Maria Luisa Moro

RISK FACTORS FOR CENTRAL VENOUS CATHETER-RELATED INFECTIONS IN SURGICAL AND INTENSIVE CARE UNITS

OBJECTIVE To identify avoidable risk factors for central venous catheter (CVC) infections in patients undergoing short-term catheterization. DESIGN Prospective multicenter cohort study. SETTING Two university teaching hospitals and five large nonteaching hospitals. PATIENTS Patients admitted to intensive care units or surgical units and exposed to short-term CVCs. RESULTS 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 for > 14 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. CONCLUSIONS 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.

Risk factors for acute renal failure in trauma patients

ObjectiveTo elucidate the risk factors for the development of acute renal failure (ARF) in severe trauma.DesignProspective observational study.SettingA general intensive care unit (ICU) of a university hospital.PatientsA cohort of 153 consecutive trauma patients admitted to the ICU over a period of 30 months.ResultsForty-eight (31 %) patients developed ARF. They were older than the 105 patients without ARF (p=0.002), had a higher Injury Severity Score (ISS) (p>0.001), higher mortality (p>0.001), a more compromised neurological condition (p=0.007), and their arterial pressure at study entry was lower (p=0.0015). In the univariate analysis, the risk of ARF increased by age, ISS>17, the presence of hemoperitoneum, shock, hypotension, or bone fractures, rhabdomyolysis with creatine Phosphokinase (CPK)>10000 IU/1, presence of acute lung injury requiring mechanical ventilation, and Glasgow Coma Score>10. Sepsis and use of nephrotoxic agents were not associated with an increased risk of ARF. In the logistic model, the need for mechanical ventilation with a positive end-expiratory pressure>6 cm H2O, rhabdomyolysis with CPK>10000 IU/1, and hemoperitoneum were the three conditions most strongly associated with ARF.ConclusionsThe identified risk factors for post-traumatic acute renal failure may help the provision of future strategies.

Nosocomial necrotising enterocolitis outbreaks: epidemiology and control measures.

Abstract Necrotising enterocolitis (NEC) is one of the most serious gastrointestinal diseases among newborns and it mainly affects those in intensive care units. The aetiology of the disease has been reported to be multifactorial and both sporadic cases and nosocomial outbreaks have occurred. In this report, we review 17 epidemics of NEC reported in the literature between 1973 and 1999. The number of confirmed cases ranged from 1 to 32 with an average of 10.5 confirmed cases. On average, 16.15% of cases required surgery (range 0–66.6%). The average mortality rate was 6.25% (range 0–87.5%). The mean age at disease onset was 9.5 days (range 6.6–29 days). Most of the infants had low birth weight (median weight 1,395 g; range 1,112–2,788 g, calculated on the reported mean weights). The main risk factors associated with NEC were: low birth weight, low gestational age, low Apgar score, perinatal complications, hyaline membrane disease, and umbilical catheterisation. The bacteria involved often included Enterobacteriaceae, particularly Escherichia coli, Klebsiella pneumoniae and Enterobacter cloacae type 3305573. The causative role of Clostridia in NEC is controversial. With regard to viral agents, coronarovirus, rotavirus and enterovirus, such as echovirus type 22, were isolated during some of the epidemics. The recommended control measures for NEC epidemics are those used for epidemics of other orofaecally transmitted infections. Conclusion Understanding the epidemiology of necrotising enterocolitis is fundamental if adequate preventive control measures are to be developed and applied.

An outbreak of multidrug-resistant tuberculosis involving Hiv-infected patients of two hospitals in Milan, Italy

Objective: To describe an outbreak of multidrug‐resistant tuberculosis (MDR‐TB), amongst HIV‐infected patients, spread from one hospital in Milan to another. Design: Descriptive epidemiological investigation and molecular typing. Methods: 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. Results: 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. Conclusions: 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.

