Impact of COVID-19 on healthcare associated infections and antimicrobial use in Italy, 2022

INTRODUCTION

We aimed to assess the impact of COVID-19 on healthcare associated infection (HAI) transmission and antimicrobial use (AMU) prevalence during the later stages of the pandemic.

METHODS

A point prevalence survey (PPS) was conducted among 325 acute-care hospitals of 19/21 regions of Italy, during November 2022. Non COVID-19 patients were matched to COVID-19 patients according to age, sex, and severity of underlying conditions. HAI and AMU prevalence were calculated as the percentage of patients with at least one HAI or prescribed at least one antimicrobial over all included patients, respectively.

RESULTS

In total, 60403 patients were included, 1897 (3.14%) of which were classified as COVID-19 patients. Crude HAI prevalence was significantly higher among COVID-19 patients compared to non COVID-19 patients (9.54% vs. 8.01%, prevalence rate ratio, PRR 1.19, 95% confidence interval, CI 1.04-1.38, p<0.05), and remained higher in the matched sample, however statistical significance was not maintained: odds ratio (OR) 1.25 (95% CI 0.99 - 1.59, p 0.067). AMU prevalence was significantly higher among COVID-19 patients prior to matching (46.39% vs. 41.52%, PRR 1.21, 95% CI 1.11-1.32, p<0.001), and significantly lower after matching: OR 0.77 (95% CI 0.66-0.89, p < 0.001).

CONCLUSIONS

COVID-19 patients could be at higher HAI risk due to underlying clinical conditions and to the intensity of healthcare needs. Further efforts should be dedicated to antimicrobial stewardship among COVID-19 patients.

Level of implementation of multimodal strategies for infection prevention and control interventions and prevalence of healthcare-associated infections in Northern Italy

BACKGROUND

In November 2022, Italy participated in the third edition of the European Centre for disease prevention and control (ECDC) point prevalence survey (PPS) of healthcare-associated infections (HAIs) in acute-care hospitals. A questionnaire based on the WHO infection prevention and control assessment framework (IPCAF) was included, which aims to investigate multimodal strategies for the implementation of IPC interventions.

METHODS

A PPS was conducted using the ECDC PPS protocol version 6.0. The Regional health authority of the region of Piedmont, in north-western Italy, chose to enlist all public acute-care hospitals. Data were collected within one day per each ward, within 3 weeks in each hospital, at hospital, ward and patient level. A score between 0-1 or 0-2 was assigned to each of the 9 items in the IPCAF questionnaire, with 14 points representing the best possible score. HAI prevalence was calculated at the hospital-level as the percentage of patients with at least one HAI over all included patients. Relations between HAI prevalence, IPCAF score, and other hospital-level variables were assessed using Spearman's Rho coefficient.

RESULTS

In total, 42 acute-care hospitals of the region of Piedmont were involved, with a total of 6865 included patients. All participant hospitals reported they employed multimodal strategies to implement IPC interventions. The median IPCAF overall score was 11/14 (interquartile range, IQR: 9.25-12). The multimodal strategy with the highest level of adherence was education and training, followed by communication and reminders. Strategies with the lowest level of adherence were safety climate and culture of change, and system change. Overall HAI prevalence was 8.06%. A weak to moderate inverse relation was found between IPCAF score and HAI prevalence (Spearman's Rho -0.340, p 0.034). No other significant correlation was found.

CONCLUSIONS

This study found a high self-reported overall level of implementation of multimodal strategies for IPC in the region. Results of this study suggest the relevance of the multimodal approach and the validity of the IPCAF score in measuring IPC programs, in terms of effectiveness of preventing HAI transmission.

Validation of the prevalence to incidence conversion method for healthcare associated infections in long-term care facilities

INTRODUCTION

Residents of long-term care facilities (LTCFs) are a population at high risk of developing severe healthcare associated infections (HAIs). In the assessment of HAIs in acute-care hospitals, selection bias can occur due to cases being over-represented: patients developing HAIs usually have longer lengths of stays compared to controls, and therefore have an increased probability of being sampled in PPS, leading to an overestimation of HAI prevalence. Our hypothesis was that in LTCFs, the opposite may occur: residents developing HAIs either may have a greater chance of being transferred to acute-care facilities or of dying, and therefore could be under-represented in PPS, leading to an underestimation of HAI prevalence. Our aim was to test this hypothesis by comparing HAI rates obtained through longitudinal and cross-sectional studies.

METHODS

Results from two studies conducted simultaneously in four LTCFs in Italy were compared: a longitudinal study promoted by the European Centre for Disease Prevention and Control (ECDC, HALT4 longitudinal study, H4LS), and a PPS. Prevalence was estimated from the PPS and converted into incidence per year using an adapted version of the Rhame and Sudderth formula proposed by the ECDC. Differences between incidence rates calculated from the PPS results and obtained from H4LS were investigated using the Byar method for rate ratio (RR).

RESULTS

On the day of the PPS, HAI prevalence was 1.47% (95% confidence interval, CI 0.38-3.97), whereas the H4LS incidence rate was 3.53 per 1000 patient-days (PDs, 95% CI 2.99-4.08). Conversion of prevalence rates obtained through the PPS into incidence using the ECDC formula resulted in a rate of 0.86 per 1000 PDs (95% CI 0-2.68). Comparing the two rates, a RR of 0.24 (95% CI 0.03-2.03, p 0.1649) was found.

CONCLUSIONS

This study did not find significant differences between HAI incidence estimates obtained from a longitudinal study and through conversion from PPS data. Results of this study support the validity of the ECDC method.

Hip prosthesis and colon surgery, a decade of surveillance on surgical site infections in Italy, a prospective cohort study: rates, trends, and disease burden in DALYs

BACKGROUND

Surveillance programs are a key element of interventions aiming to reduce rates of surgical site infections (SSIs). The aim of this study was to evaluate rates and trends of SSIs following hip arthroplasty and colon surgery procedures in Piedmont, a region in North-western Italy, from 2010 to 2019. Further, we aimed to assess the burden of SSIs in terms of Disability-Adjusted Life-Years (DALYs).

METHODS

A prospective cohort study was conducted among 42 hospitals participating in the surveillance system. Procedure-specific SSI rates were calculated and the 2010 - 2019 trend was evaluated using Spearman's Rho test. Patients were stratified according to age, sex and infection risk index according to life expectancy in order to calculate DALYs, using a modified version of the ECDC's BCoDE toolkit: disease models for both procedure types were adapted to incorporate long-term disability associated with SSIs.

RESULTS

Overall, 20,356 hip arthroplasty and 11,011 colon surgery procedures were monitored over 10 years and were included in our analyses. Hip arthroplasty and colon surgery cumulative SSIs rates were 1.5% and 8% respectively. Using the Spearman's Rho test, we evaluated a significant downward trend from 2010 to 2019 for colon surgery interventions (Rs - 0.7, p < 0.05), while there was no difference for hip arthroplasty. (Rs - 0.04, p > 0.05). Regarding disease burden, a total of 955.3 (95%CI 837.7-1102.98) and 208.65 (95%CI 180.87-240.90) DALYs were calculated for SSIs following hip arthroplasty, whilst 76.58 (95%CI 67.15-90.71) and 38.62 (95% CI 33.09-45.36) DALYs for SSIs in colon surgery, in 2010 and 2019, respectively.

CONCLUSIONS

The significant decrease both in terms of incidence and DALYs found in this study for colon surgery and the stability for hip arthroplasty support the role of surveillance networks in improving quality of care. Despite the smaller SSI rate, the burden associated with SSIs following hip arthroplasty was higher, which is important to consider in light of the aging population in Italy.

Evaluating the Trend of VRE carriages in Health Facilities: A Retrospective Study from 2019-2022

Background

Healthcare-associated infections (HAIs) and multidrug resistance (MDR) are a growing public health threat and pose a risk to patient safety in healthcare facilities. Vancomycin-resistant Enterococci (VRE) are responsible for nosocomial infections and have intrinsic and acquired resistance to many antibiotics, including glycopeptides. VRE carriage can remain undetected, increasing the risk of contact transmission. Identifying colonized patients is crucial for the implementation of preventive measures.

Aims

The aims of this study were to evaluate the trend of VRE carriage based on rectal swab results between 2019 and February 2022 in a large Italian trust and the percentage of patients with VRE colonization at the time of hospitalization.

Methods

This was a retrospective observational study based on results of rectal swabs performed for screening on admission between January 2019 and February 2022 in four hospitals part of a single trust in Turin, North-Western Italy. The study collected data on the date of specimen collection, type of specimen, isolated pathogen and the date of hospital admission. Descriptive analysis of data was performed, and duplicate samples were not considered.

Results

From January 2019 to February 2022 we collected 5025 rectal swabs performed in hospitals of the trust, of which 3037 were performed in 2019 (60%), 741 in 2020 (15%), 611 in 2021 (12%) and 636 in the first two months of 2022 (13%). VRE positivity was found in 162 (3%) rectal swabs, of which 2 cases in both 2019 (0.1%) and 2020 (0.3%), 95 in 2021 (15.5%) and 63 in the first two months of 2022 (9.9%). Furthermore, 52% (84/162) of positive rectal swabs were performed at admission, whereas the remaining 48% (78/162) of positive rectal swabs were performed after 48h.

Conclusions

This study found an increasing trend of VRE carriage in the study population during the SARS-CoV-2 pandemic, highlighting the importance of screening patients for VRE carriage to prevent worsening clinical conditions, environmental contamination, and prolonged hospitalization.

