Fighting Antimicrobial Resistance and Healthcare-Associated Infections in EU-JAMRAI: The One-Health Response from Italy.

INTRODUCTION: Antimicrobial resistance (AMR) is a serious health threat, and it has high priority among the European public health agenda. The development and implementation of the National Action Plans (NAPs) with a One-Health perspective to fight AMR was supported in 2017 by the European Union (EU) through a Joint Action on Antimicrobial Resistance and Healthcare Associated Infections (EU-JAMRAI). The Italian National Institute of Health (Istituto Superiore di Sanità), supported by the University of Udine, and the University of Foggia were among the 44 partners involved. This paper describes the results of EU-JAMRAI relevant to Italy and its impact on national policies. METHODS: The activities involved national and international experts who worked in groups, either in virtual or face-to-face meetings. Country-to-country visits were organized to assess and compare the national strategies to counteract AMR and to exchange best practices. In addition, qualitative research methods, particularly focus groups (FGs) and structured interviews, were carried out to collect information and opinions from the experts. RESULTS: The Italian team of experts from the Ministry of Health and the University of Foggia visited the Netherlands and hosted the Polish expert team in Italy. In two FG, stakeholders' opinions from different organizations were collected and analyzed to identify critical areas and provide recommendations to ensure implementation of the NAP and effective One-Health integration. In addition, attitudes of medical professionals toward antimicrobial stewardship were evaluated in a medium/large Italian hospital. Strengths were identified in the multidisciplinary approach and the hospital management's proactive involvement. As for the veterinary sector, Italy was among the 10 EU countries that did not have any national AMR surveillance in place for animal bacterial pathogens. Consequently, a European surveillance system was proposed with the adhesion of Italy. Regarding research and innovation to fight AMR and healthcare-associated infection, Italy worked with the other European partners to identify national research gaps and opportunities. As a result, recommendations were issued to the authorities to promote research and innovation with a One-Health approach. CONCLUSIONS: The Italian participation in the EU JAMRAI provided experience and examples to the Italian government for implementing the NAP and planning the roadmap to fight AMR and helped point out the system's criticalities. It also supported the promotion of the One-Health integrated vision that was included in the updated NAP.

A NIR, 1H-NMR, LC-MS and chemometrics pilot study on the origin of carvedilol drug substances: a tool for discovering falsified active pharmaceutical ingredients.

Falsification of drugs, entailing the use of drug substances from unknown unapproved suppliers, is one of the main concerns for the quality of medicines. Therefore, traceability of active ingredients represents an effective tool to fight the illegal trade of medicinal products. In this view, the present pilot study explores the profile of carvedilol active ingredients and possible differences related to the origin. Sixteen samples were examined by near-infrared spectroscopy (NIR), proton nuclear magnetic resonance (1H-NMR spectrometry) and liquid chromatography mass spectrometry (LC-MS) Q-TOF and the data were analysed by principal component analysis (PCA), cluster analysis and PLSDA discriminant analysis. The results evidenced that the combined information from the three techniques gave good classification of the samples neatly distinguishing the APIs from European countries from the APIs manufactured out of Europe. In particular, NIR spectroscopy provided effective separation between European and non-European manufacturers and 1H-NMR or LC-MS added specific information related to the separation. Concerning LC-MS Q-TOF, the analysis of multiple isobaric peaks proved to be highly predictive of the drug substance origin and emerged as a promising tool in the field of medicine traceability.

The impact of immunization programs on 10 vaccine preventable diseases in Italy: 1900-2015.

