Training and career opportunities for residencies in Hygiene and Preventive Medicine: results of a survey on 39 Italian schools

INTRODUCTION

The Italian National Health Service (SSN) is currently grappling. with a complex situation, characterized by a persistent shortage of medical personnel and the divergent aspirations of young medical graduates. Additionally, recent regulatory developments concerning specialist training further contribute to the intricacies of the landscape, calling for a comprehensive analysis of the challenges and opportunities within the sector. This study aims to provide an updated overview of the current placement of medical graduates, residents and specialists in the specific hygiene and preventive medicine (Public Health) field.

METHODS

Data on admissions, withdrawals and resignations were obtained from the Ministries of Universities and Health and from the archives of the "Associazione Liberi Specializzandi" (ALS). Information regarding the professional prospects for specialists and residents in the field of Public Health was gathered through a tailored survey conducted by the "Consulta dei Medici in Formazione Specialistica" (Council of Medical Residents) of the Italian Society of Hygiene (SItI).

RESULTS

In 2022, a total of 483 specialization contracts were granted, indicating a decrease of 37% compared to the previous year. Notably, 85 positions (17.6%) remained unallocated or resulted in dropouts. Six months after completing their residency, 1.5% of hygiene residents were still actively seeking employment. On a positive note, 75.4% of fourth-year residents secured contracts under the "Decreto Calabria". Career opportunities within the Italian SSN have witnessed growth, with a significant proportion of placements in territorial services and hospital medical directorates.

DISCUSSION AND CONCLUSIONS

The updating of training programs provided by residency schools and the exploration of innovative approaches are of paramount importance to address the urgent need for high-quality training and to cater to the requirements of the national health system.

Trends in hospital acquired NDM-producing Enterobacterales in Tuscany (Italy) from 2019 to 2021: impact of the COVID-19 pandemic

OBJECTIVES

In Tuscany, Italy, New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE) in hospitalised patients has increasingly been observed since 2018, leading in 2019 to the implementation of enhanced control measures successfully reducing transmission. We describe the NDM-CRE epidemiology during the COVID-19 pandemic in Tuscany.

METHODS

Data on NDM-CRE patients hospitalised in five Tuscan hospitals were collected from 01/2019 to 12/2021. Weekly rates of NDM-CRE cases on hospital days in medical and critical-care wards were calculated. In March-December 2020, NDM-CRE rates were stratified by COVID-19 diagnosis. Multivariate regression analysis was performed to assess outcomes' differences among two periods analysed and between COVID-19 populations.

RESULTS

Since March 2020 an increase in NDM-CRE cases was observed, associated with COVID-19 admissions. COVID-19 patients differed significantly from non-COVID-19 ones by several variables, including patient features (age, Charlson index) and clinical history and outcomes (NDM-CRE infection/colonisation, ICU stay, length of stay, mortality). During the pandemic, we observed a higher rate of NDM-CRE cases per hospital days in both non-COVID-19 patients (273/100,000) and COVID-19 patients (370/100,00) when compared with pre-pandemic period cases (187/100,00).

CONCLUSIONS

Our data suggest a resurgence in NDM-CRE spread among hospitalised patients in Tuscany during the COVID-19 pandemic, as well as a change in patients' case-mix. The observed increase in hospital transmission of NDM-CRE could be related to changes in infection prevention and control procedures, aimed mainly at COVID-19 management, leading to new challenges in hospital preparedness and crisis management planning.

Flu vaccination coverage in healthcare workers during a 3-year period in the context of the pandemic

Background

Vaccination of healthcare workers (HCWs) against seasonal influenza is considered the most effective way to protect HCWs and maintain essential healthcare services during influenza epidemics. With the present study we aimed to evaluate the efficacy of measures implemented during the three flu campaigns of 2018/19, 2019/20 and 2020/21 in a university hospital in Pisa, Italy, through the assessment of vaccination coverage (VC) in HCWs and to assess attitudes toward flu vaccination.

Methods

Flu VC was stratified according to sex, age, job and vaccination status for each season and the association between each variable and vaccination status was explored. In 2020, a survey collecting data on knowledge and attitudes on flu vaccination was distributed.

Results

Starting from the 2018/19 campaign, an increasing flu VC rate was registered: contained in 2019/20 (from 11.6% to 14.3%, Δ%=23.1) and significant (VC = 39.6%, Δ%=177.6) in 2020/21 as compared with the previous year. Physicians were the professionals most willing to get vaccinated during all seasons. Considering age the situation changed greatly over the study period, with VC rising in 2020/21 in those age groups marked by low VC in previous years (<30 and 41-50 years old, Δ%=293). Having been vaccinated in the previous year represented the most important variable to predict likelihood of accepting flu jab. However, while previously vaccinated HCWs were 13 times more likely to get the flu jab in 2019/20 compared with the others; in 2020/21 they were only 3 times. Only half of HCWS considered themselves at higher risk of contracting influenza compared to the general population, while 71% totally agreed that receiving the flu jab in 2020/21 was more important than the previous years due to COVID.

Conclusions

A significant increase in VC was observed in 2020/21, especially among those sub-groups with consistently lower uptake in previous years, due to the COVID pandemic that positively influenced vaccination uptake.

Key messages

• This study evaluates the impact of subsequent flu vaccination campaigns implemented in a large university hospital in Italy through the assessment of flu VC among HCWs.

• A significant increase in flu VC among HCWs was observed in 2020/21, especially in those categories characterized by lower VC rates in the previous years, more likely due to the COVID-19 pandemic.

Need for a competency-based approach for the Public Health Workforce training: the ISS proposal

Issue

The COVID-19 pandemic acted as a catalyst for a reconsidering health care professional workforce (HCPW) competency needed to face future public health challenges, in line with the recent WHO “Global Competency and Outcomes Framework for UHC” document. In this context, in the Italian G20 Presidency framework, the Italian National Institute of Health (ISS), launched a program named “Laboratorium” - recognised in the G20 Declarations of Ministers of Health and Leaders - aimed to the development of training tools suitable for distance learning in whatever context they are placed.

Description of the problem

Common competencies and needs of the HCPW have to be fulfilled through cross-sectional and multilevel training, to overcome the current emergency and be able to face future challenges. The aim is to provide a modular educational approach that is finalized to actively involve the participant: health professionals step in their training pathway according to their knowledge gaps, identify their specific learning objectives and, through a problem-based learning approach, acquire the proper skills for their function and tasks.

Results

We propose a two-tiered approach to training: the development of competence based courses oriented to active learning. A pilot course on Epidemic Intelligence design according to this model is ready to be released. At the same time, a repository of everything available on the web systematically selected from authorised sources by a scientific committee was created to support the training objective. It is characterised by a detailed multilevel tagging that allows an effective modularisation to reach only the content useful for its user.