Implementation of a centralized, web-based surveillance for healthcare associated infections among residents of long-term care facilities in Italy

Objective

The Italian National Action Plan to contrast AMR identified among its objectives the development and implementation of a national Healthcare-Associated Infection (HAI) surveillance system based on European Centre for Disease Prevention and Control (ECDC) indications, through point prevalence surveys (PPS) of HAIs and antibiotic use in acute-care hospitals and long-term care facilities (LTCFs). We aimed to assess feasibility and appropriateness of proposed tools for a national surveillance system of HAIs and antibiotic use in LTCFs.

Study design

Point prevalence survey.

Methods

A pilot PPS was conducted between May-June 2022, among 15 LTCFs of 7 Italian regions. Data were collected in a single day in each LTCF, at the LTCF, ward, and resident levels, using a web-based data collection tool developed ad hoc. Data collector teams of each facility were invited to complete a questionnaire investigating opinions on the proposed tools.

Results

Among 1025 included residents, the prevalence of residents with at least one HAI was 2.5% (95% CI 1.7%-3.7%) considering all HAIs and 2.2% (95% CI 1.3%-3%) without considering SARS-CoV-2 infections. The prevalence of antimicrobial use was 3% (95% CI 0.2%-4.3%). Overall, most respondents were satisfied with the web-based software, training and protocol, even though some difficulties were reported.

Conclusions

A national surveillance network was established, which will facilitate future surveillance efforts. Further studies are necessary to evaluate the impact of the pandemic on HAI transmission and antibiotic use in LTCFs.

Mortality and Case Fatality Rates Associated With Surgical Site Infections: A Retrospective Surveillance Study

Background: Surgical site infections (SSIs) have been associated with increases in terms of costs, hospital stay, morbidity, and mortality. We aimed to assess trends in SSIs monitored through 10 years of surveillance activities in our region, and to describe mortality attributable to SSIs in the two most frequently monitored surgical procedures: colorectal surgery and hip arthroplasty. Methods: A retrospective cohort study was conducted among the 42 hospitals participating in the surveillance network of our region in northern Italy. All colorectal and hip arthroplasty procedures performed between January 1st, 2010, and December 31st, 2019, and monitored through the surveillance system were included in the study. Surgical site infection rates, overall mortality, case fatality rates (CFR), and mortality attributable to SSIs were evaluated overall and by year of participation in the surveillance program. Results: In total, 11,417 colon surgery and 20,804 hip arthroplasty procedures were included. Among colon surgery procedures, SSI rates decreased from 9.21% in 2010 to 5.7% in 2019. A significant decreasing trend was found for overall mortality (p = 0.008), which progressively decreased from 4.96% in 2010 to 2.96% in 2019. Among hip arthroplasty procedures, no significant trend emerged for SSI and mortality rates. Considering the 10-year period, the CFR was 6.62% and 3.7% for SSIs after colon surgery and hip arthroplasty procedures, respectively. Conclusions: The impact of SSIs on the clinical outcomes of patients undergoing surgery highlights the importance of SSI surveillance.

Editorial for the Special Issue "Antibiotic Prescribing and Antimicrobial Resistance Patterns in Pediatric Patients"

Antibiotic overuse is among the most important factors contributing to the growing problem of antimicrobial resistance (AMR) [...].

Cost-Effectiveness of Short Course of Ceftazidime/Avibactam for K. pneumoniae-KPC Bloodstream Infections in Italy

BACKGROUND

Evidence has shown that short courses of antibiotic therapy are at least as effective as long courses with better clinical outcomes. CAZ/AVI has demonstrated its clinical efficacy in treating K. pneumoniae-KPC infections.

METHODS

We conducted an analysis based on the real-life data of our ten years retrospective cohort to assess the cost-effectiveness and cost-utility of a short course of CAZ/AVI plus source control compared to a long course plus source control. A Markov model was structured. Patient transition between health states was modeled, each transition has a probability, and each state has a cost and a utility. Incremental cost-effectiveness ratios (ICERs) were obtained by dividing the difference in costs by the difference in utilities between the two courses. Input parameter uncertainty was investigated through sensitivity analysis. We launched 1000 Monte Carlo simulations by iteratively perturbing variables within estimated variation ranges, obtaining an ICER result for each simulation.

RESULTS

In the first model (old appropriate treatment), a short course of treatment was associated with reduced costs per patient per year of €4818.60 and reduced effects (0.10 QALYs), compared to a long course. In the CAZ/AVI model, the short course was associated with increased costs of €1297.9 and with increased effects (0.04 QALYs), resulting in an ICER of €32,317.82 per QALY gained, below the WTP threshold of €40,000.

CONCLUSIONS

Our findings highlight additional evidence regarding the cost-effectiveness of CAZ/AVI for policy-makers. We outline that CAZ/AVI could be cost-effective compared to old appropriate antibiotic therapies for KPC-Kp BSI.

Hand Hygiene and Antimicrobial Resistance in the COVID-19 Era: An Observational Study

Hand hygiene (HH) is one of the most important infection prevention and control strategies at the hospital level. The aim of this study was to evaluate the potential COVID-19 pandemic impact on HH practices and rate of healthcare-associated infections. Data on alcohol-based handrub consumption (AHC) and antimicrobial resistance across 27 Italian hospitals over the period 2017–2021 were considered. Data on Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteria (CRE) were extracted from the antimicrobial resistance regional surveillance system. A significant increase was highlighted, with a peak in 2020 and a partial fall in 2021 for AHC (p < 0.001). The decrease in MRSA rates in 2021 compared to 2017–2019 was significant (p = 0.013). A significant Spearman’s correlation between AHC and CRE rates was found (Spearman’s ρ −0.646, p = 0.032). This study supports the importance of AHC monitoring and showed that improving AHC was an attainable goal in the COVID-19 era. However, other strategies are needed to maintain the high levels of AHC attained during the pandemic, in order to avoid a progressive drop that has already begun in 2021. Furthermore, our results support the inverse relationship between AHC and infection rates and antimicrobial-resistant bacteria.

Hand hygiene monitoring: Comparison between app and paper forms for direct observation

Healthcare-associated infections (HAIs) are a global public health threat. Italy is one of the countries with the highest prevalence of HAI. Hand hygiene (HH) is a pillar of infection prevention and control. Monitoring HH is necessary to improve HH compliance, and direct observation is considered the gold standard. Transcription and analysis of data collected during direct observation of HH compliance with the WHO paper form are time-consuming. We collected, during a 9-day observation period, HH opportunities and compliance both with a smartphone application (SpeedyAudit) and with the WHO paper form. Then, we investigated the difference in the required time for data transcription and analysis between the WHO paper form and the use of the app. The difference in the required time for data transcription and analysis was significant with a mean time of 2 s using the app and about 14-54 min/day using paper form (p = .004) while no significant difference was found in measured compliance rates between the two data collecting methods. HH monitoring with an app is time-saving, and the app we used was easy to use.

Antibody responses to BNT162b2 SARS-CoV-2 mRNA vaccine among healthcare workers and residents of long-term care facilities: A cohort study in Northern Italy

Background and Aims

Long-term care facilities (LTCFs) have been severely impacted by COVID-19, with a disproportionate amount of SARS-CoV-2 infections and related deaths occurring among residents.

Methods

This study is part of an ongoing multicenter, prospective cohort study conducted among healthcare workers (HCWs) and residents of 13 LTCFs in Northern Italy designed to evaluate SARS-CoV-2 specific immunoglobulin class G (IgG) titers before and following vaccination with Pfizer/BNT162b2 SARS-CoV-2 mRNA vaccine (two doses of vaccine, 21 days apart). Serum samples were obtained from participants (t0) before vaccination, and (t1) 2 weeks after and analyzed to determine anti-S1 IgG antibodies.

Results

Five hundred and thirty-four participants were enrolled (404 subjects participated in both blood draws). Seropositivity was 50.19% at t0 and 99% at t1, with a significant difference in IgG titers. A higher proportion of residents were seropositive at t0 compared with HCWs, with significantly higher IgG titers among residents at both t0 and t1. Pre-existing immunity also had a significant effect on postvaccination IgG titers. However, a significant difference in titers at t1 between HCWs and residents considering only participants seropositive at t0 was found, with higher median titers among previously seropositive residents.

Conclusion

Findings of this study provide scientific evidence endorsing the policy of universal vaccination in LTCFs.

The Italian policy of mandating SARS-CoV-2 vaccination for healthcare workers: Analysis of the policy processes and preliminary outcomes

BACKGROUND

Italy experienced the first outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Europe, and was among the most hardly hit European countries. Growing evidence suggests healthcare workers (HCWs) are at increased risk of SARS-CoV-2 infection. Infection in HCWs can lead to cross-transmission and increase community transmission. Italy was the first country in Europe to introduce mandatory vaccinations against SARS-CoV-2 for HCWs, on April 1, 2021.

AIM

To describe the policy processes and preliminary results of the introduction of compulsory vaccination against SARS-CoV-2 for HCWs in Italy.

RESULTS AND CONCLUSION

In Italy, the adoption of the policy was possible in the context of the public health and economic crisis resulting from the pandemic, with support from the scientific community and among favorable political conditions. Preliminary data suggest the policy has so far had a positive impact on increasing vaccine uptake and lowering infection rates among HCWs. Hopefully, the lack of serious vaccine-related adverse events and the growing evidence on vaccine effectiveness will progressively strengthen vaccine confidence among HCWs. In the context of a global pandemic, the Italian experience could provide insight for policymakers in other countries considering similar policies. Further, the ethical, legal, and policy challenges raised by the current public health emergency could be used to inform future pandemic preparedness plans.

