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Objectives: Frailty is a pre-disability condition in older persons providing a challenge to Health-Care Systems. Systematic reviews highlight the absence of a gold-standard for its identification. However, an approach based on initial screening by the General Practitioner (GP) seems particularly useful. On these premises, a 9-item Sunfrail Checklist (SC), was developed by a multidisciplinary group, in the context of European Sunfrail Project, and tested in the Community. Objectives: – to measure the concordance between the judgments of frailty (criterion-validity): the one formulated by the GP, using the SC, and the one subsequently expressed by a Comprehensive Geriatric Assessment Team (CGA-Team); – to determine the construct-validity through the correspondence between some checklist items related to the 3 domains (physical, cognitive and social) and the three tools used by the CGA-Team; – to measure the instrument’s performance in terms of positive predictive value (PPV) and negative predictive value (NPV). Design: Cross-sectional study, with a final sample-size of 95 subjects. Setting: Two Community-Health Centers of Parma, Italy. Participants: Subjects aged 75 years old or more, with no disability and living in the community. Measurements: We compared the screening capacity of the GP using the SC to that one of CGA-Team based on three tests: 4-meter Gait-Speed, Mini-Mental State Examination and Loneliness Scale. Results: 95 subjects (51 women), with a mean age of 81±4 years were enrolled. According to GPs 34 subjects were frail; the CGA-Team expressed a frailty judgment on 26 subjects. The criterion-validity presented a Cohen’s k of 0.353. Construct-validity was also low, with a maximum contingency-coefficient of 0.19. The analysis showed a PPV of 58.1% and a NPV equal to 84.6%. Conclusions: Our data showed a low agreement between the judgements of GP performed by SC and CGA-Team. However, the good NPV suggests the applicability of SC for screening activities in primary-care.

Hepatocytes are dynamic cells that, upon injury, can alternate between nondividing differentiated and dedifferentiated proliferating states in vivo. However, in two-dimensional cultures, primary human hepatocytes (PHHs) rapidly dedifferentiate, resulting in loss of hepatic functions that significantly limits their usefulness as an in vitro model of liver biology, liver diseases, as well as drug metabolism and toxicity. Thus, understanding the underlying mechanisms and stalling of the dedifferentiation process would be highly beneficial to establish more-accurate and relevant long-term in vitro hepatocyte models. Here, we present comprehensive analyses of whole proteome and transcriptome dynamics during the initiation of dedifferentiation during the first 24 hours of culture. We report that early major rearrangements of the noncoding transcriptome, hallmarked by increased expression of small nucleolar RNAs, long noncoding RNAs, microRNAs (miRNAs), and ribosomal genes, precede most changes in coding genes during dedifferentiation of PHHs, and we speculated that these modulations could drive the hepatic dedifferentiation process. To functionally test this hypothesis, we globally inhibited the miRNA machinery using two established chemically distinct compounds, acriflavine and poly-l-lysine. These inhibition experiments resulted in a significantly impaired miRNA response and, most important, in a pronounced reduction in the down-regulation of hepatic genes with importance for liver function. Thus, we provide strong evidence for the importance of noncoding RNAs, in particular, miRNAs, in hepatic dedifferentiation, which can aid the development of more-efficient differentiation protocols for stem-cell-derived hepatocytes and broaden our understanding of the dynamic properties of hepatocytes with respect to liver regeneration. Conclusion: miRNAs are important drivers of hepatic dedifferentiation, and our results provide valuable information regarding the mechanisms behind liver regeneration and possibilities to inhibit dedifferentiation in vitro. (Hepatology 2016;64:1743-1756)

Defined daily doses (DDD) are widely used as a unit to measure drug use in hospital and community settings. However, discrepancies exist between DDD and actual prescribed daily dose (PDD). The present study aims at estimating an alternative PDD (PDD-proxy) to calculate rates of systemic antibiotic consumption and to compare these results with those obtained using DDD. The study considered a 9-year period (2004–2012) and included the 17 Health Trusts (HTs) in the Emilia-Romagna Region, Italy. Drugs under study were antibacterials for systemic use (group J01). Data were obtained from the database for hospital drug prescription of Emilia-Romagna Region. The PDD-proxy was estimated by averaging the doses of antibiotic prescriptions from a point prevalence survey for healthcare-associated infections and antimicrobial use, conducted in Emilia-Romagna hospitals in 2012. Significant discrepancies between DDD and PDD were observed, especially for some antibiotics, resulting in DDD rates that were systematically higher than PDD-proxy rates. In 2012, HT median rates of antibiotic consumption were 90 DDD/100 bed days and 70 PDD-proxy/100 bed-days. However, PDD-proxy and DDD rates showed comparable trends within HTs, although some HTs ranked differently when one or the other measure was used. Interquartile ranges of DDD rates were systematically wider than those of PDD-proxy rates in most years in the period of interest. Comparison of HT antibiotic consumption using DDDs may artificially increase observed differences and affect the true HT ranking. Therefore, an additional unit of measurement is useful for in-depth analysis at the local level.

