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Objectives The objective of this epidemiologic study was to estimate the healing time of acute dental abscesses and to evaluate the main variables involved in the healing process itself. Subjects and Methods Among a sample of over 24 000 patients visited at the emergency dental unit, 688 subjects were diagnosed with dental abscess and enrolled in the study. Case histories of all patients were collected to investigate the clinical course and healing time of dental abscess according to anamnestic and diagnostic data and therapeutic management. A multiple logistic regression model was performed to evaluate the association of each variable with the healing time required for dental abscess. Results Variables associated with increased healing time were spring seasonality at admission, pyretic state, trismus, involvement of multiple anatomic spaces, and spontaneous drainage. Moreover, administration of some, but not all, classes of antibiotics was also associated with an increased healing time. Conclusions The knowledge of variables involved in healing time for dental abscess is crucial in the optimization of managing such infections in terms of cost-benefit ratio. This would represent a valuable way to ensure a shortened and more effective healing. [ABSTRACT FROM AUTHOR]

Purpose: Campylobacter is a frequent cause of enteric infections with common antimicrobial resistance issues. The most recent reports of campylobacteriosis in Italy include data from 2013 to 2016. We aimed to provide national epidemiological and microbiological data on human Campylobacter infections in Italy during the period 2017-2021., Methods: Data was collected from 19 Hospitals in 13 Italian Regions. Bacterial identification was performed by mass spectrometry. Antibiograms were determined with Etest or Kirby-Bauer (EUCAST criteria)., Results: In total, 5419 isolations of Campylobacter spp. were performed. The most common species were C. jejuni (n = 4535, 83.7%), followed by C. coli (n = 732, 13.5%) and C. fetus (n = 34, 0.6%). The mean age of patients was 34.61 years and 57.1% were males. Outpatients accounted for 54% of the cases detected. Campylobacter were isolated from faeces in 97.3% of cases and in 2.7% from blood. C. fetus was mostly isolated from blood (88.2% of cases). We tested for antimicrobial susceptibility 4627 isolates (85.4%). Resistance to ciprofloxacin and tetracyclines was 75.5% and 54.8%, respectively; resistance to erythromycin was 4.8%; clarithromycin 2% and azithromycin 2%. 50% of C. jejuni and C. coli were resistant to ≥ 2 antibiotics. Over the study period, resistance to ciprofloxacin and tetracyclines significantly decreased (p < 0.005), while resistance to macrolides remained stable., Conclusion: Campylobacter resistance to fluoroquinolones and tetracyclines in Italy is decreasing but is still high, while macrolides retain good activity., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Large data on moxifloxacin activity on anaerobes are old. Moxifloxacin is often used for empiric therapy therefore the knowledge of current epidemiologic data is fundamental. We analyzed 69 anaerobic strains, from a recent multicenter Italian study, for moxifloxacin susceptibility. Using EUCAST criteria 81% of Bacteroides spp. and 48% of anaerobes other than Bacteroides were resistant to moxifloxacin. Using CLSI criteria moxifloxacin resistance rates decrease to 35% for all anaerobes, and to 41% for Bacteroides spp. We reported an alarming increase in moxifloxacin resistance among anaerobes in Italy.