Seroprevalence of SARS-CoV-2 before/after case zero

Introduction

Italy was one of the first EU countries hit by the COVID-19 pandemic. Currently, Italy has reported 15.5 million cases of COVID-19 and 161000 deaths. Meanwhile, the vaccination campaign against COVID-19 began in Italy at the end of 2020, using mRNA and viral vector vaccines (immunizing people against Spike protein of SARS-CoV-2. The purpose of this study was to estimate, in a representative sample of the Italian population, the prevalence of antibodies against SARS-CoV2 in 2019 (before case zero, identified in Italy in February 2020) and in 2021, after 3 pandemic waves and a vaccination campaign.

Methods

During October / November 2019: 365 participants were selected in the Piedmontese population among those who went to a hospital for routine blood tests. The population was selected on the basis of age and gender to be representative of the Italian population. The same number of patients was selected in the first quarter of 2021, the inclusion and exclusion criteria remained the same. Sera were searched for spike protein of SARS-CoV-2 and, if positive, tested for anti-nucleocapsid antibodies.

Results

Our preliminary data show that half of the sample for both years is female. In the 2019 sample, i.e. before case zero was identified in Italy (Lombardy), five of the sera (4 males and one female) tested positive for anti-Spike,indicating a previous infection (vaccine didn't exist). In the 2021 sample, 152 males and 139 females tested positive for IgG anti-spike, for a total of 291. The prevalence therefore passed from 1.37% to 79.73%. As regards the search for ANti-Nantibodies, one male and one female tested positive in 2019; in 2021 9 males and 13 females.

Conclusions

The results of our study show that in 2019, before the first official case in Italy was highlighted, coronavirus was already circulating. The prevalence has risen exponentially, going from less than 2% to around 80%.

Key messages

• Covid-19 was circulating in Italy in 2019.

• Seroprevalence of anti-S in 2021 was about 20%.

Trends in mortality associated with surgical site infections: a cohort study in Italy, 2009-2019

Background

Surveillance programs have proven to be effective in reducing surgical site infection (SSI) rates. In 2008 Piedmont joined the Italian national surveillance system. The aim of this study was to evaluate mortality rates and trends associated with SSIs in Piedmont from 2009 to 2019 for the two most frequently performed surgical procedures, hip arthroplasty (HPRO) and colon surgery (COLO).

Methods

Data were collected through the national surveillance system, which includes 42 hospitals in Piedmont who participated in the surveillance program from 2009 to 2019. Procedure-specific SSI rates, overall mortality rates and case fatality rates (CFR) associated with SSIs were calculated, overall and per year. Trends were evaluated using the chi-squared test for trends. Analyses were performed using Epi Info v. 7.2.

Results

A total of 33438 surgical procedures (21645 HPRO, 11793 COLO) were monitored over the study period from the hospitals participating in the network. 1215 SSIs (293 HPRO, 922 COLO) were observed and 617 deaths were registered (222 HPRO, 395 COLO). For HPRO procedures, an overall SSI rate of 1.35% was found, with an overall mortality of 1.03% and a CFR of 3.75%. No significant trend was observed. Considering COLO interventions, an overall SSI rate of 7.82% was found, with an overall mortality of 3.35% and a CFR of 6.94%. There was a statistically significant downward trend in SSI and overall mortality rates (p = 0.046 and 0.005, respectively).

Conclusions

Considering HPRO, it is possible that the lack of significant trends could be due to the already low SSI and overall mortality rates, with the protective effect of surveillance having reached a plateau. Regarding COLO procedures, a significant reduction in SSI and overall mortality rates was observed during the study period. The reduction in mortality could be due to the decrease in SSI rates, however other factors not analysed in our study could have contributed.

Key messages

• This study brings further evidence to the protective effect of surveillance, attributable to an improvement in healthcare quality and patients’ safety.

• A significant decrease in COLO mortality rates was observed, which could be due to the decreasing trend in SSI rates.

Evaluating the pandemic’s impact on surgical site infections after abdominal surgery in Italy

Background

The COVID-19 pandemic led to important disruptions in surgical activity. The aim of this study was to evaluate the impact of COVID-19 on abdominal surgery outcomes in the region of Piedmont, in northern Italy.

Methods

Data were gathered from 42 hospitals participating in the regional surveillance network from 2018 to 2020. SSI, overall mortality and case fatality rates (CFR) were calculated, comparing 2020 to mean 2018-19 data. Chi-squared tests were used to assess both the differences among the proportion of urgent and oncological procedures (based on ICD-9-CM codes) and rates between the two periods. Subgroup analyses on 2020 data were carried out comparing urgent vs. elective and oncological vs. non-oncological procedures using chi-squared tests. Analyses were performed using SPSS v. 28.0.1.0.

Results

5407 procedures were recorded in 2018-19; 310 SSIs and 120 deaths were observed. The mean proportions of urgent and oncological operations were, respectively, 21.90% and 43.24%. In 2020, 1057 procedures were recorded, along with 44 SSIs and 29 deaths. 34.44% of procedures were urgent and 39.74% oncological. The mean 2018-2019 SSI rate was 5.73%, with an overall mortality of 2.22% and a CFR of 7.42%. The SSI rate in 2020 was 4.16%, with an overall mortality of 2.74% and a CFR of 9.09%. The proportion of urgent procedures significantly differed between the two periods (p < 0.001), as did the proportion of oncological procedures and SSI rates (both p = 0.05). Considering 2020, significant differences were found comparing overall mortality between urgent vs. elective procedures (4.95% vs. 1.59%, p = 0.002) and comparing SSI rates between oncological vs. non-oncological patients (3.57% vs. 2.20%, p = 0.02).

Conclusions

During the pandemic, patients undergoing surgical procedures significantly differed, reflecting public health decisions. Even though these differences did not reach statistical significance, overall mortality and CFR increased in 2020.

Key messages

Antimicrobial stewardship programs in Italy: structure, process and outcome indicators, 2017-2019

Background

The increasing spread of antimicrobial resistance (AMR) represents a global public health threat, and a significant challenge for healthcare delivery. Antimicrobial stewardship (AMS) programs have proven to be effective and cost-effective strategies for optimizing antimicrobial use. We aimed to assess key aspects of AMS programs implemented in acute-care trusts of the region of Piedmont, and to evaluate changes in antimicrobial usage against a score we attributed to structural and functional elements of AMS programs.

Methods

AMS programs operating in acute-care trusts in the region of Piedmont were investigated via a survey addressing program characteristics, divided into structure and process quality indicators. All public health trusts of the region of Piedmont were invited to complete the survey. The indicators were selected based on core elements identified by international guidelines and were reviewed by a multi-disciplinary panel. Antimicrobial usage was expressed as defined daily doses, DDD per 1000 patient-days. The annual means for the years 2017-2019 were considered, as well as the percentage change between 2017 and 2019. Variables were investigated in relation to structure and process scores using Spearman correlation. Analyses were performed using SPSS v. 27.0 (SPSS Inc., Armonk, NY).

Results

In total, 25 AMS programs were surveyed. Higher scores were achieved for process rather than structure indicators. Improvements in total antimicrobial usage (-4%) were found between 2017 and 2019. A moderate correlation was found between structure score and percentage change in antimicrobial usage (Spearman’s ρ -0.603, p 0.006).

Conslusions

This study highlighted important areas for improvement, such as accountability, microbiological laboratory quality management and feedback. Repeated measurements of structure, process and outcome indicators will be important to guide continuing quality improvement efforts.

Key messages

• Results of this study support the effectiveness of AMS programs in reducing antimicrobial use.

• Important areas for improvement were identified. Improving the organization of AMS programs in particular should be prioritized.

Vaccination policy strategies before and during the COVID-19 pandemic: an overview

Background

The debate on vaccination strategies has been periodically involving researchers, policymakers, and also the population. Interest waves have occurred both after a revival of childhood infectious diseases in 2016-2017, due to low vaccine coverages, and during the recent Coronavirus outbreak. This study aimed at overviewing vaccination strategies (and corresponding vaccine coverages) for childhood vaccinations and SARS-CoV-2.

Methods

Measles was chosen as a childhood vaccination indicator. Policy data were retrieved from health institutions (either European or national/regional) and, for COVID-19, also from press agencies and newspaper websites. Vaccine coverage data were retrieved from the World Bank, World Health Organisation, and UNICEF databases (for childhood vaccines), and from the “Our World in Data” platform for SARS-CoV-2. A qualitative comparison was performed between the two contexts.

Results

Unlike childhood vaccinations, few countries (and only Austria in Europe) imposed generalised COVID-19 mandates, most countries preferring targeted mandates for higher-risk groups. Many countries confirmed their traditional voluntary vaccination approach also for COVID-19, while countries historically relying on compulsory vaccination strategies, such as Slovenia and Hungary, surprisingly opted for voluntary SARS-CoV-2 vaccination, with unsatisfactory results. However, no tangible crude association was generally found between vaccination policies and achieved coverages, although factors such as cultural background, education, and religion appeared to influence the impact of vaccination policies.

Conclusions

The COVID-19 experience has enriched pre-existent vaccination strategy debates by adding interesting elements concerning attitudes toward vaccines in a novel context. Reading the available results in the frame of vaccine hesitancy determinants can help to understand the relationship between policies and actual coverages.

Key messages

The impact of conscientious objection on voluntary abortion in Italy in the last two decades

Background

Italian Law 194/1978 legalized voluntary abortion during the first 90 days of pregnancy. Healthcare professionals can claim conscientious objection (CO), but regional governments must guarantee women's rights. In recent years, international human rights authorities argued that access to safe abortion was limited in Italy due to widespread CO.