Lessons

Accessibility to health-related training materials is a required necessity at every level of HCPW. Profiles within healthcare are increasingly heterogeneous and there is a need to focus on disseminating tools that can provide knowledge to address different healthcare scenarios and common purposes.

Key messages

• Future public health challenges underline a need for a competencies-based learning approach in Healthcare Workforce training.

• Italian National Institute of Health propose two methods within the ‘Laboratorium’ project to enable this type of learning: specifically designed courses and a structured document repository.

Healthcare Workers Attitudes, Practices and Sources of Information for COVID-19 Vaccination: An Italian National Survey

Background: Vaccination of healthcare workers (HCWs) is a crucial element to overcome the COVID-19 pandemic. The aim of this survey was to assess attitudes, sources of information and practices among Italian Healthcare workers (HCWs) in relation to COVID-19 vaccination. Methods: From 19 February to 23 April 2021, an anonymous voluntary questionnaire was sent to the mailing list of the main National Health Service structures. Data were collected through the SurveyMonkey platform. Results: A total of 2137 HCWs answered. Hesitancy towards COVID-19 vaccination was more frequent in females, in those with lower concern about COVID-19, and in nurses, auxiliary nurses (AN) and healthcare assistants. Hesitant professionals were more likely to not recommend vaccination to their patients or relatives, while a high concern about COVID-19 was related to an increased rate of recommendation to family members. HCWs were mostly in favor of mandatory vaccination (61.22%). Female sex, a lower education level, greater hesitancy and refusal to adhere to flu vaccination campaigns were predictors influencing the aversion to mandatory vaccination. All categories of HCWs referred mainly to institutional sources of information, while scientific literature was more used by professionals working in the northern regions of Italy and in infection control, infectious diseases, emergencies and critical areas. HCWs working in south-central regions, nurses, AN, healthcare technicians, administrators and HCWs with a lower education level were more likely to rely on internet, television, newspapers, and the opinions of family and friends. Conclusions: Communication in support of COVID-19 immunization campaigns should consider the differences between the various HCWs professional categories in order to efficiently reach all professionals, including the most hesitant ones.

Digital devices to assess vaccine hesitancy and promote pertussis vaccination during pregnancy

Introduction

Vaccination against pertussis in pregnancy is the main strategy to prevent the disease in the first trimester of life of new-borns. Effective communication is essential to successfully engage pregnant women. The use of digital devices within the outpatient setting may be helpful to engage patients before and during the consultation. The aim of this study was to develop and test an e-health tool to assess vaccine hesitancy and to deliver tailored information and education interventions to raise awareness and promote vaccine acceptance.

Methods

One-hundred-and-five participants were recruited in 4 ob-gyn clinics. Participants were invited to complete a self-administered psychometric questionnaire to assess vaccine hesitancy, disease beliefs and self-efficacy perception on health behaviours on a tablet. Participants were randomly allocated to three communication-format types providing equivalent content: 1)a single video simulating a patient-doctor conversation on the topic; 2)an interactive platform with five infographics videos; 3)a paper leaflet followed by a brief consultation with the physician. The intention to get vaccinated during pregnancy was assessed through a specific question before and after the intervention.

Results

In the pre-intervention phase there was no difference observed between groups in terms of the variable “intention” to get vaccinated. After the intervention, participants of groups 1 and 3 showed a higher intention to get vaccinated than group 2 at the Kruskal-Wallis test (H(2)=6.008, p < 0.05). Post-intervention intention to vaccinate correlated with Individual Self-Efficacy (rs(105)=0.30, p < 0.001) and was inversely associated with vaccine hesitancy (rs(105)=0.34, p < 0.001).

Conclusions

We implemented and assessed the impact of different communication strategies to promote vaccine uptake among pregnant women. Our results suggest comparable effect may be obtained using simulated versus live patient-physician communication.

Key messages

The use of digital devices allows an effective and manageable communication about vaccination to pregnant women. In the present study, the implementation of digital forms of communication allowed a comparison with standard procedures of information towards vaccination, demonstrating their equivalence.

The educational role of IBD nurses in Italy in vaccinations: do not miss the moment for COVID-19

OBJECTIVE

The role of nurses has great educational-scientific potential in COVID-19 vaccination. The aim of this work is to clarify whether the educational role of IBD nurses in vaccination is perceived by IBD patients.

MATERIALS AND METHODS

A cross-sectional study was carried out, through a questionnaire, to evaluate how many IBD patients received health education about vaccinations from the dedicated nurses (IBD nurses).

RESULTS

There were four hundred questionnaires, 310 patients (77.5%) answered all questions. The nurse does not appear to help educate patients on influenza vaccination (66.1%) or pneumococcal vaccination (81.6%). Disclosed patients have many doubts about the new COVID-19 vaccination (74.4%) and many seek information (74.8%) and think that the nurse can provide the necessary information (70%).

CONCLUSIONS

IBD nurses do not seem very active in the vaccination education role, and they do not meet patients' expectations, which are conversely very high.

Effectiveness of Disinfection with Chlorine Dioxide on Respiratory Transmitted, Enteric, and Bloodborne Viruses: A Narrative Synthesis

A viral spread occurrence such as the SARS-CoV-2 pandemic has prompted the evaluation of different disinfectants suitable for a wide range of environmental matrices. Chlorine dioxide (ClO₂) represents one of the most-used virucidal agents in different settings effective against both enveloped and nonenveloped viruses. This narrative synthesis is focused on the effectiveness of ClO₂ applied in healthcare and community settings in order to eliminate respiratory transmitted, enteric, and bloodborne viruses. Influenza viruses were reduced by 99.9% by 0.5–1.0 mg/L of ClO₂ in less than 5 min. Higher concentration (20 mg/L) eliminated SARS-CoV-2 from sewage. ClO₂ concentrations from 0.2 to 1.0 mg/L ensured at least a 99% viral reduction of AD40, HAV, Coxsackie B5 virus, and other enteric viruses in less than 30 min. Considering bloodborne viruses, 30 mg/L of ClO₂ can eliminate them in 5 min. Bloodborne viruses (HIV-1, HCV, and HBV) may be completely eliminated from medical devices and human fluids after a treatment with 30 mg/L of ClO₂ for 30 min. In conclusion, ClO₂ is a versatile virucidal agent suitable for different environmental matrices.