Background: One third of coronavirus disease 2019 (COVID-19) patients have gastrointestinal symptoms. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA has been detected in stool samples of approximately 50% of COVID-19 individuals. Fecal calprotectin is a marker of gastrointestinal inflammation in the general population., Aim: To investigate if fecal calprotectin correlates with SARS-CoV-2 intestinal shedding in COVID-19 patients with pneumonia., Methods: Patients with SARS-CoV-2 pneumonia admitted to the Infectious Disease Unit (University Hospital of Trieste, Italy) from September to November 2020 were consecutively enrolled in the study. Fecal samples were collected and analyzed for quantification of fecal calprotectin (normal value < 50 mg/kg) and SARS-CoV-2 RNA presence by polymerase chain reaction (PCR). Inter-group differences were determined between patients with and without diarrhea and patients with and without detection of fecal SARS-CoV-2., Results: We enrolled 51 adults (40 males) with SARS-CoV-2 pneumonia. Ten patients (20%) presented with diarrhea. Real-time-PCR of SARS-CoV-2 in stools was positive in 39 patients (76%), in all patients with diarrhea (100%) and in more than two thirds (29/41, 71%) of patients without diarrhea. Obesity was one of the most common comorbidities (13 patients, 25%); all obese patients (100%) ( P = 0.021) tested positive for fecal SARS-CoV-2. Median fecal calprotectin levels were 60 mg/kg [interquartile range (IQR) 21; 108]; higher fecal calprotectin levels were found in the group with SARS-CoV-2 in stools (74 mg/kg, IQR 29; 132.5) compared to the group without SARS-CoV-2 (39 mg/kg, IQR 14; 71) ( P < 0.001)., Conclusion: High fecal calprotectin levels among COVID-19 patients correlate with SARS-CoV-2 detection in stools supporting the hypothesis that this virus can lead to bowel inflammation and potentially to the 'leaky gut' syndrome., Competing Interests: Conflict-of-interest statement: The authors declare no conflicts of interest., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objectives: Ceftazidime/avibactam (CAZ-AVI), approved in 2015, is an important first-line option for Klebsiella pneumoniae carbapenemase-producing Enterobacterales (KPC-E). Although still uncommon, resistance to CAZ-AVI has emerged and may represent a serious cause of concern., Methods: We performed a systematic literature review of clinical and microbiological features of infections and colonisations by CAZ-AVI-resistant KPC-E, focused on the in vivo emergence of CAZ-AVI resistance in different clinical scenarios., Results: Twenty-three papers were retrieved accounting for 42 patients and 57 isolates, mostly belonging to K. pneumoniae ST258 harbouring D179Y substitution in the KPC enzyme. The USA, Greece and Italy accounted for 80% of cases. In one-third of isolates resistance was not associated with previous CAZ-AVI exposure. Moreover, 20% of the strains were colistin-resistant and 80% were extended-spectrum β-lactamase (ESBL)-producers. The majority of infected patients had severe underlying diseases (39% cancer, 22% solid-organ transplantation) and 37% died. The abdomen, lung and blood were the most involved infection sites. Infections by CAZ-AVI-resistant strains were mainly treated with combination therapy (85% of cases), with meropenem being the most common (65%) followed by tigecycline (30%), gentamicin (25%), colistin (25%) and fosfomycin (10%). Despite the emergence of resistance, 35% of patients received CAZ-AVI., Conclusion: Taken together, these data highlight the need for prompt susceptibility testing including CAZ-AVI for Enterobacterales, at least in critical areas. Resistance to CAZ-AVI is an urgent issue to monitor in order to improve both empirical and targeted CAZ-AVI use as well as the management of patients with infections caused by CAZ-AVI-resistant strains., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The spread of resistance to vancomycin and other last-resort drugs in Enterococcus spp. remains of concern. In Italy, surveillance data for enterococcal bloodstream isolates in humans are scant. The aim of our study was to assess the incidence trends of bacteremias due to Enterococcus species and their prevalence trends of antimicrobial resistance. We retrospectively included all consecutive not-duplicate Enterococcus species isolated from blood cultures, in patients from 11 Italian hospitals (2011-2017). Incidence was defined as the number of isolates per 10,000 patient-days, while resistance prevalence was defined as the number of resistant strains divided by the number of tested strains. We included 4,858 isolates (59%, 36%, and 5% due to Enterococcus faecalis , E. faecium , and other Enterococcus spp., respectively). Over the study period, the incidence of bacteremias due to E. faecalis (incidence rate ratio [IRR]: 1.02, 95% confidence interval [CI]: 1.00-1.04, p  = 0.008) and E. faecium increased (IRR: 1.03, 95% CI: 1.01-1.05, p  < 0.001) alongside with the whole enterococcal bacteremias trend (IRR: 1.02, 95% CIs: 1.01-1.04, p  = 0.002). A progressive increase in vancomycin-resistant E. faecium (VREfm) bacteremias was observed. Resistance to tigecycline and linezolid was rarely reported. The incidence of enterococcal bloodstream isolates is increasing in Italy, together with the prevalence of VREfm. Resistance to linezolid, a cornerstone drug used in the treatment of VRE bloodstream infection, remains negligible.

Aims: COVID-19 is especially severe for elderly subjects with cardiometabolic and respiratory comorbidities. Neck circumference (NC) has been shown to be strongly related to cardiometabolic and respiratory illnesses even after adjustment for body mass index (BMI). We performed a prospective study to investigate the potential of NC to predict the need for invasive mechanical ventilation (IMV) in adult COVID-19 inpatients., Materials and Methods: We prospectively and consecutively enrolled COVID-19 adult patients admitted to dedicated medical wards of two Italian hospitals from 25 March to 7 April 2020. On admission, clinical, biochemical and anthropometric data, including BMI and NC were collected. As primary outcome measure, the maximum respiratory support received was evaluated. Follow-up time was 30 days from hospital admission., Results: We enrolled 132 subjects (55.0-75.8 years, 32% female). During the study period, 26 (19.7%) patients underwent IMV. In multivariable logistic regression analyses, after adjusting for age, sex, diabetes, hypertension and COPD, NC resulted independently and significantly associated with IMV risk (adjusted OR 1.260-per 1 cm increase 95% CI:1.120-1.417; P < .001), with a stronger association in the subgroup with BMI ≤30 Kg/m 2 (adjusted OR 1.526; 95% CI:1.243-1.874; P < .001). NC showed a good discrimination power in predicting patients requiring IMV (AUC 0.783; 95% CI:0.684-0.882; P < .001). In particular, NC > 40.5 cm (>37.5 for females and >42.5 for males) showed a higher and earlier IMV risk compared to subjects with lower NC (Log-rank test: P < .001)., Conclusions: NC is an easy to measure parameter able to predict the need for IMV in adult COVID-19 inpatients., (© 2020 John Wiley & Sons Ltd.)