Methods

An ecological study was conducted using 1997-2019 ministerial data on the number of gynecologists registered as conscientious objectors, the proportion of abortions performed timely (within 14 days of the request), and within 8-10 weeks of pregnancy. The extra workload for non-objecting gynecologists was calculated as the ratio between the workload for non-objectors and the (theoretical) workload for each gynecologist on duty. The correlation between the extra workload for non-objectors and the proportion of abortions performed within 14 days of the request or beyond 21, as well as the correlation between waiting time and gestational age at the time of the procedure. Data were analyzed for Italy and stratified for its 21 Regions.

Results

CO among gynecologists turned out to be stable around an average of 70% (median 69%, IQR 64-71%) in the last decades, with 62% of abortions performed within 14 days and 82% of procedures performed by the 10th week of pregnancy. In 13 regions (statistically significant in 5) the increase in workload for non-objectors was inversely correlated with abortions performed within 14 days, and directly correlated with those performed later than 21 days. In all regions (statistically significant in 18) a direct correlation was found between procedures performed timely and those performed within 8 weeks of pregnancy.

Conclusions

Data from the last 20 years confirm previous findings and CO still seems to have a strong impact on women's right to access safe and timely abortion in Italy. More efforts are needed to narrow the gap between the provisions of the law and its implementation.

Key messages

• A high proportion of objecting staff makes it difficult to guarantee women’s rights to access timely and safe abortion.

• Effective organizational strategies and a proper legal framework are needed to cope with the high percentage of conscientious objectors among health professionals.

Hand hygiene and HAI transmission in Piedmont, Italy: an observational study, 2017-2019

Background

Hand hygiene (HH) is one of the most important measures to prevent healthcare-associated infections (HAIs). Several indicators have been proposed to measure HH practices, including alcohol-based handrub consumption (AHC). The objective of this study was to evaluate whether AHC is associated with HAI transmission.

Methods

All 25 public hospitals/trusts of Piedmont, in Northern Italy, are required to provide data each year concerning HAIs and infection prevention and control (IPC) activities, as part of a mandatory regional indicator system. Data on AHC and HAIs were extracted from reports provided concerning the years 2017-2019. The mean annual AHC for each facility was expressed as liters per patient-day. The rate of hospital-wide Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) infections was calculated per 1000 patient-days (pd). Mean ventilation-associated infections (VAP) for 1000 days of ventilation (vd) and mean catheter-related bloodstream infections (CR-BSI) for 1000 days of catheterization (cd) were calculated for intensive care units (ICUs). Spearman's correlational analysis was conducted between AHC and HAIs: hospital-level, ICU-level.

Results

Hospital-level: mean AHC was 15.4 liters/pd; mean HAI rate was 39.6/1000 pd (MRSA) and 18.5/1000 pd (CRE). No significant correlation was found. ICU-level: mean AHC was 39.6 liters/pd; mean HAI rate was 1.7/1000 cd (CR-BSI) and 8.2/1000 vd (VAP). A moderate correlation was found between AHC and CR-BSI rate (Spearman's ρ -0.55, p 0.022). Concerning AHC and VAP, higher AHC was reported from facilities with lower VAP rates, however no significant correlation was found (Spearman's ρ -0.203, p 0.451).

Conclusions

Results of this study support the validity of AHC as an indicator of IPC practices in ICUs. The hospital-level analysis could have been affected by important differences in AHC among ward types.

Key messages

Seroprevalence of infection-induced SARS-CoV-2 antibodies among healthcare users of Northern Italy - results from two serosurveys (October-November 2019 - September-October 2021)

Objectives

The objective was to estimate the seroprevalence of SARS-CoV-2 in autumn 2019 (before case zero was identified in Italy) and 2021 among residual sera samples from health care users in the Piedmont region of northwestern Italy.

Methods

Two serosurveys were conducted. Using a semiquantitative method, samples were tested for the presence of immunoglobulin G (IgG) antibodies against the S1 domain of the spike protein. Samples with positive test results from the 2019 survey were independently retested using a multiplex panel to detect IgG antibodies against the receptor binding domain, S1 and S2 domains, and nucleocapsid. Samples with positive test results from the 2021 survey underwent repeat testing with enzyme-linked immunosorbent assay to detect anti-nucleocapsid IgG antibodies. Prevalence rates according to gender and age groups, together with their respective 95% confidence intervals (CIs), were calculated.

Results

Overall, the proportion of samples with positive test results was 2/353 in 2019 and 22/363 in 2021, with an estimated seroprevalence of 0.27% (95% CI 0-1.86) and 6.21% (95% CI 3.9-9.31) in 2019 and 2021 respectively.

Conclusion

Results of this study support the hypothesis that the virus was circulating in Italy as early as autumn 2019. The role of these early cases in broader transmission dynamics remains to be determined.

An Overview of Strategies to Improve Vaccination Compliance before and during the COVID-19 Pandemic

The debate on vaccination mandate was fuelled over the past two years by the COVID-19 pandemic. This study aimed at overviewing vaccination strategies and corresponding vaccine coverages for childhood vaccinations before the pandemic and for SARS-CoV-2 in high-income countries. A qualitative comparison was also performed between the two contexts: unlike for childhood vaccinations, only one European country (Austria) imposed generalised COVID-19 mandates, most countries preferring targeted mandates for higher-risk categories (Italy, Greece) or workers in key public services (Finland, Australia, New Zealand, UK, Germany). Many countries (Norway, Sweden, Netherlands, Portugal, Spain) confirmed their traditional voluntary vaccination approach also for COVID-19, while others (Slovenia and Hungary), historically relying on compulsory vaccination strategies, surprisingly opted for voluntary SARS-CoV-2 vaccination, with unsatisfactory results in terms of immunisation rates. However, no tangible relationship was generally found between vaccination policies and immunisation coverages: data show that, unlike some countries with mandates, countries where vaccinations are merely recommended could achieve higher coverages, even beyond the recommended 95% threshold. The COVID-19 experience has enriched pre-existent vaccination strategy debates by adding interesting elements concerning attitudes towards vaccines in a novel and unexplored context. Interpreting the available results by considering the different cultural contexts and vaccine hesitancy determinants can help to better understand the complexity of the relationship between policies and achieved coverages.

Antimicrobial Stewardship Strategies Including Point-of-Care Testing (POCT) for Pediatric Patients with Upper-Respiratory-Tract Infections in Primary Care: A Systematic Review of Economic Evaluations

Upper-respiratory-tract infections (URTIs) are among the main causes of antibiotic prescriptions in pediatric patients. Over one-third of all antibiotic prescriptions for URTIs in children are estimated to be inappropriate, as the majority of URTIs are caused by viral agents. Several strategies, including clinical scoring algorithms and different point-of-care tests (POCTs) have been developed to help discriminate bacterial from viral URTIs in the outpatient clinical setting. A systematic review of the literature was conducted following PRISMA guidelines with the objective of summarizing evidence from health–economic evaluations on the use of POCT for URTIs in pediatric outpatients. A total of 3375 records identified from four databases and other sources were screened, of which 8 met the inclusion criteria. Four studies were classified as being of high reporting quality, and three were of medium quality. Five out of eight studies concluded in favor of strategies that included POCTs, with an additional study finding several POCTs to be cost-effective compared to usual care but over an acceptable WTP threshold. This review found POCT could be a valuable tool for antimicrobial stewardship strategies targeted towards childhood URTIs in primary care.

Alcohol-Based Hand Rub Consumption and World Health Organization Hand Hygiene Self-Assessment Framework: A Comparison Between the 2 Surveillances in a 4-Year Region-Wide Experience

OBJECTIVES

Hand hygiene is essential for infection prevention. In Piedmont (Northwest Italy), hand hygiene is routinely monitored through 2 surveillance systems, the World Health Organization Hand Hygiene Self-Assessment Framework (HHSAF) and alcohol-based hand rub (ABHR) consumption. This study was aimed at (1) comparing the results of these surveillances, investigating the consistence of the 2 systems and (2) inquiring whether organizational differences among healthcare facilities significantly affected hand hygiene performances.

METHODS

A retrospective analysis was performed on data collected annually from 2015 to 2018 for both surveillances from 40 hospitals of the region: HHSAF score (500 points maximum) and ABHR consumption in milliliters per patient-day (mL/PD) were considered. Logistic regression models were built to evaluate possible correlations between these variables, and observations were clustered considering both variables to identify whether groups with significant differences could be discerned. A tree-structured partitioning model was used to confirm the obtained results.

RESULTS

A positive correlation was observed between HHSAF score and odds of belonging to the high ABHR consumption group, particularly for cutoffs set to 19 to 23 mL/PD (P = 0.033 for 23 mL/PD). Two ABHR consumption peaks were identified at approximately 10 and 22 mL/PD, corresponding to median HHSAF scores of 353.75 and 375 points, respectively. The group with better performances was mainly composed of hub hospitals (with single-hospital management).

CONCLUSIONS

The 2 surveillance systems are consistent, and the HHSAF score could work as a reasonable predictor of hand hygiene compliance in healthcare settings. Different management characteristics are crucial in creating a more/less favorable environment for hand hygiene compliance and infection prevention.

