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Background. Carbapenem-resistant (CR) Acinetobacter baumannii has been increasingly recognized as a major cause of health care-associated infections in critically ill patients and hospital outbreaks. Methods. A narrative review of literature was conducted, searching PubMed database for articles on CR Acinetobacter spp. isolates from Italy published between January 2010 and December 2019. Results. CR A. baumannii isolates assigned to international clonal lineage II (ICL II) and to ST78 clonal lineages were responsible for several epidemics in Italian hospitals during 2002-2018. Molecular analysis of carbapenem resistance showed the presence of OXA-58 CHDL in A. baumannii isolates assigned to ICL II and ST78 clonal lineage, which was replaced by OXA-23 CHDL in A. baumannii isolates assigned to ICL II since 2007 in several hospitals. CR A. baumannii was mainly responsible for respiratory tract infections and at a lesser extent for sepsis in intensive care unit patients. Conclusions. Our data reinforces the need to monitor the molecular epidemiology of CR A. baumannii and its associated antimicrobial resistance genes at national level.

J Hosp Infect. 2007 Oct;67(2):135-41.

INTRODUCTION: We investigated the efficacy of a biocide Umonium38 on multidrug-resistant strains by comparison with a chloride derivative (Decs). METHODS: In vitro susceptibility tests were performed by agar diffusion disk and results were interpreted according to Clinical and Laboratory Standards Institute (CLSI). In vitro antibacterial efficacy of Umonium38 and Decs over selected strains was evaluated according to European Standards protocol with or without organic substance. RESULTS: In vitro tests with Umoniumnr at 2.5% concentration demonstrated an overall drop in microbial and yeast charges after 5 min. contact without organic substance. The same results were obtained in presence of organic substance. In vitro tests with chloride derivative at 5% without organic substance also resulted in overall drop in bacterial and mycotic charges. Conversely, in presence of organic substance, the hypochlorite reduced the initial 10 UFC/ml to 10 UFC/ml for all bacterial strains with a decrease of 4 log except for Enterococcus faecalis and Candida albicans whose reduction was 2 and 1 log units respectively. DISCUSSION: The organic substance in water requires large use of oxidising disinfectants (chloride, ozone) implying in the need for higher-than-standard concentrations. The disinfecting effect of chloride is only visible when the "requirement" of organic substance has been met. By contrast, Umonium38 behaves like a powerful biocide even in presence of organic substance, as it is not "consumed" by possible organic residues. CONCLUSIONS: Umonium38 resulted beneficial and effective. It is to be stressed, however, that all these experiments were in vitro tests and still requires validation from a correct use of clinical practice., Journal of Preventive Medicine and Hygiene, Vol 48, No 2 (2007)

This study investigated the molecular epidemiology of a clonal outbreak of multidrug-resistant Acinetobacter baumannii that occurred between June 2003 and June 2004 in a tertiary-care hospital in Naples, Italy. A. baumannii was isolated from 74 patients, of whom 38 were infected and 36 were colonised. Thirty-three patients had ventilator-associated pneumonia, three had hospital-acquired pneumonia, and two had sepsis. Genotypic analysis of 45 available A. baumannii isolates revealed two distinct pulsed-field gel electrophoresis (PFGE) patterns. Of these, PFGE pattern 1 was represented by isolates from 44 patients and was identical to that of an epidemic A. baumannii clone isolated in another hospital of Naples during 2002. All A. baumannii isolates of PFGE type 1 showed identical multiresistant antibiotypes, characterised by resistance to all antimicrobial agents tested, including carbapenems, with the exception of colistin. In these isolates, inhibition of OXA enzymes by 200 mM NaCl reduced the imipenem MIC by up to four-fold. Molecular analysis of antimicrobial resistance genes showed that all A. baumannii isolates of PFGE type 1 harboured a class 1 integron containing the aacA4, orfX and blaOXA-20 gene cassettes, an ampC gene and a blaOXA-51-like allele. Moreover, a blaOXA-58-like gene surrounded by the regulatory elements ISAba2 and ISAba3 was identified in a 30-kb plasmid from A. baumannii isolates of PFGE type 1, but not PFGE type 2. Thus, selection of a single A. baumannii clone producing an OXA-58-type carbapenem-hydrolysing oxacillinase was responsible for the increase in the number of A. baumannii infections that occurred in this hospital.