Improving the Reprocessing Quality of Flexible Thermolabile Endoscopes: How to Learn from Mistakes

Background: Failure in the reprocessing of thermolabile flexible endoscopes has been reported as one of the most important threats to patient health. Method: A case report and observational study was conducted, from August 2014 to December 2019, in the Digestive Endoscopy Unit of a University Hospital in Italy, where two cases of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae infections in patients undergoing endoscopic retrograde cholangio-pancreatography were observed. Following the risk/safety management practices, an epidemiological investigation was started, duodenoscopes were removed from use and the reprocessing practices reviewed. Moreover, microbiological surveillance of endoscopes was carried out according to the CDC guidelines. Results: In the first phase of sampling, 10/10 (100%) endoscopes were found to be non-compliant, of which 7 showed results for high-concern organisms (HCOs), such as KPC-K. pneumoniae, P. aeruginosa and E. coli. After implementing corrective actions, 12 out of 17 endoscopes were found to be non-compliant (70.5%), of which 8 showed results for HCOs, such as KPC-K. oxytoca and P. aeruginosa. During the last year of regular microbiological surveillance, only 23% of endoscopes (35/152) were found to be non-compliant, of which 7 showed results for HCOs, such as NDM-K. pneumoniae, P. aeruginosa and A. baumannii. The crucial issues were related to samples collected from the internal channels of duodenoscopes. Conclusion: Managing the risk associated with the reprocessing of digestive endoscopes, through risk assessment at every stage of the process, is important for the prevention of infections associated with the use of these device.

Prolonged outbreak of New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE), Tuscany, Italy, 2018 to 2019

In Tuscany, Italy, New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE) have increased since November 2018. Between November 2018 and October 2019, 1,645 samples were NDM-CRE-positive: 1,270 (77.2%) cases of intestinal carriage, 129 (7.8%) bloodstream infections and 246 (14.9%) infections/colonisations at other sites. Klebsiella pneumoniae were prevalent (1,495; 90.9%), with ST147/NDM-1 the dominant clone. Delayed outbreak identification and response resulted in sustained NDM-CRE transmission in the North-West area of Tuscany, but successfully contained spread within the region.

Microbiological surveillance in reducing potential infection risk

Background

Failure in reprocessing of endoscopes has been reported as one of the top ten most important threats to patient health.

Materials/Methods

The study was conducted in two digestive endoscopy centres of a teaching hospital (29,000 endoscopies/year, of which 550 endoscopic retrograde cholangiopancreatography (ERCP). Following two cases of bacteremia due to KPC-producing Klebsiella pneumoniae temporally related to ERCP and 89% of non-compliance detected on endoscopes subjected to microbiological surveillance, the reprocessing activities were audited and implemented to ensure guideline compliance. Clinical and microbiological surveillance were reinforced and all responsibilities for each phase identified according to UNI/TR11662. Microbiological surveillance was performed according to the 'Duodenoscope Surveillance Sampling and Culturing Protocols' protocol, CDC, 2018.

Results

In the 11 months of surveillance, 47 endoscopes were sampled (13 colonoscopes, 9 gastroscopes, 23 duodenoscopes and 2 echoendoscopes), 19 washer-disinfector machines and 9 medical cabinets. 36% (17/47) of endoscope internal channels resulted non-compliant, 17% (4/23) in duodenoscopes. NDM-producing K. pneumoniae was isolated in 2 gastroscopes always associated with the use on a colonized patient. The inlet and final rinsing water of washer-disinfectors and medical cabinets resulted always conformed. Non-conformities were managed immediately in order to avoid infectious risks for patients.

Conclusions

Microbiological surveillance of endoscopes after reprocessing allowed to prevent infections in patients undergoing endoscopic procedures.

Key messages

Training of health workers followed by strict adherence to guidelines is the most appropriate tool in preventing and controlling infections related to the use of endoscopes. Endoscopy and reprocessing staff should follow a formal recognized endoscopy reprocessing training program, followed by regular practice and periodically updated training to maintain competency.

Core competencies for public health medicine: protocol for an Italian inter-society Delphi consensus

Background

Developing core competencies is crucial for the quality of educational curricula in Public Health Medicine (PHM). The postgraduate medical School of Public Health of the University of Pisa developed a core curriculum for PHM specialists (CCV0), adapted from the list of core competencies promoted by the Association of Schools in Public Health of the European Region (ASPHER).

Objectives

We will apply the Garavalia method, a three-round step-wise Delphi consensus, for adapting the CCV0 to the Italian context. Participants will be enrolled through purposive sampling among the members of the Italian Society of Hygiene, Public Health and Preventive Medicine, aiming at the best possible balance between geographical distribution and professional profiles (PHM residents, academics, and Public Health operators). A sample of representatives of other PHM-related Italian Societies will also be included.

Results

We will invite 139 participants through e-mail invitations. During round zero, we will collect additional suggested competencies through an open-ended question. We will analyze data qualitatively and integrate the most relevant suggestions with the CCV0, resulting in the CCV1. A subgroup of 64 experts (among PHM residents, academics, and representatives of the included Societies) will participate in the following rounds. The first round will use Likert scales to measure agreement on the appropriateness of the CCV1 competencies. Consensus and agreement will be computed using the RAND/UCLA criteria. The final round will reach out for consensus repeating the same ratings for competencies classified as uncertain, with the help of quali-quantitave summaries of the answers of the first round. The final document (CC2) will report competencies classified as consensus or uncertain, with the corresponding level of consent.

Conclusions

The CC2 will enable current courses to be assessed and inform the design of future educational programs for Italian PHM residents.

Key messages

The Delphi method ensures anonymity and a balanced involvement of all stakeholders –including medical residents- in the development of a core curriculum for Public Health Medicine specialists. A consensus on core competencies in Public Health Medicine will enable the evaluation of current training curricula and the development of future educational programs.

Surveillance and control of M. chimaera infections in the Tuscany Region, Italy

Background

Disseminated M. chimaera infections among patients who underwent open-chest surgery with cardiopulmonary bypass have been associated with the contamination of heater-cooler devices (HCDs). The Tuscany region in the Decree 3822/2019 issued recommendations for the surveillance and control of M. chimaera infections.

Methods

In three Tuscan cardiac surgery centers, the case finding was carried out through evaluation and testing of patients with a history of HCD exposure (past 6 years) was performed. Water and aerosol samples were analyzed from each HCDs to determine the microbiological parameters required by the Directive 98/83/CE and to assess the presence of non-tuberculous mycobacteria (NTMs), according to the regional protocol.

Results

M. chimaera infection was not found in any patient and all clinical specimens tested negative. 22 HCDs were sampled (n.12 LivaNova, n.1 Terumo and n.9 Maquet) for a total of 114 samples (45, 8, 2 and 59 respectively). All the microbiological parameters were compliant, excepted for total microbial count at 36 °C that exceeded 100 CFU/ml in 50% (57/114) of samples and for the presence of P.aeruginosa in 10% (12/114). NTMs were detected in 16% (18/114) of HCDs: M. chimaera was identified in 11% (13/114) of samples and in 4% (5/114) M. gordonae. All aerosol samples were negative for NTMs, but in the HCDs Maquet, B.cereus were detected in 7% (4/59) of the samples, K.oxytoca in 2% (1/59), B.ursincola in 2% (1/59) and S. paucimobilis in 3% (2/59). Only S. paucimobilis was isolated also in the same HCD water sample.

