Paola Antonioli

Impact of a Probiotic-Based Cleaning Intervention on the Microbiota Ecosystem of the Hospital Surfaces: Focus on the Resistome Remodulation.

Background Contamination of hospital surfaces by clinically-relevant pathogens represents a major concern in healthcare facilities, due to its impact on transmission of healthcare-associated infections (HAIs) and to the growing drug resistance of HAI-associated pathogens. Routinely used chemical disinfectants show limitations in controlling pathogen contamination, due to their inefficacy in preventing recontamination and selection of resistant strains. Recently we observed that an innovative approach, based on a cleanser added with spores of non-pathogenic probiotic Bacilli, was effective in stably counteracting the growth of several pathogens contaminating hospital surfaces. Methods Here, we wanted to study the impact of the Bacillus-based cleanser on the drug-resistance features of the healthcare pathogens population. In parallel, the ability of cleanser-derived Bacilli to infect hospitalized patients was also investigated. Results Collected data showed that Bacilli spores can germinate on dry inanimate surfaces, generating the bacterial vegetative forms which counteract the growth of pathogens and effectively substitute for them on treated surfaces. Strikingly, this procedure did not select resistant species, but conversely induced an evident decrease of antibiotic resistance genes in the contaminating microbial population. Also importantly, all the six HAI-positive patients hosted in the treated areas resulted negative for probiotic Bacilli, thus adding evidences to their safety-to-use. Conclusions These results indicate that this probiotic-based procedure is active not only in controlling surface microbial contamination but also in lowering drug-resistant species, suggesting that it may have relevant clinical and therapeutical implications for the management of HAIs.

Hard surface biocontrol in hospitals using microbial-based cleaning products.

Background Healthcare-Associated Infections (HAIs) are one of the most frequent complications occurring in healthcare facilities. Contaminated environmental surfaces provide an important potential source for transmission of many healthcare-associated pathogens, thus indicating the need for new and sustainable strategies. Aim This study aims to evaluate the effect of a novel cleaning procedure based on the mechanism of biocontrol, on the presence and survival of several microorganisms responsible for HAIs (i.e. coliforms, Staphyloccus aureus, Clostridium difficile, and Candida albicans) on hard surfaces in a hospital setting. Methods The effect of microbial cleaning, containing spores of food grade Bacillus subtilis, Bacillus pumilus and Bacillus megaterium, in comparison with conventional cleaning protocols, was evaluated for 24 weeks in three independent hospitals (one in Belgium and two in Italy) and approximately 20000 microbial surface samples were collected. Results Microbial cleaning, as part of the daily cleaning protocol, resulted in a reduction of HAI-related pathogens by 50 to 89%. This effect was achieved after 3–4 weeks and the reduction in the pathogen load was stable over time. Moreover, by using microbial or conventional cleaning alternatively, we found that this effect was directly related to the new procedure, as indicated by the raise in CFU/m2 when microbial cleaning was replaced by the conventional procedure. Although many questions remain regarding the actual mechanisms involved, this study demonstrates that microbial cleaning is a more effective and sustainable alternative to chemical cleaning and non-specific disinfection in healthcare facilities. Conclusions This study indicates microbial cleaning as an effective strategy in continuously lowering the number of HAI-related microorganisms on surfaces. The first indications on the actual level of HAIs in the trial hospitals monitored on a continuous basis are very promising, and may pave the way for a novel and cost-effective strategy to counteract or (bio)control healthcare-associated pathogens.

Multidimensional evaluation of performance with experimental application of balanced scorecard: a two year experience

BackgroundIn todays dynamic health-care system, organizations such as hospitals are required to improve their performance for multiple stakeholders and deliver an integrated care that means to work effectively, be innovative and organize efficiently. Achieved goals and levels of quality can be successfully measured by a multidimensional approach like Balanced Scorecard (BSC). The aim of the study was to verify the opportunity to introduce BSC framework to measure performance in St. Anna University Hospital of Ferrara, applying it to the Clinical Laboratory Operative Unit in order to compare over time performance results and achievements of assigned targets.MethodsIn the first experience with BSC we distinguished four perspectives, according to Kaplan and Norton, identified Key Performance Areas and Key Performance Indicators, set standards and weights for each objective, collected data for all indicators, recognized cause-and-effect relationships in a strategic map. One year later we proceeded with the next data collection and analysed the preservation of framework aptitude to measure Operative Unit performance. In addition, we verified the ability to underline links between strategic actions belonging to different perspectives in producing outcomes changes.ResultsThe BSC was found to be effective for underlining existing problems and identifying opportunities for improvements. The BSC also revealed the specific perspective contribution to overall performance enhancement. After time results comparison was possible depending on the selection of feasible and appropriate key performance indicators, which was occasionally limited by data collection problems.ConclusionsThe first use of BSC to compare performance at Operative Unit level, in course of time, suggested this framework can be successfully adopted for results measuring and revealing effective health factors, allowing health-care quality improvements.

Safety of probiotics used for hospital environmental sanitation.

