Hospital-acquired infections and leading pathogens detected in a regional university adult acute-care hospital in Genoa, Liguria, Italy: results from a prevalence study.

BACKGROUND: A prevalence study aimed to update the epidemiological scenario of Hospital-Acquired Infections (HAI) was performed at the San Martino University Hospital of Genoa, the Regional Reference Adult-care Center in Liguria, Italy, with more than 1300 beds. MATERIALS AND METHODS: The investigation was performed in all the wards, except the Psychiatric Units, between 19th March and 6Ih April, 2007, using a one-day monitoring system for each ward. International standardized criteria and definitions for the surveillance of HAI were used for the collection of data, which were recorded in specific software for subsequent consolidation, analysis and quality control. RESULTS: The hospital infection control staff actively monitored 912 inpatients: a total of 84 HAI among 72 patients were diagnosed, with an overall prevalence of infections and affected cases of 9.2% (95% CI: 7.3-11.1) and 7.9% (95% CI: 6.1-9.7), respectively. Urinary Tract Infections (UTI) (30.9%), Respiratory Tract Infections (RTI) (28.6%) and Blood Stream Infections (BSI) (21.4%) were found to be the most frequent infections. As expected, both specific prevalence and localization of HAI varied considerably between wards, with the highest values recorded in Intensive Care Units (ICU) and in Functional Rehabilitation wards. RTI (26.3%) and BSI (13.2%) were found primarily represented in ICU, while the highest values of UTI (13.3%) were registered in Functional Rehabilitation Units. Enterococcus spp. (16.8%), Candida spp. (14%), Pseudomonas spp. (12.2), Staphylococcus aureus (10.7%), Escherichia coli (10.3%) and Coagulase-negative staphylococci (CNS) (9.3%) were the most frequent pathogens isolated. The overall rate of administration of antibiotics was 55.3% and penicillin (26.7%), cephalosporins (22.8%) and fluoroquinolones (17.9%) were found to be the leading antibacterial administered. CONCLUSION: Results of the present study have been, and are currently, used for orientating surveillance and control hospital policies, planning activities according to a rational and evidence-based approach.

Surgical site infections in HIV-infected patients: results from an Italian prospective multicenter observational study.

BACKGROUND: The quality of life of the HIV-infected population in developed countries has substantially improved over the years. Accordingly, the clinical limitations in the surgical treatment of the HIV-infected patients are becoming fewer, and the number of HIV-infected patients undergoing surgical interventions of all types is increasing. However, available data on the incidence and risk factors for post-surgical complications, such as surgical site infections (SSI), in HIV-infected patients are still limited and often controversial. The aim of this study was to determine the incidence and the associated risk factors for SSI in HIV-infected patients. METHODS: A 1-year observational prospective multicenter surveillance study was conducted in 11 Italian Infectious Diseases Clinical Centers from which 305 consecutive HIV-infected patients undergoing different surgical procedures were enrolled. Postdischarge surveillance was conducted within 30 days after surgery. A number of variables were included in a multivariate analysis aimed at assessing potential risk factors for SSI, including body mass index, diabetes, Hepatitis C (HCV) and hepatitis B virus infection, lipodistrophy, HIV viral load, CD4 cell count and white blood cell count, preoperative hospital stay, National Nosocomial Infection Surveillance (NNIS) risk score, and any antimicrobial prophylaxis. RESULTS: SSI occurred in 29 of 305 (9.5%) patients, of which 17 (58.6%) SSI occurred during hospital stay, and 12 (41.4%) occurred during the postdischarge period. The SSI of the 29 patients were classified as superficial (21, 72.4%), deep (four, 13.8%), organ/space (one, 3.4%), and sepsis (three, 10.3%). Nearly 50% of the superficial and 50% of the deep SSI occurred during the postdischarge period. Organ/space infection and sepsis accounted for 13.7% of all SSI and were observed during the in-hospital stay. The multivariate analysis revealed that HCV co-infection was significantly associated to SSI occurrence. Total hospital stay was longer among patients with SSI than among those without SSI (p = 0.041). CONCLUSION: Although 92.5% of our HIV-infected patients presented a NNIS score < or = 1, the SSI rate was twofold higher than that reported in Italian and European studies for the general population, with more severe clinical presentations. This is the first report of an association between HCV-HIV co-infection and SSI occurrence. Additionally, the viro-immunological status of our patients was not related to SSI occurrence, which suggests the need for further research for other potential risk factors that may be implicated in the occurrence of SSI.

Medical report type in liver transplantation as a quality system document: new prospects for computerization.