Conclusions

The implementation of maintenance and disinfection procedures of HCDs was able to reduce the risk of contamination and aerosolization by NTMs but not of other microorganisms.

Key messages

Further strategies should be put in place for the cases finding. Moreover, reliable decontamination and identification of agents that can disrupt biofilms and increase chlorine susceptibility of mycobacteria are required.

“Nudge” in Lucca’s Hospital: separate waste collection improvement and cigarettes dumping reduction

Background

Positive behaviour and user's collaboration improved by using choices orientation techniques; in Lucca's Hospital (North-West Tuscany Sanitary Authority) this approach has improved separate waste collection execution and has decreased cigarettes dumping in commons areas.

Objectives

Phase 1 (May 2019): amendment of choices architecture recyclable waste bins in commons areas and into the wards were boosted, with “islands” clearly visible from any point of common paths; in the transit areas were installed exclusively multi-material and paper bins, equipped with signs that clearly indicate which products deliver; residual waste bins were allowed exclusively in certain points.ashtrays at the hospital entrances were eliminated and replaced with signage indicating smoking cessation benefits and the presence of areas “put your cigarette out” along the structure approach routes.

Phase 2 (scheduled for May 2020): “nudge” action

Spreading in community (using press and social-media) and locally (using poster) of the slogan “In San Luca we are taking a step forward: don't lag behind!”. This message stimulate the perception of an ongoing change to join.

Results

A decrease in residual waste collection and in instances of non-compliance in separate waste collection was detected. Decorum in the outdoor environments improved, with a reduction of user's reports and extra-cleaning interventions.

Conclusions

The described actions have improved user's collaboration, management efficiency of waste disposal and cleaning service, perceived quality and cost.

Key messages

Imitating a social model appears to be successful motivator of virtuous behaviours. Choices architecture and “nudge” techniques may improve citizens’ care pathways governance.

Impact of vaccination on invasive pneumococcal disease in Italy 2007-2017: surveillance challenges and epidemiological changes

Surveillance of new cases of invasive pneumococcal disease (IPD) in Italy was started in 2007 by the Ministry of Health (MoH). In 2012, pneumococcal childhood vaccination was introduced at the national level and, in 2017, for citizens aged 65 years and over. We describe here IPD epidemiology in Italy over the past 10 years investigating the impact of the vaccine programme on disease burden. Reports of IPD cases, data on serotype and vaccination coverage (VC) data were obtained from MoH annual reports, for the period 2007-2017. IPD notification rate and proportion by year, region, age and serotype were calculated. In 2007, 525 cases were reported (rate 0.88/100 000), rising to 1703 cases (rate 2.82/100 000) in 2017. The distribution of IPD cases by age group over time registered the largest share among individuals aged 65 years and over. A decreasing trend in notification rate was observed among those aged 0-4 years. During the same period, the 24-month VC increased, ranging from 80.9% to 96.7% in 2017. Molecular data indicated re-emergence of PPSV23-specific serotypes and non-vaccine serotypes. We observed an increase in IPD notifications during 2007-2017, likely due to an improved surveillance system, at least in some regions, with the relative quota of IPD notifications decreasing among vaccinated children cohorts. Further strengthening of IPD surveillance system, including molecular and vaccine coverage data, would be needed to assess and inform pneumococcal vaccination strategies in Italy.

Prevention and Control of Legionella and Pseudomonas spp. Colonization in Dental Units

Introduction: Dental Unit Waterlines (DUWLs) have shown to be a source of Legionella infection. We report the experience of different dental healthcare settings where a risk management plan was implemented. Materials and methods: In a Hospital Odontostomatology Clinic (HOC) and three Private Dental Clinics (PDCs) housing 13 and six dental units (DUs), respectively, an assessment checklist was applied to evaluate staff compliance with guideline recommendations. DUWLs microbial parameters were investigated before and after the application of corrective actions. Results: In the HOC a poor adherence to good practices was demonstrated, whereas protocols were carefully applied in PDCs. L. pneumophila sg 2-15 was isolated in 31% (4/13) and 33% (2/6) of DUs in HOC and PDCs, respectively, mainly from handpieces (32%, 6/19) with counts >102 colony-forming units per milliliter (CFU/L), often associated with P. aeruginosa (68%, 13/19). The shock disinfection with 3% v/v hydrogen peroxide (HP) showed a limited effect, with a recolonization period of about 4 weeks. Legionella was eradicated only after 6% v/v HP shock disinfection and filters-installation, whilst P. aeruginosa after the third shock disinfection with a solution of 4% v/v HP and biodegradable surfactants. Conclusions: Our data demonstrate the presence and persistence of microbial contamination within the DUWLs, which required strict adherence to control measures and the choice of effective disinfectants.

Essential strategies in HAI prevention and control: performance assessment through the implementation of the HAI-CoSIP tool of the GISIO-SItI group. A pilot study in a sample of Italian Organizations

BACKGROUND

Healthcare-Associated Infections are a great concern for worldwide healthcare systems and represent a considerable threat to patient safety, leading to adverse clinical outcomes. A defined panel of indicators represents a key element to guide Healthcare Organizations towards identification of main gaps, implementation of effective actions and continuous improvements on Healthcare-Associated Infections prevention and control activities. A review on accreditation systems conducted by the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene Preventive Medicine and Public Health revealed a substantial heterogeneity of implemented standards and led to the development of a core set of indicators and requirements for Healthcare-Associated Infections' prevention and control within the hospital setting. The main aim of the study was to test the feasibility of the Healthcare-Associated Infections' prevention and control within the hospital setting tool to calculate performance scores on a sample of Italian Healthcare Organizations and to identify major critical issues. The potential benefits of the possibility of future implementation of the tool within Institutional Accreditation Programs is discussed.

STUDY DESIGN

Cross sectional pilot survey.

METHODS

The Healthcare-Associated Infections' prevention and control within the hospital setting included 96 criteria and 20 key areas including an area for outcomes indicators. For applicable criteria, standards fulfilment was evaluated according to a 4 point Likert scale. A composite score was calculated for each Healthcare Organization and five performance levels were identified. Data were further analysed by computing performance scores at the level of each area and requirement.

RESULTS

20 Healthcare Organizations agreed to take part in this pilot study including two rehabilitative Healthcare Organizations. Among the whole sample a mean of 12.20% of requirements resulted not fulfilled, leaving space for further improvements. Critical areas were easily identified and the instrument was able to capture substantial differences between Healthcare Organizations. Only a few number of standards resulted "Not Applicable" (Mean = 4.71%) and most of them regarded Rehabilitative Healthcare Organizations. Mean composite performance index resulted 74.06% (SD = 16.96, range 36.30 - 94.27%); area of outcome indicators obtained a mean score of 56.17.