Introduction: Since the beginning of the 2020 Sars-CoV-2 Italian outbreak, healthcare workers have been among the most exposed categories. There is little information about community pharmacists' on occupational exposure, symptoms development, and testing practices in the community pharmacist cohort., Methods: Between April 30th and May 10th, a questionnaire was administered through social media to Italian community pharmacists. From 67000 pharmacists currently working in community pharmacies, 1632 answered the survey., Results: The survey population reflected the general Italian community pharmacists population in terms of age, gender, and number of co-workers. Protective measures were adopted in up to 99.9% of pharmacies. 624 pharmacists (38.2%) developed at least one COVID-19 related symptom in the period between February 28th and May 10th. Also, 102 pharmacists (6.2%) were tested for COVID-19 and 15, the 15% of the tested population and 0.92% of the whole survey population, resulted positive on nasopharyngeal swab. However, while the number of symptomatic pharmacists decreased, a higher number of tests were performed, thus COVID-19 prevalence among community pharmacists could have been underestimated and is probably intermediate between other healthcare workers and the general population (0.31%)., Conclusion: Community pharmacists have probably been one of the first categories to experience increased contact risk to SARS-CoV-2. COVID-19 prevalence among pharmacists could have been underestimated. In addition, the rates of protection measures adoption might have helped to reduce the spread of COVID-19 among co-workers and the community., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Pentraxin 3 (PTX3) is an acute phase protein; its plasmatic levels significantly rise during severe infections. Data on PTX3 levels in cerebrospinal fluid (CSF) of patients with central nervous system (CNS) infections are lacking. We aimed (a) to assess the diagnostic potential of measuring CSF PTX3 levels in patients with CNS infections and (b) to establish CSF PTX3 cutoffs to distinguish between bacterial and aseptic meningoencephalitis (ROC curve). PTX3 levels were measured in CSF from 19 patients admitted to Trieste Hospital, Italy, with CNS infection. A diagnosis of bacterial infection and aseptic meningoencephalitis was made in 7 (37%) and 12 (63%) patients, respectively. Subjects with bacterial infections showed significantly higher PTX3 levels (13.5 vs 1.27 ng/mL in aseptic meningoencephalitis, p = 0.010). We identified two different CSF PTX3 levels cutoffs. (1) The best cutoff to maximise Youden's J was 9.6 ng/mL with a sensitivity, specificity, positive predictive value and negative predictive value (NPV) of 71.4%, 91.4%, 83.3%, 84.6%, respectively. (2) The cutoff with higher NPV (100%) was 3.6 ng/mL; a diagnosis of bacterial infections was obtained in 0% patients with CSF PTX3 levels < 3.6 ng/mL vs 58% of those with CSF PTX3 levels ≥ 3.6 ng/mL (p = 0.017). CSF PTX3 levels are higher in bacterial meningitis than aseptic meningoencephalitis. A cutoff of 3.6 ng/mL of CSF PTX3 has a high NPV and can be used to exclude bacterial CNS infections.

Introduction: Being elderly is a well-known risk factor for candidemia, but few data are available on the prognostic impact of candidemia in the very old (VO) subjects, as defined as people aged ≥75 years., Objective: The aim of this study was to assess risk factors for nosocomial candidemia in two groups of candidemia patients, consisting of VO patients (≥75 years) and adult and old (AO) patients (18-74 years). In addition, risk factors for death (30-day mortality) were analysed separately in the two groups., Methods: We included all consecutive candidemia episodes from January 2011 to December 2013 occurring in six referral hospitals in north-eastern Italy., Results: A total of 683 nosocomial candidemia episodes occurred. Of those, 293 (42.9%) episodes were in VO and 390 (57.1%) in AO patients. Hospitalization in medical wards, chronic renal failure, urinary catheter, and peripheral parenteral nutrition (PPN) were more common in VO than in AO patients. In the former patient group, adequate antifungal therapy (73.2%) and central venous catheter (CVC) removal (67.6%) occurred less frequently than in AO patients (82.5 and 80%, p < 0.002 and p < 0.004, respectively). Thirty-day mortality was higher in VO compared to AO patients (47.8 vs. 23.6%, p < 0.0001). In AO patients, independent risk factors for death were age (OR 1.04, 95% CI 1.00-1.09, p = 0.038), recent history of chemotherapy (OR 22.01, 95% CI 3.12-155.20, p = 0.002), and severity of sepsis (OR 40.68, 95% CI 7.42-223.10, p < 0.001); CVC removal was associated with higher probability of survival (OR 0.10, 95% CI 0.03-0.33, p < 0.001). In VO patients, independent risk factors for death were PPN (OR 3.5, 95% CI 1.17-10.47, p = 0.025) and hospitalization in medical wards (OR 2.58, 95% CI 1.02-6.53, p = 0.046), while CVC removal was associated with improved survival (OR 0.40, 95% CI 0.16-1.00, p = 0.050)., Conclusion: Thirty-day mortality was high among VO patients and was associated with inadequate management of candidemia, especially in medical wards., (© 2020 S. Karger AG, Basel.)

