Maria Luisa Cristina

Fungal Contamination in Hospital Environments

OBJECTIVES To assess the degree of fungal contamination in hospital environments and to evaluate the ability of air conditioning systems to reduce such contamination. METHODS We monitored airborne microbial concentrations in various environments in 10 hospitals equipped with air conditioning. Sampling was performed with a portable Surface Air System impactor with replicate organism detection and counting plates containing a fungus-selective medium. The total fungal concentration was determined 72-120 hours after sampling. The genera most involved in infection were identified by macroscopic and microscopic observation. RESULTS The mean concentration of airborne fungi in the set of environments examined was 19 +/- 19 colony-forming units (cfu) per cubic meter. Analysis of the fungal concentration in the different types of environments revealed different levels of contamination: the lowest mean values (12 +/- 14 cfu/m(3)) were recorded in operating theaters, and the highest (45 +/- 37 cfu/m(3)) were recorded in kitchens. Analyses revealed statistically significant differences between median values for the various environments. The fungal genus most commonly encountered was Penicillium, which, in kitchens, displayed the highest mean airborne concentration (8 +/- 2.4 cfu/m(3)). The percentage (35%) of Aspergillus documented in the wards was higher than that in any of the other environments monitored. CONCLUSIONS The fungal concentrations recorded in the present study are comparable to those recorded in other studies conducted in hospital environments and are considerably lower than those seen in other indoor environments that are not air conditioned. These findings demonstrate the effectiveness of air-handling systems in reducing fungal contamination.

Epidemiology of tick-borne encephalitis (TBE) in Europe and its prevention by available vaccines

Tick-borne Encephalitis (TBE), which is caused by a Flavivirus, is the most common tick-transmitted disease in Central and Eastern Europe and Russia. Today, TBE is endemic in 27 European countries, and has become an international public health problem. The epidemiology of TBE is changing owing to various factors, such as improvements in diagnosis and case reporting, increased recreational activities in areas populated by ticks, and changes in climatic conditions affecting tick habitats. Vaccination remains the most effective protective measure against TBE for people living in risk zones, occupationally exposed subjects and travelers to endemic areas. The vaccines currently in use are FSME-Immun®, Encepur®, EnceVir® and TBE vaccine Moscow®. The numerous studies performed on the efficacy and safety of these vaccines have shown a high level of immunogenicity and an excellent safety profile. Several studies have also shown a high level of cross-protection among strains belonging to different subtypes. In the present paper we attempted to describe the continuously changing epidemiology of TBE in European States and to overview clinical development of available vaccines paying particular attention on cross-protection elicited by the vaccines.

The epidemiology of domestic injurious falls in a community dwelling elderly population: an outgrowing economic burden

In Italy, more than 3 million people annually sustain a domestic injury; the elderly experience it the most. From a healthcare perspective, elderly falls are a major clinical issue with an outgrowing socioeconomic burden. The aim of the study was to evaluate the epidemiology of injurious falls in a community dwelling population, admitted to the emergency room (ER) because of a domestic injury, to assess the socioeconomic burden. Seventy-four hospitalized patients among 227 were examined. Falls represented the main cause of admittance to the ER; the average cost for fall-related hospitalization was of €5479.09.

The impact of aerators on water contamination by emerging gram-negative opportunists in at-risk hospital departments

OBJECTIVE Our aim was to evaluate the impact of aerators on water microbiological contamination in at-risk hospital departments, with a view to quantifying the possible risk of patient exposure to waterborne microorganisms. DESIGN We analyzed the microbiological and chemical-physical characteristics of hot and cold water in some critical hospital departments. SETTING Two hospitals in northern Italy. METHODS We took 304 water samples over a 1-year period, at 3-month intervals, from taps used by healthcare personnel for handwashing, surgical washing, and the washing of medical equipment. We analyzed heterotrophic plate counts (HPCs) at 36°C and 22°C, nonfastidious gram-negative bacteria (GNB-NE), and Legionella pneumophila. RESULTS The percentages of positivity and mean values of HPCs at 22°C, HPCs at 36°C, and GNB-NE loads were significantly higher at outlet points than in the plumbing system. In particular, GNB-NE positivity was higher at outlet points than in the plumbing system in both the cold water (31.58% vs 6.58% of samples were positive) and hot water (21.05% vs 3.95%) supplies. Our results also revealed contamination by L. pneumophila both in the plumbing system and at outlet points, with percentages of positive samples varying according to the serogroup examined (serogroups 1 and 2-14). The mean concentrations displayed statistically significant (P < .001) differences between the outlet points (27,382.89 ± 42,245.33 colony-forming units [cfu]/L) and the plumbing system (19,461.84 ± 29,982.11 cfu/L). CONCLUSIONS These results reveal a high level of contamination of aerators by various species of gram-negative opportunists that are potentially very dangerous for immunocompromised patients and, therefore, the need to improve the management of these devices.