Hepatocytes are dynamic cells that, upon injury, can alternate between nondividing differentiated and dedifferentiated proliferating states in vivo. However, in two-dimensional cultures, primary human hepatocytes (PHHs) rapidly dedifferentiate, resulting in loss of hepatic functions that significantly limits their usefulness as an in vitro model of liver biology, liver diseases, as well as drug metabolism and toxicity. Thus, understanding the underlying mechanisms and stalling of the dedifferentiation process would be highly beneficial to establish more-accurate and relevant long-term in vitro hepatocyte models. Here, we present comprehensive analyses of whole proteome and transcriptome dynamics during the initiation of dedifferentiation during the first 24 hours of culture. We report that early major rearrangements of the noncoding transcriptome, hallmarked by increased expression of small nucleolar RNAs, long noncoding RNAs, microRNAs (miRNAs), and ribosomal genes, precede most changes in coding genes during dedifferentiation of PHHs, and we speculated that these modulations could drive the hepatic dedifferentiation process. To functionally test this hypothesis, we globally inhibited the miRNA machinery using two established chemically distinct compounds, acriflavine and poly-l-lysine. These inhibition experiments resulted in a significantly impaired miRNA response and, most important, in a pronounced reduction in the down-regulation of hepatic genes with importance for liver function. Thus, we provide strong evidence for the importance of noncoding RNAs, in particular, miRNAs, in hepatic dedifferentiation, which can aid the development of more-efficient differentiation protocols for stem-cell-derived hepatocytes and broaden our understanding of the dynamic properties of hepatocytes with respect to liver regeneration.miRNAs are important drivers of hepatic dedifferentiation, and our results provide valuable information regarding the mechanisms behind liver regeneration and possibilities to inhibit dedifferentiation in vitro. (Hepatology 2016;64:1743-1756).

Starting in 2010, there was a sharp increase in infections caused by Klebsiella pneumoniae resistant to carbapenems in the Emilia-Romagna region in Italy. A region-wide intervention to control the spread of carbapenemase-producing K. pneumoniae (CPKP) in Emilia-Romagna was carried out, based on a regional guideline issued in July 2011. The infection control measures recommended to the Health Trusts (HTs) were: phenotypic confirmation of carbapenemase production, active surveillance of asymptomatic carriers and contact isolation precautions for carriers. A specific surveillance system was activated and the implementation of control measures in HTs was followed up. A significant linear increase of incident CPKP cases over time (p

This study aims to describe the pattern of antibiotic treatments in the community for children ages 0–23 months in Emilia-Romagna (a northern Italy region) pointing out possible changes of prescribed agents when first treatments in the life of each children are compared to successive ones. The Regional Drug Prescription and the Resident Population databases were used as data sources to study the cohort of children born between January 1 and December 31, 2000 and resident in Emilia-Romagna. The cumulative incidences of children with at least one treatment were 22%, 55% and 82% at 6, 12 and 24 months of age, respectively. Broad spectrum penicillins were the most prescribed antibiotic class for children at their first treatment while cephalosporins were the most prescribed class for successive treatments and when pooling all treatments. Cephalosporins and other second line antibiotics are frequently prescribed to 0 to 23-month-old residents in Emilia-Romagna even when only first treatments are considered; further research is needed to quantify inappropriateness of antibiotic prescription.

The aim of the study was to compare prospectively indicator-condition (IC)-guided testing versus testing of those with non-indicator conditions (NICs) in four primary care centres (PCCs) in Barcelona, Spain.From October 2009 to February 2011, patients aged from 18 to 65 years old who attended a PCC for a new herpes zoster infection, seborrhoeic eczema, mononucleosis syndrome or leucopenia/thrombopenia were included in the IC group, and one in every 10 randomly selected patients consulting for other reasons were included in the NIC group. A proportion of patients in each group were offered an HIV test; those who agreed to be tested were given a rapid finger-stick HIV test (€6 per test). Epidemiological and clinical data were collected and analysed.During the study period, 775 patients attended with one of the four selected ICs, while 66,043 patients presented with an NIC. HIV screening was offered to 89 patients with ICs (offer rate 11.5%), of whom 85 agreed to and completed testing (94.4 and 100% acceptance and completion rates, respectively). In the NIC group, an HIV test was offered to 344 persons (offer rate 5.2%), of whom 313 accepted (90.9%) and 304 completed (97.1%) testing. HIV tests were positive in four persons [prevalence 4.7%; 95% confidence interval (CI) 1.3-11.6%] in the IC group and in one person in the NIC group (prevalence 0.3%; 95% CI 0.01-1.82%; P0.009). If every eligible person had taken an HIV test, we would have spent €4650 in the IC group and €396,258 in the NIC group, and an estimated 36 (95% CI 25-49) and 198 persons (95% CI 171-227), respectively, would have been diagnosed with HIV infection. The estimated cost per new HIV diagnosis would have been €129 (95% CI €107-153) in the IC group and €2001 (95% CI €1913-2088) in the NIC group.Although the number of patients included in the study was small and the results should be treated with caution, IC-guided HIV testing, based on four selected ICs, in PCCs seems to be a more feasible and less expensive strategy to improve diagnosis of HIV infection in Spain than a nontargeted HIV testing strategy.