The management of patients with heart disease or suspected heart disease, who are hospitalized and/or who should undergo surgery or an invasive procedure, is very complex for the comorbidities often present, the multiple therapies taken and the frequent presence of advanced cardiac devices.The purpose of this document is to provide indications and standardize the behavior of different clinicians in the management of heart disease patients or those with suspected heart disease in order (i) to manage acute cardiac conditions with appropriate timing and accuracy, and (ii) to define the cardiovascular risk in the individual patient with appropriate timing and indications, allowing patients to face any surgery or invasive procedure with the lowest risk correlated to his heart disease.

SETTING: Early diagnosis of latent tuberculous infection (LTBI) should be pursued in healthcare workers (HCWs). While HCWs in hospitals are screened for LTBI, HCWs in outpatient settings are usually not. In 2017, in Italy, a tuberculosis (TB) infected paediatrician working in an outpatient vaccination service infected 15 adults and nine children. The investigation involved 2490 children and 151 adults. Among children, nine were tuberculin skin test-positive, and four developed active TB. Among 123 adult contacts with longer exposure, seven were interferon-gamma release assay (IGRA) positive and none had active TB. Among 28 close contacts, eight had a positive IGRA, and three had pulmonary TB. The total outbreak cost €1 017 903. OBJECTIVE: To compare the outbreak cost with those of potential screening programme strategies. RESULTS: Regular screening of paediatric outpatient HCWs would have cost between €2592 and €11 373. Extending the screening to all outpatient HCWs (caring for adults and children) would have cost between €66 384 and €155 043. Investigating only close contacts would have cost €42 857. CONCLUSION: Each of these screening strategies would have been cost-effective compared with the outbreak investigation occurring in real life with a cut-off of 474 for the maximum number of tested outpatient HCWs needed for the screening strategy to be cost-saving.

An alarming increase of vancomycin-resistant Enterococcus faecium (VREfm) isolates was detected in an Italian referral hospital subjected to policies of infection control validated by the Joint Commission International. Analysis of the population structure of 122 consecutive, nonreplicate VREfm isolates collected over an 18-month period identified a single major clone that spread around the whole hospital, rapidly establishing an endemic state. It belonged to sequence type (ST) 17 and showed a highly multidrug-resistant phenotype, being resistant to all antimicrobial classes for the carriage of several resistance determinants. Furthermore, some strains with decreased susceptibility to daptomycin were detected. Eighteen out of the 122 isolates did not group in the major clone. They showed a low spreading potential inside the hospital wards, even if most of them displayed a multidrug-resistant phenotype and belonged to a hospital-adapted lineage. Causes that led to the VREfm endemic state have not been fully elucidated. However, it is conceivable that the increase in systemic antibiotic consumption and the use of selective digestive tract decontamination, including vancomycin in critically ill patients during the period before 2014, may have played a role in the ST17 clone dissemination, but additional traits conferring high fitness in hospital environment cannot be excluded.

Background: Imported malaria cases continue to occur in non-endemic regions among travellers returning from tropical and subtropical countries. At particular risk of acquiring malaria is the group of travellers identified as immigrants who return to their home country with the specific intent of visiting friends or relatives (VFRs) and who commonly believe they are immune to malaria and fail to seek pre-travel advice. Our aim was to review the current trends of imported malaria in the three main hospitals of the Friuli-Venezia Giulia region (FVG), North Eastern Italy, focusing in particular on patient characteristics and laboratory findings., Methods: In this retrospective study, we examined all malaria cases among patients admitted from January 2010 through December 2014 to the emergency department of the three main hospitals located in FVG., Results: During the 5-year study period from 2010 to 2014, there were a total of 140 patients with a diagnosis of suspected malaria and who received microscopic confirmation of malaria. The most common species identified was P. falciparum, in 96 of 140 cases (69%), followed by P. vivax (13%), P. ovale (4%), P. malariae (4%), and mixed infection (4%). The most common reason for travel was VFRs (54%), followed by work (17%), and recent immigration (15%). Moreover, 78% of all patients took no chemoprophylaxis, 80 (79%) of whom were foreigners. Notably, the percentage of Italian travellers who took chemoprophylaxis was only 20% (8 of 39 Italian cases), and the regimen was appropriate in only four cases. Parasitaemia greater than 5% was observed in 11 cases (10%), all due to P. falciparum infection., Conclusions: We highlight that VFRs have the highest proportion of malaria morbidity and the importance of improving patient management in this category. These data are useful for establishing appropriate malaria prevention measures and recommendations for international travellers., (Copyright © 2017 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.)

