Maria De Giusti

Reliability of Procalcitonin Concentrations for the Diagnosis of Sepsis in Critically Ill Neonates

We evaluated the reliability of serum concentrations of procalcitonin for the diagnosis of early- and late-onset sepsis in a neonatal intensive care unit (NICU) setting. Timed procalcitonin determinations were prospectively obtained during two postnatal periods: 0-48 hours of age (period 1) and 3-30 days of age (period 2). In period 1, we measured procalcitonin concentrations in 83 healthy newborns (group 0) and in 120 NICU patients (14 with culture-proven sepsis, group 1A; 14 with clinical septicemia, group 1B; 75 with no evidence of infection, group 2; and 17 with uncertain findings, group 3). After we established 95% hour-specific reference ranges for group 0, we performed multiple linear regression analyses to determine which maternal, intrapartum, and neonatal complications would affect normal procalcitonin values. Maternal diabetes was the only variable identified in group 2 patients that induced a significant deviation from procalcitonin reference ranges. Analyses of the pooled procalcitonin values obtained for group 1 patients over the 48-hour period after birth yielded a sensitivity of 92.6% and a specificity of 97.5% for procalcitonin concentrations in the detection of early-onset sepsis. In period 2, blood samples from 23 cases with systemic infections were analyzed for procalcitonin concentrations at the onset of signs of infection. The control group was formed by matching four uninfected NICU patients to each infected case. None of the procalcitonin values for the 92 controls overlapped those for the cases (sensitivity and specificity, 100%). Procalcitonin is a promising marker for the diagnosis of early- and late-onset sepsis in neonates at high risk for this infection.

Physicians' knowledge, attitudes and professional use of RCTs and meta-analyses: A cross-sectional survey

BACKGROUND Familiarity with Randomized Control Trials (RCTs) and meta-analyses is essential to practice Evidence Based Medicine (EBM). The aims of this study were to describe knowledge, attitudes and professional behavior of physicians towards methods to evaluate the efficacy of health interventions, particularly meta-analysis and to find out their possible associated factors. METHODS A cross-sectional survey was carried out on a random sample of Italian physicians through a self-administered questionnaire. RESULTS A response rate of 70.1% was achieved (654 questionnaires). Despite satisfactory knowledge and substantial positive attitudes, Italian physicians have not integrated the use of RCTs and meta-analyses into their practice to a large extent, because they infrequently read and use RCTs and meta-analyses to make decisions in clinical practice. There is a high correlation between knowledge, attitudes and professional use of RCTs and meta-analyses. Moreover, the results of our multivariate analysis show that the probability of an appropriate professional use, that is higher for doctors who know the English language, have internet access and dedicate a proper amount of time to continuing medical education, increases significantly with a previous exposure to meta-analysis during graduate/post-graduate training (OR 2.25, 95% CI 1.44-3.52), and with the attendance of post-graduate courses about EBM (OR 1.75, 95% CI 1.09-2.82). Finally, Italian physicians demonstrate a high level of interest in further training. CONCLUSIONS The association between the EBM educational background of doctors and the appropriate professional use of RCTs and meta-analyses suggest that EBM training may promote a more evidence-based practice among physicians.

Microbiological air quality in an urban solid waste selection plant

Background: Exposure to bioaerosols may pose health risks to workers operating in the processing of Urban Solid Waste (USW). The aim of this study is to evaluate microbiological air quality within an USW selection facility. Methods: Nine sampling points in an USW selection plant situated in central-southern Italy were selected. One outdoor sampling point provided the background data. Sampling was performed on a yearly basis (2005 ‐ 2009) upon request by the management of the selection plant. Total Mesophilic Counts (TMC), as well as fungal and Gram-negative concentrations were determined. Results: The highest viable fungal particles concentrations (medians) were found in waste delivery areas (about 20000 CFU/m 3), while the lowest were found in the control rooms (485 ‐ 967 CFU/m 3). TMC (median) was highest (6116 CFU/m 3) at the delivery pit, followed by the machine shop (3147 CFU/m 3), where no waste processing takes place. Medians of Gram-negative bacteria are below the suggested Occupational Exposure Limit of 1000 CFU/m 3, although this limit was exceeded at several single time-points in the waste delivery areas, and also in a personnel resting room. The lowest Gram-negative contamination was found in the control rooms (medians <1 CFU/m 3). Conclusions: Some areas within a USW selection plant act as internal sources of contamination towards those areas where partially processed waste, or no waste at all, is present. Well-designed air flows, or carefullythought positioning of areas that are not directly involved in waste processing are necessary and effective in obtaining satisfactory microbiological air quality, provided that personal protection practices are strictly enforced.

