Silvana Castaldi

Tuberculosis Outbreak in a Primary School, Milan, Italy

Investigation of an outbreak of tuberculosis (TB) in a primary school in Milan, Italy, found 15 schoolchildren had active TB disease and 173 had latent TB infection. TB was also identified in 2 homeless men near the school. Diagnostic delay, particularly in the index case-patient, contributed to the transmission of infection.

Knowledge, Attitudes, and Smoking Behaviours among Physicians Specializing in Public Health: A Multicentre Study

Background. Healthcare professionals have an important role to play both as advisers—influencing smoking cessation—and as role models. However, many of them continue to smoke. The aims of this study were to examine smoking prevalence, knowledge, attitudes, and behaviours among four cohorts physicians specializing in public health, according to the Global Health Profession Students Survey (GHPSS) approach. Materials and Methods. A multicentre cross-sectional study was carried out in 24 Italian schools of public health. The survey was conducted between January and April 2012 and it was carried out a census of students in the selected schools for each years of course (from first to fourth year of attendance), therefore among four cohorts of physicians specializing in Public Health (for a total of n. 459 medical doctors). The GHPSS questionnaires were self-administered via a special website which is created ad hoc for the survey. Logistic regression model was used to identify possible associations with tobacco smoking status. Hosmer-Lemeshow test was performed. The level of significance was P ≤ 0.05. Results. A total of 388 answered the questionnaire on the website (85%), of which 81 (20.9%) declared to be smokers, 309 (79.6%) considered health professionals as behavioural models for patients, and 375 (96.6%) affirmed that health professionals have a role in giving advice or information about smoking cessation. Although 388 (89.7%) heard about smoking related issues during undergraduate courses, only 17% received specific smoking cessation training during specialization. Conclusions. The present study highlights the importance of focusing attention on smoking cessation training, given the high prevalence of smokers among physicians specializing in public health, their key role both as advisers and behavioural models, and the limited tobacco training offered in public health schools.

Epidemiology of Clostridium difficile-associated disease in internal medicine wards in northern Italy

Clostridium difficile-associated disease (CDAD) is a growing health care problem. Elderly patients with multiple comorbidities and repeated hospitalization are at high risk for developing the disease. Few data are available on epidemiology of CDAD in Italy and no studies have focused on CDAD burden in internal medicine wards. We retrospectively analysed all CDAD cases in four internal medicine wards of a city hospital in northern Italy and reviewed the medical records of patients who developed CDAD during hospitalization. We identified 146 newly acquired cases, yielding a cumulative incidence of 2.56 per 100 hospitalizations and an incidence rate of 23.3 per 10,000 patient-days. Main risk factors were advanced age and length of hospitalization. A high proportion of CDAD patients had several comorbidities and had been treated with more than one antibiotic. The incidence is among the highest previously reported, this may be due to the characteristics of patients admitted to internal medicine wards and to the wards per se. We conclude that efforts are needed to reduce CDAD’s burden in this setting, paying attention to logistics, patients care and antibiotic use.

Control of scabies outbreaks in an Italian hospital: An information-centered management strategy

BACKGROUND Scabies is a dermatologic infestation caused by Sarcoptes scabiei. In industrialized countries, hospitals and other health structures can sometimes be hit. The optimal management of scabies outbreaks still has to be established, mass prophylaxis being one possible option. METHODS To identify the optimal approach to containing this re-emerging disease, a local health authority in Lombardy, Northern Italy, carried out an epidemiologic study into 2 scabies epidemics that took place from September to December 2012 in a 600-bed hospital with 26,000 admissions a year. RESULTS Over a 3-month period, there were 12 cases of scabies on 4 wards; 43 contacts received prophylaxis. When the first cases were identified, an information campaign involving all hospital personnel was immediately set up. Regular staff meetings were organized, and information leaflets were distributed to patients. Family doctors of discharged patients were informed of the outbreak. CONCLUSION A management model based on an information-centered strategy was used in place of mass prophylaxis to deal with scabies epidemics. The success of this approach was confirmed by the managers of the hospital involved (reduced expenditure for prophylactic drugs) and by hospital staff who did not have to deal with potential drug adverse effects.

Payment for performance (P4P): any future in Italy?