The aim of this investigation was to study the molecular epidemiology of Stenotrophomonas maltophilia in a university hospital in Italy. Sixty-one clinical isolates were collected from 43 patients during a two-year period. The majority of specimens were from the respiratory tract (41 of 43) of patients in the adult intensive care unit (ICU) (19 of 43) or cystic fibrosis (CF) patients (13 of 43). Genotypic analysis by pulsed-field gel electrophoresis (PFGE) of clinical isolates identified 31 different PFGE patterns. Although most patients were infected or colonized by different S. maltophilia clones, clones with identical genotype were isolated in patients from ICU, where two separate outbreaks were identified. Antimicrobial susceptibility identified a multi-resistant phenotype in all S. maltophilia PFGE clones. The majority of PFGE clones identified (six of seven clones from patients in the ICU) were susceptible to fluoroquinolones. Mechanical ventilation was associated with S. maltophilia acquisition in the ICU.

Serial body site swabbing is used to monitor horizontal spread of aggressive bacterial species in the neonatal intensive care unit (NICU). Since colonization/carriage is thought to precede systemic infection, one might expect to retrieve colonizing pathogens from blood cultures. This hypothesis, however, has not been fully investigated in very low birth weight (VLBW) infants that are at high sepsis’ risk. The primary outcome was, in a population of VLBW infants with late-onset sepsis, the matching between blood culture results and pathogens isolated from rectal and nose/pharyngeal surveillance swabs in the preceding 2 weeks. The secondary outcomes were the site of swabbing and time interval from colonization to blood culture positivity. Out of 333 VLBW neonates, 80 (24%) were diagnosed with bacterial sepsis. In 46 (57%) neonates, the blood culture showed the same pathogen species cultured from a swab. Of these, 30 were isolated from infants with both body sites colonized with an average time interval of 3.5 days; 2/16 were isolated from rectal swabs and 14 /16 from nose/pharyngeal samples.Conclusion: Our data show a fair correspondence between bacteria colonizing the nasopharynx and/or the rectum and pathogens later isolated from blood cultures. This association depends on the swabbing site, number of sites, and pathogen species. Although these data constitute valuable results, they are not sufficient for providing the sole base of a thoughtful clinical decision. What is Known:• Body site’s colonization may precede systemic infection.• Little is known on this mechanism in VLBW infants that are at higher sepsis’ risk.What is New:•Colonizing bacteria partially correspond to pathogens of blood cultures in VLBW infants with sepsis.• Correspondence depends on swabbing site, number of sites, and pathogen species.

Summary Aim To report an outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii in the neonatal intensive care unit (NICU) of an Italian university hospital. Patient risk profiles for acquisition of A. baumannii and measures used to control the outbreak are described. Methods Antibiotic susceptibility of strains was evaluated by microdilution. Genotyping was performed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing. Carbapenemase genes were analysed by polymerase chain reaction and DNA sequencing. A case–control study was designed to identify risk factors for acquisition of A. baumannii . Findings A. baumannii was isolated from 22 neonates, six of whom were infected. One major PFGE type was identified, assigned to sequence type (ST) 2, corresponding to International Clone II; this was indistinguishable from isolates from the adult ICU in the same hospital. A. baumannii isolates were resistant to aminoglycosides, quinolones and classes of β-lactam antibiotics, but were susceptible to tigecycline and colistin. Carbapenem resistance was associated with the presence of transposon Tn 2006 carrying the bla OxA-23 gene. Length of NICU stay, length of exposure to A. baumannii , gestational age, use of invasive devices and length of exposure to invasive devices were significantly associated with acquisition of A. baumannii on univariate analysis, while length of exposure to central venous catheters and assisted ventilation were the only independent risk factors after multi-variate analysis. Conclusions This XDR A. baumannii outbreak in an NICU was probably caused by intrahospital transfer of bacteria via a colonized neonate whose mother was admitted to the adult ICU. Strengthened infection control measures were necessary to control the outbreak.

We investigated the basis of the carbapenem resistance of 17 multidrug-resistant Acinetobacter baumannii clinical isolates collected from 2004 to 2005 at the Saint George University Hospital in Beirut, Lebanon. A. baumannii isolates were clonally related and were susceptible to colistin and trimethoprim-sulfamethoxazole, susceptible or intermediate to ampicillin-sulbactam and meropenem, and resistant to all other antimicrobials. Conjugation experiments demonstrated that resistance to imipenem could be transferred along with a plasmid containing the carbapenem-hydrolyzing oxacillinase bla OXA-58 gene. The plasmid that we called pABIR was 29,823 bp in size and showed a novel mosaic structure composed of two origins of replication, four insertion sequence (IS) elements, and 28 open reading frames. The bla OXA-58 gene was flanked by IS 18 and IS Aba3 elements at the 5′ and 3′ ends, respectively. The production of the carbapenem-hydrolyzing oxacillinase OXA-58 was apparently the only mechanism for carbapenem resistance in A. baumannii isolates causing the outbreak at the Lebanese Hospital.