The usage of a computerized system to organize data and ease the activity procedures of liver transplantation is useful in clinical transplantation. Preliminary cognitive research on systems of clinical transplantation database concerning medical reports was performed to verify their development level. The survey highlighted that, so far, there has been no experimentation that can be applied to a medical report type devoted to liver transplantation. Regulations in force substantially point out that the medical report ought to contain all items that have to be taken into account in handling the patient from pretransplantation to follow-up. The Department of Transplantation of Genoa chose its medical report model for liver transplantation. The medical report model included the following items: personal data; case history; diagnosis; initial examination for prelisting; fitness for transplantation; assistance context; clinical data including subjective, objective, and instrumental parameters; pharmacological therapies; informed consent, evaluation of fitness; nursing data; counseling and clinical evaluations according to protocols and guidelines of the national transplantation centers. If the computing is well trained, it is supposed to help maintain a whole data view provided it is supplied information in an adequate way. Immediate clinical procedural advantages and useful scientific observations may be obtained from a high-quality database. In fact, all functions have to be applied to specific clinical, administrative needs to be remotely shared and conveniently integrated with each other to make the liver transplantation medical report an easy and handy instrument for inputting and handling data. It must be a precise, complete instrument that may be accessible in real time from any site connected with the intranet network, be unchangeable, and be protected to ensure certification and forensic medicine value.

Characterization of EBV-positive lymphoblastoid cell lines obtained from HIV seropositive patients with or without lymphomas.

Epstein-Barr-virus- (EBV-) positive lymphoblastoid cell lines (LCLs) spontaneously arising in vitro were obtained from the peripheral blood of six HIV-seropositive patients and from the peripheral blood and the bone marrow of one patient (LAM) with AIDS and lymphoma. The LCLs from HIV-seropositive patients had phenotypic, cytogenetic, and biological characteristics indistinguishable from those of normal LCLs obtained by infecting B cells with EBV in vitro. The LCLs from LAM patient comprised composite cell populations. Cloning analysis and cell fractionation procedures showed that, beside normal EBV-infected cells, these lines contained a malignant subset population characterized by c-myc rearrangement, abnormal karyotype, and a surface phenotype similar to that of Burkitt's lymphoma cells. Analyses of Ig heavy chain and c-myc oncogene loci showed that these malignant cells were the progeny of a single precursor. Nevertheless, these cells had heterogeneous EBV-fused termini, a finding which indicates that EBV infection followed c-myc rearrangement.

Detection of T cell CD4 epitopes in HIV-infected individuals.

HIV antigens can be detected in the circulation of HIV-infected patients and are associated with active virus production. Free virions and shedded gp120 bind CD4 with high affinity. We have studied the expression of Leu3a and OKT4 epitopes on a CD4+ T cell line (HPB-ALL), pretreated with HIV rgp120, and on CD4+ pheripheral blood T lymphocytes of HIV-infected patients. The associated determination of these epitopes (the Leu3a mapping at the gp120 binding site of CD4 and the OKT4 mapping at a site independent of gp120 binding) allowed to monitor binding of gp120 to surface CD4 and maintenance of CD4 expression. The comparison of MFI of gp120-treated versus untreated Leu3a+ HPB-ALL cells suggested that the Leu3a epitope was masked by treatment with 20 micrograms/ml rgp120, while with 1 microgram/ml rgp120 masking was undetectable, although gp120 was bound to cells. The determination of the Leu3a and OKT4 epitopes in 105 HIV-infected individuals and in 50 normal controls, showed that the Leu3a epitope is detected equally well in HIV-infected and in normal subjects, provided the anti-Leu3a is used at saturation. Therefore the binding to epitopes distinct from the gp120-binding site does not seem to be a requisite for the selection of anti-CD4 mAbs for immunophenotyping. To optimize the detection of CD4 masking, a limiting amount of conjugated anti-Leu3a has to be used. Measurements of CD4 binding by gp120 in terms of gp120-free CD4 molecules, as detected by reactivity with anti-Leu3a, may be used to monitor disease progression in HIV-infected subjects.

[Role of surgery in the prognosis of AIDS and related syndromes. Case reports ]. / Ruolo della chirurgia nella prognosi dell'AIDS e sindromi correlate. Contributo casistico.

The authors review the epidemiologic and etiopathogenetic aspects of AIDS, in agreement with data published in december by the Center for Disease Control and by the WHO for the States, Europe and Italy. In their experience twenty-one patients, with clinical clues of AIDS, undergoing lymph node biopsy, have been analysed (18 LAS-ARC and 3 AIDS) and the role of prophylaxis for the surgical approach to the patient with aids or related syndrome has been underlined.

[Infectious complications in liver transplant in Italy: current status and prospectives]. / Complicanze infettive nel trapianto di fegato in Italia: stato attuale e prospettive di studio.

The impact of infections in orthotopic liver transplantation (OLT) is remarkable. Studies have shown that about 60% of patient may develop at least 1 infectious episode during the first 3 months after transplant. Within the frame of a Finalized Research Project of the Italian Ministry of Health, during the year 2000 a group of investigators belonging to the major Italian Liver Transplant Centers (LTC)--18 out of 20 Centers--met three times in Genoa with the aim of constituting a Research Group aimed at improving our knowledge of infectious complications in liver transplant recipients (PITF = Program of Infections in Liver Transplantation). The group first collected information about anti-infective procedure in LTC. The study shows that no Center is supported by a Intensive Care Unit (ICU) exclusively dedicated to the LTC, although 37% of them have a partially dedicated Unit. Surveillance cultures are routinely performed and are frequently used to address the choice of the antibacterial and antifungal regimes. Selective Bowel Decontamination is also very common. The management of CMV infection is usually performed as indicated in international guidelines.

