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The increase in the aged population led to a global rise in the demand for elderly healthcare services, such as long-term care facilities (LTCFs), nursing homes, residential homes. Unfortunately, the spread of multidrug-resistant organisms (MDROs) in these structures represent an urgent public health threat requiring immediate action. The aim of this review is to provide a practice guide for the prevention of infections in European LTCFs. A team of experts identify specific problems and proposed practical solutions for the management of colonized and infected patients residing in LTCFs. The heterogeneity of LTCF represents one of the main problems for the implementation of standardized surveillance and infection control programs. Crucial steps involved in the spread of infections among LTCF residents are represented by patient's accommodation, MDRO screening on admission, management of patients with rectal colonization by MDROs, management of patients at high risk of MDRO infections, MDRO transmission by staff and implementation of antimicrobial stewardship. Efforts to implement specific actions in each of these fields are required to reduce the infections in this setting.

Background Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting. Objectives This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting. Source PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively. Content Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions. Implications There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.

Background When performing minimally invasive spine surgery in trauma patients, a short operation time and a perfect positioning of pedicle screws are demanded. In this study, we show that a Minimally Invasive Pedicle Screw System allows both. Methods One hundred and twenty-one patients (131 fractures) with fractures between Th 3 and L 5 were treated. The most common fracture type was A3. We treated 52 females and 69 men with a mean age of 56.7 years. In 72% of the cases, the procedure was performed by two experienced spine surgeons. Postoperatively, all patients were examined using a CT-scan. In 61 patients, an anterior stabilization was additionally performed in 33 patients, vertebroplasty or cyphoplasty was performed. Fifteen patients underwent laminectomy. Results No patient postoperatively developed any additional neurological compromise. In total, 682 screws were placed. In the postoperative CT-scan, we found 16 screws (2.2%) in suboptimal position, 8 with medial and 8 with lateral deviation. Discussion With the Minimally Invasive Pedicle Screw System used in this study, spinal fractures can be treated in a short operation time with percutaneous stabilization and a correct positioning of the pedicle screws in almost 98%. In our study, no screw was so much malpositioned that revision surgery would have been necessary. Level of evidence Level III – Case-control study.

The increased knowledge of the natural history of cystic echinococcosis (CE) by the recent expansion in the use of ultrasound (US) in field and clinical studies has necessitated the development of a new WHO standardised classification of US images. Use of such a classification will enable clinicians to examine recommended clinical procedures for the different cyst types. It will also allow scientists to compare data on the occurrence of cyst types in different parts of the world providing evidence to examine strain differences in the causative organism Echinococcus granulosus. The classification proposed follows that of the first classification developed by Gharbi et al. [Radiology 139 (1981) 459] which has been widely used, but in modified forms, since its publication. The classification presented here is intended for use in field epidemiological studies as well as for clinical investigators. The classification is intended to follow the natural history of CE and starts with undifferentiated simple cysts, as presumably hydatid cysts evolve from these structures. These simple cysts, however, may be due to a number of different aetiologies (parasitic lesions, congenital disorders, biliary cysts or neoplasms) and, therefore, require further diagnostic tests to reveal their identity. As their origin is uncertain they are not given the designation of a CE type lesion, and, in the proposed classification, should be recorded as cystic lesions (CL). The first clinical group starts with cyst types CE 1 and 2 and such cysts are active, usually fertile cysts containing viable protoscoleces. CE Type 3 are cysts entering a transitional stage where the integrity of the cyst has been compromised either by the host or by chemotherapy and this transitional stage is assigned to the second clinical group. The third clinical group comprises CE Types 4 and 5 which are inactive cysts which have normally lost their fertility and are degenerative. The use of the standardised US classification will facilitate the application of uniform standards and principles of treatment currently recommended for each cyst type.

Chronic graft versus host disease (cGVHD), the most common late complication of allogeneic haematopoietic stem cell transplantation (HSCT), may present with sclerodermatous lesions resembling in some cases the cutaneous involvement of systemic sclerosis (SSc). Certain pathogenetic findings connect the two diseases. In this report we describe ten subjects affected by cGVHD who underwent the examinations routinely carried out to stage SSc patients. Demographic, clinical, serologic and instrumental data were recorded. These patients showed differences in appearance, extent and progression of the sclerodermatous lesions with greater involvement of the trunk and proximal part of the limbs than the extremities. In seven subjects ANA test was positive; scleroderma-associated autoantibodies were not detected in any of the cases. Moreover, typical organ involvement of SSc was not found. Only one patient developed Raynaud's phenomenon after HSCT and only one patient demonstrated a nailfold videocapillaroscopic scleroderma pattern. Except for cutaneous involvement of cGVHD, that may resemble SSc, the clinical features of the two diseases are quite different, suggesting that the fibrotic process characterizing cGVHD and SSc has different etiologies and different initial pathobiologic events.