Evaluation of the risk of infection through exposure to aerosols and spatters in dentistry

BACKGROUND Many dental procedures produce extensive aerosols and splatters that are routinely contaminated with microorganisms. METHODS Air containing blood-bearing aerosols and surfaces contaminated by sedimenting blood particulate was sampled in 5 different dental cubicles. To assess contamination by blood particulate, the concentration of hemoglobin (Hb) in the air and on the sedimentation surfaces was determined. RESULTS The mean concentration of Hb in the air aspirated in the 5 cubicles was 0.14 +/- 0.23 microg/m(3), corresponding to a blood volume of 8.7 x 10(-4) microL/m(3). Similarly, the mean concentration of blood particulate sedimented on surfaces was calculated and found to be 1.56 microL/m(2). In 80% of the cubicles monitored, 100% positivity to the Hb determination test was recorded in all of the surface samples. CONCLUSIONS The results obtained revealed contamination of both air and surfaces by blood particulate. Moreover, with the exception of those obtained in 1 cubicle, all of the samples of sedimenting particulate analyzed were positive for the presence of Hb.

Spread of multidrug carbapenem-resistant Acinetobacter baumannii in different wards of an Italian hospital

BACKGROUND Multidrug-resistant Acinetobacter baumannii (MDRAB) is an important cause of hospital acquired infection. We describe a 7-month outbreak of a MDRAB infection involving various wards of an Italian hospital and an investigation of the possible source of the infection was conducted. METHODS A baumannii was isolated from various biological samples from 22 colonized or infected patients, and was identified and characterized for its antibiotic sensitivity. Typing of A baumannii was performed by multilocus sequence typing (MLST). Investigation of the outbreak involved extensive microbiological sampling of the environment. RESULTS In 50% of cases the infection occurred in the ICU. Invasive procedures were performed in 63.6% of patients. The strain isolated proved to be resistant to all the antibiotics tested, including carbapenems, and displayed the same allelic profile in all patients. None of the 141 samples taken during environmental monitoring showed positivity for A baumannii. CONCLUSION The results of the present study reveal the importance of strict adherence to control measures by all health care personnel and highlight the fact that regular staff training and frequent revision of control measures are essential to the successful management of an outbreak.

Legionella pneumophila in healthcare facilities

Legionella pneumophila are gram-negative bacteria found in freshwater environments; they can survive as intracellular parasites of free-living protozoa and within biofilms in building water systems. L. pneumophila multiply at temperatures between 25 and 42°C, with an optimal growth temperature of 35°C. There are 16 serogroups of L. pneumophila. In Europe, approximately 70% of Legionella infections are caused by L. pneumophila serogroup 1 and 20–30% by other serogroups. These bacteria cause respiratory disease (legionellosis) in humans when a susceptible host inhales aerosolized water containing the bacteria or aspirates water containing the bacteria. Legionellosis classically presents as two distinct clinical entities: Legionnaires’ disease, a severe multisystem disease involving pneumonia, and Pontiac fever, a self-limited flu-like illness. Urine antigen tests and cultures of sputum or bronchoalveolar lavage are the most suitable clinical laboratory tests for Legionella. The new macrolide antibiotics, such as clarithromycin and azithromycin, show more effective in-vitro activity and a better intracellular and tissue penetration than erythromycin, as do the quinolones. Hospitals represent ideal locations for Legionnaires’ disease transmission: at-risk individuals are present in large numbers; plumbing systems are frequently old and complex, favouring multiplication of the organism; and water temperatures are often reduced to prevent scalding of patients. Safe water is vital to ensure patient safety and reduce costs where waterborne infections cause increasing morbidity, mortality, treatment costs, longer hospital stays and compensation claims. The WHO has developed Water Safety Plans for preventing or controlling the risks through system assessment, monitoring, surveillance and management/communication, so that health outcomes can be improved, that is a systematic approach is required to secure microbial safety.

Multidrug-resistant Acinetobacter baumannii outbreak: an investigation of the possible routes of transmission

OBJECTIVES To establish the possible sources and routes of transmission of a multidrug-resistant Acinetobacter baumannii outbreak involving 22 patients. STUDY DESIGN Descriptive, retrospective study. METHODS An environmental investigation was undertaken, monitoring surfaces, air and water. Reconstruction of the spread of the infection took several factors into account such as intrahospital movements of patients and healthcare personnel, hospitalization of patients in the same ward and in chronologically compatible periods, and length of stay. A. baumannii clinical samples were typed using the Multilocus Sequence Typing scheme. RESULTS The outbreak originated from a patient admitted to the sub-intensive care unit, and the infection subsequently spread to other wards. The allelic profile proved to be the same for all the clinical isolates. Environmental monitoring yielded negative results for A. baumannii. CONCLUSIONS The results suggest that this epidemic spread through cross-transmission involving healthcare workers.