Background: An increasing prevalence of candidemia has been reported in Internal Medicine wards (IMWs). The aim of our study was to identify risk factors for candidemia among non-neutropenic patients hospitalized in IMWs., Methods: A multicenter case-control study was performed in three hospitals in Italy. Patients developing candidemia (cases) were compared to patients without candidemia (controls) matched by age, time of admission and duration of hospitalization. A logistic regression analysis identified risk factors for candidemia, and a new risk score was developed. Validation was performed on an external cohort of patients., Results: Overall, 951 patients (317 cases of candidemia and 634 controls) were included in the derivation cohort, while 270 patients (90 patients with candidemia and 180 controls) constituted the validation cohort. Severe sepsis or septic shock, recent Clostridium difficile infection, diabetes mellitus, total parenteral nutrition, chronic obstructive pulmonary disease, concomitant intravenous glycopeptide therapy, presence of peripherally inserted central catheter, previous antibiotic therapy and immunosuppressive therapy were factors independently associated with candidemia. The new risk score showed good area under the curve (AUC) values in both derivation (AUC 0.973 95% CI 0.809-0.997, p<0.001) and validation cohort (0.867 95% CI 0.710-0.931, p<0.001). A threshold of 3 leads to a sensitivity of 87% and a specificity of 83%., Conclusion: Non-neutropenic patients admitted in IMWs have peculiar risk factors for candidemia. A new risk score with a good performance could facilitate the identification of candidates to early antifungal therapy., (Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

This study describes the dissemination of a carbapenem-resistant Acinetobacter baumannii (CRAB) strain in a university hospital in Northeast Italy. Characterization of the outbreak strain was combined with a retrospective analysis of all CRAB isolates collected in the same hospital during the 5 years preceding the outbreak, with the aim of elucidating the origin of the epidemic spread. The outbreak strain was shown to belong to the International Clone II and carry the bla OXA-23 gene, flanked by two ISAba1 sequences in opposite orientation (Tn2006 arrangement). The epidemic clone harbored also the bla OXA-66 allele of the carbapenemase intrinsic to A. baumannii, the determinant of ArmA 16S rRNA methylase and a class 1 integron, with the aacA4, catB8, and aadA1 cassette array. Genotype analysis, performed by macrorestriction analysis and VRBA, revealed that isolates related to outbreak strain had been sporadically collected from inpatients in the 2 years preceding outbreak start. Carriage of bla OXA-66 , armA, and the integron further supported relatedness of these isolates to the outbreak clone. Outbreak initially involved three medical wards, typically hosting elderly patients with a history of prolonged hospitalization. The study highlights the need to adopt strict infection control measures also when CRAB isolation appears to be a sporadic event.

Objectives: The Gatti score is a weighted scoring system based on risk factors for deep sternal wound infection (DSWI) that has been specifically created to predict DSWI risk after routine bilateral internal thoracic artery (BITA) grafting. It has not undergone an external validation. The aim of the present study was to perform this validation., Methods: BITA grafts were used as skeletonized conduits in 304 (90.7%) of 335 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution between January 2014 and July 2015. Baseline characteristics, operative data and immediate outcomes of every patient were prospectively collected in a computerized data registry. A score was assigned to each patient preoperatively. The goodness-of-fit and the discrimination power of both models, preoperative and combined, of the Gatti score were assessed with the Hosmer-Lemeshow test and the calculation of the area under the receiver-operating characteristic curve, respectively., Results: Eighteen (5.9%) patients suffered from DSWI. Major differences were found between the original series whence the Gatti score has been derived and the present prospective series. The Gatti score goodness-of-fit was satisfactory for both the preoperative (P = 0.61) and the combined model (P = 0.81). The area under the receiver-operating characteristic curve was 0.82 (95% confidence interval: 0.72-0.91) for the preoperative model and 0.8 (95% confidence interval: 0.71-0.9) for the combined model., Conclusions: On the basis of the results of the present prospective study, the Gatti score has proved to be effective in predicting DSWI following BITA grafting despite some differences between the original and the present series of patients. More studies have to be performed in order to strengthen the evidence of this first external validation., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: Clinical data on patients with intra-abdominal candidiasis (IAC) is still scarce., Methods: We collected data from 13 hospitals in Italy, Spain, Brazil, and Greece over a 3-year period (2011-2013) including patients from ICU, medical, and surgical wards., Results: A total of 481 patients were included in the study. Of these, 27% were hospitalized in ICU. Mean age was 63 years and 57% of patients were male. IAC mainly consisted of secondary peritonitis (41%) and abdominal abscesses (30%); 68 (14%) cases were also candidemic and 331 (69%) had concomitant bacterial infections. The most commonly isolated Candida species were C. albicans (n = 308 isolates, 64%) and C. glabrata (n = 76, 16%). Antifungal treatment included echinocandins (64%), azoles (32%), and amphotericin B (4%). Septic shock was documented in 40.5% of patients. Overall 30-day hospital mortality was 27% with 38.9% mortality in ICU. Multivariate logistic regression showed that age (OR 1.05, 95% CI 1.03-1.07, P < 0.001), increments in 1-point APACHE II scores (OR 1.05, 95% CI 1.01-1.08, P = 0.028), secondary peritonitis (OR 1.72, 95% CI 1.02-2.89, P = 0.019), septic shock (OR 3.29, 95% CI 1.88-5.86, P < 0.001), and absence of adequate abdominal source control (OR 3.35, 95% CI 2.01-5.63, P < 0.001) were associated with mortality. In patients with septic shock, absence of source control correlated with mortality rates above 60% irrespective of administration of an adequate antifungal therapy., Conclusions: Low percentages of concomitant candidemia and high mortality rates are documented in IAC. In patients presenting with septic shock, source control is fundamental.

