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Background We evaluated the incidence of invasive pulmonary aspergillosis among intubated patients with critical COVID-19 and evaluated different case definitions of invasive aspergillosis. Methods Prospective, multicenter study in adult patients with microbiologically confirmed COVID-19 receiving mechanical ventilation. All included participants underwent a screening protocol for invasive pulmonary aspergillosis with bronchoalveolar lavage galactomannan and cultures performed on admission at 7 days and in case of clinical deterioration. Cases were classified as coronavirus-associated pulmonary aspergillosis (CAPA) according to previous consensus definitions. The new definition was compared with putative invasive pulmonary aspergillosis (PIPA). Results 108 patients were enrolled. Probable CAPA was diagnosed in 30 (27.7%) patients after a median of 4 (2–8) days from intensive care unit (ICU) admission. Kaplan-Meier curves showed a significantly higher 30-day mortality rate from ICU admission among patients with either CAPA (44% vs 19%, P = .002) or PIPA (74% vs 26%, P < .001) when compared with patients not fulfilling criteria for aspergillosis. The association between CAPA (OR, 3.53; 95% CI, 1.29–9.67; P = .014) or PIPA (OR, 11.60; 95% CI, 3.24–41.29; P < .001) with 30-day mortality from ICU admission was confirmed, even after adjustment for confounders with a logistic regression model. Among patients with CAPA receiving voriconazole treatment (13 patients; 43%) a trend toward lower mortality (46% vs 59%; P = .30) and reduction in galactomannan index in consecutive samples were observed. Conclusions We found a high incidence of CAPA among critically ill COVID-19 patients and its occurrence seems to change the natural course of disease.

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Objectives We hypothesised that treatment with a tigecycline-based antimicrobial regimen for intra–abdominal infection (IAI) could be associated with lower rates of subsequent carbapenem-resistant Enterobacteriaceae (CRE) colonisation or Clostridium difficile infection (CDI) compared with a meropenem-based regimen. Methods We performed a retrospective, single-centre, matched (1:1) cohort analysis of all patients who received at least 5 days of empirical or targeted tigecycline (TIG)- or meropenem (MER)-based treatment regimens for IAI over a 50-month period. Patients with previous CRE colonisation and CDI were excluded. Risk factors for CRE and CDI were assessed with a Cox regression model that included treatment duration as a time-dependent variable. Thirty-day mortality was assessed with Kaplan-Meier curves. Results We identified 168 TIG-treated and 168 MER-treated patients. The cumulative incidence rate ratio of CDI was 10-fold lower in TIG-treated vs. MER-treated patients (incidence rate ratio [IRR] 0.10/1000 patient-days, 95%CI 0.002–0.72, P = 0.007), but similar incidence rates were found for CRE colonisation (IRR 1.39/1000 patient-days, 95%CI 0.68–2.78, P = 0.36). In a multivariate Cox regression model, the receipt of a TIG- vs. MER-based regimen was associated with significantly lower rates of CDI (HR 0.07, 95%CI 0.03–0.71, P = 0.02), but not CRE (HR 1.12, 95% CI 0.45–2.83, P = 0.80). All-cause 30-day mortality was similar in the two groups (P = 0.46). Conclusion TIG-based regimens for IAI were associated with a 10-fold lower incidence of CDI compared with MER-based regimens, but there was no difference in the incidence of CRE colonisation.

Background More than one-third of candidemia episodes occur in Internal Medicine Wards (IMWs) but only few studies have focused on this setting and specific data about epidemiology, clinical characteristics and risk factors for mortality are scant. Objective To describe epidemiology and to assess risk factors for in-hospital mortality among patients with candidemia in IMWs. Methods Multicenter retrospective cohort study on patients with candidemia cared for in IMWs of an Italian region (Emilia Romagna) from January 2012 to December 2013. Non survivors were compared with survivors; variables with p ≤ 0.1 at univariate analysis were entered into a multivariate Cox regression model. Results 232 patients were included. Overall candidemia incidence was 2.2 cases/1000 admissions. Candida albicans accounted for 59% of cases. Antifungal treatment was started  72 h from blood cultures in 47%, 27% and 12% of patients, respectively; 13.8% of patients received no antifungal treatment. In-hospital mortality was 40%. At multivariate analysis, chronic-obstructive-pulmonary-disease (HR 2.72, 95%CI 1.66–4.45, pÂ