The objective of this study was to determine the effects of a continuous infusion of the phosphodiesterase inhibitor enoximone on mucosal villus blood flow in a normotensive model of endotoxemia.Twenty-four anesthetized and ventilated rats underwent laparotomy and a ileal portion was exteriorized and opened by an antimesenteric incision. The ileal segment was fixed on a plexiglass stage with the mucosal surface upward. Microcirculatory parameters were assessed by intravital videomicroscopy. The animals were randomly assigned to receive one of three treatments: infusion of Escherichia coli lipopolysaccharides (LPS, 2 mg/kg/h) without phosphodiesterase inhibitor pretreatment (LPS group); or infusion of LPS with enoximone pretreatment (10 microg x kg(-1) x min(-1), start 30 min before LPS infusion, enoximone group), or infusion of an eqivalent volume of NaCl 0.9% (control group). Macrohemodynamic parameters (MAP, HR) and microhemodynamic parameters of ileal mucosa (mean diameter of central arterioles = DA, and mean erythrocyte velocity within the arterioles = VE) were measured 30 min before and at 0, 60, and 120 min after induction of endotoxemia. Mucosal villus blood flow was calculated from DA and VE.In this normotensive endotoxemia model MAP remained stable in the control and the LPS group but significantly decreased in the enoximone group. The endotoxin-induced decrease of VE and DE of central arterioles of mucosal villi could be prevented. Thus, mucosal villus blood flow did not decrease compared to the LPS group.Our results indicate that enoximone during an early stage of sepsis contributes to systemic hypotension but prevents mucosal hypoperfusion.

Background The current health network structure and a lack of a proper filter for pre-hospital care makes every hospital potentially involved into the management of any critical paediatric patient regardless the local experience and organisation. Any first patient’s stabilisation will have to be followed by a secured secondary transport until the hospitalisation at the new facility. Objective Explore the hospitals’ organisational set up concerning the secondary transport of paediatric critical care patients. Materials and methods Structured survey delivered to 92 hospitals in Lombardy Results The response rate was 56%, corresponding to 52 health care facilities. In 29 facilities a dedicated transport service for critical care patients does exist but just in one hospital it’s specific for paediatric patients and it has dedicated staff. Forty facilities are equipped with a paediatric medical bag and the more involved operator is an anesthesiologist for 39% of cases, followed by the paediatrician in 13% of cases. The nurse participates to the transport in 50% of cases; in 28% of the hospitals a critical care nurses is involved, in 7% of cases the nurse is not specialised and in 4% the nurses is specialised in paediatrics. Discussion The data shows an non homogeneity management of the critical care patient secondary transport. Conclusions It’s highly desirable the activation of a secondary transport service with an organisational level compared to the neonatal emergency transport service because the child has its own characteristics as like as the newborn or the adult.

Background When performing minimally invasive spine surgery in trauma patients, a short operation time and a perfect positioning of pedicle screws are demanded. In this study, we show that a minimally invasive pedicle screw system allows both. Methods One hundred and twenty-one patients (131 fractures) with fractures between Th 3 and L 5 were treated. The most common fracture type was A3. We treated 52 females and 69 men with a mean age of 56.7 years. In 72% of the cases, the procedure was performed by two experienced spine surgeons. Postoperatively, all patients were examined using a CT scan. In 61 patients, an anterior stabilization was additionally performed in 33 patients, vertebroplasty or cyphoplasty was performed. Fifteen patients underwent laminectomy. Results No patient, postoperatively, developed any additional neurological compromise. In total, 682 screws were placed. In the postoperative CT scan, we found 16 screws (2.2%) in suboptimal position, 8 with medial and 8 with lateral deviation. Discussion With the minimally invasive pedicle screw system used in this study, spinal fractures can be treated in a short operation time with percutaneous stabilization and a correct positioning of the pedicle screws in almost 98%. In our study, no screw was so much malpositioned that revision surgery would have been necessary. Level of evidence Level III Case-control study.