Inflammatory Cytokine Expression Is Associated with Chikungunya Virus Resolution and Symptom Severity

The Chikungunya virus infection zones have now quickly spread from Africa to parts of Asia, North America and Europe. Originally thought to trigger a disease of only mild symptoms, recently Chikungunya virus caused large-scale fatalities and widespread economic loss that was linked to recent virus genetic mutation and evolution. Due to the paucity of information on Chikungunya immunological progression, we investigated the serum levels of 13 cytokines/chemokines during the acute phase of Chikungunya disease and 6- and 12-month post-infection follow-up from patients of the Italian outbreak. We found that CXCL9/MIG, CCL2/MCP-1, IL-6 and CXCL10/IP-10 were significantly raised in the acute phase compared to follow-up samples. Furthermore, IL-1β, TNF-α, Il-12, IL-10, IFN-γ and IL-5 had low initial acute phase levels that significantly increased at later time points. Analysis of symptom severity showed association with CXCL9/MIG, CXCL10/IP-10 and IgG levels. These data give insight into Chikungunya disease establishment and subsequent convalescence, which is imperative to the treatment and containment of this quickly evolving and frequently re-emerging disease.

Chikungunya virus in North-Eastern Italy: a seroprevalence survey.

After an outbreak of Chikungunya infection in Emilia-Romagna Region (North-eastern Italy), a survey was performed to estimate the seroprevalence of antibody to Chikungunya virus and the proportion of asymptomatic infections, to identify factors associated with infection, and evaluate the performance of the surveillance system. The method used was a survey on a random sample of residents of the village with the largest number of reported cases. The prevalence was 10.2% (33 of 325), being higher in older people and males, and lower when window screens and insect repellents were used. Only 18% of infected persons were fully asymptomatic, 85% of the 27 symptomatic confirmed cases satisfied the surveillance case definition, and 63% of the persons meeting the criteria for suspect case were identified by the active surveillance system. This study provides basic parameters for modeling the transmission potential of outbreaks and planning control measures for Chikungunya infection in temperate settings.

Surgical site infections in Italian Hospitals: a prospective multicenter study

BackgroundSurgical site infections (SSI) remain a major clinical problem in terms of morbidity, mortality, and hospital costs. Nearly 60% of SSI diagnosis occur in the postdischarge period. However, literature provides little information on risk factors associated to in-hospital and postdischarge SSI occurrence. A national prospective multicenter study was conducted with the aim of assessing the incidence of both in-hospital and postdisharge SSI, and the associated risk factors.MethodsIn 2002, a one-month, prospective national multicenter surveillance study was conducted in General and Gynecological units of 48 Italian hospitals. Case ascertainment of SSI was carried out using standardized surveillance methodology. To assess potential risk factors for SSI we used a conditional logistic regression model. We also reported the odds ratios of in-hospital and postdischarge SSI.ResultsSSI occurred in 241 (5.2%) of 4,665 patients, of which 148 (61.4%) during in-hospital, and 93 (38.6%) during postdischarge period. Of 93 postdischarge SSI, sixty-two (66.7%) and 31 (33.3%) were detected through telephone interview and questionnaire survey, respectively. Higher SSI incidence rates were observed in colon surgery (18.9%), gastric surgery (13.6%), and appendectomy (8.6%). If considering risk factors for SSI, at multivariate analysis we found that emergency interventions, NNIS risk score, pre-operative hospital stay, and use of drains were significantly associated with SSI occurrence. Moreover, risk factors for total SSI were also associated to in-hospital SSI. Additionally, only NNIS, pre-operative hospital stay, use of drains, and antibiotic prophylaxis were associated with postdischarge SSI.ConclusionOur study provided information on risk factors for SSI in a large population in general surgery setting in Italy. Standardized postdischarge surveillance detected 38.6% of all SSI. We also compared risk factors for in-hospital and postdischarge SSI, thus providing additional information to that of the current available literature. Finally, a large amount of postdischarge SSI were detected through telephone interview. The evaluation of the cost-effectiveness of the telephone interview as a postdischarge surveillance method could be an issue for further research.