A persistent tick-borne encephalitis virus infection in an immune-suppressed patient is presented. Such an unusual clinical case offers the unique chance of detecting persistent viremia associated to the erythrocyte fraction and shedding of the virus in the urine for more than six weeks. The infection occurred in a new area of the Friuli Venezia-Giulia region (North Eastern Italy) where two additional cases are also being reported., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Italy is considered at low incidence of tick-borne encephalitis (TBE), and the occurrence of human cases of TBE appears to be geographically restricted to the north east of the country. However, most information to date derives from case series, with no systematic data collection. To estimate incidence rates (IR) and spatial distribution of TBE cases, we conducted a retrospective study in north-eastern Italy. Data were collected through the infectious disease units and public health districts of three regions (Friuli Venezia Giulia, Trentino Alto Adige and Veneto) between 2000 and 2013. Overall, 367 cases were identified (IR: 0.38/100,000). The cases' median age was 56 years and 257 (70%) were male. Central nervous system involvement was reported in 307 cases (84%). Annual fluctuations in case numbers occurred, with peaks in 2006 and in 2013, when 44 and 42 cases were respectively observed. A strong seasonality effect was noted, with the highest number of cases in July. In terms of geographical location, three main endemic foci with high TBE IR (>10/100,000) were identified in three provinces, namely Belluno (Veneto region), Udine (Friuli Venezia Giulia) and Trento (Trentino Alto-Adige). When investigating the whole study area in terms of altitude, the IR between 400 and 600 m was greater (2.41/100,000) than at other altitudes (p<0.01). In conclusion, the incidence of TBE in Italy is relatively low, even considering only the three known affected regions. However, three endemic foci at high risk were identified. In these areas, where the risk of TBEV infection is likely high, more active offer of TBE vaccination could be considered.

Candidemia has become an important bloodstream infection that is frequently associated with high rates of mortality and morbidity, and its growing incidence is related to complex medical and surgical procedures. We conducted a multicenter study in five tertiary care teaching hospitals in Italy and Spain and evaluated the epidemiology, species distribution, antifungal susceptibilities, and outcomes of candidemia episodes. In the period of 2008 to 2010, 995 episodes of candidemia were identified in these hospitals. The overall incidence of candidemia was 1.55 cases per 1,000 admissions and remained stable during the 3-year analysis. Candida albicans was the leading agent of infection (58.4%), followed by Candida parapsilosis complex (19.5%), Candida tropicalis (9.3%), and Candida glabrata (8.3%). The majority of the candidemia episodes were found in the internal medicine department (49.6%), followed by the surgical ward, the intensive care unit (ICU), and the hemato-oncology ward. Out of 955 patients who were eligible for evaluation, 381 (39.9%) died within 30 days from the onset of candidemia. Important differences in the 30-day mortality rates were noted between institutions: the lowest mortality rate was in the Barcelona hospital, and the highest rate was in the Udine hospital (33.6% versus 51%, respectively; P = 0.0005). Overall, 5.1% of the 955 isolates tested were resistant or susceptible dose dependent (SDD) to fluconazole, with minor differences between the hospitals in Italy and Spain (5.7% versus 3.5%, respectively; P = 0.2). Higher MICs for caspofungin were found, especially with C. parapsilosis complex (MIC90, 1 μg/ml). Amphotericin B had the lowest MICs. This report shows that candidemia is a significant source of morbidity in Europe, causing a substantial burden of disease and mortality.

In July 2013, an Italian tourist returning from Cuba was hospitalised in Trieste, Italy, for cholera caused by Vibrio cholerae O1 serotype Ogawa with severe renal failure. An outbreak of cholera was reported in Cuba in January 2013. Physicians should consider the diagnosis of cholera in travellers returning from Cuba presenting with acute watery diarrhoea.

Antibiotic therapy is a crucial and often life-saving strategy. This study assessed the ability to prescribe antibiotic therapy among a series of Italian postgraduate students in geriatrics and internal medicine. Participants were administered an anonymous questionnaire consisting of self-assessment of their ability to prescribe antibiotics and then manage a case of community-acquired pneumonia. The Wilcoxon test for comparisons between two independent samples was used for statistical analysis. Almost half the 70 students considered their knowledge of antibiotic therapy insufficient and were not satisfied with the notions received during their studies. Indeed, the change in antibiotic therapy required to control acute exacerbation of pneumonia was correctly identified by only 36% of students. Moreover, 38% of them gave the correct answer on factors influencing the duration of antibiotic therapy in the presence of definite improvement of pneumonia. No significant difference was found between the responses of residents in geriatrics and internal medicine. Overall, our study shows that nearly half of our students think they have inadequate antibiotic prescribing skills. This is confirmed by a low ability to establish the best management of the clinical case. To repair this severe shortcoming, different training methods need to be compared and more effective forms of instruction adopted.