BackgroundPay for Performance (P4P) programs, based on provision of financial incentives for service quality, have been widely adopted to enhance quality of care and to promote a more efficient use of health care resources whilst improving patient outcomes. In Italy, as in other countries, the growing concern over the quality of health services provided and the scarcity of resources would make P4P programs a useful means of improving their performance. The aim of this paper is to evaluate whether it is possible to implement P4P programs in the Lombardy Region, in Italy, based on the existing data set.MethodsThirteen quality measures were identified regarding four clinical conditions (acute myocardial infarction (AMI), heart failure (HF), ischemic stroke and hip and knee replacement) on the basis of an international literature review. Data was collected using the database of three institutions, which included hospital discharge records (Scheda di Dimissione ospedaliera-SDO-) and letters of discharge. The study population was identified using both the Principal ICD-9-CM diagnosis codes and the discharge date. A Statistical Analysis System (SAS) program was used for the text analysis.ResultsIt was possible to calculate almost all the parameters pertaining to the three hospitals as all the data required was available with the exception of inpatient mortality in two hospitals and smoking cessation advice/counseling in one hospital.ConclusionsOn the ground of this analysis, we believe that it is possible to implement a P4P program in the Lombardy Region. However, for this program to be initiated, all necessary data must be available in electronic format and uniformly collected. Moreover, several other factors must be assessed: which clinical conditions should be included, the threshold for each quality parameter, the amount of financial incentives offered and how they will be provided.

Risk factors and epidemiology of Acinetobacter baumannii infections in a university hospital in Northern Italy: A case-control study

BACKGROUND Acinetobacter baumannii has emerged as a major cause of outbreaks of hospital-associated infections with increased morbidity and mortality among those affected. METHODS We performed a 1:1 matched case-control study involving 68 cases in a teaching hospital in Northern Italy. Risk factors included general health conditions, comorbidities, diagnostic and therapeutic procedures, and antibiotic therapies. A multiple correspondence analysis (MCA) was performed to highlight possible association patterns among risk factors. After this, a conditional logistic regression model was applied. RESULTS The combined results of the MCA and univariate regression models suggest that invasive procedures performed before intensive care unit admission, in particular bronchoscopy (odds ratio, 48.06) and oxygen therapy (odds ratio, 2.11), are associated with development of an infection. Malnutrition or obesity, lack of self-sufficiency, and severe liver diseases also proved to be significantly associated with infection. When analyzing antibiotic therapies, both the number of molecules administered and duration of therapy were significantly associated. CONCLUSIONS Early recognition of patients at high risk, environmental hygiene control measures, appropriate antibiotic prescriptions, especially regarding carbapenems, and high-quality training of health care workers in all hospital departments are all key aspects for prevention and control of Acinetobacter infection. Further studies are needed to investigate the role of antibiotics on microbial competition dynamics in relation to multidrug-resistant outbreaks.

Isolation and Characterization of a New Clostridium difficile Ribotype During a Prospective Study in a Hospital in Italy

Clostridium difficile is one of the most important agent of hospital infection with increasing rate of incidence [4]. During a prospective study conducted between 15 March 2011 and 15 March 2012, 142 C. difficile associated disease (CDAD) cases from four internal medicine wards of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milano, were analyzed. The CDAD was confirmed by laboratory tests. After alcolic shock, the isolates were recovered by inoculating a loopful of diarrheic stool samples onto C. difficile agar (CDA; Oxoid). They were identified with the rapid ID 32A system (bioMerieux) and toxins detected by the enzyme-linked immunosorbent assay (C. diff Quik Chek Complete, Alere); toxigenic culture was also performed using the same enzyme-linked immunosorbent assay. The isolates were typed by ribotyping [2]. The set of primer used were 16S and 23S, corresponding to bases 1482–1501 of the 16S ribosomal RNA gene of C. difficile (EMBL accession number AJI32322) and bases 1-24 of the 23S ribosomal RNA gene of C. difficile (EMBL accession number X65602). DNA was extracted from a single C. difficile colony by the use of a Chelex resin-based commercial kit (InstaGene Matrix; Bio-Rad) as recommended by the manufacturer. Amplification reactions were performed in a 50 ll volume containing 1x reaction buffer, 1.5 mM MgCl2, 200 lM of each dNTP (Sigma), 50 pmol of each primer, 1.25 U of Taq polymerase (Sigma),and 5 ll of DNA extract (or distilled water as negative control). After a denaturation of 5 min at 94 C, the DNA was amplified by 35 cycles of 1 min at 94 C, 1 min at 57 C, and 30 s at 72 C. At the end, samples were held at 72 C for 7 min. Amplification products were electrophoresed in a 3 % agarose (SeaKem LE; Lonza) and visualized under UV light following ethidium bromide staining. After electrophoresis, the clustering of banding patterns was checked visually. Each unique pattern was assigned its own ribotype. A sample of each strain with different ribotypes, was sent to Istituto Superiore di Sanità (ISS), in Rome, in order to code them by matching against reference strains present in the only data bank available on line (https:// webribo.ages.at) after capillary-sequencer-based PCR-ribotyping [6]. It was found that one strain, indicated as Pro7388 was not present. Herein, we report only some data about this new strain. The strain was analyzed by PCR for the detection of the tcdA, tcdB, and cdtB genes with oligonucleotides and conditions reported elsewhere [7, 8] using 5 ll of crude DNA extract. These genes code for toxin A, toxin B, and the binding component of binary toxin, respectively. The toxin A and B genes are part of the pathogenicity locus (PaLoc), a 19.6-kb genetic locus F. Sisto (&) M. M. Scaltrito Department of Biomedical, Surgical and Dental Sciences, University of Milan, Via Pascal 36, 20133 Milan, Italy e-mail: francesca.sisto@unimi.it