Cross-sectional study of SARS-CoV-2 seropositivity among health-care workers and residents of long-term facilities in Italy, January 2021

Long‐term care facilities (LTCFs) are high‐risk settings for SARS‐CoV‐2 infection. This study aimed to describe SARS‐CoV‐2 seropositivity among residents of LTCFs and health‐care workers (HCWs). Subjects were recruited in January 2021 among unvaccinated HCWs of LTCFs and hospitals and residents of LTCFs in Northern Italy. Information concerning previous SARS‐CoV‐2 infections and a sample of peripheral blood were collected. Anti‐S SARS‐CoV‐2 IgG antibodies were measured using the EUROIMMUN Anti‐SARS‐CoV‐2 QuantiVac ELISA kit (EUROIMMUN Medizinische Labordiagnostika AG). For subjects with previous COVID‐19 infection, gender, age, type of subject (HCW or resident), and time between last positive swab and blood draw were considered as possible determinants of two outcomes: the probability to obtain a positive serological result and antibody titer. Six hundred and fifty‐eight subjects were enrolled. 56.1% of all subjects and 65% of residents presented positive results (overall median antibody titer: 31.0 RU/ml). Multivariable models identified a statistically significant 4% decrease in the estimated antibody level for each 30‐day increase from the last positive swab. HCWs were associated with significant odds for seroreversion over time (OR: 0.926 for every 30 days, 95% CI: 0.860–0.998), contrary to residents (OR: 1.059, 95% CI: 0.919–1.22). Age and gender were not factors predicting seropositivity over time. Residents could have a higher probability of maintaining a seropositive status over time compared to HCWs.

Chemical susceptibility testing of non-tuberculous mycobacterium strains and other aquatic bacteria: Results of a study for the development of a more sensitive and simple method for the detection of NTM in environmental samples

The methods employed to detect non-tuberculous mycobacteria on environmental samples are essentially those classically used in clinical microbiology, which envisage a decontamination step to reduce the overgrowth of non-mycobacterial organisms before plating them on the culture medium. The aim of this study was to propose alternative culture techniques to improve non-tuberculous mycobacteria detection in environmental samples. We used artificially contaminated samples to compare the membrane filter washing procedure against direct plating of membrane filters on culture media in relation to M.chimaera and M.chelonae recovery efficiency. Moreover, we compared the efficacy of NTM Elite agar in inhibiting the growth of aquatic bacteria with that of cetylpyridinium chloride and N-acetyl-L-cysteine sodium hydroxide decontamination treatments. The washing procedure yielded a low release of both mycobacterium strains (6.6% for Mycobacterium chimaera and 7.5% for Mycobacterium chelonae) from the membrane filters; on the contrary, direct plating of membrane filters led to a 100% cell recovery. Water sample pretreatment with N-acetyl-L-cysteine sodium hydroxide (1%), despite achieving complete suppression of non-acid fast bacilli, caused a reduction in mycobacteria growth. Decontamination with cetylpyridinium chloride (0.005%) was found to be ineffective against Methylobacterium spp. and Burkholderia multivorans. NTM Elite agar was ineffective against B. multivorans, but it inhibited the growth of all other aquatic bacteria. Our results indicate that NTM Elite agar provides a valid alternative method of recovering non-tuberculous mycobacteria from environmental samples. It does not involve a decontamination step and provides greater recovery efficiency by skipping the washing step and directly plating the filters on the media.

First assessment of covid-19 vaccine response in a population at risk

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), has led to a global pandemic. Currently, the diagnosis of COVID-19 is confirmed by detecting SARS-CoV-2 via RealTime-RT-PCR in rhino-pharyngeal swab. Serological test is required to evaluate a previous exposure to the virus, as well as antibody response. The aim of this multicentric study is to analyse the antibody response following COVID-19 vaccination in healthcare workers and guests of nursing homes, and to determine differences between subjects with or without a confirmed previous infection.

Methods

Our study included 657 subjects, recruited from guests and healthcare workers of nursing homes in the Piedmont region. 10 days after the completion of the vaccination cycle, a blood sample was taken from the subjects to measure IgG against SARS-CoV-2 spike protein. Serological testing was performed using an enzyme immunoassay kit (EUROIMMUN Anti-SARS-CoV-2 QuantiVac ELISA). We performed statistical analysis with R software.

Results

We recruited 657 subjects aged between 19 to 106. Among them, 404 had a previous infection and 253 didn't have a known previous infection. The serological examination resulted positive in 655 subjects and negative in 2 (X¯ IgG 1095 RU/ml). Samples with titer&gt; 1200 RU/ml will be further diluted to identify the titer and differences from the baseline situation.

Conclusions

This study analyses neutralizing antibodies, which should prevent the virus from binding to target cells via spike protein. According to literature, immunological response to vaccine presents a great variability of antibodies level in the study population. However, no significantly correlations were found between the available variables. Preliminary data show the presence of a very intense antibody response after active vaccine immunization both in subjects with previous infection and in the rest of the study population.

Key messages

Covid-19 vaccine response in a population at risk. Differences between subjects with or without a confirmed previous infection.

Impact of COVID-19 on healthcare waste generation: correlations and trends from a tertiary hospital

Background

COVID-19 has represented an emergency not only for the sanitary issues, but also from the environmental and operative perspective, with largely increased waste disposal due to non-reusable personal protective equipment and packaging. This study aimed at estimating the increase in healthcare waste (HW) generation during the outbreak, based on data from a tertiary hospital.

Methods

From the purveying office statements of “SS Antonio e Biagio e Cesare Arrigo” Hospital of Alessandria (Italy), monthly data on HW generation from January 2015 to March 2021 were retrospectively retrieved. Trend analyses were performed through linear regression and the impact of COVID was evaluated following the Interrupted-Time Series regression model. Moreover, HW generation data were compared to the proportion of patient-days and admissions due to COVID (out of respective totals) through Pearson's correlation test.

Results

HW generation rose from a baseline of 35.9 ± 3.8 tons/month (2.4 ± 0.2 kg per patient-day, kg/PD) in 2015-2019, to 46.3 ± 6.0 tons/month (3.3 ± 0.6 kg/PD) during the outbreak (2020-2021), with a peak in March-April 2020. Segmented regression showed that the already increasing trend was not appreciably modified as for its slope, whereas a significant level change could be detected between baseline and outbreak period (+0.6 kg/PD, corresponding to a 28.6% increase compared to baseline intercept, p &lt; 0.001). HW generation was significantly correlated to the proportion of admissions (p = 0.005, R2=0.70) and patient-days (p = 0.006, R2=0.69) related to COVID-19.

Conclusions

The study showed a significant rise in HW generation in 2020-2021, reasonably due to the COVID-19 outbreak. Moreover, this happened without affecting the generally increasing trend. These results underline the effect of the pandemic on the amounts of waste generated by healthcare facilities, with noticeable impact on the environment and higher costs associated with HW management and disposal.

Key messages

Due to extensive use of disposable equipment and packaging, COVID-19 strongly impacted on healthcare waste generation, with an average 28.6% increase compared to baseline levels (+0.6 kg/patient-day). The generally increasing trend in healthcare waste generation, along with the remarkable increase due to COVID-19, results in high environmental impact and management costs for healthcare facilities.

Preliminary assessment of COVID-19 serological situation in a high-risk cohort

Introduction

Studies on the duration of immune response in subjects with COVID-19 could facilitate understanding of how immunity develops and persists during the natural course of infection, as well as providing epidemiological information useful in public health decisions on the use of vaccines. The study aims to analyse antibody response in a cohort of subjects with high-risk of exposure to SARS-CoV-2 due to the long-term care facility environment.

Methods

We recruited 657 subjects between guests and healthcare workers from Piedmontese nursing homes. IgG directed against the S1 domain of SARS-CoV-2 spike protein were assayed on serum. We used EUROIMMUN kit, which exploits ELISA method. Reference values are (RU/mL): positive ≥ 11; borderline 8 ≤ value &lt; 11; negative &lt; 8.

Results

Among the 657 subjects, we examined 494 health workers and 163 guests. The average age was 56.2. In relation to COVID-19, 402 subjects had a previous infection, 255 had not. About serology: positive 369; negative 261; borderline 27. The mean of the IgG values was 35.68 RU/mL. Swabs/serology: 77.36% with previous infection were positive to serology, 18.66% negative; of all subjects who were always negative to swabs, 72.94% were negative, 22.74% positive. Moreover, the mean time elapsed from positive swab to serology test was 144.08 days.

Conclusions

Preliminary results show that the antibody response is present and persistent in the study population, even a long time after the infection. According to literature, antibody persistence has great variability in our population, as no statistically significant correlations were found between antibody titer and other variables such as time elapsed since infection. The examined sample, belonging to high-risk category (long-term care facilities), is most likely to present repeated exposure to SARS-CoV-2, highlighted by the seropositivity of never infected subjects. These findings might help policy makers better address resources regarding vaccines.

Key messages

Antibody response is present and persistent in the study population, even a long time after the infection. Antibody persistence has great variability in our population, as no statistically significant correlations were found between antibody titer and other variables such as time elapsed since infection.

Hospital-level risk factors for healthcare-associated infections: insight from the Italian PPS Study

Background

In 2016-2017, a Point Prevalence Survey (PPS) was conducted by the European Centre for Disease Prevention and Control (ECDC) in 29 European countries to investigate healthcare-associated infections (HAIs) and antimicrobial use. The aim of this study was to identify significant determinants of HAIs at a hospital level according to Italian data.

Methods

Among variables considered by the ECDC Protocol for the PPS, those with most plausible relationship with HAI occurrence according to the literature were a priori selected. Hence, conceptual causal models were built for each reference variable, by adjusting for an established set of confounders (geographical region, hospital type and number of beds), and also considering the possible interaction of the number of blood cultures per 100 patient-days (a proxy of how thoroughly HAIs are searched). Direct effects were estimated in the form of risk ratios through multivariable log-binomial regression models.

Results

Data were available for 135 Italian hospitals participating in the survey. Factors with significant impact on HAIs resulted to be: percentage of single rooms (RR = 0.91 for every 5% increase, p = 0.013), presence of a plan for infection prevention and control (IPC, RR = 0.51, p = 0.007), routine production of an IPC report (RR = 0.50, p = 0.001), adoption of measures for HAI prevention (RR = 0.21, p = 0.002) and antimicrobial stewardship (RR = 0.50, p = 0.015). The interaction of the number of blood cultures was significant for the effect of IPC report (p = 0.038), number of measures for HAI prevention (p = 0.037) and antimicrobial stewardship (p = 0.02).

