load in turbulent airflow operating theatres in operational and at rest conditions using the percentile distribution of data through a 17-year environmental monitoring campaign in various Italian hospitals that implemented a continuous quality improvement policy. The quartile distribution analysis has shown how in operational and at rest conditions, 75% of the values were below 110 CFU/m 3 and 18 CFU/m 3 , respectively, which can be considered a new benchmark for the monitored OTs. During the initial stages of the monitoring campaign, 28.14% of the concentration values in operational conditions and 29.29% of the values in at rest conditions did not conform to the Italian guidelines' reference values. In contrast, during the last 5 years, all values in both conditions conformed to the reference values and 98.94% of these values were below the new benchmarks. Continuous improvement has allowed contamination to be reduced to levels well below the current reference values.

Demographic studies show that life expectancy is increasing in developed countries; increased longevity has also increased the share of the older population with often concomitant chronic conditions. An ageing population and increased comorbidities lead to more complex pharmacological therapies (polypharmacy). The particular picture provided by chronic conditions and polypharmacy can lead to longer hospital stays and a greater need for healthcare. Elderly patients are identified as being in the high-risk group for the development of healthcare-associated infections (HAIs) due to the age-related decline of the immune system, known as immunosenescence. Comorbid conditions can often complicate infections, diminishing our ability to treat them effectively. Respiratory tract infections are the most common healthcare-associated infections, followed by urinary tract infections. HAIs in geriatric patients are responsible for longer hospital stays, extended antibiotic therapy, significant mortality, and higher healthcare costs. This is because the microorganisms involved are multidrug-resistant and, therefore, more difficult to eliminate. Moreover, geriatric patients are frequently transferred from one facility (nursing homes, skilled nursing facilities, home care, and other specialty clinics) to another or from one hospital ward to another; these transitions cause care fragmentation, which can undermine the effectiveness of treatment and allow pathogens to be transferred from one setting to another and from one person to another. Multifactorial efforts such as early recognition of infections, restricted use of invasive devices, and effective infection control measures (surveillance, isolation practices, hand hygiene, etc.) can contribute to significant reduction of HAIs in geriatric patients.

Liguria is a northwestern region of Italy that, since the WHO has declared COVID-19 as a pandemic (11 March 2020), presented 108 patients hospitalized, 34 of which were in the intensive care unit. Due to this serious epidemiological emergency, the transformation of a long-distance ferry ship into a hospital ship for COVID-19 patients who were still positive after the acute phase of the illness was carried out to free up hospital beds for patients in the acute phase. The ship was moored in the port of Genoa, the capital of Liguria. The conversion was localized to a single deck, where designated healthcare areas were identified. From 23 March to 18 June 2020, 191 patients were admitted onto the ship; they were provided with high-level healthcare guaranteed by the multi-disciplinary nature of clinical competencies available. Patients had a favorable outcome in all cases, confirmed by their recovery and negative swab results. Moreover, no cases of voluntary discharge were recorded. To the best of our knowledge, this is the only example in the world in which a passenger ship was transformed into a ship hospital for COVID patients.

Background: The use of a contaminated endoscope may lead to infections due to the transmission of potential pathogens from patient to patient. Methods: Post-reprocessing microbiological surveillance of four duodenoscopes was carried out over a three-year period in the Digestive Endoscopy Unit of an Italian hospital. Sampling of duodenoscopes was performed after the devices have been reprocessed. The initial phase of surveillance involved the contemporary evaluation of the four duodenoscopes; afterwards, microbiological surveillance proceeded at monthly intervals. Results: The initial phase of surveillance revealed that three duodenoscopes presented a high level of contamination with "high-concern" micro-organisms, some of which were multi-drug-resistant. The highest values of contamination regarded the species P. aeruginosa (2500 CFU/duodenoscope), K. pneumoniae (2580 CFU/duodenoscope), and A. baumannii (2600 CFU/duodenoscope). Since the cultures were repeatedly positive on three successive occasions, the contaminated devices were sent to the manufacturer for evaluation. Audits were carried out with the personnel responsible for reprocessing, which was aimed to optimize the procedures used, and subsequently, only one case of non-conformity was found. Conclusions: Our study highlighted both the potential risk of transmitting pathogens through the use of duodenoscopes and the importance of implementing a well-structured system of microbiological surveillance and training programs, in order to reduce the risk of spreading retrograde cholangiopancreatography (ERCP)-associated infections.

Implementation of environmental cleaning and disinfection has been shown to reduce the incidences of healthcare-associated infections. The effect of an enhanced strategy for terminal room disinfection, applying the pulsed xenon-based ultraviolet light no-touch disinfection systems (PX-UVC) after the current standard operating protocol (SOP) was evaluated. In a teaching hospital, the effectiveness in reducing the total bacterial count (TBC) and in eliminating high-concern microorganisms was assessed on five high-touch surfaces in different critical areas, immediately pre- and post-cleaning and disinfection procedures (345 sampling sites). PX-UVC showed only 18% (15/85) of positive samples after treatment compared to 63% (72/115) after SOP. The effectiveness of PX-UVC was also observed in the absence of manual cleaning and application of a chemical disinfectant. According to the hygienic standards proposed by the Italian Workers Compensation Authority, 9 of 80 (11%) surfaces in operating rooms showed TBC ≥15 CFU/24 cm 2 after the SOP, while all samples were compliant applying the SOP plus PX-UVC disinfection. Clostridium difficile (CD) spores and Klebsiella pneumoniae (KPC) were isolated only after the SOP. The implementation of the standard cleaning and disinfection procedure with the integration of the PX-UVC treatment had effective results in both the reduction of hygiene failures and in control environmental contamination by high-concern microorganisms.