Bovine and human hydatid antigens collected from hepatic cysts and characterized by SDS-PAGE immunoblotting show similar patterns. The bovine hydatid antigen has been used to develop a simple and fast in vitro diagnostic assay for human hydatidosis. This method, named HA-DIA (hydatid antigen dot immunobinding assay), consists of incubation of a serum sample with a textile colloidal dye (pink) and a nitrocellulose stick to which the hydatid antigen has been bound. The presence of parasite-specific antibodies leads to dyeing of the stick reactive area, and a coloured spot appears. HA-DIA sensitivity and specificity have been studied in comparison with RAST-IgE and ELISA-IgG by testing 17 sera of patients with hydatid disease and 36 control sera from patients affected with other parasitic and non-parasitic diseases. HA-DIA showed positive results in all the patients' sera and in none of the control sera. Correlation with ELISA--IgG and RAST-IgE was significant. HA-DIA has been demonstrated to be of good predictive value, allowing a speedy diagnosis of hydatid disease. In view of its simplicity, not requiring any laboratory instruments, it is particularly suitable for large-scale field screening.

Serum samples from 487 ambulatory I.V. drug users were screened for HIV and HCV antibodies to determine the prevalence of coinfection in this high risk group for AIDS. For anti-HCV antibody screening we first used a 3rd generation EIA using, as antigen synthetic peptides which were not subjected to false positive results due to antibodies against superoxide dismutase or against yeast proteins (which may copurify with the recombinant proteins employed in the first and second generation test). The specimens that were positive in the screening test were confirmed by a more specific EIA system that detect antibodies to proteins encoded by structural (HCV-st EIA) and non structural (HCV-nst-EIA) regions of the HCV genome. A second confirmation assay was also performed: sera were run in presence or absence of blocking reagents which inhibits antibodies to C200 and C22 HCV epitopes for binding to the solid phase. The sensitivity of the HCV EIA screening for human HCV antibody detection revealed a 100% positivity for HCV infection. The confirmatory strategy presented in this paper revealed an HCV EIA specificity of 98.6%. In this work we demonstrated a significantly higher prevalence (p0.001) of HCV exposure in HIV infected individuals compared to the general population. Our experimental data also confirmed that HBV infection in drug-users at high risk for HIV infection was significantly associated with HCV infection (p0.001). In contrast, the acquisition of HIV by sexual contact was not a statistically significant risk factor for HCV coinfection.

The epidemiological, clinical and therapeutical findings are described in a case of recurrent pulmonary histoplasmosis due to Histoplasma capsulatum. The patient, a bulldozer-operator, worked in Africa for a long period in extremely dusty conditions without any protection. Three different episodes of H. capsulatum pneumonia recurred during eighteen months after his return from Africa. A full dose treatment by Amphotericin B failed to eliminate disease recurrence on three occasions. The high concentration of airborne H. capsulatum spores inhaled could have been the main cause of the difficulty obtaining a rapid sterilization of the microorganism by Amphotericin B and disease recurrence. The late start of the treatment or the unexplained ability of some persons to develop repeated infections even with normal immunological parameters could be another explanation for the reported phenomenon.

We report the follow-up and treatment of HCMV infections in three patients with AIDS. The patients, affected by HCMV retinitis, have been followed 24, 12 and 6 months respectively. The antiviral treatment was based on the DHPG administration which was substituted in one case of resistance to DHPG with Foscarnet. In the follow-up period, virological tests have been performed to detect the presence of the HCMV antigenemia/viremia. The results show that, to avoid the progression of the retinitis, the antiviral treatment must not be stopped or discontinued. DHPG and Foscarnet were able to limit the infection to the eye and were well tolerated. In the HCMV-infected patients, the continuous monitoring of the antigenemia/viremia is of main importance to follow the clinical and therapeutical course of the disease.

The present study was set up to evaluate the efficacy of hyperimmune anti-CMV immunoglobulins (IVIG) in the prophylaxis of CMV infection in five patients suffering from dilatative myocardiopathy and submitted to hearth transplant. Different commercial IVIG were tested for anti-CMV neutralizing antibodies before administrated them to patients; the lots immunochemically prepared by PEG resulted to have the highest anti-CMV titer. IVIG treatment, when administered at high doses and at closes intervals of time, proved able to prevent and control CMV infections; when treatment was stopped, a primary infection occurred, easily controlled by short courses of DHPG. Even if our survey was limited to only five cases, it should be emphasized that after the suspension of the therapy, clinical symptoms were restricted to simple mononucleosis syndrome without organ disease. Furthermore it should be noted that during IVIG therapy no immediate or delayed adverse effects were observed.