The Role of Education in Improving Physicians' Professional Use of Economic Evaluations of Health Interventions Some Evidence From a Cross-Sectional Survey in Italy

A cross-sectional survey was carried out on a random sample of Italian physicians through a self-administered questionnaire to describe knowledge, attitudes, and professional behavior toward economic evaluations of health interventions. A response rate of 74.1% was achieved (760 questionnaires). Although many physicians show a positive attitude toward cost-minimization and, to a lesser extent, to cost-effectiveness analysis, they rated their methodological knowledge as unsatisfactory, and the professional use of the economic evaluations of the health interventions in clinical practice is quite low. Multiple logistic regression analysis showed that adequate knowledge and positive attitudes are associated with increased physicians’ use of health economic evaluations, as well as time dedicated to continuing medical education and previous training experience about health economics and management. Education and specific training may play an important role in promoting a more cost-conscious behavior of physicians.

Legionella control in the water system of antiquated hospital buildings by shock and continuous hyperchlorination: 5 years experience

BackgroundTo control the presence of Legionella in an old hospital water system, an integrated strategy of water disinfection-filtration was implemented in the university hospital Umberto I in Rome.MethodsDue to antiquated buildings, hospital water system design and hospital extension (38 buildings), shock hyperchlorination (sodium hypochlorite, 20–50 ppm of free chlorine at distal points for 1–2 h) followed by continuous hyperchlorination (0.5-1.0 mg/L at distal points) were adopted, and microbiological and chemical monitoring of the water supply was carried out in the university hospital (December 2006-December 2011).ResultsOverall, 1308 samples of cold <20°C (44.5%), mixed ≥20°C ≤ 45°C (37.7%) and hot >45°C (17.8%) water were collected, determining residual free chlorine (0.43 ± 0.44 mg/L), pH (7.43 ± 0.29) and trihalomethanes (8.97 ± 18.56 μg/L). Legionella was isolated in 102 (9.8%) out of 1.041 water samples without filters (L. pneumophila sg 1 17.6%, L. pneumophila sg 2–14 28.4%, L. non pneumophila 53.9%), and in none of the 267 samples with filters. Legionella was recovered in 23 buildings out of 38 and 29 samples (28.4%) exceeded 103 cfu/L. When considering the disinfection treatment Legionella was isolated: before shock hyperchlorination (21.1%), 15 days after shock hyperchlorination (7.8%), 30 days after shock hyperchlorination (3.5%), during continuous hyperchlorination (5.5%) and without continuous hyperchlorination (27.3%). Continuous hyperchlorination following the shock treatment achieved >70% reduction of positive samples, whereas no continuous hyperchlorination after shock treatment was more frequently associated to Legionella isolation (OR 6.41; 95% CI 3.10–13.26; p <0.001). Independent risk factors for Legionella isolation were: residual free chlorine <0.5 mg/L (OR 13.0; 95% CI 1.37 – 123.2; p <0.03), water T° ≥20°C ≤ 45°C (OR 12.0; 95% CI 1.28 – 111.48; p <0.03) and no continuous hyperchlorination after shock treatment (OR 10.3; 95% CI 1.06 – 100.05; p <0.05).ConclusionsShock and continuous hyperchlorination achieved significant Legionella reduction, but effective chlorine levels (>0.5 < 1.0 mg/L) deteriorated water quality (organoleptic and chemical). However, shock and continuous hyperchlorination remains a valid-term option in old buildings with no water system rational design, managing problems due to hospital extension and absence of a proper hot water recirculation system.

Epidemiology of emerging foodborne pathogens

Foodborne diseases still represent an important global public health issue, including Europe and Italy, which endangers the health of the population and leads to socio-economic costs and a threat to the market trend. In developed countries it is estimated that up to one third of the population are affected by microbiological foodborne diseases each year. In these countries, it has been observed that traditional infectious foodborne diseases have decreased while re-emerging and emerging pathogens like Escherichia coli O157, Listeria monocytogenes, Campylobacter jejuni, Norovirus and Hepatitis A virus have increased. In 2004, in Italy the incidence for Listeriosis was 0.06 per 100,000 population and is included among the statutory notifiable diseases. E. coli O157:H7 is not subject to statutory notification in Italy; however, a voluntary national surveillance system for HUS in paediatric patients and for VTEC, has lead to the notification of 429 paediatric HUS cases and 344 clinical cases of VTEC from 1988 to 2004. Data on campylobacteriosis are available thanks to the voluntary notifications received from the Enternet Laboratories: 582 cases were isolated from human clinical specimens in 2004. Furthermore, data from a specific surveillance system for acute viral hepatitis (SEIEVA) shows that the incidence of reported cases in Italy is declining. The necessity to alert the authorities responsible for epidemiological surveillance nationally remains paramount. Communication as well as educational campaigns aimed at different target groups, for example consumers, will play an important role in the prevention of foodborne diseases.