Conclusions

The results confirm the importance of HAI prevention and antimicrobial stewardship as means of lowering the occurrence of HAIs. Therefore, investigating, testing and correctly reporting the onset and evolution of HAIs is paramount to ensure better understanding of the phenomenon and to provide useful insights to create a safer background for clinical practice.

Key messages

Adopting preventive measures and antimicrobial stewardship is crucial in lowering the occurrence of HAIs and ensuring safer care. Investigating, testing and correctly reporting the onset and evolution of HAIs is paramount to ensure better understanding of the phenomenon and to enable effective HAI prevention.

Hand hygiene compliance: the experience of three Italian tertiary care hospitals

Introduction

Hand hygiene is an important measure in infection prevention to decrease transmission of microbial pathogens. Especially in these last two years, COVID-19 pandemic brought focus on the importance of a correct and frequent hand hygiene. Currently, direct observation is considered the gold standard for hand hygiene surveillance. The purpose of this observational study is to assess healthcare professionals hand hygiene compliance during the World Health Organization's ‘Five Moments for hand hygiene'.

Methods

In this study we examined perceptions, compliance, techniques, and contextual issues of hand hygiene practices among healthcare workers, in three different hospitals. Twelve different wards were observed, including ICU, surgical wards and medical wards. At least 200 hand hygiene opportunities (based on the WHO's ‘Five Moments') were recorded for each ward, using a mobile application called SpeedyAudit™.

Results

The results showed highly variable levels of adherence to the hygiene practices, with compliance rates ranging from 20% to 84%. There was also a wide variability of compliance between the different moments, with compliance rates ranging from 75% after touching patient surroundings to 59% before touching a patient. Overall, physicians had the worst score among the healthcare workers, resulting in 55% of compliance, while social health operators performed best with 70%.

Conclusions

There is still a huge variability in hand hygiene among healthcare workers. Despite the conceivable Hawthorne Effect influence, general compliance was not optimal. Overall hand hygiene adherence and knowledge should be achieved by implementing hand sanitizer distribution, offering further education and raising awareness on the importance of a correct hand hygiene, for the sake of both patients and healthcare workers.

Key messages

Hand hygiene adherence and knowledge should be achieved by implementing hand sanitizer distribution, offering further education and raising awareness on the importance of a correct hand hygiene.

There is still a huge variability in hand hygiene among healthcare workers.

Interrupted time series analysis of the impact of a bundle on surgical site infections after colon surgery

BACKGROUND

Surgical site infections (SSIs) are monitored in Italy through a national surveillance system. A 4-element bundle was introduced in 2012, consisting of: appropriate preoperative shower and hair removal, perioperative normothermia, and antibiotic prophylaxis. The aim of this study was to evaluate the effect of the intervention on SSI rates after colon surgery.

METHODS

A retrospective cohort study was conducted between 2008 and 2019 in 29 hospitals of northern Italy. An interrupted time series analysis (ITSA) was modeled to assess the bundle's impact on SSI trends. Logistic regression was performed to identify predictors of SSI among procedures performed in the postintervention period, comparing full and partial bundle compliance.

RESULTS

Data of 5487 colon surgery procedures were collected (1243 preintervention and 4244 postintervention). The ITSA identified a significant change in the monthly postintervention SSI trend of -0.19% and a change in level of -2.09%. A significant protective effect of full bundle compliance compared to partial bundle compliance (OR 0.74, P.043) was found, whereas the single effect of the bundle elements was nonsignificant.

CONCLUSIONS

Results of this study suggest this relatively simple bundle protocol is effective in reducing SSI risk.

Pertussis immunisation during pregnancy: Antibody levels and the impact of booster vaccine

Pertussis (whooping cough) is a highly infectious disease caused by Bordetella pertussis. Mothers lacking adequate immunity and contracting the disease represent the biggest risk of transmission to new-borns, for which the disease is often a threat. The aim of the study was to estimate the frequency of pertussis susceptibility among pregnant women, in order to point out the need for a vaccine recall during pregnancy, and to evaluate the antibody response in already vaccinated women. A cross-sectional observational study was conducted in the blood test centre of "St. Anna" Obstetrics and Gynaecology Hospital in Turin (Piedmont, Italy). Eligibility criteria included pregnant women coming to the centre for any blood test, aged 18 or above and with gestational age between 33 and 37 weeks at the moment of the blood draw. The data collection was carried out from May 2019 to January 2020 and the concentration of anti-Pertussis Toxin (anti-PT) IgG was measured through the Enzyme-Linked Immunosorbent Assay (ELISA) technique. Two-hundred women (median age 35) were enrolled: 132 (66%) had received at least one dose of pertussis vaccine, 82 of which during pregnancy. Recently vaccinated women had significantly higher antibody titres (even 12-15 times as high) compared to those vaccinated more than 5 years before or never vaccinated at all (p < 0.0001). Moreover, 95.1% of recently vaccinated women had anti-PT IgG levels above 10 IU/ml, and 85.4% above 20 IU/ml, while the same proportions were as low as 37% and 21% (respectively) in the group of women not vaccinated in pregnancy. This study confirmed that the vaccination is greatly effective in ensuring high antibody titres in the first months after the booster vaccine, with considerable differences in anti-PT IgG compared to women vaccinated earlier or never vaccinated at all, and therefore vaccinating pregnant women against pertussis still represents a valuable strategy.

Burden of healthcare-associated infections in Italy: incidence, attributable mortality and disability-adjusted life years (DALYs) from a nationwide study, 2016

BACKGROUND

Healthcare-associated infections (HAIs) are an increasing public health threat. Measuring disease burden in disability-adjusted life-years (DALYs) allows the combination of morbidity and mortality into one figure, as it represents the summation of years lived with disability and years of life lost.

AIM

To evaluate the incidence, attributable deaths and burden of the most significant HAIs in Italy.

METHODS

Prevalence data from the study sample of the 2016 national Point Prevalence Survey of HAIs in acute-care settings were used to estimate the incidence of five HAIs. The methodology from the Burden of Communicable Diseases in Europe (BCoDE)-project was employed for DALY calculations, adapting the disease models to the Italian population.

FINDINGS

We estimated a total of 641,065 (95% uncertainty interval, UI 585,543.00-699,207.90) new yearly cases of HAIs and 29,375 (95% UI 23,705.97-35,905.80) deaths in Italy in 2016. The total annual DALYs were estimated to be 424,657.45 (95% UI 346,240.35-513,357.28), corresponding to 702.53 DALYs (95% UI 575.22-844.66) per 100,000 general population. Bloodstream infections accounted for the majority of total DALYs (59%), healthcare-associated pneumonia for 29%, surgical site infections for 9%, CDI for 2% and urinary tract infections accounted for less than 1% of total DALYs.

CONCLUSION

Results of this study suggest HAIs have a substantial burden in Italy. Reducing the burden of HAIs through infection prevention and control efforts is an achievable goal. This study provides data that could be used to guide policy-makers in the implementation of these measures.

Data quality assessment and subsampling strategies to correct distributional bias in prevalence studies

Background

Healthcare-associated infections (HAIs) represent a major Public Health issue. Hospital-based prevalence studies are a common tool of HAI surveillance, but data quality problems and non-representativeness can undermine their reliability.

Methods

This study proposes three algorithms that, given a convenience sample and variables relevant for the outcome of the study, select a subsample with specific distributional characteristics, boosting either representativeness (Probability and Distance procedures) or risk factors’ balance (Uniformity procedure). A “Quality Score” (QS) was also developed to grade sampled units according to data completeness and reliability.

The methodologies were evaluated through bootstrapping on a convenience sample of 135 hospitals collected during the 2016 Italian Point Prevalence Survey (PPS) on HAIs.

Results

The QS highlighted wide variations in data quality among hospitals (median QS 52.9 points, range 7.98–628, lower meaning better quality), with most problems ascribable to ward and hospital-related data reporting. Both Distance and Probability procedures produced subsamples with lower distributional bias (Log-likelihood score increased from 7.3 to 29 points). The Uniformity procedure increased the homogeneity of the sample characteristics (e.g., − 58.4% in geographical variability).

The procedures selected hospitals with higher data quality, especially the Probability procedure (lower QS in 100% of bootstrap simulations). The Distance procedure produced lower HAI prevalence estimates (6.98% compared to 7.44% in the convenience sample), more in line with the European median.

Conclusions

The QS and the subsampling procedures proposed in this study could represent effective tools to improve the quality of prevalence studies, decreasing the biases that can arise due to non-probabilistic sample collection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01277-y.

Cost-Effectiveness Analysis of the Prophylactic Use of Ertapenem for the Prevention of Surgical Site Infections after Elective Colorectal Surgery

Standard surgical antimicrobial prophylaxis (SAP) regimens are less effective in preventing surgical site infections (SSIs) due to rising antimicrobial resistance (AMR) rates, particularly for patients undergoing colorectal surgery. This study aimed to evaluate whether ertapenem should be a preferred strategy for the prevention of SSIs following elective colorectal surgery compared to three standard SAP regimens: amoxicillin-clavulanate, cefoxitin, and cefazolin plus metronidazole. A cost-effectiveness analysis was conducted using decision tree models. Probabilities of SSIs and AMR-SSIs, costs, and effects (in terms of quality-adjusted life-years) were considered in the assessment of the alternative strategies. Input parameters integrated real data from the Italian surveillance system for SSIs with data from the published literature. A sensitivity analysis was conducted to assess the potential impact of the decreasing efficacy of standard SAP regimens in preventing SSIs. According to our models, ertapenem was the most cost-effective strategy only when compared to amoxicillin-clavulanate, but it did not prove to be superior to cefoxitin and cefazolin plus metronidazole. The sensitivity analysis found ertapenem would be the most cost-effective strategy compared to these agents if their failure rate was more than doubled. The findings of this study suggest ertapenem should not be a preferred strategy for SAP in elective colorectal surgery.