The present study describes a case of AIDS with asymptomatic intracranial focal lesions. The DDD-enhancement CT technique detected the lesions as inflammatory or neoplastic. A subsequent MR demonstrated the vascular nature of the intracranial findings. MR in the neuropathology of AIDS can be of primary importance in the detection of the intracranial focal lesions, thus avoiding a cerebral stereotaxic needle biopsy.

On July 27, 1989, the International Conference on Molecular Aspects of Immune Response and Infectious Diseases devoted a symposium to the subject of the use of intravenous gamma globulin (IVIG) in acquired immunodeficiency syndrome (AIDS). The information presented confirmed that IVIG benefits human immunodeficiency virus (HIV)-infected children with recurrent infections and that much remains to be learned about the influence of IVIG in adult AIDS. The symposium participants recognized the urgent need to develop randomized clinical trials using a control group to assess the efficacy of a treatment with IVIG in PGL (persistent generalized lymphadenopathy), ARC (AIDS-related complex), and AIDS. To prepare this report, a committee was established, including individuals with expertise in immunology, immunopharmacology, microbiology, virology, infectious diseases, general medicine, and pediatrics and representing research experience in academia and hospitals. After an introduction to the report with a summary of immunotherapeutic agents under evaluation to treat HIV infection, section 1 lays out the present understanding of the disease pathogenesis. Section 2 then outlines the treatment of HIV-seropositive individuals, discussing the uncertainties that any treatment entails. Section 3 discusses the rationale for treating HIV-infected individuals with WIG, and Section 4 examines the major differences between IVIG and hyperimmuneglobulins for the treatment of HIV infection. Section 5 looks at IVIG as a mean to delay the emergence of opportunistic infections and restore immunocompetence in AIDS and related illnesses, and Sections 6 and 7 suggest a pilot protocol on the use of WIG in association with low-dose or standard-dose zidovudine (AZT). Limited time precluded the committee's addressing certain important aspects, and it must be remembered that, since this report represents the committee evaluations as of July 1989, the use of WIG in adults infected with HIV should be studied on a continuous basis according to more up-todate knowledge of HIV infection.

Serum IgE levels and IgE antibodies against four intestinal parasites, and the presence and abundance of parasites in stool samples were investigated in 161 Rwanda natives. Most of the IgE turn out to be helminth-reacting antibodies. The stimulation and production of these antibodies are much different from those of anti-amoeba antibodies in their relation to the specific intestinal parasite load; helminth infestations seem to play a major role in the development of anti-amoeba antibodies as well.

Serum IgE determinations and coproparasitological analyses were carried out on 161 individuals from two distinct ethnic groups (Hutus and Twas) from two regions in Rwanda (North and South). The cumulative parasitosis index (calculated for each individual as the sum of the scores for the four most frequent intestinal parasites) shows a linear relation with IgE levels up to a plateau, with no clear pattern of correlation between the score for any given parasite and the IgE level. Such a direct quantitative (but not qualitative) relation reproposes the question on the role of IgE immunoglobulins in intestinal parasitoses.

Toxocariasis, Hydatidosis and Fascioliasis are common autochthonous parasitic infections in Italy. RAST and ELISA have been evaluated for serological diagnosis. Eight sera from Toxocariasis, fifty from Hydatidosis and two from Fascioliasis have been examined. Excretory/secretory antigen has been employed for the serology of Toxocariasis, hydatic fluid for Hydatidosis and embryonated-eggs antigen for Fascioliasis. The RAST resulted positive in 4/5 cases of the visceral form of Toxocariasis and 3/3 in the ocular form, in 2/2 cases of Fascioliasis and 27/50 of Hydatidosis. The ELISA resulted positive respectively in 5/5, 3/3, 2/2, and 19/50 cases. The sensitivity and specificity of the tests employed have been proved.

Three cases of aspergillosis observed in Pavia Infectious Disease Clinic in 1983-85 are described. The cases differed both in the site of the infection (lungs, bones and liver) and in the patients' basic immunological situation. The importance of mycological investigations during diagnosis is emphasised, though they should of course be flanked by instrumental examinations and blood chemical assays. The efficacy of specific treatment with amphotericin B combined with surgery and plasma exchange is also emphasised.