Cancrum oris (or noma) is a rapidly progressive disease characterized by destructive necrosis of oral tissues and underlying bone. It is part of a multistage condition and may represent the outcome of untreated necrotizing stomatitis. Necrotising stomatitis and cancrum oris predominantly affect children in developing countries, especially in Africa. Only few cases have been reported in developed countries, and were associated with debilitating diseases and disorders of the immune system. We report a case of noma in an elderly immunosuppressed Italian patient in whom necrosis caused an external buccal communication. This case stresses the importance of an early identification and prompt management of the necrotic condition, in order to avoid diffusion of the destructive process within the oro-facial tissues.

The prevalence of antibodies to Rickettsiae and other tick-borne microrganisms in the sera of 181 forestry rangers from Friuli-Venezia-Giulia, Italy, was examined. Seven (3.9%) sera were positive for Rickettsia conorii and Rickettsia helvetica, as single or dual infections; four of these sera had been found previously to be positive for Borrelia burgdorferi. Antibodies to Coxiella burnetii were detected in five (2.8%) sera, four of which were also positive for B. burgdorferi. These findings indicate that patients in this north-eastern Italian region with fever subsequent to tick-bite should be investigated for Rickettsia and Coxiella infections.

A retrospective study was performed in an Italian tertiary hospital to evaluate trends in candidaemia between 1992 and 2001, and to compare the characteristics of episodes of fungaemia between 1992--1997 and 1998--2001. In total, 370 episodes of candidaemia were identified, with an average incidence of 0.99 episodes/10 000 patient-days/year (range 0.49--1.29 episodes). On an annual trend basis, the overall incidence was essentially stable in surgical and medical wards, but decreased in intensive care units (ICUs) (p 0.0065). The average use of fluconazole was 37.9 g/10 000 patient-days/year (range 21.4--56.1 g), and did not change significantly during the 10-year period. Nearly two-thirds of patients were in ICUs at the onset of candidaemia, but none was neutropenic in either study period. Candida albicans remained the predominant species isolated (53.8% vs. 48.1%), followed by Candida parapsilosis, Candida glabrata and Candida tropicalis, the distribution of which did not change significantly. The 30-day crude mortality rate was essentially similar (44% vs. 35%) in both study periods. Thus the incidence of nosocomial candidaemia, although high in this institution, decreased among critically-ill patients during the 10-year period. This finding seemed to be related to an improvement in infection control practices, particularly regarding the prevention of intravascular catheter-related infections in ICUs. Although the overall use of fluconazole was considerable, no increase in azole-resistant non-albicans Candida spp. was detected.

The aim of this study was to estimate the seroprevalence of antibodies to Borrelia burgdorferi, Anaplasma phagocitophilum and tick-borne encephalitis (TBE) virus, and risk factors, in forestry rangers from the Friuli-Venezia-Giulia region in northeastern Italy. Sera from 181 forestry rangers were examined with two-tiered serological tests for TBE, Lyme borreliosis and ehrlichiosis. Information about risk factors such as job location, residence, number of tick bites and outdoor leisure activities was collected with a questionnaire. Seropositivity was 0.6% for TBE virus, 23.2% for Lyme borreliosis and 0.6% for ehrlichiosis. Lyme borreliosis positivity, as determined by Western blot, was associated with working in the foothills, with gardening in the northeastern part of the region, and with a history of yearly tick bites. Risk factors were similar when a case of Lyme borreliosis was defined either by Western blot positivity or by clinical history.

A nosocomial cluster of Candida guillermondii fungemia ( n=5 episodes) occurred in a surgical unit over a 2-week period. The five infected patients had received parenteral nutrition through central lines and three of them had catheter-related candidemia. All of the isolates were resistant to 5-flucytosine (MIC >32 microg/ml) and they had strictly related fingerprints, as generated by randomly amplified polymorphic DNA analysis. Although no isolate of Candida guillermondii was recovered from other clinical, surveillance or environmental samples, nosocomial spread of this yeast stopped following the reinforcement of infection control measures. Candida guillermondii may require an intravascular foreign body to cause fungemia, but the outbreak reported here shows that it can be transmitted nosocomially and cause epidemics.