Analysis of the Fatality Rate in Relation to Testing Capacity during the First 50 days of the COVID-19 Epidemic in Italy

Italy has been one of the most severely affected countries by the COVID-19 pandemic, and the case fatality rate (CFR) estimated based on Italian data is one of the highest worldwide. We analyzed public data from the first 50 days of the epidemic in Italy (from February 24 to April 13, 2020) to evaluate whether evolving testing strategies and capacity could account for trends in the CFR. The CFR increased during the study period, and a significant positive correlation was found between the CFR and the percentage of positive tests among performed real-time PCR tests (positive tests % [POS%]) until March 25, suggesting the surveillance system did not detect a growing number of cases in the initial phase of the epidemic. To avoid distortion due to the delay between the identification of cases and deaths, the expected CFR (expCFR) was calculated, which represents the ratio between the predicted number of cases and deaths at the end of the epidemic based on the best fitting logistic curves of the cumulative numbers of cases and deaths. The expCFR began a downward trend from the 40th day. In the final phase, a decrease in both expCFR and POS% was identified, suggesting an improvement in surveillance. The results of this study suggest data from the first 50 days of the COVID-19 epidemic in Italy were severely affected by ascertainment bias. Insufficient testing and isolation of cases could have facilitated the widespread transmission of COVID-19 in the early stages of the outbreak.

Burden of Healthcare-Associated Infections in Italy: Disability-Adjusted Life Years

Background

Healthcare-Associated Infections (HAIs) significantly increase adverse clinical outcomes and healthcare costs. In 2016 Italy participated in the second European Centre for Disease Prevention and Control (ECDC) Point Prevalence Survey (PPS) of HAIs and antimicrobial use in acute care hospitals. The aim of this study was to estimate the burden of the 5 most common HAIs in Italy, by evaluating incidence, attributable deaths, Years of Life Lost (YLL), Years Lived with Disability (YLD) and Disability-Adjusted Life-Years (DALYs).

Methods

National PPS data were used to establish sex- and age-specific incidence of Healthcare-associated Pneumonia (HAP), HA Urinary tract infections (HA UTI), HA Bloodstream Infections (HA BSI) excluding neonatal BSI, Surgical Site Infections (SSI), HA Clostridium Difficile infections (HA CDI). Patients' life expectancy was adjusted according to the severity of underlying conditions using the McCabe score. Following the methodology from the Burden of Communicable Diseases in Europe (BCoDE)-project, an adapted version of the disease models of the BCoDE toolkit was used.

Results

An overall yearly incidence of 643434 new cases of HAI in Italy was estimated. The aggregate burden of the 5 HAIs was 426411.98 DALYs (86731.03 YLD + 339680.96 YLL), corresponding to 702.53 DALYs per 100000 total population. HA BSI and HAP had the highest burden with respectively 253868.22? and 126038.26 DALYs. The population strata with the highest burden were the ones with McCabe Score 1 for every considered HAI. The age groups with the highest burden were 70-74 for male and 45-49 for female patients. In total, 56% of DALYs were attributable to men and 44% to women.

Conclusions

This nation-wide study found a significant burden of disease due to HAIs in Italy. Results of this study could be used to guide policy-makers in the implementation of measures aiming to reduce the impact of HAIs.

Key messages

This study estimated the burden of 5 HAIs in Italy was 426411.98 DALYs (86731.03 YLD + 339680.96 YLL according to 2016 PPS data. Considering the significant burden of HAIs found in this study, infection prevention and control measures should be a Public Health priority in Italy.

Failure to eradicate non-tuberculous mycobacteria upon disinfection of heater-cooler units: results of a microbiological investigation in northwestern Italy

BACKGROUND

Heater-cooler units (HCUs) used during cardiopulmonary bypass may become colonized with non-tuberculous mycobacteria (NTM), including Mycobacterium chimaera. Recently, a worldwide investigation conducted in hospitalized infected patients has detected M. chimaera in several Stockert 3T HCUs manufactured by LivaNova.

AIM

Microbiological surveillance on Stockert 3T (LivaNova) and Maquet HCU40 (Getinge) devices as well as an evaluation of the efficacy of their recommended decontamination protocols.

METHODS

A total of 308 water samples were collected from 29 HCUs: 264 samples were collected from 17 Stockert 3T HCUs and 44 samples from 12 Maquet HCU40 devices. Samples were tested for total viable counts (TVCs) at both 22 and 36°C, Pseudomonas aeruginosa, coliform bacteria, and NTM. The microbiological surveillance began in June 2017 and ran until October 2019.

FINDINGS

A total of 308 HCU water samples were analysed, 65.5% of which yielded NTM. The most frequently colonized device with NTM was the Stockert 3T (88.2%), with a frequency of positive samples of 59.5% (157/264). The Maquet HCU40 devices less frequently yielded NTM (33.3%), with a frequency of positive water samples of 13.6% (6/44). Disinfection procedures were effective in reducing TVCs of bacteria with the exception of NTM species. NTM were detected in both pre-disinfection (50.1%) and post-disinfection (55.7%) samples, and no significant association was found between disinfection and NTM results both in Stockert 3T and Maquet HCU40 devices.

CONCLUSION

This study suggests that manufacturers' procedures for disinfection are ineffective and/or inadequate. Until effective disinfection protocols become available, the only way to minimize the risk of NTM contamination is to closely monitor the water quality in the HCU, keep it as clean as possible, and treat it like any other biohazardous material.

Is obligation the proper policy to increase immunization coverage? A comparison of 16 OECD countries

Issue

Globally, between 2016 and 2018, low vaccination coverage rates led to an increase of measles cases and related deaths. The WHO European Region reported a total of 83540 measles cases and 74 deaths in 2018, versus the 5273 cases and 13 deaths in 2016, with WHO global estimates reporting 333445 cases. In order to contrast these outbreaks, the European Vaccine Action Plan 2015-2020 states that the ideal immunization coverage for measles must be 95%. Although, this rate is not reached and maintained everywhere, thus one debated solution is to adopt compulsory vaccination plans rather than recommended. Our aim is to analyse if compulsory policies may increase coverage.

Description

Between 2014 and 2018 3 countries (Italy, France and California) changed their measles vaccination policies from recommended to compulsory to fight low immunization. In order to describe the effects of this action, we compared their measles coverage rates in 2014 and 2018 together with other 12 OECD countries rates who adopt both recommendation and obligation, evaluating the trend variations. Data were collected from OECD's, WHO's and Ministries of Health's documents.

Results

After the introduction of obligation, California (91% in 2014; 95% in 2018) and Italy (87% to 94%) coverage rates increased, while France's reduced (91% to 90%). Of other mandatory countries, only Australia showed an increase (94% to 95%); totally, 37.5% mandatory countries showed an increase among the analysed ones. Through the same period, 50% of analysed countries with recommendation maintained rates over 95%, 10% increased, while 40% remained below 95%.

Lessons

Even if mandatory vaccinations can lead to a sharp increase of coverage in a short time in response to emergency situations, the causes and solutions of hesitancy are more complex than law enforcement. Some countries without obligation show rates constantly above 95% throughout the years, demonstrating that other measures can be taken to fight low immunization.

Key messages

Apart from estimates coming from WHO and OECD, it is difficult to find extensive and official information about the application and the effectiveness of vaccination policies in different countries. Low immunization coverage rates rely on different causes (information, religion, personal beliefs, trust), thus the application of mandatory vaccination alone is not sufficient to fight hesitancy.

Meta-analysis of the efficacy of ertapenem in preventing SSIs after elective colorectal surgery

Background

The efficacy of standard surgical antimicrobial prophylaxis (SAP) regimens in preventing surgical site infections (SSIs) after colorectal surgery is declining, along with rising rates of intestinal colonization with antimicrobial resistant (AMR) Enterobacteriaceae and Bacteroides spp. Ertapenem has been approved by the FDA and EMA for SAP in this context, however it has not been used extensively for this indication out of concern for increasing carbapenem-resistance rates. A limited number of studies have investigated the efficacy of ertapenem in preventing SSIs after colorectal surgery, comparing ertapenem with different agents or combinations of agents.

Methods

A systematic review was conducted following the PRISMA checklist. PubMed, Embase and Cochrane databases were searched for studies measuring the efficacy of ertapenem in preventing SSIs following elective colorectal procedures. Studies were considered eligible if they reported extractable data on the proportion of SSIs and/or on the proportion of AMR pathogens isolated from SSIs. Data from all ertapenem study arms were extracted. A random effects meta-analysis was performed to estimate the overall proportion of SSI.

Results

Of 1109 identified studies, 5 met the inclusion criteria and were included in the meta-analysis, totalling 3176 participants. The pooled proportion of SSI was 0.10 (95% CI 0.05-0.18; I2=96%; τ2=0.6323; p ≤ 0.01). Only one study reported data on carbapenem resistance: out of 124 isolates from 30 patients, 1 gram negative carbapenem-resistant isolate was identified.

Conclusions

The pooled proportion of SSI using ertapenem as SAP found in this study is in line with the proportion of SSI using standard SAP found by a recent meta-analysis (Gandra, 2019). According to this analysis, the benefit of ertapenem does not outweigh the risk of further promoting AMR, although results should be interpreted with caution due to the high heterogeneity among included studies.