CONCLUSION

The Healthcare-Associated Infections' prevention and control within the hospital setting resulted an useful tool to assess Healthcare Organizations' performance in the field of Healthcare-Associated Infections prevention and control and to identify necessary actions for further improvements. The distribution of total scores by Healthcare Organizations showed a high heterogeneity. Implementation of the Healthcare-Associated Infections' prevention and control within the hospital setting tool as an institutional accreditation tool may help to drive the required harmonization at a national level of Healthcare-Associated Infections management and control strategies and overcome current substantial regional differences.

Detection and decontamination of Mycobacterium chimaera and other non-tuberculosis mycobacteria in heater-cooler devices used in cardiopulmonary bypass: a Manufacturer and National guidelines summary, and a potential resolution to the problem requiring further investigation

Since 2011, invasive infections due to Mycobacterium chimaera have been diagnosed in patients with previous cardiac surgery. The use of heating/cooling devices (heater-cooler units), necessary to regulate the blood temperature in extra-corporeal circulation, has been identified as a source of contaminated aerosol. Adhering to a strict maintenance program according to the manufacturer's instructions for use including sanitizing is essential to reduce the risk. Current manufacturer guidelines and national recommendations for detection and decontamination of Mycobacterium chimaera and other non-tuberculosis mycobacteria should organically update units' policies and protocols as they are published.

[Asbestos in drinking water and hazards to human health: a narrative synthesis]

The term asbestos refers to six unique fibrous minerals mostly used in the production of asbestos cement sheets and pipes. According to the World Health Organization and the International Agency for Research on Cancer (IARC), there exists at least "sufficient evidence" that all types of asbestos may cause cancer in humans (mesothelioma, lung cancer, laryngeal tumor and ovarian cancer). The only asbestos limit in drinking water is 7 million fiber/liter. This study is a narrative synthesis about the possible hazards to human health related to the presence of asbestos in drinking water. The various scientific studies and epidemiological reports examined highlight that there is an ongoing debate on the possible carcinogenic risk associated with asbestos exposure through ingestion. Nevertheless, considering the latency with which diseases caused by asbestos may emerge, control measures should be adopted.

Assessment, control, and prevention of microbiological and chemical hazards in seasonal swimming pools of the Versilia district (Tuscany, central Italy)

Although in Europe the quality of swimming pools (SPs) is dictated by regulations, microbiological and chemical hazards are described in the literature. Environmental bacteria or toxic disinfection by-product (DBP) compounds may indeed be recovered in waters even after disinfection. We evaluated the water quality from 26 outdoor seasonal SPs of the Versilia district, according to requirements of Regional Decree 54R/2015. In spring 2017, supply and reinstatement waters were collected after shock hyperchlorination (10 mg/L) while in summertime, a second sampling of waters before entering the pools, as well as in the pools, was performed after SPs were open to the public. In all samples, microbiological and chemical parameters were determined as defined by Directive 98/83/EC and the Italian Health Ministry. Microbiological data were within suggested limits. The first chemical analyses showed that in 35% of the feeding-pool seawater samples, the halogenated organic compounds were higher than the maximum permissible concentrations (30 μg/L). Pool waters were then dechlorinated and re-treated with hydrogen peroxide (10 mg/L) to ensure the abatement of DBPs (from 164 ± 107 to 0.9 ± 0.8 μg/L; p = 0.002). Results highlighted the need of self-controlled procedures for the SPs waters to prevent waterborne diseases and suggested hydrogen peroxide as the most appropriate disinfection method.

Microbiological Air Quality in Heating, Ventilation and Air Conditioning Systems of Surgical and Intensive Care Areas: The Application of a Disinfection Procedure for Dehumidification Devices

International literature data report that the increase of infectious risk may be due to heating, ventilation and air conditioning (HVAC) systems contaminated by airborne pathogens. Moreover, the presence of complex rotating dehumidification wheels (RDWs) may complicate the cleaning and disinfection procedures of the HVAC systems. We evaluated the efficacy of a disinfection strategy applied to the RDW of two hospitals’ HVAC systems. Hospitals have four RDW systems related to the surgical areas (SA1 and SA2) and to the intensive and sub-intensive care (IC and sIC) units. Microbiological air and surface analyses were performed in HVAC systems, before and after the disinfection treatment. Hydrogen peroxide (12%) with silver ions (10 mg/L) was aerosolized in all the air sampling points, located close to the RDW device. After the air disinfection procedure, reductions of total microbial counts at 22 °C and molds were achieved in SA2 and IC HVAC systems. An Aspergillus fumigatus contamination (6 CFU/500 L), detected in one air sample collected in the IC HVAC system, was eradicated after the disinfection. The surface samples proved to be of good microbiological quality. The results suggest the need for a disinfection procedure to improve the microbiological quality of the complex HVAC systems, mostly in surgical and intensive care areas.

Survey on Energy Drinks consumption and related lifestyle among students of two Italian high schools

BACKGROUND

The European Food Safety Authority (EFSA) has identified some risk factors for the occurrence of side effects linked to energy drinks (EDs) consumption by young people. EDs consumption has been evaluated in a sample of students in Italy together with some aspects of their lifestyle.

METHODS

The survey was performed in two high schools from September 2016 to June 2017. 583 students between 14 to 18 years were recruited and a standard questionnaire (EFSA checklist) was used to collect information on responders characteristics, beverages consumption, EDs with alcohol, and EDs and sports.

RESULTS

Despite 350 out of 583 responders (60%) consumed EDs, only 146 out of 583 (25%) were EDs-alcohol consumers. Moreover, 208 out of 379 (55%) of all physically active adolescents reported frequent EDs consumption before sport trainings.

CONCLUSIONS

Study results highlight the need for primary prevention measures in communication campaigns and training delivered by school to limit potential health threats related to excess of EDs consumption.