HS-1, Old S. Anna Hospital (Ferrara), PCHS application March 16 to August 28, 2011; HS-2, S. Giorgio Hospital (Ferrara), PCHS application since November 1, 2011; HS-3, New S. Anna Hospital (Cona, Ferrara), PCHS application since January 1, 2013; HS-4, Delta Hospital (Lagosanto, Ferrara), PCHS application since June 1, 2012; HS-5, Cento Hospital (Cento, Ferrara), PCHS application since July 1, 2012; HS-6, Argenta Hospital (Argenta, Ferrara), PCHS application since July 1, 2012; HS-7, Quisisana Hospital (Ferrara), PCHS application since January 1, 2015. a A quota of these samples was simultaneously analysed also by molecular assays (qPCR). b A unique central Microbiology Laboratory (S. Anna University Hospital, Ferrara) performed the analyses by conventional microbiological assays. Sir,

Reducing healthcare-associated infections incidence by a probiotic-based sanitation system: a multicentre, prospective, intervention study

Healthcare Associated Infections (HAI) are a global concern, further threatened by the increasing drug resistance of HAI-associated pathogens. On the other hand, persistent contamination of hospital surfaces contributes to HAI transmission, and it is not efficiently controlled by conventional cleaning, which does not prevent recontamination, has a high environmental impact and can favour selection of drug-resistant microbial strains. In the search for effective approaches, an eco-sustainable probiotic-based cleaning system (Probiotic Cleaning Hygiene System, PCHS) was recently shown to stably abate surface pathogens, without selecting antibiotic-resistant species. The aim of this study was to determine whether PCHS application could impact on HAI incidence. A multicentre, pre-post interventional study was performed for 18 months in the Internal Medicine wards of six Italian public hospitals (January 1st 2016—June 30th 2017). The intervention consisted of the substitution of conventional sanitation with PCHS, maintaining unaltered any other procedure influencing HAI control. HAI incidence in the pre and post-intervention period was the main outcome measure. Surface bioburden was also analyzed in parallel. Globally, 11,842 patients and 24,875 environmental samples were surveyed. PCHS was associated with a significant decrease of HAI cumulative incidence from a global 4.8% (284 patients with HAI over 5,930 total patients) to 2.3% (128 patients with HAI over 5,531 total patients) (OR = 0.44, CI 95% 0.35–0.54) (P<0.0001). Concurrently, PCHS was associated with a stable decrease of surface pathogens, compared to conventional sanitation (mean decrease 83%, range 70–96.3%), accompanied by a concurrent up to 2 Log drop of surface microbiota drug-resistance genes (P<0.0001; Pc = 0.008). Our study provides findings which support the impact of a sanitation procedure on HAI incidence, showing that the use of a probiotic-based environmental intervention can be associated with a significant decrease of the risk to contract a HAI during hospitalization. Once confirmed in larger experiences and other target populations, this eco-sustainable approach might be considered as a part of infection control and prevention (IPC) strategies. Trial registration—ISRCTN International Clinical Trials Registry, ISRCTN58986947.

Use of terminal filters to prevent Legionnaires' disease

In developed countries, the incidence of inpatient hospital-acquired infections has been estimated to range between 5.1% and 11.6%, worsening patients’ health and leading to a number of deaths that would not have been expected on the basis of the pathologies for which they had been admitted. Water in the mains plays an important role in the onset of hospital-acquired infections, particularly given the rise in pulmonary disease due to Legionella pneumophila. Advantages of using antibacterial terminal filters at the points where such water is drawn are that application can be limited to the departments with high-risk patients, and installation and maintenance are simple and inexpensive. We assessed the efficacy of SBS water main terminal filters (Nuova S.B. System S.r.l., Paderno Dugnano, Milan, Italy; Model WF1 for washbasins and bidets and Model WF2 for showers and water-birth tubs) composed of a polypropylene prefilter (1 mm) and a double-layer polyethersulphone filtration membrane (0.2 mm). Under experimental laboratory conditions, we initially assessed the ability of these filters to retain high bioburdens (> 1 10) of Brevundimonas diminuta ATCC 19146 which, given its reduced size (0.2e0.9 mm), is indicated in the ASTM F 838-05 Guidelines as the micro-organism of choice for testing filtering membranes. Subsequently, the effectiveness of these filters as a method of prevention of legionellosis was tested for 30 days in hospital departments. For each filter analysed, one 100-mL aliquot of the suspension was drawn upstream of the filter and three 100mL aliquots of the filtered suspension were drawn downstream. From the prefilter aliquot, following dilution of 1 10 , 1-mL replicates of the suspension were used for mass seeding in a suitable agar culture medium. The postfilter aliquots were filtered through sterile membrane filters (0.20 mm) and deposited on the surfaces of a suitable agar culture medium. The number of developed colonies was counted. The filters remained able to retain the entire initial bioburden of B. diminuta for up to 42 days, and thus beyond the 31 days stated by the manufacturer. Next, the ability of the filters, installed at the terminal points along the water mains in three hospital facilities in northern Italy, to retain Legionella pneumophila was evaluated. At Facility A, 40 points along the mains were taken into account (37 washbasins and bidets, three showers), all of which were devoid of terminal filters. The number of L. pneumophila colonies was <1000 colony-forming units (CFU)/L at 20 points, between 1000 and 10,000 CFU/L at 17 points, and >10,000 (peak of 26,000 CFU/L) at three points along the mains. The most common serotype was Group 2e14 (34 cases), while Group 1 was found in five cases. Legionella was not found in any of the water samples drawn at the 26 points along the mains where filters had been installed for 30 days, including 21 showers or bidets. At Facility B, 21 terminal points without filters and 13 taps with filters were examined. Of the points without filters, the L. pneumophila count was <1000 CFU/L at 18 points and >10,000 (peak of 60,000 CFU/L) at three points. When identified, Group 1 was the main serotype, and three cases of Group 2e14 were identified. Legionella was not found at any of the points where the filters had been installed for 30 days. At Facility C, 16 terminal points without filters and 18 taps with filters were examined. At the points without filters, the L. pneumophila count was <1000 CFU/L at two points, between 1000 and 10,000 CFU/L at eight points, and >10,000 CFU/L (peak of 34,000 CFU/L) at six points. Legionella was not found at any of the points where the filters had been installed for 30 days. From the above, it is clear that SBS filters (Model WF) are an effective way to reinstate the quality of water from contaminated mains under experimental conditions.