Ready-to-eat vegetables production with low-level water chlorination: an evaluation of water quality and of its impact on end products

INTRODUCTION We evaluated the microbiological impact of low-level chlorination (1 ppm free chlorine) on the production of ready-to-eat (RTE) vegetables by monitoring the microbiological quality of irrigation and processing water in two production plants over a 4-season period, as well as the microbiological quality of unprocessed vegetables and RTE product. Water samples were also characterized in terms of some chemical and physico-chemical parameters of relevance in chlorination management. MATERIALS AND METHODS Both producers use water with maximum 1 ppm free chlorine for vegetables rinsing, while the two processes differ by the number of washing cycles. RESULTS AND CONCLUSIONS Salmonella spp and Campylobacter spp were detected once in two different irrigation water samples out of nine from one producer. No pathogens were found in the vegetable samples. As expected, the procedure encompassing more washing cycles performed slightly better in terms of total mesophilic count (TMC) when comparing unprocessed and RTE vegetables of the same batch. However, data suggest that low-level chlorination may be insufficient in preventing microbial build-up in the washing equipment and/or batch-to batch cross-contamination.

Occupational biological risk knowledge and perception: results from a large survey in Rome, Italy

BACKGROUND A cross-sectional survey on knowledge and perception of occupational biological risk among workers in several occupations was carried out in the industrial area of Rome. METHODS The study was carried out in the period of March-April 2010 using a questionnaire with 33 items on the following areas: a) socio-demographic data; b) perception of the biological risks in ordinary occupational activity; c) knowledge about biological risks; d) biological risks in the working environment. The questionnaire was submitted to a convenience sample of workers of an industrial area in Southern Rome. RESULTS 729 participants entered the study from the following work activities: food, catering, service, farming and breeding, healthcare, school and research (males 57.2%; mean age 37.4 years, SD = 10.9). Significant associations were found between different activity areas with respect to the relevance of the biological risk (p = 0.044) and the perception of the biological risk (p < 0.001). With respect to vehicles of infectious agents, the highest percentages of the most common biological risk exposures were: air and physical contact for the catering and food group, 66.7% and 61.90% respectively; air and blood for the health and research group, with 73.50% and 57.00% respectively; and physical contact and blood for the service group, 63.10 % and 48.30%. Significant difference of proportions were found about the prevalent effect caused by the biological agents was the occurrence of infectious diseases (59.90% food group, 91.60% health and research and 79.30% service group) (p < 0.001). The perception of knowledge resulted in a good rank (sufficient, many or complete) in the food and catering group, 78.3% with significant difference compared to other professions (p < 0.001). CONCLUSIONS All participants show good knowledge the effects induced by biological agents and it is significant that almost half of the respondents are aware of the risks concerning allergies. Nevertheless, it is surprising that this risk is known mainly by workers of service, farming and breeding, to a greater extent than it is known by health workers.

FoodBioTimerAssay: a new microbiological biosensor for detection of Escherichia coli food contamination

Background : Prevention of foodborne diseases is a fundamental goal for public health and industries engaged in food preparation and distribution. The correct procedure to ensure an effective prevention of foodborne diseases consists essentially in microbiological monitoring and enumeration of indicator microorganisms of faecal contamination at critical control points along the food producing procedures. Here, we propose a new microbiological biosensor, called FoodBioTimerAssay (FBTA), for rapid and reliable detection of Escherichia coli as indicator of faecal contamination in food and surface samples. Methods : A total of 122 samples were analysed using both experimental FBTA and Reference method. FBTA employs FBTM medium and counts bacteria through microbial metabolism measure: the time required for colour switch (red-to-yellow) of FBTM, due to E. coli metabolism, is correlated to initial bacterial concentration. Results : FBTA results showed an overall agreement percentage with Reference method equal to 97.54%. Discrepancies concerned three samples (1 food and 2 surface samples). Moreover, the time required to perform FBTA method was 3-fold shorter than Reference one. Conclusions : FBTA method may be considered a useful tool for detection of E. coli contamination in food and surface samples. Therefore, FBTA method may be successfully employed in risk analysis of foodborne diseases.

Factors influencing persistence of Legionella pneumophila serogroup 1 in laboratory cocultures

BackgroundRisk for infections from Legionella pneumophila for immunocompromised individuals increases greatly when this species is present within the biofilm of the water distribution systems of hospitals or other health facilities. Multiplication and persistence of Legionella may dependent also upon planktonic growth in alternative to sessile growth. Here we compared the persistence of L. pneumophila serogroup 1 in experimental planktonic co-cultures subsided with iron, Pseudomonas aeruginosa and other non Legionella bacteria (quantified as Heterotrophic Plate Count, HPC at 37°C), isolated from drinking water sources of a large hospital.ResultsConcentrations of L. pneumophila showed a decreasing pattern with incubation time in all co-cultures, the degree of reduction depending on the experimental treatment. In co-cultures with added P. aeruginosa, no L. pneumophila was detectable already after 4 days of incubation. In contrast in co-cultures without P. aeruginosa, HPC but not iron were significant factors in explaining the pattern of L. pneumophila, although the HPC effect was different according to the incubation time (HPC x time interaction, p <0.01).ConclusionsOur results highlight the need of controlling for both HPC and metal constituents of the water systems of buildings used by individuals at particular risk to the effects of Legionella exposure.