Control and prevention measures for legionellosis in hospitals: A cross-sectional survey in Italy

Risk assessment, environmental monitoring, and the disinfection of water systems are the key elements in preventing legionellosis risk. The Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine, and Public Health and the Italian Multidisciplinary Society for the Prevention of Health Care-Associated Infections carried out a national cross-sectional survey to investigate the measures taken to prevent and control legionellosis in Italian hospitals. A multiple-choice questionnaire was developed, comprising 71 questions regarding hospital location, general characteristics, clinical and environmental surveillance, and control and preventive measures for legionellosis in 2015. Overall, 739 hospitals were enrolled from February to June 2017, and 178 anonymous questionnaires were correctly completed and evaluated (response rate: 24.1%). The survey was conducted using the SurveyMonkey® platform, and the data were analyzed using Stata 12 software. Of the participating hospitals, 63.2% reported at least one case of legionellosis, of which 28.2% were of proven nosocomial origin. The highest case numbers were reported in the Northern Italy, in hospitals with a pavilion structure or cooling towers, and in hospitals with higher numbers of beds, wards and operating theaters. Laboratory diagnosis was performed using urinary antigen testing alone (31.9%), both urinary antigen testing and single antibody titer (17.8%), or with seroconversion also added (21.5%). Culture-based or molecular investigations were performed in 28.8% and 22.1% of the clinical specimens, respectively. The water systems were routinely tested for Legionella in 97.4% of the hospitals, 62% of which detected a positive result (> 1000 cfu/L). Legionella pneumophila serogroup 2-15 was the most frequently isolated species (58.4%). The most common control measures were the disinfection of the water system (73.7%), mostly through thermal shock (37.4%) and chlorine dioxide (34.4%), and the replacement (69.7%) or cleaning (70.4%) of faucets and showerheads. A dedicated multidisciplinary team was present in 52.8% of the hospitals, and 73% of the hospitals performed risk assessment. Targeted training courses were organized in 36.5% of the hospitals, involving nurses (30.7%), physicians (28.8%), biologists (21.5%), technicians (26.4%), and cleaners (11%). Control and prevention measures for legionellosis are present in Italian hospitals, but some critical aspects should be improved. More appropriate risk assessment is necessary, especially in large facilities with a high number of hospitalizations. Moreover, more sensitive diagnostic tests should be used, and dedicated training courses should be implemented.

Procedures in endoscope reprocessing and monitoring: an Italian survey

BACKGROUND

The high diffusion of endoscopes worldwide and the need for effective reprocessing methods requested the development of guidelines and implementation of surveillance procedures at local level.

STUDY DESIGN

In order to collect data on everyday's practice and adherence to available guidelines, endoscopy units from different public institutions were surveyed using a dedicated questionnaire.

METHODS

Between July and November 2015 a survey was carried in 12 main hospitals from 10 different Italian regions, involving 22 endoscopy units. The state of the art of national and international guidelines was investigated to compare the protocols adopted at local level.

RESULTS

In all the surveyed hospitals, the reprocessing activity is based on pre-established protocols in adherence with principal guidelines. Enzymatic detergents, which are recommended by the international guidelines, are used in 55.6% of units and peracetic acid is currently the most widely used chemical disinfectant. Discrepancies were observed in the application of periodic quality controls.

CONCLUSION

Updated guidelines are generally applied in reprocessing practice. Quality controls may represent a critical issue to improve effectiveness and surveillance. The whole of acquired data can promote a positive trend towards the application of best practices.

Evaluation of the Cleaning Procedure Efficacy in Prevention of Nosocomial Infections in Healthcare Facilities Using Cultural Method Associated with High Sensitivity Luminometer for ATP Detection

In healthcare facilities, environmental surfaces may be a reservoir of infectious agents even though cleaning and disinfection practices play a role in the control of healthcare-associated infections. In this study, the effectiveness of cleaning/disinfection procedures has been evaluated in two hospital areas, which have different risk category classifications. According to the contract with the cleaning service, after the daily ambulatory activities, the housekeeping staff apply an alcohol-based detergent followed by a chlorine-based disinfectant (2% Antisapril, Angelini; 540 mg/L active chlorine), properly diluted and sprayed. The contract provides for the use of disposable microfiber wipes which must be replaced with new ones in each health out-patient department. Surface contamination was analyzed using cultural methods and ATP detection, performed with a high-sensitivity luminometer. The values 100 CFU/cm² and 40 RLU/cm² were considered as the threshold values for medium-risk category areas, while 250 CFU/cm² and 50 RLU/cm² were defined for the low-risk category ones. Air quality was evaluated using active and passive sampling microbiological methods and particle count (0.3 μm⁻10 μm) detection. The cleaning/disinfection procedure reduced the medium bacterial counts from 32 ± 56 CFU/cm² to 2 ± 3 CFU/cm² in the low-risk area and from 25 ± 40 CFU/cm² to 7 ± 11 CFU/cm² in the medium-risk one. Sample numbers exceeding the threshold values decreased from 3% and 13% to 1% and 5%, respectively. RLU values also showed a reduction in the samples above the thresholds from 76% to 13% in the low-risk area. From the air samples collected using the active method, we observed a reduction of 60% in wound care and 53% in an ambulatory care visit. From the air samples collected using the passive method, we highlighted a 71.4% and 50% reduction in microbial contamination in the medium-risk area and in the low-risk one, respectively. The 10 μm size particle counts decreased by 52.7% in wound care and by 63% in the ambulatory care visit. Correct surface sanitation proved crucial for the reduction of microbial contamination in healthcare settings, and plays an important role in ensuring air quality in hospital settings.

Definition of criteria and indicators for the prevention of Healthcare-Associated Infections (HAIs) in hospitals for the purposes of Italian institutional accreditation and performance monitoring

BACKGROUND

Healthcare-associated infections (HAIs) are an important issue in terms of quality of care. HAIs impact patient safety by contributing to higher rates of preventable mortality and prolonged hospitalizations. In Italy, analysis of the currently available accreditation systems shows a substantial heterogeneity of approaches for the prevention and surveillance of HAIs in hospitals. The aim of the present study is to develop and propose the use of a synthetic assessment tool that could be implemented homogenously throughout the nation.

METHODS

An analysis of nine international and of the 21 Italian regional accreditation systems was conducted in order to identify requirements and indicators implemented for HAI prevention and control. Two relevant reviews on this topic were further analyzed to identify additional evidence-based criteria. The project team evaluated all the requirements and indicators with consensus meeting methodology, then those applicable to the Italian context were grouped into a set of "focus areas".

RESULTS

The analysis of international systems and Italian regional accreditation manuals led to the identification respectively of 19 and 14 main requirements, with relevant heterogeneity in their application. Additional evidence-based criteria were included from the reviews analysis. From the consensus among the project team members all the standards were compared and 20 different thematic areas were identified, with a total of 96 requirements and indicators for preventing and monitoring HAIs.

CONCLUSIONS

The study reveals a great heterogeneity in the definition of accreditation criteria between the Italian regions. The introduction of a uniform, synthetic assessment instrument, based on the review of national and international standards, may serve as a self-assessment tool to evaluate the achievement of a minimum standards set for HAIs prevention and control in healthcare facilities. This may be used as an assessment tool by the Italian institutional accreditation system, also useful to reduce regional disparities.

Potential testing of reprocessing procedures by real-time polymerase chain reaction: A multicenter study of colonoscopy devices

BACKGROUND

Reprocessing of endoscopes is key to preventing cross-infection after colonoscopy. Culture-based methods are recommended for monitoring, but alternative and rapid approaches are needed to improve surveillance and reduce turnover times. A molecular strategy based on detection of residual traces from gut microbiota was developed and tested using a multicenter survey.