Summary We investigated the molecular epidemiology of gentamicin-resistant, extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae and Serratia marcescens , and risk factors associated with their acquisition in a neonatal intensive care unit (NICU) of a university hospital in Italy. During the study period (April–November 2004), S. marcescens was responsible for six infections and 31 colonisations, while K. pneumoniae was responsible for six infections and 103 colonisations. Concurrent isolation of both organisms occurred in 24 neonates. Molecular typing identified one major pulsed-field gel electrophoresis pattern each for S. marcescens and K. pneumoniae strains isolated during the study period. An 80kb plasmid containing bla SHV-12 , bla TEM-1 and aac(6′)-Ib genes, isolated from both S. marcescens and K. pneumoniae strains, and showing identical restriction profiles, transferred resistance to third-generation cephalosporins to a previously susceptible Escherichia coli host. Birthweight, gestational age and use of invasive devices were significantly associated with S. marcescens and K. pneumoniae acquisition on univariate analysis, while empiric antimicrobial treatment with ampicillin and gentamicin, and duration of hospital stay, proved to be the only independent risk factors. In conclusion, conjugal plasmid transfer and empiric antimicrobial therapy with ampicillin and gentamicin might have contributed to the selection and spread of gentamicin-resistant ESBL-producing Enterobacteriaceae in the NICU.

OBJECTIVES: To investigate the molecular epidemiology of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in the neonatal intensive care unit of a university hospital in Italy. METHODS: Antibiotic susceptibility was evaluated by disc diffusion and Etest. ESBLs were identified by isoelectric focusing, PCR and DNA sequencing analysis. Genotyping was performed by PFGE analysis. Conjugation was performed by broth mating. RESULTS: Molecular typing of K. pneumoniae isolates identified three distinct PFGE patterns. Isolates of PFGE profile A were isolated during an epidemic in 1996, while isolates of PFGE profiles B and C were sequentially isolated from September 2002 to December 2004, when 233 colonizations and 19 infections by K. pneumoniae occurred. All K. pneumoniae strains of different PFGE types were identified as ESBL producers. DNA sequencing of amplified beta-lactamase genes identified a novel bla(TEM) ESBL (bla(TEM-136)) along with bla(SHV-1) in chromosomal and plasmid DNA from K. pneumoniae of PFGE type A, respectively, and bla(TEM-1) and bla(SHV-12) in plasmid DNA from K. pneumoniae of PFGE types B and C. Conjugation experiments demonstrated that resistance to third-generation cephalosporins, along with an approximately 80 kb plasmid containing bla(SHV-12) and bla(TEM-1), was transferred from K. pneumoniae epidemic strains of PFGE types B and C to a susceptible Escherichia coli host at a frequency of 4 x 10(-6) and 1 x 10(-6) cfu/recipient cell, respectively. CONCLUSIONS: The selection of ESBL-producing clones and the transfer of the bla(SHV-12) ESBL gene between different clones were responsible for the spread of K. pneumoniae in the neonatal intensive care unit.

OBJECTIVES We evaluated the genetic and molecular basis of high-level resistance to gentamicin and amikacin in 91 clinical isolates of Enterococcus faecalis and Enterococcus faecium in a university hospital in southern Italy from 1987 to 2003. METHODS Antibiotic susceptibility was evaluated by disc diffusion and microdilution methods. Genotyping was performed by PFGE and dendrogram analysis. Aminoglycoside resistance genes were analysed by multiplex PCR. Aminoglycoside resistance gene transfer was performed by filter mating. RESULTS In our strain collection, 44% of E. faecalis and 52% of E. faecium were high-level-resistant to gentamicin. Fifty-two PFGE profiles were identified for E. faecalis and 15 for E. faecium. Although the majority of PFGE patterns were single isolates, four patterns (two for E. faecalis and two for E. faecium) were isolated each in 8 and 4, and 6 and 4 different patients, respectively. The aac(6')-Ie-aph(2'')-Ia gene was responsible for high-level resistance to gentamicin and amikacin in E. faecalis and E. faecium; the aph(2'')-Id gene responsible for resistance to gentamicin was also isolated in E. faecium; the aph(3')-IIIa and ant(4')-Ia genes responsible for resistance to amikacin were also isolated in E. faecalis and E. faecium. High-level resistance to gentamicin, along with the aac(6')-Ie-aph(2'')-Ia gene, was transferred at a frequency of about 10(-5) to 10(-8) per recipient cell in 14 of 17 E. faecalis and 3 of 4 E. faecium different genotypes. CONCLUSIONS The spread of the aac(6')-Ie-aph(2'')-Ia gene was responsible for high-level resistance to gentamicin and amikacin among enterococci isolated from patients in our geographical area.