Influenza epidemiology in Italy two years after the 2009–2010 pandemic: Need to improve vaccination coverage

Since 2000, a sentinel surveillance of influenza, INFLUNET, exists in Italy. It is coordinated by the Ministry of Health and is divided into two parts; one of these is coordinated by the National Institute of Health (NIH), the other by the Inter-University Centre for Research on Influenza and other Transmissible Infections (CIRI-IT). The influenza surveillance system performs its activity from the 42nd week of each year (mid-October) to the 17th week of the following year (late April). Only during the pandemic season (2009/2010) did surveillance continue uninterruptedly. Sentinel physicians – about 1,200 general practitioners and independent pediatricians – send in weekly reports of cases of influenza-like illness (ILI) among their patients (over 2% of the population of Italy) to these centers. In order to estimate the burden of pandemic and seasonal influenza, we examined the epidemiological data collected over the last 3 seasons (2009–2012). On the basis of the incidences of ILIs at different ages, we estimated that: 4,882,415; 5,519,917; and 4,660,601 cases occurred in Italy in 2009–2010, 2010–2011 and 2011–2012, respectively. Considering the ILIs, the most part of cases occurred in < 14 y old subjects and especially in 5–14 y old individuals, about 30% and 21% of cases respectively during 2009–2010 and 2010–2011 influenza seasons. In 2011–2012, our evaluation was of about 4.7 million of cases, and as in the previous season, the peak of cases regarded subjects < 14 y (about 29%). A/California/07/09 predominated in 2009–2010 and continued to circulate in 2010–2011. During 2010–2011 B/Brisbane/60/08 like viruses circulated and A/H3N2 influenza type was sporadically present. H3N2 (A/Perth/16/2009 and A/Victoria/361/2011) was the predominant influenza type-A virus that caused illness in the 2011–2012 season. Many strains of influenza viruses were present in the epidemiological scenario in 2009–2012. In the period 2009–2012, overall vaccination coverage was low, never exceeding 20% of the Italian population. Among the elderly, coverage rates grew from 40% in 1999 to almost 70% in 2005–2006, but subsequently decreased, in spite of the pandemic; this trend reveals a slight, though constant, decline in compliance with vaccination. Our data confirm that 2009 pandemics had had a spread particularly important in infants and schoolchildren, and this fact supports the strategy to vaccinate schoolchildren at least until 14 y of age. Furthermore, the low levels of vaccination coverage in Italy reveal the need to improve the catch-up of at-risk subjects during annual influenza vaccination campaigns, and, if possible, to extend free vaccination to at least all 50–64-y-old subjects. Virologic and epidemiological surveillance remains critical for detection of evolving influenza viruses and to monitor the health and economic burden in all age class annually.

Operating theatre ventilation systems and microbial air contamination in total joint replacement surgery: Results of the GISIO-ISChIA study

BACKGROUND Recent studies have shown a higher rate of surgical site infections in hip prosthesis implantation using unidirectional airflow ventilation compared with turbulent ventilation. However, these studies did not measure the air microbial quality of operating theatres (OTs), and assumed it to be compliant with the recommended standards for this ventilation technique. AIM To evaluate airborne microbial contamination in OTs during hip and knee replacement surgery, and compare the findings with values recommended for joint replacement surgery. METHODS Air samplings were performed in 28 OTs supplied with unidirectional, turbulent and mixed airflow ventilation. Samples were collected using passive sampling to determine the index of microbial air contamination (IMA). Active sampling was also performed in some of the OTs. The average number of people in the OT and the number of door openings during the sampling period were recorded. FINDINGS In total, 1228 elective prosthesis procedures (60.1% hip and 39.9% knee) were included in this study. Of passive samplings performed during surgical activity in unidirectional airflow ventilation OTs (U-OTs) and mixed airflow OTs (M-OTs), 58.9% and 87.6% had IMA values >2, respectively. Of samplings performed during surgical activity in turbulent airflow OTs (T-OTs) and in turbulent airflow OTs with the surgical team wearing Steri-Shield Turbo Helmets (TH-OTs), 8.6% and 60% had IMA values ≤ 2, respectively. Positive correlation was found between IMA values and the number of people in the OT and the number of door openings (P < 0.001). In addition, correlation was found between active and passive sampling (P < 0.001). CONCLUSION These findings challenge the belief that unidirectional systems always provide acceptable airborne bacterial counts.