METHODS

A simplified sampling and DNA extraction protocol using nylon-tipped flocked swabs was optimized. A multiplex real-time polymerase chain reaction (PCR) test was developed that targeted 6 bacteria genes that were amplified in 3 mixes. The method was validated by interlaboratory tests involving 5 reference laboratories. Colonoscopy devices (n = 111) were sampled in 10 Italian hospitals. Culture-based microbiology and metagenomic tests were performed to verify PCR data.

RESULTS

The sampling method was easily applied in all 10 endoscopy units and the optimized DNA extraction and amplification protocol was successfully performed by all of the involved laboratories. This PCR-based method allowed identification of both contaminated (n = 59) and fully reprocessed endoscopes (n = 52) with high sensibility (98%) and specificity (98%), within 3-4 hours, in contrast to the 24-72 hours needed for a classic microbiology test. Results were confirmed by next-generation sequencing and classic microbiology.

CONCLUSIONS

A novel approach for monitoring reprocessing of colonoscopy devices was developed and successfully applied in a multicenter survey. The general principle of tracing biological fluids through microflora DNA amplification was successfully applied and may represent a promising approach for hospital hygiene.

[Employment opportunities and job satisfaction in the field of Public Health: a survey among recent graduates of the Hygiene and Preventive Medicine residency in Italy]

We conducted an on-line survey among 255 specialists in Hygiene and Preventive Medicine in Italy who completed their training between October 2014 and July 2016, to assess their training experience, employment opportunities and current job satisfaction. Response rate was 49%. Mean age was 35 years. A high employment rate within two years from obtaining specialist qualification was reported by the 125 specialists who completed the questionnaire (76% are currently employed). The three main work settings of the participating specialists are hospital health directions (37%), universities (19%) and local Prevention Departments (16%). Two thirds (66%) have temporary positions and only 6% permanent positions. Job, pay, and training satisfaction are often below expectations with geographical differences that would need to be further investigated.

Detection of viable but non-culturable legionella in hospital water network following monochloramine disinfection

BACKGROUND

Prevention of legionellosis remains a critical issue in healthcare settings where monochloramine (MC) disinfection was recently introduced as an alternative to chlorine dioxide in controlling Legionella spp. contamination of the hospital water network. Continuous treatments with low MC doses in some instances have induced a viable but non-culturable state (VBNC) of Legionella spp.

AIM

To investigate the occurrence of such dormant cells during a long period of continuous MC treatment.

METHODS

Between November 2010 and April 2015, 162 water and biofilm samples were collected and Legionella spp. isolated in accordance with standard procedures. In sampling sites where MC was <1.5mg/L, VBNC cells were investigated by ethidium monoazide bromide (EMA)-real-time polymerase chain reaction (qPCR) and 'resuscitation' test into Acanthamoeba polyphaga CCAP 1501/18. According to the Health Protection Agency protocol, free-living protozoa were researched in 60 five-litre water samples.

FINDINGS

In all, 136 out of 156 (87.2%) of the samples taken from sites previously positive for L. pneumophila ST269 were negative by culture, but only 47 (34.5%) negative by qPCR. Although no positive results were obtained by EMA-qPCR, four out of 22 samples associated with MC concentration of 1.3 ± 0.5mg/L showed VBNC legionella resuscitation. The presence of the amoeba A. polyphaga in the hospital water network was demonstrated.

CONCLUSION

Our study is the first report evidencing the emergence of VNBC legionella during a long period of continuous MC treatment of a hospital water network, highlighting the importance of keeping an appropriate and uninterrupted MC dosage to ensure the control of legionella colonization in hospital water supplies.

Childhood neurofibromatosis type 2 (NF2) and related disorders: from bench to bedside and biologically targeted therapies

Neurofibromatosis type 2 [NF2; MIM # 101000] is an autosomal dominant disorder characterised by the occurrence of vestibular schwannomas (VSs), schwannomas of other cranial, spinal and cutaneous nerves, cranial and spinal meningiomas and/or other central nervous system (CNS) tumours (e.g., ependymomas, astrocytomas). Additional features include early onset cataracts, optic nerve sheath meningiomas, retinal hamartomas, dermal schwannomas (i.e., NF2-plaques), and (few) café-au-lait spots. Clinically, NF2 children fall into two main groups: (1) congenital NF2 - with bilateral VSs detected as early as the first days to months of life, which can be stable/asymptomatic for one-two decades and suddenly progress; and (2) severe pre-pubertal (Wishart type) NF2- with multiple (and rapidly progressive) CNS tumours other-than-VS, which usually present first, years before VSs [vs. the classical adult (Gardner type) NF2, with bilateral VSs presenting in young adulthood, sometimes as the only disease feature]. Some individuals can develop unilateral VS associated with ipsilateral meningiomas or multiple schwannomas localised to one part of the peripheral nervous system [i.e., mosaic NF2] or multiple non-VS, non-intradermal cranial, spinal and peripheral schwannomas (histologically proven) [schwannomatosis]. NF2 is caused by mutations in the NF2 gene at chromosome 22q12.1, which encodes for a protein called merlin or schwannomin, most similar to the exrin-readixin-moesin (ERM) proteins; mosaicNF2 is due to mosaic phenomena for the NF2 gene, whilst schwannomatosis is caused by coupled germ-line and mosaic mutations either in the SMARCB1 gene [SWNTS1; MIM # 162091] or the LZTR1 gene [SWNTS2; MIM # 615670] both falling within the 22q region and the NF2 gene. Data driven from in vitro and animal studies on the merlin pathway [e.g., post-translational and upstream/downstream regulation] allowed biologically targeted treatment strategies [e.g., Lapatinib, Erlotinib, Bevacizumab] aimed to multiple tumour shrinkage and/or regression and tumour arrest of progression with functional improvement.

Evaluation of Legionella Air Contamination in Healthcare Facilities by Different Sampling Methods: An Italian Multicenter Study

Healthcare facilities (HF) represent an at-risk environment for legionellosis transmission occurring after inhalation of contaminated aerosols. In general, the control of water is preferred to that of air because, to date, there are no standardized sampling protocols. Legionella air contamination was investigated in the bathrooms of 11 HF by active sampling (Surface Air System and Coriolis^®μ) and passive sampling using settling plates. During the 8-hour sampling, hot tap water was sampled three times. All air samples were evaluated using culture-based methods, whereas liquid samples collected using the Coriolis^®μ were also analyzed by real-time PCR. Legionella presence in the air and water was then compared by sequence-based typing (SBT) methods. Air contamination was found in four HF (36.4%) by at least one of the culturable methods. The culturable investigation by Coriolis^®μ did not yield Legionella in any enrolled HF. However, molecular investigation using Coriolis^®μ resulted in eight HF testing positive for Legionella in the air. Comparison of Legionella air and water contamination indicated that Legionella water concentration could be predictive of its presence in the air. Furthermore, a molecular study of 12 L. pneumophila strains confirmed a match between the Legionella strains from air and water samples by SBT for three out of four HF that tested positive for Legionella by at least one of the culturable methods. Overall, our study shows that Legionella air detection cannot replace water sampling because the absence of microorganisms from the air does not necessarily represent their absence from water; nevertheless, air sampling may provide useful information for risk assessment. The liquid impingement technique appears to have the greatest capacity for collecting airborne Legionella if combined with molecular investigations.