Background: Prompt administration of antibiotics, adjunctive steroid therapy, and optimization of antibiotic delivery to cerebrospinal fluid (CSF) are factors associated with improved outcome of patients hospitalized for acute bacterial meningitis (ABM). However, the impact of a bundle of these procedures has not been reported. Objective: To assess mortality and neurological sequelae at hospital discharge in a cohort of patients with ABM managed according to a predefined bundle. Methods: Prospective study of all the patients hospitalized for ABM in two provinces of Northern Italy, over two consecutive periods (2005-2009, 2010-2013). The bundle included: i) supportive care if needed; ii) immediate administration of dexamethasone and 3rd generation cephalosporin; and iii) addition of levofloxacin if turbid CSF. Patients managed according to the bundle were compared with a historical group of patients cared for ABM before the bundle was implemented. Results: Overall, 85 patients with ABM were managed according to the bundle and were compared with 92 historical controls. In-hospital mortality rates for bundle and control group were 4.7% and 14.1% (p=0.04). Among survivors, 13.5% and 18.9% (p=0.4) of bundle and control-group patients presented neurological sequelae. The only variable associated with mortality at multivariate analysis was ICU admission (HR 3.65). After adjusting for ICU admission, patients managed according with the ABM bundle had significantly lower mortality rate compared to historical controls. Conclusions: Use of a bundled protocol and antibiotics with excellent CSF penetration for the initial management of ABM in emergency department is feasible and associated with significant reduction in mortality.

To assess risk factors for recurrent carbapenem-resistant Klebsiella pneumoniae bloodstream-infection (CR-KP BSI), we performed a prospective observational cohort study of all consecutive adult patients cured of a CR-KP BSI at our hospital over a six-year period (June 2010 to June 2016). Maximum follow-up per patient was 180 days from the index blood cultures (BCs). Recurrent CR-KP BSI was defined as new evidence of positive BCs in patients with documented clinical response after completing a course of anti-CR-KP therapy. Univariate and multivariate cause-specific Cox proportional hazards analysis were performed. During the study period 249 patients were diagnosed with a CR-KP BSI, 193 were deemed as cured within 14 days after index BCs and were analysed. Recurrence occurred in 32/193 patients (16.6%) within a median of 35 (IQR 25–45) days after index BCs. All but one of the recurrences occurred within 60 days after the index BCs. Comparison of recurrent and non-recurrent cases showed significant differences for colistin use (84.4% vs. 62.2%, p = 0.01), meropenem-colistin-tigecycline regimen (43.8% vs. 24.8%, p = 0.03) and length of therapy for the index BSI episode (median 18 vs. 14 days, p = 0.004). All-cause 180-day mortality (34.4% vs. 16.1%, p = 0.02) was higher in recurrent cases. In the multivariate analysis, the only independent variable was source control as a protective factor for recurrence. Recurrence is frequent among patients cured of a CR-KP BSI and is associated with higher long-term mortality. When feasible, source control is mandatory to avoid recurrence. The role of antibiotic treatment should be further investigated in large multicentre studies.

OBJECTIVETo assess the impact of an antimicrobial stewardship program (ASP) on antibiotic consumption, Clostridium difficile infections (CDI), and antimicrobial resistance patterns in a rehabilitation hospital.DESIGNQuasi-experimental study of the periods before (from January 2011 to June 2012) and after (from July 2012 to December 2014) ASP implementation.SETTING150-bed rehabilitation hospital dedicated to patients with spinal-cord injuries.INTERVENTIONBeginning in July 2012, an ASP was implemented based on systematic bedside infectious disease (ID) consultation and structural interventions (ie, revision of protocols for antibiotic prophylaxis and education focused on the appropriateness of antibiotic prescriptions). Antibiotic consumption, occurrence of CDI, and antimicrobial resistance patterns of selected microorganisms were compared between periods before and after the ASP implementation.RESULTSAntibiotic consumption decreased from 42 to 22 defined daily dose (DDD) per 100 patient days (PP=.01) and fluoroquinolones (from 11.8 to 0.99 DDD per 100 patient days; P=.006), with no increases in mortality or length of stay. The incidence of CDI decreased from 3.6 to 1.2 cases per 10,000 patient days (P=.001). Between 2011 and 2014, the prevalence of extensively drug-resistant (XDR) strains decreased from 55% to 12% in P. aeruginosa (PA. baumannii (P=.03). The prevalence of ESBL-producing strains decreased from 42% to 17% in E. coli (P=.0007) and from 62% to 15% in P. mirabilis (P=.0001). In K. pneumoniae, the prevalence of carbapenem-resistant strains decreased from 42% to 17% (P=.005), and the prevalence of in methicillin-resistant S. aureus strains decreased from 77% to 40% (PCONCLUSIONSAn ASP based on ID consultation was effective in reducing antibiotic consumption without affecting patient outcomes and in improving antimicrobial resistance patterns in a rehabilitation hospital.Infect Control Hosp Epidemiol. 2016;1–7