Leucoencephalopathy with neuroaxonal spheroids (LENAS) is a rare disease of cerebral and cerebellar white matter. LENAS usually presents as a disorder of cognition and behaviour, or with gait dysfunction and ataxia. This report describes a patient who had a 14 year course of progressive neurological decline consistent with a clinical diagnosis of probable multiple system atrophy, with prominent cerebellar dysfunction and dysautonomia. Formal autonomic laboratory testing was consistent with global autonomic dysfunction of central origin. However, magnetic resonance imaging showed extensive white matter signal abnormalities, in addition to moderate cerebral and cerebellar atrophy. On postmortem microscopic examination, there were numerous axonal spheroids throughout the white matter of both regions. This case of LENAS presented unique clinical characteristics, and typical pathological findings.

Prevalence surveys are mostly used in European countries for infection surveillance in long-term care facilities (LTCFs). The purpose of this paper is to document the prevalence of infections in LTCFs and to identify and discuss the potential sources of variation in the overall prevalence of infections.Six repeated prevalence surveys were carried out over a period of 3 years in 11 LTCFs in the Emilia-Romagna region, involving a mean of 812 residents in each survey. In one facility, continuous surveillance was also conducted. McGeer's infection criteria were used. Observers undertook a 1-day training course and on-field training.The average prevalence of infected residents was 11.5/100 residents: respiratory tract infections were the most common (5.7/100 residents), followed by urinary tract infections (2.6%), skin infections (1.9%), and ocular infections (1.4%). In a multivariate model, the prevalence significantly varied by season (p0.001) and residents' case-mix index (CMI, p0.001). In individual homes, the case mix varied from 0.91 to 1.1 and the observed prevalence varied from 6.6 to 40.4%. One facility set up and maintained continuous surveillance: three clusters of lower respiratory tract infection were identified in 1.5 years by a temporal scan test. Cases belonging to one outbreak only were captured by the prevalence surveys conducted in the same periods.The prevalence of infections in LTCFs needs to be interpreted cautiously, given the effects of seasonality and case-mix variation. Repeated prevalence surveys may be a good start in individual facilities, but the identification of outbreaks requires a continuous surveillance system.

Since 2006, several projects have been initiated in Europe to describe the distribution and characteristics of infection control programs in long#x2010;term care facilities and to quantify the burden of infections, antimicrobial resistance, and antimicrobial use in long#x2010;term care facilities. This article summarizes the results and activities that are underway.

Hardly any data on the occurrence of infection in Italian nursing homes have been published; yet Italy has the second oldest population in the world. The objective of the study was to assess the frequency of infections in a sample of Italian nursing homes. A 1-day prevalence survey was conducted in three local health authorities (LHAs) of the Emilia-Romagna region in Italy, aimed at describing the prevalence of patients with long-term care facilityassociated infections and their associated factors among residents of nursing and residential facilities. All nursing homes (NHs) and a stratified random sample of residential homes (RHs) in the three LHAs were included in the study, for a total of 1,926 elderly people in 49 facilities. The following data were recorded: infections, medical condition, activities of daily living (ADL), use of antibiotics. The main outcome of the study was infection prevalence. The prevalence of patients with long-term care facility-associated infection was 8.4/100 residents overall (CI 95% 7.9–9.0), 14.6/100 in NHs and 7.5/100 in RHs (CI 95% 6.8–8.1). The prevalence of infection significantly varied with LHA and facility. It was associated with level of dependency and exposure to invasive procedures, such as urinary catheterization and parenteral procedures. Six percent of residents received a systemic antimicrobial on the day of the study, and in 22% of cases there was no evidence of suspected or diagnosed infections. The prevalence study identified a high prevalence of infected patients in nursing homes in Italy, consistent with observation in other geographic areas.

La medicina defensiva se puede definir como el empleo de procedimientos diagnostico terapéuticos con el propósito explícito de evitar demandas por mala práctica. En la práctica médica profesional existe el riesgo de demandas judiciales interpuestas por los pacientes contra los médicos, lo cual genera un estado de intranquilidad y preocupación que conduce a la práctica de una medicina defensiva. Obviamente la medicina defensiva no sólo altera el aspecto médico esencial sino que, además, genera un incremento notable del coste económico para el sistema.