Evaluation and control of microbial and chemical contamination in dialysis water plants of Italian nephrology wards

BACKGROUND

Patients receiving haemodialysis are exposed to a large volume of dialysis fluid. The Italian Society of Nephrology (ISN) has published guidelines and microbial quality standards on dialysis water (DW) and solutions to ensure patient safety.

AIM

To identify microbial and chemical hazards, and evaluate the quality of disinfection treatment in DW plants.

METHODS

In 2015 and 2016, water networks and DW plants (closed loop and online monitors) of nine dialysis wards of Italian hospitals, hosting 162 dialysis beds overall, were sampled on a monthly basis to determine the parameters provided by ISN guidelines. Chlorinated drinking water was desalinated by reverse osmosis and distributed to the closed loop which feeds all online monitors. Disinfection with peracetic acid was performed in all DW plants on a monthly basis.

FINDINGS

Over the 24-month study period, seven out of nine DW plants (78%) recorded negative results for all investigated parameters. Closed loop contamination with Burkholderia cepacia was detected in a DW plant from January 2015 to March 2015. Pseudomonas aeruginosa was isolated from March 2016 to May 2016 in the closed loop of another DW plant. These microbial contaminations were eradicated by shock disinfection with sodium hypochlorite and peracetic acid, followed by water flushing.

CONCLUSION

These results highlight the importance of chemical and physical methods of DW disinfection. The maintenance of control measures in water plants hosted in dialysis wards ensures a microbial risk reduction for all dialysis patients.

Evaluation of a modified cleaning procedure in the prevention of carbapenem-resistant Acinetobacter baumannii clonal spread in a burn intensive care unit using a high-sensitivity luminometer

BACKGROUND

Enhanced environmental cleaning practices are among the most accepted measures for controlling the spread of carbapenem-resistant Acinetobacter baumannii (CR-Ab).

AIM

To evaluate the impact of heightened cleaning on an ongoing CR-Ab outbreak in a burn intensive care unit (BICU) of an Italian teaching hospital, where chlorhexidine-60% isopropyl alcohol was applied as a complementary disinfectant on high-touch surfaces.

METHODS

Compliance with the microbial limit proposed for the BICU by AFNOR-NF-S90-351 (20 colony-forming units/100cm²) was assessed by plate count, and compared with the results obtained with intracellular adenosine triphosphate (ATP) detection. Genotyping was performed using pulsed-field gel electrophoresis.

FINDINGS

During the standard cleaning regimen, three out of 23 samples (13%) gave results over the AFNOR limit and five (21.7%) showed unacceptable ATP levels with 100 relative light units/100cm² as the benchmark limit (sensibility 86.4%, specificity 92.2%). Following improvement of the cleaning procedure, only two samples out of 50 (4%) did not satisfy the microbiological criteria and seven (14%) exceeded the ATP limit. In a successive phase, eight of 30 samples collected showed unacceptable results (27%).

CONCLUSIONS

Adding chlorhexidine-60% isopropyl alcohol as complementary disinfectant proved to be effective for reducing environmental microbial contamination, ATP levels and CR-Ab infection/colonization in patients admitted to the BICU. Real-time monitoring by ATP assay was useful for managing the cleaning schedule and reducing hospital infections, although the calculated values must be interpreted as cleanliness indicators rather than risk indicators.

Clinical Assessment of Risk Management: an INtegrated Approach (CARMINA)

Purpose - The European Union recommendations for patient safety calls for shared clinical risk management (CRM) safety standards able to guide organizations in CRM implementation. The purpose of this paper is to develop a self-evaluation tool to measure healthcare organization performance on CRM and guide improvements over time. Design/methodology/approach - A multi-step approach was implemented including: a systematic literature review; consensus meetings with an expert panel from eight Italian leader organizations to get to an agreement on the first version; field testing to test instrument feasibility and flexibility; Delphi strategy with a second expert panel for content validation and balanced scoring system development. Findings - The self-assessment tool - Clinical Assessment of Risk Management: an INtegrated Approach includes seven areas (governance, communication, knowledge and skills, safe environment, care processes, adverse event management, learning from experience) and 52 standards. Each standard is evaluated according to four performance levels: minimum; monitoring; outcomes; and improvement actions, which resulted in a feasible, flexible and valid instrument to be used throughout different organizations. Practical implications - This tool allows practitioners to assess their CRM activities compared to minimum levels, monitor performance, benchmarking with other institutions and spreading results to different stakeholders. Originality/value - The multi-step approach allowed us to identify core minimum CRM levels in a field where no consensus has been reached. Most standards may be easily adopted in other countries.

Colonization by Legionella spp. of water networks in residential buildings of the Province of Pisa, Italy

BACKGROUND

Despite the increase of community acquired cases of legionellosis in Italy over the last years, the Italian guidelines do not give indications for prevention and control of Legionella in the hot water networks (or centralized conditioning systems) of residential buildings. We performed a survey on eight medium sized apartment buildings in the Pisa district to assess the prevalence of Legionella spp. in the water network and the respondance to drinking water requisites at the point of use, according to the Italian norms.

METHODS

For each building two hot water and three cold water samples (located at water entrance from the aqueduct network into the building pipework, at the exit from pressure autoclave, and at a remote tap) were collected.

RESULTS

Legionella was detected in 20% of residential buildings, mostly in those with a central hot water production system.

CONCLUSIONS

The study highlights a condition of potential risk for susceptible population subgroups and supports the need for measures of risk assessment and control.

Hypothesis on etiopathogenesis, congenital or acquired, of an imperforate distal ureter: a case report

INTRODUCTION

Ureteral atresia is a rare disease usually associated with a non-functioning kidney. Its association with other urinary anomalies is rare.

CASE PRESENTATION

In this study we discuss the possibility of congenital or acquired etiology of a right imperforate distal ureter. Here we report the case of 11-month-old white boy with a right ureteropelvic junction obstruction. He underwent a right pyeloplasty when he was 11-months old, and 3 weeks after surgery a cystoscopy was performed. Two months after the first operation, he underwent a right ureteral meatoplasty and a new pyeloplasty.

CONCLUSIONS

To the best of our knowledge, few cases of imperforate distal ureter have been described in the literature. The suspicion of a non-patent terminal ureter, occurring during upper urinary tract surgery, must be intraoperatively clarified to preserve the renal function and to avoid more complex surgical approaches.