Epidemiology of SARS-CoV-2 among healthcare workers in North-Eastern Italy from March 1, 2020 to May 10, 2020.

BACKGROUND: During major epidemic outbreaks, the preparedness of public health systems is challenged and -healthcare workers (HCWs) are at the frontline. Italy was among the first- and worst-hit countries by COVID-19. AIM: To analyze the prevalence and incidence of infection among HCWs in Friuli Venezia Giulia region (north-eastern Italy) from March 1 to the end of the Italian lock-down, May 10, 2020. METHODS: HCWs exposed to COVID-19 patients were actively surveyed and all HCWs were routinely tested with nasopharyngeal and oropharyngeal swab for RNA virus detection (n. 54,670). RESULTS: Infected HCWs (n. 595) represented the 32.3% of all COVID-19 cases in the region under 65 years of age, and incidence of infection was 11.4 cases/1000 workers. HCWs accounted for a significant proportion of coronavirus infection and experienced high infection incidence after unprotected contact. CONCLUSIONS: HCWs' knowledge of SARS-CoV-2 epidemiology and proper infection control practices are critical to the control of the disease.

White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the animal sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks.

BACKGROUND: The JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks have joined efforts to formulate a set of target actions to link the surveillance of antimicrobial usage (AMU) and antimicrobial resistance (AMR) with antimicrobial stewardship (AMS) activities in four different settings. This White Paper focuses on the veterinary setting and embraces the One Health approach. METHODS: A review of the literature was carried out addressing research questions in three areas: AMS leadership and accountability; AMU surveillance and AMS; and AMR surveillance and AMS. Consensus on target actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine and public health, from 18 countries. RESULTS/DISCUSSION: Forty-six target actions were developed and qualified as essential or desirable. Essential actions included the setup of AMS teams in all veterinary settings, building government-supported AMS programmes and following specific requirements on the production, collection and communication of AMU and AMR data. Activities of AMS teams should be tailored to the local situation and capacities, and be linked to local or national surveillance systems and infection control programmes. Several research priorities were also identified, such as the need to develop more clinical breakpoints in veterinary medicine. CONCLUSIONS: This White Paper offers a practical tool to veterinary practitioners and policy makers to improve AMS in the One Health approach, thanks to surveillance data generated in the veterinary setting. This work may also be useful to medical doctors wishing to better understand the specificities of the veterinary setting and facilitate cross-sectoral collaborations.

A Longitudinal Case Study on Dissemination of ST398 Methicillin-Resistant Staphylococcus aureus Within a Dairy Cow Herd.

The study was conducted to describe the dynamics of ST398 methicillin-resistant Staphylococcus aureus (MRSA) on a dairy herd in northeastern Italy. MRSA was first identified in this herd of 120 cows in 2016, after which the herd was sampled once every 3 months for 1 year (April 2016-May 2017). Samples collected included nasal swabs and milk samples from cows and nasal swabs from farmworkers. In addition, pen fencing and teat milk liners were swabbed and air samples from cow pens and the milking parlor were collected. All samples were tested for MRSA using a selective medium; positive isolates were confirmed by mecA PCR. A representative set of MRSA isolates was genotyped using spa typing and multilocus sequence typing. Overall, 34 (mean 23%, range 16-30%) milking cows were found harboring MRSA in the mammary gland and only 6 recovered from infection or colonization. The mean incidence rate was 14% (range 8-20%), mean cure rate was 23% (range 13-43%), and estimated basic reproduction number (R0) was 1.08. The average of positive quarters found was 35.1% and most of the positive quarters (82.4%) developed subclinical mastitis. The mean duration of MRSA colonization in quarters during the study was 247 days, but quarters affected by subclinical mastitis harbored MRSA for a longer time than healthy ones (285 days vs. 131 days). After the second sampling, the farmer segregated MRSA-positive cows from the uninfected cows and milked them last. Despite segregation, 25 newly infected or colonized cows were detected. MRSA isolates from cows, environment, and two farmworkers belonged to the same sequence type (ST398) and spa type (t034). This study highlights the ability of ST398 MRSA to cause a persistent infection of the mammary gland and to survive in the farm environment.

Cerebral toxoplasmosis in a cat with feline leukemia and feline infectious peritonitis viral infections.

A diarrheic young cat died after neurological involvement. Biochemistry pointed to feline infectious peritonitis (FIP). The final diagnosis was severe multifocal meningoencephalitis due to Toxoplasma gondii. The presence of the parasite in the brain was confirmed using immunohistochemical staining. Concomitant feline leukemia virus (FeLV) and FIP were possible contributors to the clinical, fatal outcome.