We conducted a one-year prospective study on intensive care unit (ICU)-acquired infections and antimicrobial resistance patterns in an 18-bed medical-surgical ICU of a tertiary-care university hospital. We divided the study into two six-month periods in order to evaluate the impact of antibiotic changes in empirical therapy on antimicrobial resistance profiles of the principal isolated micro-organisms. In the first period no changes were made to the previously applied empirical antibiotic protocol; at the end of this period we found high rates of methicillin resistance (MR) among staphylococci, 93% for Staphylococcus aureus (69 isolates) and 79% for coagulase-negative staphylococci (CNS) (48 isolates), and of multiple drug resistance for Pseudomonas aeruginosa (57 isolates), in particular 67% resistance to piperacillin/tazobactam (PIP/TZ). We therefore decided to substitute PIP/TZ with imipenem in nosocomial pneumonia and with cefepime plus metronidazole in peritonitis. We also considered the previous use of amoxicillin/clavulanate (AM/CL) at admission in critically ill patients inadequate; we therefore advised that no antibiotics should be given unless fever developed and eventually to replace AM/CL with trimethoprim/sulfamethoxazole (TMP/SMX). At the end of this intervention period, we observed a significant decrease of S. aureus MR (93 vs. 73%, P = 0.003) and of P. aeruginosa resistance to PIP/TZ (67 vs. 29%, P < 0.001). A reduction in MR was also seen in CNS (79 vs. 64%, P = 0.09). Other resistance patterns also improved among staphylococci; in contrast P. aeruginosa resistance to imipenem increased in the second period (24 vs. 41%, P = 0.06). A non-premeditated change of antibiotics in empirical therapy, on the basis of detected resistance patterns, provided promising results in reducing some antimicrobial resistance rates. We believe, however, that antibiotic changes must be tailored to local microbiological situation monitoring, and that a repeated rotation is crucial to limit the emergence of new resistance profiles. Furthermore the adoption of this policy should be accompanied by other infection control practices aimed at reducing antimicrobial resistance and nosocomial infection rates., (Copyright 2002 The Hospital Infection Society)

Background: Nosocomial infection is one of the most common complications affecting patients admitted in intensive care units (ICU). The aim of this study is to evaluate rates of ICU-acquired infections, potential risk factors for these infections, causative microorganisms and antibiotic resistance patterns., Methods: A 1-day point-prevalence study was conducted in 39 ICUs in Triveneto area (Italy) in November 1998. The overall study population included 188 patients with mean age of 61.4+/-19.3 years; the mean SAPS II score at entry into the ICU was 44.4+/-16.8 and the median duration of hospitalization was 9 days (range 2-636)., Results: A total of 59 patients (31.4%) had 79 episodes of ICU-acquired infections; pneumonia (45.5%), bloodstream infection (30.4%), and urinary tract infection (11.4%) were the most frequent types of infection. The leading causative microorganisms were S. aureus (24.4%, 77% of them were resistant to methicillin), Enterobacteriaceae (24.4%), P. aeruginosa (23.2%), fungi (12.2%), coagulase-negative staphylococci (7.3%) and Enterococcus spp (4.9%). Independent risk factors for nosocomial infections were duration of hospitalization >7 days (OR 4.29, 95% CI 1.82-10.1), SAPS II score >30 (OR 3.34, 95% CI 1.0-11.18), total parenteral nutrition (OR 2.69, 95% CI 1.19-6.07) and tracheostomy (OR 1.88, 95% CI 0.84-4.20)., Conclusions: Nosocomial infections are relatively frequent in Triveneto area ICUs. The predominance of pneumonia and bloodstream infection, and the high frequency of antibiotic-resistant pathogens indicate that resources had to be assigned towards the implementation of control programs of those infections, monitoring of antibiotic resistance and prescription, and antibiotic therapy guidelines.

In a retrospective study conducted in an Italian tertiary care hospital, the incidence of nosocomial candidemia was evaluated together with causative pathogens, treatment, and risk factors for death. Over a 6-year period (1992-1997), a total of 189 episodes of candidemia occurred in 189 patients (mean age 58+/-19 years), accounting for an average incidence of 1.14 episodes per 10,000 patient-days per year. The most common reasons for hospitalization were solid neoplasia (21%), trauma (17%), abdominal diseases requiring surgery (13%), and cardiovascular diseases (13%). No patient was neutropenic within 3 weeks prior to the onset of candidemia. One hundred thirty patients were hospitalized in intensive care units, 47 patients in surgical wards, and 12 patients in medical wards. Candida albicans was the most frequently isolated pathogen, accounting for 54% of fungal isolates, followed by Candida parapsilosis (23%), Candida glabrata (7%), Candida tropicalis (5%), Candida pelliculosa (4%), Candida lusitaniae (1%), Candida humicula (1%), and other non-albicans Candida spp. (5%). Seventy-six (41%) patients received adequate antifungal therapy. Seventy-one (58%) of the 123 evaluable patients with central venous catheters underwent line removal; 51 of them had catheter-related candidemia. The 30-day crude mortality rate was 45%. Older age, hospitalization in an intensive care unit, a longer duration of candidemia, retention of central lines, and inadequate antifungal therapy were significantly associated with poor outcome. In the present study, nosocomial candidemia was a frequent and relatively underestimated illness. Adequate antifungal therapy and central line removal independently reduced the high mortality of the disease.

In an investigation of a nosocomial outbreak of tuberculosis, 18 HIV-infected inpatients were found to have been exposed to Mycobacterium tuberculosis; active tuberculosis developed in 8, 7 within 60 days of diagnosis of the index case. The patients with lower total lymphocyte and CD4 lymphocyte counts were more likely to get the disease than were those with higher counts. A low score on multiple antigen skin testing was also associated with the development of active tuberculosis. 4 of the 18 patients had a positive tuberculin skin test before exposure to M tuberculosis; none of them subsequently got the disease.