To quantify patient and health care delays in the treatment of pulmonary tuberculosis (PTB) in Emilia-Romagna region, Italy, and to study the association between migration status and delay.All patients with symptomatic PTB, aged15 years, who were notified in Emilia-Romagna during 2003 and were alive at time of data collection, were included. An individual form was completed for each notified patient by the local health authority officer in charge of surveillance data.Median patient delay, health care delay and total delay were 7, 36 and 65 days, respectively. Recent migrants (stay in Italyor = 3 years) had the longest patient delay (16 days), while Italian patients had the longest health care delay (60 days). Migration status was independently associated with both patient and health care delay, although the direction of association changed according to which delay was considered.Public health interventions aiming to reduce delay in treatment of PTB should improve the access of recent migrants to health care and increase suspicion of TB among Italian patients. Studies on delays in treatment of TB should investigate patient delay and health care delay as distinct outcomes.

Emilia Romagna region, Italy.To explore chest and infectious disease physicians' views of barriers to effective tuberculosis (TB) control and possible solutions.A series of nine focus groups including a total of 49 physicians.Three categories of barriers to effective TB control were identified: 1) uncertainty about appropriate clinical practice in the treatment of specific sub-groups of patients, such as the elderly or immigrants; 2) organisational factors, such as the availability of diagnostic services and of sufficient resources; and 3) multiple barriers to a viable and effective TB control programme in a country with a low prevalence of TB.The lack of integration and coordination of health services, as well as the scarcity of dedicated TB nurses, were perceived by the participants as crucial barriers to effective TB control. As a result of this study, a regional programme was started with the goals of quantifying the need for TB nurses and developing a better network for required health services. Qualitative studies such as this can be useful in improving TB control in a low-prevalence TB country, to identify problems and increase the participation of key professionals.

The aim of this study is to assess the compliance with evidence based medicine of the practices of administration of perioperative surgical chemoprophylaxis in the Emilia Romagna region. Prospective study of 1 month duration including 31 of the 36 public hospital existing in the region. For all the patients admitted to one of the 121 participating units and undergoing a surgical operation, data were collected on the surgical prophylaxis administered, including type of antibiotic, time of administration and duration. Surgical prophylaxis was given in 4,946 surgical operations of the 6,167 included in the study. The median frequency of surgical prophylaxis administration was 81% ranging from 67% to 97% in different Local Health Authorities. Chemoprophylaxis was given also for surgical operations where, according to systematic literature reviews, the cost-benefit ratio is absolutely unfavourable to the use of antibiotics. In 2,120 cases (42.9%) the time of administration was not perioperative and, thus, differed from the recommended practice: in 264 cases (5%), antibiotics were administered after the operation. In 42.6% of the cases the duration of administration was not a short-term prophylaxis, being longer than 24 hours: in these 2,108 cases, the median duration was 4 days ranging form 1 to 90 days. In 48% of the cases cefazolin was administered; in 1,347 cases (23.4%), instead, a third or fourth generation cephalosporin was used. The survey pointed out an overuse of antibiotics, both for indications and duration, even when clear evidences of efficacy are lacking; moreover, the criteria for selection of specific antibiotics frequently did not take into account the risk of selecting antimicrobial resistance strains.

This paper presents the results of an Italian multicentric study conducted in the period April 1999-April 2000 in 64 clinical microbiology laboratories, aimed at collecting antimicrobial resistance data using a standard European protocol (EARSS Project, European Antimicrobial Surveillance System). A total of 1701 strains of Staphylococcus aureus were isolated from blood and 367 strains of Streptococcus pneumoniae were isolated from blood (72.7%) or from CSF (27.3%). Methicillin resistance in S. aureus was found to be 42.1%; it was significantly higher in adults (RR = 6.6, CI 95% 2.5-17.0), in hospitals of Centre and North of Italy (respectively RR = 1.45, CI 95% 1.1-2.0; RR = 1.6, CI 95% 1.1-2.2), and in intensive care and surgery units (respectively RR = 1.8, IC 95% 1.6-2.0 and RR = 1.7, CI 95% 1.4-1.9). Penicillin resistance in S. pneumoniae was found to be 12.1%; it was higher in South Italy (RR = 3.5, CI 95% 1.9-6.6, in meningitis compared to sepsis (RR = 2.5, CI 95% 1.4-2.5) and in intensive care units compared to other departments (RR = 2.2, CI 95% 1.0-4.8). The level of erythromycin resistance in S. pneumoniae was of 28.2%, reaching 56.4% in penicillin resistant strains. These results suggest that a continued surveillance and effective control measures are required.