Toxoplasmose cérébrale chez un chat atteint des infections virales de leucémie féline et de péritonite infectieuse féline. Un jeune chat diarrhéique est mort après des symptômes neurologiques. La biochimie a signalé une péritonite infectieuse féline (FIP). Le diagnostic final a été une méningo-encéphalite multifocale grave causée par Toxoplasma gondii. La présence du parasite dans le cerveau a été confirmée à l'aide de la coloration immunohistochimique. La présence concomitante du virus de la leucémie féline (FeLV) et de la FIP sont des facteurs possibles ayant contribué au résultat clinique mortel.(Traduit par Isabelle Vallières).

Exploring the Needs and Expectations of Expectant and New Parents for an mHealth Application to Support the First 1000 Days of Life: Steps toward a Co-Design Approach.

To improve maternal and child health, it is essential to adhere to health-promoting and preventive measures. However, reliable information as well as effective tools are not easy to identify in this field. Our cross-sectional study investigated the needs and expectations of expectant and new mothers and fathers as potential primary users of a hypothetical application supporting the first 1000 days of life. Between May and August 2022, we recruited expectant and new parents by administering an 83-item 5-point Likert scale questionnaire related to the content, functionalities, and technical features of the hypothetical app. We stratified responses using sociodemographic characteristics and then performed ward hierarchical clustering. The 94 women and 69 men involved in our study generally agreed with the proposed content, but expressed low interest in certain app functionalities or features, including those related to the interaction mechanism and interactivity. Women were generally more demanding than men. Our findings, resulting from the engagement of end-users, may be useful for designers and technology providers to implement mHealth solutions that, in addition to conveying reliable information, are tailored to the needs and preferences of end-users in the first 1000 days of life.

What do hospital-based health professionals need and expect from an mHealth app to support the first 1000 days of life? Results from a cross sectional study.

BACKGROUND: Several attempts have been made to introduce mHealth solutions to support maternal, newborn, and child health (MNCH). However, most of the available apps do not meet the needs of end-users, underscoring the urgency of involving them in the co-design of telehealth interventions. OBJECTIVE: With this in mind, we investigated the needs and expectations of hospital-based health professionals (i.e., secondary users) providing care to pregnant women and new mothers with their babies for a hypothetical mHealth app to support the first 1000 days of life. METHODS: From November 2021 to March 2022, we surveyed health professionals using a questionnaire that explored the perceived importance of specific content, functionalities, and technical features of the proposed app. We also collected sociodemographic information from secondary users. We performed descriptive analysis and then used Ward hierarchical clustering method to classify respondents according to their response patterns. RESULTS: We recorded the needs and expectations of 145 hospital-based health professionals from obstetrics/gynecology, nursery/neonatology, and pediatrics. We found general agreement with the proposed content of the app, particularly general information about health during pregnancy (92%) and potential risky infections during pregnancy (91%). Three clusters emerged from the analysis, with the high and medium demanding clusters rating the importance of app content and technical features as very high and high, respectively, while low demanding cluster expressing more skepticism, especially about some of the proposed functionalities of the app. CONCLUSIONS: Assessing the needs and expectations of end-users is an essential process for developing tailored and effective mHealth solutions. This study has shown that hospital-based health professionals generally recognize the value of the proposed app, suggesting their propensity to integrate such a telehealth solution into mainstream clinical practice.

EPI-Net One Health reporting guideline for antimicrobial consumption and resistance surveillance data: a Delphi approach.

Strategic and standardised approaches to analysis and reporting of surveillance data are essential to inform antimicrobial resistance (AMR) mitigation measures, including antibiotic policies. Targeted guidance on linking full-scale AMR and antimicrobial consumption (AMC)/antimicrobial residues (AR) surveillance data from the human, animal, and environmental sectors is currently needed. This paper describes the initiative whereby a multidisciplinary panel of experts (56 from 20 countries-52 high income, 4 upper middle or lower income), representing all three sectors, elaborated proposals for structuring and reporting full-scale AMR and AMC/AR surveillance data across the three sectors. An evidence-supported, modified Delphi approach was adopted to reach consensus among the experts for dissemination frequency, language, and overall structure of reporting; core elements and metrics for AMC/AR data; core elements and metrics for AMR data. The recommendations can support multisectoral national and regional plans on antimicrobials policy to reduce resistance rates applying a One Health approach.

SPiNCAR: A systematic model to evaluate and guide actions for tackling AMR.