Vaccination recommendations for patients with neuromuscular disease

Neuromuscular diseases (NMDs) encompass a broad spectrum of conditions. Because infections may be relevant to the final prognosis of most NMDs, vaccination appears to be the simplest and most effective solution for protecting NMD patients from vaccine-preventable infections. However, very few studies have evaluated the immunogenicity, safety, tolerability, and efficacy of different vaccines in NMD patients; therefore, detailed vaccination recommendations for NMD patients are not available. Here, we present vaccination recommendations from a group of Italian Scientific Societies for optimal disease prevention in NMD patients that maintain high safety levels. We found that NMD patients can be classified into two groups according to immune function: patients with normal immunity and patients who are immunocompromised, including those who intermittently or continuously take immunosuppressive therapy. Patients with normal immunity and do not take immunosuppressive therapy can be vaccinated as healthy subjects. In contrast, immunocompromised patients, including those who take immunosuppressive therapy, should receive all inactivated vaccines as well as influenza and pneumococcal vaccines; these patients should not be administered live attenuated vaccines. In all cases, the efficacy and long-term persistence of immunity from vaccination in NMD patients can be lower than in normal subjects. Household contacts of immunocompromised NMD patients should also be vaccinated appropriately.

Antibiotic resistance: Italian awareness survey 2016

Antimicrobial resistance has become a public health priority worldwide. The WHO conducted a survey concerning the personal use of antibiotics, knowledge of appropriate use and awareness of the issue of resistance. A similar survey was conducted in Italy involving 666 young university students and 131 seniors attending courses of the University of the third age. Antibiotics seem to be taken with moderate frequency and appropriately: 30% of respondents took them in the past six months and 94% took these drugs only prescribed by a doctor, in the correct dose and for the proper duration. Notable confusion concerning the conditions treatable with antibiotics was detected (only 30% indicated gonorrhea, and 30-40% believed that antibiotics should be employed for fever, cold, and flu), while 94% of participants seemed aware of the problem of antibiotic resistance. Most of the respondents identified the behaviors that can reduce the phenomenon of resistance (regular handwashing and use of antibiotics only when prescribed and needed). The results of our survey, that involved people of high level of instruction and living in urban areas of northern regions, cannot be extended to all the Italian population. However, they provide valid elements to promote initiatives aimed to a more aware use of antibiotics.

Clostridium difficile infection epidemiology and management: Comparison of results of a prospective study with a retrospective one in a reference teaching and research hospital in Northern Italy

BACKGROUND Clostridium difficile-associated disease (CDAD) is the most common infectious antibiotic-associated diarrhea and is a growing health care problem. Prevention of Clostridium difficile infection focuses on clinical and epidemiologic infection control measures. METHODS Between 2008 and 2009, we conducted a retrospective study that showed an incidence of CDAD among the highest reported in the literature. Subsequently, we developed a preventive protocol that was adopted in our hospital in 2010. We then conducted a prospective study to investigate prevalence, incidence, and mortality of CDAD and to compare the results with those of the retrospective study, evaluating adherence to preventive measures and their efficacy. RESULTS In both studies, prevalence and incidence significantly increased in older patients. Crude prevalence was similar in the 2 studies. The incidence rate increased by 36%, with a significant increase only in the C and D wards. In-hospital mortality rose in both prevalent and incident cases. Regarding adhesion to hospital protocol, 77% of prevalent cases were treated with the required procedure. The highest percentage of isolated patients was achieved in C and D wards. In these wards we detected lower training hours per nurse. However, in 2013, we observed a significant decrease in incidence of CDAD and found a hospital prevalence of 0.33%. CONCLUSIONS Health care personnel education could be more important than the possibility of isolating infected patients in single rooms.