Surveillance of nosocomial infections is the single most effective tool for nosocomial infection prevention. There are two main targets: a) prompt identification of indicators and epidemic events, in order to immediately start adequate interventions; b) comparison of local "own" experience to the nosocomial infections which would be expected in a population with similar clinical features. The microbiological laboratory is a reliable and economical source of information: it allows identification of "dangerous" microorganisms, monitoring of antimicrobial resistances, identification of epidemics due to a single agent. Active surveillance is necessary in every unit, in order to identify those specific indicators of infection, which are able to detect preventable events and which can be useful for "homogeneous" comparisons among ICUs. Accuracy (sensitivity and specificity) of identification methods and of case definition is of uttermost importance. It is equally important to collect patient data and care plan data targeted to document differences in type of treated patient and in type of level of care. A recent national survey among Italian public hospitals revealed a poor diffusion of surveillance: out of 428 responder hospitals, surveillance of epidemics and of antimicrobial resistance was active in less than 10%, surveillance in the unit was active in 15%, surveillance of sentinel pathogens was active in 22%.

To determine the accuracy of drug-susceptibility testing (DST) for isoniazid, rifampicin, ethambutol and streptomycin in a provisional network of 22 regional laboratories in Italy.Methods, definitions and reference Mycobacterium tuberculosis strains were derived from the WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. The laboratories were selected based on technical skills required by the project, the number of DST performed annually and geographic localisation. The results (sensitive/resistant strain) were compared with the gold standard (global project results). Sensitivity (ability to detect true resistance), specificity (ability to detect true susceptibility), positive predictive values for resistance and susceptibility, efficiency and reproducibility were calculated in two rounds.Eighteen of 22 laboratories completed the first round of proficiency testing for the four drugs. Sensitivity was 76.6%, specificity 97.2%, predictive value of a resistant test 89.8% and of a susceptible test 86.8%, efficiency 87.8% and reproducibility 92.8%. A second round was performed by all those laboratories that did not achieveor = 90% agreement with the results of the Global Project. Overall, after the second round, all the parameters except specificity improved, exceeding 90%.A network of 15 regional laboratories that fulfil the quality criteria for determining the susceptibility of M. tuberculosis to the four primary antituberculosis drugs was established in Italy.

Between October 1992 and February 1994, 33 cases of multidrug-resistant tuberculosis (MDR-TB) were diagnosed among patients infected by the human immunodeficiency virus (HIV) and hospitalised in an HIV ward in Milan, Italy. This outbreak was part of a much larger outbreak, begun in another hospital and probably transferred through a patient.To evaluate risk factors for transmission and the effectiveness of infection control measures.1) Active follow-up of exposed patients, 2) cohort study among HIV-infected patients exposed to MDR-TB cases before and after the implementation of control measures, 3) screening of close contacts of MDR-TB cases, and 4) molecular typing by restriction fragment length polymorphism (RFLP) analysis.The risk of MDR-TB was higher in patients with lower CD4+ lymphocyte percentages and longer duration of exposure. No difference in the daily risk was observed for in-patients vs day-hospital patients or by room distance from an infectious case. Of the 90 patients exposed before the implementation of infection control measures (i.e., October 1992-June 1993) 26 (28.9%) developed MDR-TB, whereas none of the 44 patients exclusively exposed after implementation developed MDR-TB, despite the continuing presence of infectious MDR-TB cases in the ward.Simple control measures were effective in significantly reducing nosocomial transmission among patients.

A descriptive multicentre study based on laboratory data was carried out in patients with culture-confirmed tuberculosis (TB) who were cared for between September 1995 and August 1996 in 14 general hospitals with at least one human immunodeficiency virus (HIV) ward, a hospital specializing in TB or a large chest clinic, all in the Lombardy region of Italy. For each culture positive for Mycobacterium tuberculosis, the results of susceptibility tests to the five first-line anti-TB drugs were collected; other information collected included: the patient's name, the ward/service where the patient was staying and the characteristics of the culture (biological sample, date of arrival and type of mycobacterium isolated). Foreign-born persons were identified through their names; acquired immune deficiency syndrome (AIDS) patients were identified through record linkage with the National AIDS Registry. Given that only one-quarter of the laboratories performed pyrazinamide-susceptibility tests, resistance to this drug was not analysed. Of the isolates tested, 28.1% were resistant to at least one drug, i.e. single-drug-resistant (SDR) and 12.9% were multidrug-resistant (MDR). The frequency of SDR and MDR strains showed considerable variation by healthcare centre (range 0.0-94.3% and 0.0-37.1%, respectively). In three hospitals, the time of occurrence and the susceptibility pattern of the MDR-TB isolates indicated that clusters of the disease occurred. The frequency of both SDR and MDR strains was significantly higher among AIDS patients (48.8% and 23.6%, respectively) than among foreign-born persons (30.2% and 6.9%) or persons belonging to no known risk group (98.3% and 11.3%). The frequency of drug resistance observed in this study is much higher than that reported in other European surveys and is comparable only to that observed in New York, before the implementation of an effective control programme. Acquired immune deficiency syndrome patients are at very high risk of multidrug-resistant tuberculosis: effective containment and infection control practices should be rigorously implemented to prevent the occurrence of this alarming phenomenon.