BACKGROUND: Vaccination has determined a dramatic decline in morbidity and mortality from infectious diseases over the last century. However, low perceived risk of the infectious threat and increased concern about vaccines' safety led to a reduction in vaccine coverage, with increased risk of disease outbreaks. METHODS: Annual surveillance data of nationally communicable infectious diseases in Italy between 1900 and 2015 were used to derive trends in morbidity and mortality rates before and after vaccine introduction, focusing particularly on the effect of vaccination programs. Autoregressive integrated moving average models were applied to ten vaccine-preventable diseases: diphtheria, tetanus, poliomyelitis, hepatitis B, pertussis, measles, mumps, rubella, chickenpox, and invasive meningococcal disease. Results of these models referring to data before the immunization programs were projected on the vaccination period to estimate expected cases. The difference between observed and projected cases provided estimates of cases avoided by vaccination. RESULTS: The temporal trend for each disease started with high incidence rates, followed by a period of persisting reduction. After vaccine introduction, and particularly after the recommendation for universal use among children, the current rates were much lower than those forecasted without vaccination, both in the whole population and among the 0-to-4 year olds, which is, generally, the most susceptible age class. Assuming that the difference between incidence rates before and after vaccination programs was attributable only to vaccine, more than 4 million cases were prevented, and nearly 35% of them among children in the early years of life. Diphtheria was the disease with the highest number of prevented cases, followed by mumps, chickenpox and measles. CONCLUSIONS: Universal vaccination programs represent the most effective prevention tool against infectious diseases, having a major impact on human health. Health authorities should make any effort to strengthen public confidence in vaccines, highlighting scientific evidence of vaccination benefits.

Antimicrobial resistance: a global multifaceted phenomenon.

Antimicrobial resistance (AMR) is one of the most serious global public health threats in this century. The first World Health Organization (WHO) Global report on surveillance of AMR, published in April 2014, collected for the first time data from national and international surveillance networks, showing the extent of this phenomenon in many parts of the world and also the presence of large gaps in the existing surveillance. In this review, we focus on antibacterial resistance (ABR), which represents at the moment the major problem, both for the high rates of resistance observed in bacteria that cause common infections and for the complexity of the consequences of ABR. We describe the health and economic impact of ABR, the principal risk factors for its emergence and, in particular, we illustrate the highlights of four antibiotic-resistant pathogens of global concern - Staphylococcus aureus, Klebsiella pneumoniae, non-typhoidal Salmonella and Mycobacterium tuberculosis - for whom we report resistance data worldwide. Measures to control the emergence and the spread of ABR are presented.

Bioaccumulation and biomagnification potential of pharmaceuticals with a focus to the aquatic environment.

Pharmaceuticals, among the emerging contaminants, are one of the most relevant groups of substances in aquatic ecosystems due to universal use, their chemico-physical properties and known mode of action in aquatic organisms at low concentrations. After administration many drugs and their transformation products are only retained to some extent in wastewater treatment plants therefore entering the aquatic environment in considerable high amounts. The yearly consumption to treat human and animal diseases, also in livestock and aquaculture was estimated to be hundred thousands tons per year leading to high concentrations in surface water of developed countries. Mostly, pharmaceutical residues in effluents of wastewater treatment plants or in the water column of surface waters have been reported, but data about concentrations in the aquatic biota, partitioning of pharmaceuticals to biosolids, soils, and sediments and the bioaccumulation properties are often lacking. Chronic and subtle effects can be expected when aquatic organisms are long term exposed by pseudo-persistent, persistent and accumulative compounds. This review aims to summarize the current state of research about the fate of pharmaceuticals regarding bioconcentration, bioaccumulation and potential biomagnification in aquatic ecosystems. More comprehensive approaches for the evaluation of environmental (ERA) and human health risk assessment (HRA) are included and analytical methods required to detect bioaccumulation of pharmaceuticals are discussed.

Quantitative assay of total dsDNA with PicoGreen reagent and real-time fluorescent detection.

We describe a quantitative assay of dsDNA based on real-time PCR measurement of fluorescence due to the interaction of PicoGreen dye with dsDNA. An aliquot of 1 to 5 ml of the sample is mixed with 45 ml of diluted PicoGreen reagent within an optical PCR tube. This is placed into the real-time apparatus set to read SYBR Green I dye at the end of three cycles of 94 degrees C for 30 s and 65 degrees C for 30 s. The averaged fluorescence value is converted into DNA amount using a calibration curve prepared with lambda-DNA standard. The calibration curve has a dynamic linear range from 0.20 to 50 ng and a standard deviation variability below 5.0%. In conclusion, this method allows reliable determinations on minimal amounts of DNA from biological samples and PCR products in clinical applications of molecular biology.