Studies conducted over the last 40 years have demonstrated that the water output from dental unit waterlines (DUWLs) is often contaminated with high densities of microorganisms. It has been monitored the microbiological quality of the water in 30 public dental facilities in northern Italy in order to assess the health risk for patients and dental staff. In each facility, samples of water both from taps and from DUWLs were analyzed in order to evaluate heterotrophic plate counts (HPCs) at 22 °C and 36 °C, and to detect coliform bacteria, Pseudomonas aeruginosa , Legionella pneumophila and amoebae. In 100% of the samples taken from the DUWLs, the concentration of HPCs was above the threshold as determined by the Ministère de la Santé et des Solidarités (2007). The concentration of P. aeruginosa was greater than the indicated threshold in 16.67% of the hand-pieces analyzed. A total of 78.33% of samples were contaminated by L. pneumophila , while in the samples taken from the DUWLs alone, this percentage rose to 86.67%. Amoebae were detected in 60% of the samples taken from hand-pieces; all belonging to the species V. vermiformis . This study documented the presence of various microorganisms, including Legionella spp., at considerably higher concentrations in water samples from DUWLs than in samples of tap water in the same facilities, confirming the role of the internal DUWLs in increasing microbial contamination, especially in the absence of proper management of waterborne health risks., Competing Interests: The authors declare no conflicts of interest.

Serratia marcescens belongs to the family Enterobacteriaceae, which is commonly found in water, soil, animals, insects, plants. Although S. marcescens displays relatively low virulence, it causes nosocomial infections and outbreaks in severely immunocompromised or critically ill patients, particularly in settings such as intensive care units (ICUs), especially neonatal units (NICUs). This microorganism gives rise to a wide range of clinical manifestations in newborns: from asymptomatic colonization to keratitis, conjunctivitis, urinary tract infections, pneumonia, surgical wound infections, sepsis, bloodstream infection and meningitis. The most frequent site of infection is the bloodstream, followed by the respiratory apparatus and the gastrointestinal tract. Strains of S. marcescens involved in epidemic events have frequently proved to be multi-resistant. Indeed, this species displays intrinsic resistance to several classes of antibiotics. Often, the specific source of the infection cannot be identified. However, the contaminated hands of healthcare workers are believed to be a major vehicle of its transmission. In neonatal intensive care units, colonized or infected newborns are the main potential source of S. marcescens , particularly in the respiratory apparatus, but also in the gastrointestinal tract. The early identification of colonized or infected patients and the prompt implementation of infection control measures, particularly rigorous hand hygiene and contact precautions, are essential in order to curb the spread of infection.

Healthcare facilities (HF) represent an at-risk environment for legionellosis transmission occurring after inhalation of contaminated aerosols. In general, the control of water is preferred to that of air because, to date, there are no standardized sampling protocols. Legionella air contamination was investigated in the bathrooms of 11 HF by active sampling (Surface Air System and Coriolis ® μ) and passive sampling using settling plates. During the 8-hour sampling, hot tap water was sampled three times. All air samples were evaluated using culture-based methods, whereas liquid samples collected using the Coriolis ® μ were also analyzed by real-time PCR. Legionella presence in the air and water was then compared by sequence-based typing (SBT) methods. Air contamination was found in four HF (36.4%) by at least one of the culturable methods. The culturable investigation by Coriolis ® μ did not yield Legionella in any enrolled HF. However, molecular investigation using Coriolis ® μ resulted in eight HF testing positive for Legionella in the air. Comparison of Legionella air and water contamination indicated that Legionella water concentration could be predictive of its presence in the air. Furthermore, a molecular study of 12 L. pneumophila strains confirmed a match between the Legionella strains from air and water samples by SBT for three out of four HF that tested positive for Legionella by at least one of the culturable methods. Overall, our study shows that Legionella air detection cannot replace water sampling because the absence of microorganisms from the air does not necessarily represent their absence from water; nevertheless, air sampling may provide useful information for risk assessment. The liquid impingement technique appears to have the greatest capacity for collecting airborne Legionella if combined with molecular investigations., Competing Interests: The authors declare no conflict of interest.

Background: Exposure to the particulate matter produced in underground railway systems is arousing increasing scientific interest because of its health effects. The aim of our study was to evaluate the airborne concentrations of PM10 and three sub-fractions of PM2.5 in an underground railway system environment in proximity to platforms and in underground commercial areas within the system, and to compare these with the outdoor airborne concentrations. We also evaluated the metal components, the cytotoxic properties of the various fractions of particulate matter (PM) and their capacity to induce oxidative stress., Method: We collected the coarse fraction (5-10 µm) and the fine fractions (1-2.5 µm; 0.5-1 µm; 0.25-0.5 µm). Chemical characterisation was determined by means of spectrometry. Cytotoxicity and oxidative stress were evaluated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and Reactive Oxygen Species (ROS) assessment., Results: The concentrations of both PM10 and PM2.5 proved to be similar at the three sampling sites. Iron and other transition metals displayed a greater concentration at the subway platform than at the other two sites. The 2.5-10 µm and 1-2.5 µm fractions of PM from all three sampling sites determined a greater increase in ROS; the intensity of oxidative stress progressively declined as particle diameter diminished. Moreover, ROS concentrations were correlated with the concentrations of some transition metals, namely Mn, Cr, Ti, Fe, Cu, Zn, Ni and Mo. All particulate matter fractions displayed lower or similar ROS values between platform level and the outdoor air., Conclusions: The present study revealed that the underground railway environment at platform level, although containing higher concentrations of some particularly reactive metallic species, did not display higher cytotoxicity and oxidative stress levels than the outdoor air.