To describe the epidemiological trend of tuberculosis (TB) in Italy.Descriptive study on the basis of routine information sources: TB deaths (1955-1993) and TB notifications (1955-1995). To identify persons with AIDS (PWAs) among notified TB cases, a record linkage with the National AIDS Registry was performed.From 1955 to 1993, the TB mortality constantly decreased by a mean of 7.6% per year. From 1955 to 1995, the crude annual total incidence of TB decreased from 25.26 to 9.12 per 100,000. The trend of decrease of pulmonary TB ceased in 1980, whereas the incidence of extrapulmonary TB began to markedly increase in 1980. Between 1992 and 1995, the average annual meningitis notification rate in childrenfive years was 0.045 per 100,000. In 1995, the curve of incidence rates by age shows two peaks (75 years and 25-34 years). Persons with AIDS and foreigner-born persons represented in total 11.3% of TB cases (1992-1995); in the age class 25-34 years, this proportion was 32.5% (34.1% in 1995). A considerable undernotification of TB among PWAS was detected.The TB incidence is no longer decreasing due to the changes of TB case definition in 1987 and the.

To determine the incidence of nosocomial infections (NI) in HIV-infected patients and to analyse some of the associated risk factors.Multicentre prospective study on consecutive HIV-infected patients admitted to 19 Italian acute-care infectious disease wards.All patients admitted during a 1-year period were followed-up for NI until their discharge. Univariate and multivariate analyses were performed for NI risk factors.As of June 1998 a total of 344 NI occurred in 4330 admissions, with at least one NI in 273 admissions (6.3%). The incidence rate of NI was 3.6 per 1000 patient days [95% confidence interval (CI), 3.2-4.1]. Overall distribution by site was 36.6% bloodstream infections (BSI), 30.5% urinary tract infections, 18.4% pneumonia, 5.2% skin/soft tissue infections, 2.0% surgical wound infections and 7.3% others. Fifty-five out of the 126 BSI were related to a central venous catheter (CVC); the rate of CVC-associated infections was eight infections per 1000 devices. At multivariate analysis, variables independently associated with NI included CD4 T-lymphocyte count200 x 10(6)/l [odds ratio (OR), 2.21; 95% CI, 1.35-3.62], Karnofsky Performance Status40 (OR, 1.89; 95% CI, 1.28-2.78), therapy with corticosteroids (OR, 1.78; 95% CI, 1.29-2.45), CVC (OR, 3.24; 95% CI, 2.41-4.35), urinary catheter (OR, 6.53; 95% CI, 4.81-8.86) and surgery (OR, 3.13; 95% CI, 1.90-5.15).Results suggest that NI occur commonly in HIV-infected patients. As the number of cases of HIV continues to increase, the number of HIV-infected patients requiring hospitalization may also increase. Clinicians need to be aware of the risk factors for NI and must consider these infections in the overall management of HIV-infected, hospitalized patients.

Several sources of infection for pneumonia, both endogenous and exogenous, have been implicated in ventilated patients. Colonized or contaminated hands and/or gloves, inadequately disinfected/sterilized devices, and contaminated water/solutions have all been found to be associated with the contamination of respiratory equipment and subsequent aspiration or inhalation of bacteria into the lower respiratory tract [1]. Most of the available evidence has come from outbreak investigations.

To describe an outbreak of multidrug-resistant tuberculosis (MDR-TB), amongst HIV-infected patients, spread from one hospital in Milan to another.Descriptive epidemiological investigation and molecular typing.All cases identified by intensive case-finding were described in terms of clinical characteristics, previous nosocomial exposure to an infectious MDR-TB patient, previous stays in other institutional settings where exposure to MDR-TB could have occurred, and restriction fragment length polymorphism (RFLP) pattern.Between October 1991 and July 1995, 116 cases of MDR-TB were identified (85 at hospital A and 31 at hospital B). A single case patient, infected at hospital A, introduced the strain into hospital B. Eighty-two of the 92 strains available for fingerprinting revealed an identical pattern; 10 strains had unique RFLP patterns. Nosocomial exposure to an infectious MDR-TB patient was ascertained for 39 of the 56 patients with the 'outbreak' RFLP strain at hospital A (69.6%) and for 24 of the 26 patients at hospital B (92.3%). The median duration of exposure was 32 days at hospital A and 40 days at hospital B. For eight patients with the outbreak strain, exposure was determined to have probably occurred in other hospitals, in the community or in prison.This is the largest nosocomial outbreak of MDR-TB reported in Europe. Exposure to MDR-TB cases in other institutions caring for HIV-infected patients probably contributed to the spread of this epidemic. Strict control measures should be immediately adopted in order to prevent the spread of TB amongst HIV-infected patients in institutional settings in Europe.