The molecular epidemiology of multidrug-resistant Acinetobacter baumannii was investigated in the medical-surgical intensive care unit (ICU) of a university hospital in Italy during two window periods in which two sequential A. baumannii epidemics occurred. Genotype analysis by pulsed-field gel electrophoresis (PFGE) of A. baumannii isolates from 131 patients identified nine distinct PFGE patterns. Of these, PFGE clones B and I predominated and occurred sequentially during the two epidemics. A. baumannii epidemic clones showed a multidrug-resistant antibiotype, being clone B resistant to all antimicrobials tested except the carbapenems and clone I resistant to all antimicrobials except ampicillin-sulbactam and gentamicin. Type 1 integrons of 2.5 and 2.2 kb were amplified from the chromosomal DNA of epidemic PFGE clones B and I, respectively, but not from the chromosomal DNA of the nonepidemic clones. Nucleotide analysis of clone B integron identified four gene cassettes: aacC1 , which confers resistance to gentamicin; two open reading frames (ORFs) coding for unknown products; and aadA1a , which confers resistance to spectinomycin and streptomycin. The integron of clone I contained three gene cassettes: aacA4 , which confers resistance to amikacin, netilmicin, and tobramycin; an unknown ORF; and bla OXA-20 , which codes for a class D β-lactamase that confers resistance to amoxicillin, ticarcillin, oxacillin, and cloxacillin. Also, the bla IMP allele was amplified from chromosomal DNA of A. baumannii strains of PFGE type I. Class 1 integrons carrying antimicrobial resistance genes and bla IMP allele in A. baumannii epidemic strains correlated with the high use rates of broad-spectrum cephalosporins, carbapenems, and aminoglycosides in the ICU during the study period.

In order to compare oral and high-dose iv corticosteroid therapy for Graves' disease, 25 patients with Graves' ophthalmopathy were treated with two weekly iv injections of 1 g of methylprednisolone diluted in 250-500 ml of physiological solution for 6 weeks, and were compared to a group of 26 patients treated with oral prednisone at a dose of 60-80 mg/day progressively reduced every 2 weeks for a total duration of 4-6 months. The efficacy of treatment was evaluated using the ophthalmopathy index score. Patients were followed at 3, 6, 12 months, and afterwards yearly. All patients showed a significant improvement in signs and symptoms of orbital inflammation and a slight improvement in proptosis and diplopia. Relevant side-effects were reported from patients receiving oral therapy, but no significant side-effects were observed in patients treated with high iv doses; a few cases presented with gastric pain (highly sensitive to aluminium oxide or ranitidine), while most of the patients referred to cutaneous rashes and a metal taste that disappeared some hours after the infusion. Improvements observed after treatment have been stable in both groups. In conclusion, in addition to a lower incidence of side-effects compared to the classic oral therapy, the high-dose iv steroid therapy provides efficient and stable improvement in Graves' ophthalmopathy.

Background Air conditioning systems represent one important source of microbial pollutants for indoor air. In the past few years, numerous strategies have been conceived to reduce the contamination of air conditioners, mainly in hospital settings. The biocidal detergent BATT2 represents a natural product obtained through extraction from brown seaweeds, that has been tested previously on multidrug-resistant microorganisms. Methods BATT2 has been utilized for the disinfection of fan coil units from four air conditioning systems located in hospital environments with a mean degree of risk. Samples were collected from the air supplied by the conditioning systems and from the surfaces of fan coil units, before and after sanitization procedures. Total microbial counts at 37°C and 22°C and mycotic count at 32°C were evaluated. Staphylococci and Pseudomonas aeruginosa were also detected on surfaces samples. Results The biodetergent was able to reduce up 50% of the microbial pollution of fan coil units surfaces and air supplied by the air conditioners. Conclusions BATT2 could be considered for cleaning/disinfection of air conditioning systems, that should be performed on the basis of accurate and verifiable sanitization protocols.