Silvia Pittalis

Leishmania infantum leishmaniasis in corticosteroid – treated patients

BackgroundThe number of leishmaniasis cases associated with immunosuppression has increased regularly over the past 20 years. Immunosuppression related to HIV infection, immunosuppressive treatment, organ transplantation, and neoplastic diseases increases the risk for Leishmania-infected people to develop visceral illness.Case presentationThree cases of Leishmania infantum leishmaniasis in corticosteroid (CS)-treated patients are reported: an isolated lingual leishmaniasis in a farmer treated with CS for asthma, a severe visceral leishmaniasis associated with cutaneous lesions in a woman with myasthenia gravis, and a visceral involvement after cutaneous leishmaniasis in a man receiving CS.ConclusionPhysicians should recognise CS-treated patients as a population likely to be immunesuppressed. In immunodeficiency conditions, unusual forms of leishmaniasis can develop and foster the risk of a diagnostic delay and of poor response to therapy.

Imported malaria at Italy's National Institute for Infectious Diseases Lazzaro Spallanzani, 1984-2003.

Imported malaria is the most common cause of fatal infections in returning travellers. The increased amount of both tourist movement and migration has resulted in a growing number of people at risk of infection. In the present study, 507 malaria patients admitted to Italy’s National Institute for Infectious Diseases in Rome between January 1984 and December 2003 were studied. Overall, 445 cases, or 87.7%, were acquired in Africa, of which 55% were acquired in five sub-Saharan countries. Plasmodium falciparum accounted for 393 (77.5%) of the imported cases. Patients consisted of short-term travellers (n = 213, 42%), long-term visitors (n = 134, 26.4%), and immigrants from endemic areas (n = 137, 27%). Malaria chemoprophylaxis was completed in less than one-quarter of all patients, with immigrants having the lowest rate of completion: only 3.6% of immigrants fully completed chemoprophylaxis compared to 31% of short-term travellers and 29.1% of long-term visitors (p < 0.001). Upon multivariate analysis, the lack of chemoprophylaxis was independently associated with the occurrence of severe malaria (p = 0.009). Severe malaria was reported in 59 (11.6%) individuals: all 11 deaths due to severe P. falciparum infection occurred in patients from sub-Saharan countries, two of whom were immigrants from countries where malaria is endemic. Malaria poses a serious health threat to individuals visiting endemic areas. Ensuring the correct chemoprophylaxis for all travellers, including immigrants from endemic areas, and providing prompt access to healthcare providers for unhealthy returning travellers are major points still to be addressed in Italy.

The added value of long-lasting preparedness for the management of a patient with Ebola

In the interesting description of his experience in Sierra Leone, Satolli refers to an Italian physician from the Emergency team who developed the infection inAfrica andwas urgently airlifted by the Italian Air Force [1]. The patient, a 50-year old male, was admitted to the L. Spallanzani National Institute for Infectious Diseases (INMI) on November 25, 2014. During his stay which lasted 5 weeks, he received different experimental treatments and needed intensive care support for 7 days. The patient recovered fully and was discharged on January 2, 2015 [2]. No secondary cases occurred. Treating an Ebola patient in an effective and safe manner is a challenge, and requires a strong background in preparedness, including logistics, procedures and skills, all of which are available at INMI, thanks to a 20-year long preparedness activity for rapid diagnosis and appropriate caring of patients with highly infectious diseases (HIDs). Over the years, INMI developed a hospital preparedness model, continuously refined and employed during all recent events involving emerging or re-emerging HIDs [3,4]. In 1995 INMI was identified by the Italian Ministry of Health as the national reference centre for the management of patients affected by naturally occurring HIDs, such as viral hemorrhagic fevers. A few years later, the Institute was made the national centre for cases of deliberate release of biological agents (in late 2001) and for severe acute respiratory syndrome (SARS) in 2003. INMI also became a WHO Collaborating Centre for clinical care, diagnosis, response and training on HIDs. Finally, in 2009 and in 2014 it was confirmed by the Ministry of Health as the national reference centre for patients with Ebola Virus Disease during the current West African outbreak. Our hospital preparednessmodel is based on the following independent but mutually beneficial pillars. Specific vehicles for transport: a long-lasting collaboration with the Italian Air Force, already employed in the past for the transport of other patients with suspected HIDs, was used for the bio-containment transport from Sierra Leone, using a dedicated aircraft with an air transport isolator (ATI). On the ground, the patient was transported by using a special ambulance, fitted with double chambers, isolated driving cabins, negative pressure and HEPA filters for expelled air, and was placed inside a stretcher transport isolator (STI) also fitted with HEPA filters. The patient was moved from the ATI to the STI in a way that preserved the biocontainment condition, following procedures already established and exercised in the past with the Italian Air Force. Logistics for effective isolation: having arrived at INMI, the patientwas admitted into a high isolation unit (HIU) placed inside a dedicatedward and later transferred to another special HIUwith Intensive Care capabilities (HI-ICU, see figure) for seven days, when his condition worsened. Both units are sealed and equipped with anteroom, negative pressure, HEPA filtration of exhausting air, dedicated pathway for patient

Appropriateness of Surgical Antimicrobial Prophylaxis in the Latium Region of Italy, 2008: A Multicenter Study

BACKGROUND There is still wide variability in surgical antimicrobial prophylaxis (SAP) practice by different surgical teams and specialties, with potential impact on adverse events and the emergence of antibiotic resistance. METHODS We assessed SAP appropriateness in a regional prospective multicenter study on the basis of the agreement of the Surgical Care Improvement Project indicators (SCIP-Inf) with Italian guidelines (GL). RESULTS Prophylaxis was administered in 2,664 of 2,835 procedures (94%): In 2,346 of 2,468 (95%) as indicated and in 318 of 367 (86.6%) in which they were not indicated. The SCIP-Inf1 (timing), SCIP-Inf2 (antibiotic choice), and SCIP-Inf3 (duration) were in agreement with GL in 1,172 (50%), 1,983 (84.5%), and 1,121 (48%) of 2,346 procedures, respectively. CONCLUSIONS These results suggest the need for implementation of an antimicrobial stewardship program in this surgical setting.