We measured the chemiluminescence (CL) of human leukocytes (PMNs) exposed to different concentrations of Clindamycin (1; 5; 1 mcg/ml) using a standardized luminolamplified reagent-instrument methodology (Auto Picolite 6500 Luminometer and ZAP/Picolite Kits, Packard Instruments Co. Drowners Grove, IL. USA). Cells obtained from healthy donors were also tested for chemotaxis with Boyden chambers, for phagocytosis and for killing activity against Staphylococcus aureus by the agar-medium culture plate technique. Clindamycin does not induce significant variations of the CL response in whole blood, or changes in phagocytosis and killing activity. On the contrary, concentrations of drug corresponding to therapeutically obtainable levels significantly increase light emission by isolated cells. A concentration effect was seen on leukotaxis, that was increased, but not significantly, at 1 and 5 mcg/ml and decreased (P less than 0.01) at 10 mcg/ml. CL assay is a simple, sensitive, reproducible technique to assess the PMNs functions during antibiotic therapy.

A case of recurrent pulmonary aspergillosis in a young girl with common variable hypogammaglobulinaemia and the treatment adopted is described. We employed the plasma-exchange, at the beginning of immunosubstitutive treatment, to provide a high serum concentration of all classes of immunoglobulins and to better control the patient's state of shock. Intravenous immunoglobulins and Amphotericin B were also given in combination with plasma-exchange, having a synergic therapeutic effect. The good condition of the patient, despite the recurrent episodes of fungal pneumonia, suggests that such an approach can lead to long-term, high quality survival in humoral immunodeficient patients.

The Authors have evaluated the use of anti-human immunoglobulins conjugated with peroxidase, alkaline-phosphatase, glucose-oxidase as a diagnostic tool for assaying autoantibodies. A comparison study was done using the classical indirect immunofluorescence technique. Immunoenzymatic techniques, of minor cost compared to immunofluorescence, have revealed a better appreciation of global and particular structure of the tissue in examination. From the three enzymes examined peroxidase revealed itself as first choice, because, other than having on overlapping sensitivity to immunofluorescence, it can allow a further ultrastructural study.

Morphological, cytochemical and ultrastructural studies of mast cells were carried out in a patient affected with systemic mastocytosis. Neoplastic mast cells showed morphological features between classic tissue mast cells and circulating basophils. They showed strong granule metachromasia after toluidine blue, faint positivity to Hotchkiss reaction, strong positivity to chloroacetate esterase, while they were negative to alkaline phosphatase. Ultrastructural observations showed heterogeneity of granules, most of which had homogenous fine dotted contents. The origin and linkage between mast cells and circulating basophils are discussed.

This paper describes a case of cavernous sinus septic thrombosis with cerebellar complication. The CNS was involved after a primitive piodermitis of the face. The diagnostic tools employed in the management of the case and the therapeutic procedures in the acute phase and in the convalescence are discussed. The patient completely recovered after chemotherapeutic treatment.

Background Long-term survival of HIV-1 infected individuals is usually achieved by continuous administration of combination antiretroviral therapy (ART). An exception to this scenario is represented by HIV-1 infected nonprogressors (NP) which maintain relatively high circulating CD4+ T cells without clinical symptoms for several years in the absence of ART. Several lines of evidence indicate an important role of the T-cell response in the modulation of HIV-1 infection during the acute and chronic phase of the disease. Results We analyzed the functional and the differentiation phenotype of Nef- and Tat-specific CD8+ T cells in a cohort of HIV-1 infected NP in comparison to progressors, ART-treated seropositive individuals and individuals undergoing a single cycle of ART interruption. We observed that a distinctive feature of NP is the presence of Nef-specific CD45RA+ CD8+ T cells secreting MIP-1beta but not IFN-gamma. This population was present in 7 out of 11 NP. CD45RA+ IFN-gammaneg MIP-1beta+ CD8+ T cells were not detected in HIV-1 infected individuals under ART or withdrawing from ART and experiencing a rebounding viral replication. In addition, we detected Nef-specific CD45RA+ IFN-gammaneg MIP-1beta+ CD8+ T cells in only 1 out of 10 HIV-1 infected individuals with untreated progressive disease. Conclusion The novel antigen-specific CD45RA+ IFN-gammaneg MIP-1beta+ CD8+ T cell population represents a new candidate marker of long-term natural control of HIV-1 disease progression and a relevant functional T-cell subset in the evaluation of the immune responses induced by candidate HIV-1 vaccines.