To evaluate compliance with recommended patient-care practices for the prevention of hospital-acquired infections (HAI) in the intensive care unit (ICU).European descriptive survey by questionnaire mailed to all the directors of ICUs.A total of 1642 general ICUs with more than three beds in 14 countries were contacted; 1005 units participated in the study (overall response rate of 61.2%).Data on the general characteristics of the hospital and of the ICU, surveillance activities, and patient-care practices relevant to the control of HAIs were collected. Compliance varied significantly by the type of practice evaluated. Comprehensive programs adopting all the recommended preventive practices for specific infections were maintained in a very low proportion of units, ranging from 18% for antibiotic policy to 39% for urinary tract infections. Moreover, 14% of the units claimed to adopt three or more practices that are clearly unsafe, and only 35% of the units claimed not to adopt any risky practice. The presence of an infection control nurse was significantly associated with a lower frequency of substandard care. A great variability was observed by country in the adoption of 29 patient-care practices, mostly for practices for which clear-cut guidelines are lacking.Interpretation of data is made difficult by the lack of consensus among experts with respect to some of the practices investigated. Nevertheless, the implementation of standard practices for preventing HAIs is far from satisfactory in the hospitals surveyed, even in a high priority hospital area such as intensive care. Documented European guidelines could be worth-while in increasing awareness of the ICU staff. The availability of at least one infection control nurse in each hospital should be strongly advocated.

Urinary tract infection incidence can be a possible indicator of the quality of health care in hospital. It is now clear that some kind of health care, practice and particular organizational and structural orders change the risk of UTI during hospitalizations. One third of hospital infections can be prevented by carrying out specified rules and guidelines. About 80% of UTI are a consequence of bladder catheterism. According to Major Health Institute, our Hospital takes part in a Study Group on the incidence and prevention of UTI related to bladder catheterism. Preliminary results show how much surgery activity still weighs in the cases of necessity of catheterism. Differently, urinary retention and incontinence and diuresis monitoring have a minor incidence. However the incidence of UTI after bladder catheterism is very high in our study (until 85%) also and hence the subsequent necessary antimicrobical therapy.

The aim of this study was to identify risk factors and to describe epidemiological patterns for early-(EOB) and late-onset bacteremias (LOB) after trauma.A prospective study conducted on 141 consecutive trauma patients.A general intensive care unit (ICU) of a university hospital.All multiple trauma patients admitted to our general intensive care unit (ICU) from December 1990 to May 1992 were prospectively enrolled in the study. The following information was collected for each patient and recorded in a computer database: demography, severity of trauma according to the Abbreviated Injury Scale (AIS), severity of coma according to the Glasgow Coma Scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and abdominal trauma, use of mechanical ventilation, and placement of central venous catheters. Bacteremias were defined as EOB when onset occurred within 96 h after trauma, and as LOB when appearing after 96 h from trauma.Thirty-seven patients developed bacteremia during their ICU stay (26%): 11 (29.7%) EOB and 26 (70.3%) LOB. Gram-positive cocci were isolated more frequently in EOB than in LOB (chi 2 = 4.1, P = 0.04). The risk of EOB was significantly increased by the presence of pulmonary contusion [relative risk (RR) 15.0; confidence interval (CI) 1.99-113.25], pneumonia before the onset of bacteremia (RR 3.56; CI 1.17-10.69), AIS score greater than 32 and an abdominal injury score greater than 9 (RR 3.11; CI 1.02-9.49), while intravascular catheters and mechanical ventilation did not represent risk factors for EOB. LOB had a very different pattern and their risk was significantly increased by exposure to intravascular catheters (RR 4.96; CI 1.23-19.94) and to mechanical ventilation lasting more than 7 days (RR 3.6; CI 1.6-8.1).Scoring with the AIS of the abdominal and thoracic trauma at admission to the ICU appears a useful tool for identifying trauma patients at increased risk of EOB. A rigorous policy of catheter placement and maintenance as a means of reducing late bacteremias in trauma patients is essential.