QTc interval prolongation during favipiravir therapy in an Ebolavirus-infected patient

Introduction Life-threatening arrhytmias, including torsades de pointes and ventricular fibrillation, may be induced by corrected QT (QTc) interval prolongation. Several antimicrobial drugs have been associated with QTc interval prolongation [1,2]. Favipiravir is an inhibitor of the RNA-dependent RNA polymerase of many RNA viruses, including influenza viruses, arenaviruses, phleboviruses, hantaviruses, flaviviruses, enteroviruses, and noroviruses [3]. Favipiravir has also been used in the recent epidemic of Ebolavirus (EBOV) in West Africa [4]. To date, no significant effects of favipiravir on the QT/QTc interval have been detected [5]. We report a case of QTc interval prolongation during favipiravir therapy in an EBOV-infected patient treated at our institution.

Disinfection of personal protective equipment for management of Ebola patients.

Bessesen et al highlight the potential utility of reusable elastomeric face masks to bypass the risk of N95 respirator shortages during a respiratory illness pandemic and stress the importance of efficacious disinfection to reuse facial protective equipment safely.1 We would like to take the opportunity to underline the need that awareness on personal protective equipment (PPE) stocks is included in any pandemic preparedness plan. The demand for PPE must be established on the basis of the health care facility’s role, defined by public health authorities to create a coordinated network approach.2 Moreover, we agree that standard operating procedures (SOPs) should be developed to be used by health care workers (HCWs) to disinfect reusable PPE. In our recent experience with 2 Ebola cases at National Institute for Infectious Diseases “Lazzaro Spallanzani” in Rome, Italy, we followed a written protocol for management of patients with Ebola virus disease (EVD), developed and updated since the beginning of the current West Africa outbreak.3 A voluntary clinical task force of infectious diseases specialists, intensivists, and nurses underwent rigorous training to became practiced and competent with the protocol and PPE donningdoffing discipline. PPE to be used was carefully selected according to international updated technical recommendations and lessons learned from previous experiences in endemic areas and western countries. The following 3 PPE options were selected: gogglesbased option (goggles, splash-proof fit-tested FFP3-N95 respirator, disposable hood [covering head, neck, and shoulders] with integrated surgical type IIR face mask (high filtration efficiency and spash resistance), double or triple layer of gloves, rubber boots, full body head-to-foot impermeable biohazard suit, plastic apron); face maskebased option (elastomeric face mask with disposable filters rather than goggles-N95 respirator-hood); and powered airpurifying respirator (PAPR)ebased option (with a PAPR [composed of hood, motor unit, waist belt, and breathing tube to be

Socioeconomic status and biomedical risk factors in migrants and native tuberculosis patients in Italy.

Action on social determinants is a main component of the World Health Organization End Tuberculosis (TB) Strategy. The aim of the study was to collect information on socioeconomic characteristics and biomedical risk factors in migrant TB patients in Italy and compare it with data collected among Italian TB patients. A cross-sectional study was conducted among TB patients aged ≥18 years over a 12-months enrolment period in 12 major Italian hospitals. Information on education, employment, housing and income was collected, and European Union Statistics on Income and Living Conditions index was used to assess material deprivation. Among migrants, we also analyzed factors associated with severe material deprivation. Migrants were compared with younger (18–64 years) and older (65+ years) Italians patients. Out of 755 patients enrolled (with a median age of 42 years, interquartile range: 31–53), 65% were migrants. Pulmonary, microbiologically confirmed, and new cases were 80%, 73%, and 87% respectively. Prevalence of co-morbidities (i.e. diabetes, chronic kidney disease, neoplastic diseases and use of immunosuppressive drugs) was lower among migrants compared to Italian TB patients, while indicators of socioeconomic status, income and housing conditions were worst in migrants. Forty-six percent of migrants were severely deprived vs. 9% of Italians (p<0.0001, 11.3% and 5.5% among younger and older Italians, respectively). Among migrants, being male, older, irregular, unemployed, with a shorter time spent in Italy, a lower education level, and without a co-morbidity diagnosis were factors associated with severe material deprivation at multi-variable logistic regression. Moreover, socioeconomic indicators for Italian patients did not differ from those reported for the general Italian population, while migrant TB patients seem to have a higher prevalence of severe material deprivation than other migrants residing in Italy. Intervention to address the needs of this population are urgent.

Noninvasive positive-pressure ventilation

In their in-depth review of noninvasive positive-pressure ventilation in acute respiratory failure,[1][1] Oscar Penuelas and colleagues did not discuss the use of this treatment in patients with infections that are transmitted through aerosols. The efficacy of noninvasive positive-pressure