Nocardiosis in a kidney-pancreas transplant.

34-year-old man with chronic renal and pancreas failure in complicated diabetic disease received a kidney-pancreas transplantation. On the 32nd postoperative day, an acute kidney rejection occurred and resolved with OKT3 therapy. The patient also presented refractory urinary infection by E. Fecalis and M. Morganii, and a focal bronchopneumonia in the right-basal lobe resolved with elective chemotherapy. During the 50th post-operative day, an intense soft tissue inflammation localized in the first left metatarsal-phalangeal articulation occurred (Figure 1) followed by an abscess with a cutaneous fistula and extension to the almost totality of foot area. The radiological exam revealed a small osteo-lacunar image localized in the proximal phalanx head of the first finger foot. From the cultural examination of the purulent material, N. Asteroides was identified. An amoxicillin-based treatment was started and continued for three months, with the complete resolution of infection This case is reported for its rarity in our casuistry, and for its difficult differential diagnosis with other potentially serious infections.

Infections after simultaneous pancreas and kidney transplantation: a single-center experience.

Simultaneous pancreas-kidney transplantation (SPKT) is now an accepted therapy for patients with insulin-dependent diabetes mellitus. However, SPKT has an high rate of morbidity and mortality, mainly for infection. From October 1986 to June 2008, in our center 54 patients (18 female; 36 male) affected by diabetes and end-stage renal disease underwent SPKT. The mean duration of diabetes mellitus was 25 +/- 4 years. Only 4 patients had not been treated by dialysis before SPKT. Three operative techniques were used: duct injection (n = 5), bladder diversion (n = 14), and enteric diversion (n = 39). The kidneys were always placed into the left retroperitoneal space. The pancreas was placed extraperitoneally in 5 patients. Thirty-four recipients are alive, including 30 with function of both grafts. Six patients died during the first year after transplantation. Infectious complications were the main cause of death in 3 subjects whereas 98 infections were diagnosed in 51 patients. All patients were treated with immunosuppressive agents: steroids associated with calcineurin inhibitors and mycophenolic acid, or azathioprine. Antibody induction was used in 41 patients with anti-interleukin-2 monoclonal antibody or antithymocyte globulin. We detected 41 episodes of cytomegalovirus infection: systemic (n = 38), bladder (n = 2), and duodenal (n = 1). The 51 bacterial infections were systemic: (n = 10); urinary tract: (n = 22); pulmonary (n = 11); wound (n = 5); intestinal (n = 3). The 5 fungal infections were gastrointestinal tract (n = 3); and arteritis (n = 2). Some patients experienced more than 1 type of infection. The predominant etiology of the systemic infections was bacterial. In conclusion, infectious complications were the main causes of morbidity after SPKT. An early diagnosis of infection, particularly fungal complications, is essential. We recommend administration of broad-spectrum prophylactic antibiotics, antifungals, and antiviral agents.

Torque Teno Virus--cause of viral liver disease following liver transplantation: a case report.

Torque Teno Virus (TTV), a nonenveloped human virus of the Circoviridae family, is hepatotropic, causing liver damage, cirrhosis, and, rarely, fulminant hepatitis. It prevails in 10% to 75% of blood donors due to environmental differences, independent of chronic hepatitis B virus (HBV)/HCV hepatitis, cryptogenic cirrhosis, alcoholic cirrhosis, and in fulminant hepatitis non-A-G. Reports about the efficacy of clinical alpha interferon are rare. In July 2007, a 65-year-old man who was serologically negative for A-E viruses presented with acute liver failure due to a ruptured hepatic artery aneurysm and underwent orthotopic liver transplantation (OLT). Immunosuppression was based on cyclosporine and steroids. At postoperative day 20, there was persistent hypertransaminasemia with otherwise normal liver function. A percutaneous hepatic biopsy documented pattern suggestive of a viral etiology. Multiple tests for hepatotropic viruses in the donor and the recipient from the pre- and post-OLT periods remained negative. Only the TTV qualitative test, assessed by polymerase chain reaction (PCR) on patient sera, was positive. Immunosuppressive therapy was not changed; no antiviral therapy was undertaken. At 6 months posttransplantation, transaminase levels spontaneously normalized and the clinical situation was unchanged. No complications were observed; the patient is in good clinical condition. No graft rejection was observed. In histologically proven non-A-E viral hepatitis, it is important to consider TTV as an incidental pathogenic agent. It may be useful to extend virological tests to TTV among transplant recipients and donors and to gain further knowledge about this virus.