Risk factors for nosocomial sepsis in newborn intensive and intermediate care units

AbstractA multicentre prospective study was performed to estimate the incidence of hospital infections and to identify the most relevant risk factors for sepsis in a large and unselected population of high-risk newborns. The study involved 49 neonatal intensive care units and 17 neonatal intermediate care units in Italy. Newborns were followed up from admittance to the units until discharge. Data on demographics and clinical characteristics, exposure to the principal invasive procedures, and onset of infectious complications were prospectively collected. Only infections developing after 48 h from admittance to the unit were recorded. A multiple logistic regression was performed to identify which factors were independently associated with sepsis. Among the 8263 newborns included in the analysis, the incidence of infected newborns was 14.4 per 100 newborns and 0.9/100 days of stay. The incidence of infections was 19.1/100 newborns and 1.2/100 days of stay. Sepsis represented 15.4% of all infections (incidence 2.9/100 newborns and 0.2/100 days of stay). The following factors were independently associated with sepsis: umbilical catheterization, both through the vein and the artery for more than 5 days; mechanical ventilation for more than 5 days; necrotizing enterocolitis; birth weight equal to or less than 2500 g; nasogastric tube; total parenteral nutrition; and transfer from other hospitals. Umbilical catheters accounted for the highest proportion of sepsis (62%), followed by arterial catheters (31%), nasopharyngeal cannulae (26%), tracheal cannulae (20%), and nasal cannulae (20%). The population attributable risk for the other procedures was less than 10%.ConclusionThis study demonstrates that in a large and unselected newborn population, several host factors and invasive procedures are independently associated with an increased risk of sepsis. After adjustment for clinical severity, intravascular catheterization and assisted ventilation were found to be responsible for a considerable proportion of observed sepsis. They shoudl therefore be considered as priorities for interventions, aimed both at reducing unnecessary use and promoting more strict compliance with aseptic practices.

Long-term chikungunya infection clinical manifestations after an outbreak in Italy: A prognostic cohort study

OBJECTIVES Following a Chikungunya (CHIKV) outbreak in Italy, a cohort study was conducted to describe the infection long-term clinical course and outcome. METHODS Persons identified through active and passive surveillance as confirmed or possible CHIKV cases during the outbreak were enrolled and interviewed by trained public health nurses, between 4-5 and 12-13 months following the acute stage. Patients reporting persistent clinical symptoms were evaluated by rheumatologists. Serum samples were obtained and anti-CHIKV specific IgG and IgM immune responses detected. Only confirmed cases who completed the follow-up were analysed. RESULTS Out of 250 patients, 66.5% still reported myalgia, asthenia or arthralgia (most frequent sign) after 12 months. Functional ability, measured by the ROAD index, was more impaired for lower extremities (3.75; Inter Quartile Range - IQR 4.4), and the activities of daily living (average 4.2; IQR 5). Variables independently associated with the presence of joint pain at 12-13 months were increasing age, and history of rheumatologic diseases). Elderly, females, and persons with history of rheumatologic diseases had higher anti-CHIKV IgG titres at 12-13 months. CONCLUSIONS This study confirms, in an unselected population, that the long-lasting burden of CHIKV infection is significant.

Nosocomial outbreak of systemic candidosis associated with parenteral nutrition.

Eight patients in two surgical units developed systemic candidosis during a 40-day period from June 5 to July 13, 1987 (in five cases Candida albicans was identified). Three of them died. All cases belonged to a group of 27 patients receiving parenteral nutrition (PN), while among the 108 patients who did not receive PN, no cases were observed (p = .000001). Candida was cultured from two PN bags administered to the cases. A specialized nutrition nurse was responsible for the PN compounding and for maintaining administration sets in the two wards involved. An epidemiological investigation, in which 19 uninfected patients who had had PN were used as controls, showed no significant difference between cases and controls except that lipids were more frequently added to bags administered to cases (p = .0005). Furthermore, the bags administered to cases contained a higher average number of multidose constituents (p = .0008) when the comparison was focused on the two days before the onset of symptoms. Given the favorable medium provided by lipids, even a low level contamination of PN solutions during compounding and/or administration could have been responsible for the exposure of cases to multidose vials suggests, although not conclusively, that an extrinsic contamination occurred during compounding. Six isolates of C albicans were available from four cases. C albicans was cultured from the pharyngeal swabs of two physicians and three nurses, including the specialized nutrition nurse.