To identify avoidable risk factors for central venous catheter (CVC) infections in patients undergoing short-term catheterization.Prospective multicenter cohort study.Two university teaching hospitals and five large nonteaching hospitals.Patients admitted to intensive care units or surgical units and exposed to short-term CVCs.Of 623 catheterization episodes, 9.3% were associated with catheter-related infections (CRI). The skin at the catheter site was frequently colonized (16.2%) and was the potential source of infection in 56.1% of the cases, mostly local infections. The hub was colonized less frequently (3.5%) but was responsible for systemic infections more frequently. The following variables were independently associated with CRI: duration of catheterization (for 7 to 14 days, odds ratio [OR], 3.9; 95% confidence interval [CI]95, 1.4 to 10.7; and for14 days, OR, 5.1; CI95, 1.7 to 15.4), coronary care unit service (OR, 6.7; CI95, 1.1 to 42.9) or surgery service (OR, 4.4; CI95, 1.03 to 18.5), second episode of catheterization (OR, 7.6; CI95, 1.8 to 32.3), skin colonization at the insertion site (OR, 56.5; CI95, 10.8 to 296), and hub colonization (OR, 17.9; CI95, 2.4 to 132). The risk associated with skin colonization varied with use of jugular access or simultaneous colonization of the hub. When only symptomatic CRI was considered, the risk associated with hub colonization was consistently higher (OR, 36.6; CI95, 7 to 190) than that associated with skin colonization (OR, 3.2; CI95, 0.7 to 14). Age, transparent dressing, jugular insertion, male gender, duration of catheterization, and hub colonization were independent risk factors for skin colonization. The effect of age varied by type of dressing and vice versa; the effect of jugular access varied by sex; and the effect of transparent dressing varied by length of catheterization and vice versa. Total parenteral nutrition and skin colonization were independently associated with an increased risk of hub colonization.Skin and hub colonization are the two major determinants for endemic CRIs; colonization of the hub, however, is more frequently associated with more severe infections. In order to reduce CRIs, more efforts should be focused on understanding which factors increase the risk of colonization both of the skin and of the hub.

In a six-month incidence study of surgical wound infections (SWI) in two Italian hospitals, 1,019 surgical patients, in three general surgery wards, and 433 surgical patients in one orthopedics ward were studied. For the SWI surveillance, the DANOP-DATA system was used: this microcomputer program was developed by Danish authors and tested in a European multicenter study coordinated by the World Health Organization in 1989. Two Italian hospitals participated in the multicenter study. The overall infection rate was 1.2 per 100 operations in orthopedics and 4.9/100 in general surgery. The risk of infection increased with age (RR = 2.06; 95% CL = 1.20-3.53), wound class (RR = 3.38; 95% CL = 1.97-5.8), length of pre-operative stay (RR = 2.71; 95% CL = 1.54-4.74), and duration of operation (RR = 2.59; 95% CL = 1.48-4.54). The infection rates ranged from 3.7 to 7.3/100 among the three general surgery wards; this variability by ward was only partially explained by differences in the age distribution of in-patients, wound class, duration of operation and length of pre-operative stay. When all these risk factors were simultaneously taken into account using a logistic regression model, the odds radio, comparing one of the three general surgical wards with the other two, was still 2.29 (95% CL = 1.23-4.26). The observed variability can be attributed to differences, among the participating wards, in the case-mix of patients treated and/or to differences in the quality of infection control programs implemented.

From 1987 to 1989, the National Health Institute carried out a before and after intervention study in order to evaluate the effectiveness of active surveillance and of modification of patient care practices in reducing the incidence of postoperative infections. The initial study population consisted of 20 general and thoracic surgical wards in 12 hospitals; 11 wards were not able to complete the study and were therefore excluded from the analysis. In December 1988, after a 13-month period in which baseline infection rates were assessed in 4,096 patients, written protocols regarding modification of patient care practices were defined and applied. Effectiveness of intervention was evaluated comparing infection rates measured in a 6-month period in 1989 on 1,638 operated patients with those of the previous period. In the overall population, a reduction of 19% of nosocomial infections was observed after the intervention. When individual infection sites were considered, pneumonia rates were statistically significantly reduced by 39%; for the other infection sites the observed differences were not significant. Effectiveness of intervention varied by subgroups of wards. In three of the studied wards, surgical wound infections were significantly reduced by 72%, whereas in the remaining wards the intervention seemed to have no positive impact on infection rates. Nevertheless, the intervention seemed to have been effective in increasing the awareness of infection problems in two other wards. Results of the study suggest that a consistent reduction of postoperative infections can be achieved in surgical wards where usual patient-care practices differ from standard of patient care policies. Nevertheless, the observed variation in effectiveness of intervention by individual wards suggests that differences in structural and behavioral characteristics can affect the compliance with recommended standards.

Surveillance activities in Italy during the last 5 years can be summarized in three broad categories: collection of data in order to describe the epidemiological pattern of hospital acquired infections, achieved through multicenter studies, involving hospitals or focused on specialized units; organizational efforts for the implementation of Infection Control Committees in Hospitals stimulated by official guidelines (the 1985 Health Ministry Act on this issue); evaluation of preventive strategies in Italy. Results of a one-day prevalence survey conducted in 1983, involving 130 public hospitals, are presented. Out of 34,577 patients surveyed, prevalence of hospital acquired infection was 6.8% and of community-acquired infections 12.5%. Preliminary results of PRINOS (Preventive Study on Hospital Infections) show a 4.6% incidence rate of infections in 16 surgical wards surveilled. Design of the study and target objectives are discussed.