Key messages

According to this study, the efficacy of ertapenem in preventing surgical site infections after elective colorectal surgery is comparable to the efficacy of standard surgical antibiotic prophylaxis. The emergence of carbapenem resistance after surgical prophylaxis with ertapenem should be further investigated through longer term studies before widespread use for this indication.

Hand hygiene: are WHO Framework scores consistent with hand rub consumption data? A regional study

Background

Hand hygiene represents one of the most effective measures to prevent infection transmission in healthcare facilities and may reduce healthcare-associated infections by up to 15-30%. In Piedmont (a region in North-West Italy), hand hygiene compliance is routinely monitored through the WHO Hand Hygiene Self-Assessment Framework (HHSAF) and each hospital is also required to provide data about alcohol-based hand rub (ABHR) consumption as part of the regional performance indicator surveillance system. The aim of this study is to assess whether these two systems yield consistent results, i.e. whether numerical data matches the self-reported status of hand hygiene compliance.

Methods

For the years 2015-2018, data on ABHR consumption (in millilitres per patient-day, ml/PD) were collected annually at a facility level (40 hospitals) and then aggregated according to the corresponding local health unit/hospital unit, whereas the HHSAF scores were collected at a health/hospital unit level (18 units). The analysis was performed through logistic regression, by taking the WHO HHSAF score (continuous variable) as predictor and ABHR consumption as response variable, dichotomously considered as “low” or “high” (respectively below or above the 20 ml/PD threshold commonly accepted for good practice in hand hygiene).

Results

This study found that a high level of ABHR consumption is more likely to be observed in hospitals/health units with higher HHSAF scores, with a 1.14-fold increase in the odds for every 10-point increase in the HHSAF score. Despite the limited number of observations due to data aggregation, the result reached borderline statistical significance (p = 0.05).

Conclusions

The ABHR consumption surveillance provides feedback heading in the same direction as the results of the HHSAF, therefore the two surveillance systems are consistent. These findings provide further support for the validity of the HHSAF score as a reasonable predictor of hand hygiene compliance.

Key messages

The WHO Hand Hygiene Self-Assessment Framework score is a reliable predictor of hand hygiene compliance, as a high hand rub consumption is more likely to occur in hospitals with higher HHSAF score. Surveillance through the WHO HHSAF should be encouraged, along with alcohol-based hand rub (ABHR) measurement, and these results should be used to guide action plans to promote hand hygiene.

Predicting needlestick and sharps injuries in nursing students: Development of the SNNIP scale

Aim

To develop an instrument to investigate knowledge and predictive factors of needlestick and sharps injuries (NSIs) in nursing students during clinical placements.

Design

Instrument development and cross-sectional study for psychometric testing.

Methods

A self-administered instrument including demographic data, injury epidemiology and predictive factors of NSIs was developed between October 2018-January 2019. Content validity was assessed by a panel of experts. The instrument's factor structure and discriminant validity were explored using principal components analysis. The STROBE guidelines were followed.

Results

Evidence of content validity was found (S-CVI 0.75; I-CVI 0.50-1.00). A three-factor structure was shown by exploratory factor analysis. Of the 238 participants, 39% had been injured at least once, of which 67.3% in the second year. Higher perceptions of "personal exposure" (4.06, SD 3.78) were reported by third-year students. Higher scores for "perceived benefits" of preventive behaviours (13.6, SD 1.46) were reported by second-year students.

Effectiveness of Oncology Network model in pancreas cancer surgery in Piedmont, IT: a survival study

Background

The Oncology Network of Piedmont and Aosta Valley (North-West Italy) was started in 2000 and fully established in 2010 as a regional organisational model offering multidisciplinary care by experienced reference centres for cancer diagnosis and surgical treatment. In particular, the San Giovanni Bosco Hospital in Turin is the regional reference centre for pancreatic cancer since 2015 (50-70 oncologic surgery operations performed annually). The aim of study is to assess the effectiveness of this model for pancreatic cancer surgery by comparing survival outcomes before and after the adoption of the Oncology Network model.

Methods

The study included 178 patients, aged 37-84, who underwent duodenocephalo- or total pancreatectomy for ductal cancer in the years 2007-2019. Clinical data were retrieved from surgical records, whereas the vital status was ascertained through an application connected to the Regional Registry Office. The Kaplan-Meier method was used to estimate survival and the log-rank test was then used to compare survival rates between the two groups (before vs. after 2015). Cox's regression was employed to assess the difference between the groups, also adjusting for age, sex and ASA score.

Results

The median survival for included patients was 19 months. No significant differences were found between patients of the two groups (before vs. after 2015), neither considering all patients (p = 0.4) nor for any single ASA or age category (p-values ranging from 0.1 to 0.6). The multivariate Cox model accounting for ASA, age and sex confirmed absence of significant survival differences between the two groups.

Conclusions

Despite increased case complexity, due to the extension of surgery indication to more critical patients, the Oncology Network model allowed achieving an overall survival in pancreatic cancer surgery that is consistent with international literature and not inferior to survival outcomes previously reached in patients more strictly selected.

Key messages

This study found survival after pancreatic cancer surgery was similar before and after the center entered an Oncological Network, which led to include patients with an increased severity in case-mix. Promoting the implementation of Oncology Networks should be a public health priority as it allows to improve health outcomes and quality of care.

Appropriateness of antibiotics for medical prophylaxis: evaluation of data from the Italian PPS-2

Background

Antibiotics (AB) are administered for medical prophylaxis (MP) to prevent infectious complications. The second national point prevalence survey (PPS) of healthcare-associated infections and AB use was conducted in Italy in 2016-2017. The survey found MP accounted for nearly 25% of all registered ABs, more than twice the EU/EEA proportion. The aim of this study was to evaluate how many ABs were administered for MP and how frequently general indications were followed.

Methods

Data from the PPS were used to evaluate the prevalence of indications for MP over the total number of ABs, the proportion - among these indications - of those justified by a motivation in the patients' charts, and the prevalence of ABs considered appropriate for MP. The evaluation was made in 12 hospitals out of 14 participating in the PPS in Piedmont, chosen on the basis of patient traceability. According to national guidelines, the indications for MP that were considered appropriate in this study were: Trimethoprim/sulfamethoxazole for P. carinii pneumonia, Rifaximin for diverticulitis, Penicillin for Streptococcal infections and for splenectomized patients, and Rifampin for TB infections.

Results

1844 AB prescriptions were registered among 1334 traceable inpatients in Piedmont. The prevalence of indications for MP was 16.2% and 253 ABs (84.6%) were prescribed with a motivation. Only 3% of ABs registered as MP were appropriate for this indication: Bactrim 2%, Rifaximin 0.3%, Penicillin 0.2% and Rifampin 0.4%.

Conclusions

This study found an extremely high rate of inappropriate ABs for MP, that will be further investigated through qualitative analysis of medical records to evaluate whether a misunderstanding of the PPS protocol occurred and empirical therapy was confused with MP. Nevertheless, this study highlighted the need for interventions to improve prescribing appropriateness for MP.

Key messages

This study found that only 2.98% of ABs registered as MP among traceable patients in Piedmont were appropriate for this indication. 15.38% of prescriptions for MP were not justified by a motivation. Interventions to improve prescribing appropriateness for MP could lead to a considerable reduction in inappropriate use of ABs, which is crucial in a country facing hyperendemic levels of AMR.

Seroprevalence of anti-pertussis antibodies and immunization status of pregnant women in Turin, 2019

Background

Pertussis is an acute respiratory infection caused by B. pertussis. An acellular vaccine is available, but the protection it confers is estimated to wane after 5 years. Infants under 6 months have the highest risk of complications and mortality. In Italy, the first dose of vaccine is administered in the third month of life and maternal vaccination is recommended in the final weeks of pregnancy. This study aimed to evaluate the seroprevalence of IgG antibodies to pertussis toxin (IgG anti-PT) among pregnant women as a potential source of transplacental transfer of antibodies, which may reduce neonatal risk of disease.

Methods

An observational cross-sectional study was conducted. Two hundred women between the 33rd and 37th weeks of pregnancy were recruited among patients undergoing routine pregnancy check-up at the S.Anna Hospital of Turin, from May to December 2019. Participants were interviewed on their immunization status and a serum sample was collected. Anti-PT levels were assessed using ELISA “NovaLisa B. Pertussis toxin (PT) IgG”. Lacking a correlate of protection, we have distinguished contact with microorganism (10-39 IU/mL), exposure in the previous 2-3 years (40-99 IU/mL), recent infection or immunization &lt;12 months ( &gt; =100 IU/mL).

Results

The median age of participants was 35. Women who had anti-PT titers &gt; =10 IU/mL were 120 (60%) (10-39 IU/mL: 26%, 40-99 IU/mL: 14%, &gt; = 100 IU/mL: 20%). Around 70.5% of women declared previous vaccination (42.5% during pregnancy). Among women vaccinated in the previous 12 months, 7% presented antibodies titer &lt;100 IU/ml. Two women not vaccinated had a titer &gt; 100 IU/ml, indicative of recent pertussis exposure.

Conclusions

This study found 40% of women with antibody titers under cut-off (&lt;10 IU/mL) and 1% prevalence of recent exposure. Despite the late introduction of vaccination against pertussis during pregnancy, a good adherence to the program offered is evident.

Key messages

40% of pregnant women in this study were lacking in antibodies against Pertussis and could not transfer anti-PT to their newborn for early protection. Improving maternal vaccination coverage against pertussis should be a public health priority in Italy; a good adherence to intervention was reported.