We report our clinical experience with the use of daptomycin, administered in the dosage of 8 mg/kg/d in 3 minutes, in treating 12 critically ill children younger than 12 years, with bloodstream infections (n = 9) and complicated skin and soft-tissue infections (n = 3). Mean treatment duration was 14 ± 5 days; microbiologic eradication was achieved in all patients, and no drug related adverse events occurred.

Purpose Infective endocarditis (IE) is widely underdiagnosed or diagnosed after a major delay. The diagnosis is currently based on the modified DUKE criteria, where the only validated imaging technique is echocardiography, and remains challenging especially in patients with an implantable cardiac device. The aim of this study was to assess the incremental diagnostic role of F-18-FDG PET/CT in patients with an implanted cardiac device and suspected IE. Methods We prospectively analysed 27 consecutive patients with an implantable device evaluated for suspected device-related IE between January 2011 and June 2013. The diagnostic probability of IE was defined at presentation according to the modified DUKE criteria. PET/CT was performed as soon as possible following the clinical suspicion of IE. Patients then underwent medical or surgical treatment based on the overall clinical evaluation. During follow-up, we considered: lead cultures in patients who underwent extraction, direct inspection and lead cultures in those who underwent surgery, and a clinical/instrumental reevaluation after at least 6 months in patients who received antimicrobial treatment or had an alternative diagnosis and were not treated for IE. After the follow-up period, the diagnosis was systematically reviewed by the multidisciplinary team using the modified DUKE criteria and considering the new findings. Results Among the ten patients with a positive PET/CT scan, seven received a final diagnosis of "definite IE", one of "possible IE" and two of "IE rejected". Among the 17 patients with a negative PET/CT scan, four were false-negative and received a final diagnosis of definite IE. These patients underwent PET/CT after having started antibiotic therapy (>= 48 h) or had a technically suboptimal examination. Conclusion In patients with a cardiac device, PET/CT increases the diagnostic accuracy of the modified Duke criteria for IE, particularly in the subset of patients with possible IE in whom it may help the clinician manage a challenging situation.

The increase in incidence/prevalence of infections of implantable pacemakers and defibrillators (implantable cardioverter defibrillator, ICD) is outweighing that of the implanting procedures, mainly favored by the changes in patient profile. Despite the high impact on patient's outcome and related costs for healthcare systems, we lack specific evidence on the preventive measures with the exception of antibiotic prophylaxis. The aim of this study is to focus on common approaches to pacemaker/ICD implantation to identify the practical preventive strategies and choices that can (potentially) impact on the occurrence of this feared complication. After a brief introduction on clinical presentation, pathogenesis, and risk factors, we will present the results from a survey on the preventive strategies adopted by different operators from the 25 centers of the Emilia Romagna region in the northern Italy (4.4 million inhabitants). These data will provide the basis for reviewing available literature on this topic and identifying the gray areas. The last part of the article will cover the available evidence about pacemaker/ICD implantation, focusing on prophylaxis of pacemaker/ICD infection as a 'continuum' starting before the surgical procedure (from indications to patient preparation), which follows during (operator, room, and techniques) and after the procedure (patient and device follow-up). We will conclude by evaluating the relationship between adherence to the available evidence and the volume of procedures of the implanting centers or operators' experience according to the results of our survey.