BACKGROUND: Italy records very alarming levels antimicrobial resistance (AMR), so a National Action Plan on Antimicrobial resistance (PNCAR) was developed, adopting the AMR European Union's recommendations based on the results of the ECDC site visit of January 2017. For achieving PNCAR objectives, it is necessary to support and harmonize the implementation of recommendations in all the different healthcare levels (regional authorities and local trusts), so the SPiNCAR project was launched to create a tool for reaching this goal. METHODS: We developed a framework based on a scientific literature and national and international guidelines. Firstly, we identified the major intervention areas for tackling AMR, then, for each area, we built a set of standards, both for regional authorities than for local trusts. Every standard is composed by a set of essential and additional criteria, which refer to a minimum or supplemental performance level respectively. The contents were firstly discussed by the project's team during face-to-face kick-off meetings, then confirmed with Delphi methodology and finally validated through a pilot study. RESULTS: The final framework consists of seven different areas that reflect the PNCAR structure: Governance, Surveillance and Monitoring, Appropriate Use of antimicrobials, Healthcare-associated Infections (HAIs) control and prevention, Education and Training, Alliance among Stakeholders, Implementation. The total number of standards for the regional framework was 34 with 264 criteria and for the local version 36 criteria with 279 standards. CONCLUSION: The ongoing use of this tool, developed on international evidences and recommendations that were tailored on the Italian specific context, allows monitoring the improvement achieved over time and plan the next steps.

Extended-spectrum ß-lactamase-producing Escherichia coli from extraintestinal infections in humans and from food-producing animals in Italy: a 'One Health' study.

Recently, Escherichia coli producing extended-spectrum ß-lactamases (ESBLs) have become a serious public-health problem, and food-producing animals (FPAs) have been suggested as a potential reservoir/source. This study aimed to compare ESBL-producing E. coli isolates from different sources. ESBL-producing E. coli isolates were collected from humans (n = 480) and FPAs (n = 445) in Italy (2016-2017). Isolates were screened for the presence of ESBL and carbapenemase genes and were classified according to phylogenetic group and MLST genotyping. The genes mcr-1 to -5 were searched for in colistin-resistant isolates. CTX-M was the most frequent ESBL type both in human and animal isolates. CTX-M-15 prevailed in humans (75.0%) and cattle (51.1%) but not in poultry (36.6%). CTX-M-1 was common (58.3%) in pigs. SHV-type and CMY-2-like were found in FPAs, especially in poultry (17.0% and 29.9%, respectively). Additionally, 29 isolates were mcr-1 carriers (3 from humans and 26 from FPAs). No carbapenemase genes were detected. Human isolates mostly belonged to phylogroup B2 (76.5%). Animal isolates were distributed among groups A (35.7%), B1 (26.1%) and C (12.4%). Few animal isolates (almost all from poultry) were classified into group B2 (4.3%). Most human isolates (83.4%) belonged to the pandemic ST131 clone and frequently carried CTX-M-15 (75.9%). ST131 was rarely detected in FPAs (three isolates from poultry). Nineteen STs were shared in both sources, with ST10, ST410 and ST69 being more frequently detected. Potential exchange of ESBL genes from animals to humans is feasible, underlying the need for strict monitoring based on a 'One Health' approach.

Humoral immunity in natural infection by tick-borne encephalitis virus.

Tick-borne encephalitis (TBE) virus is one of the most important flaviviruses associated with neurological disease in Europe. Cross-reactive antibodies elicited by different flaviviruses can make difficult the interpretation of ELISA and hemagglutination-inhibition (HI) tests for the diagnosis of TBE. Neutralization tests, which are more specific, are not in common use because they are difficult to perform and standardize. A plaque reduction neutralization test (PRNT), optimized previously in vaccinated children, was evaluated in sera from acute cases of TBE, collected for diagnostic purposes, and from healthy human population and wild ruminants, collected for serosurvey purposes. The PRNT results were compared with the results of ELISA and HI tests. In acute TBE disease, most sera were positive for IgM antibodies by ELISA and with high HI antibody titers; neutralizing antibodies were detected in 71.4% of patients, at a very low titer (1:10 NT(50)) in almost all cases. Seroprevalences of 8% and 6.5% for anti-TBE ELISA antibodies were found in healthy subjects and wild ruminants, respectively. Among anti-TBE positive healthy subjects, a very low 1:10 NT(50) titer was detected in 17.4% of cases, while NT(80) titers ranging from 1:10 to 1:80 were detected in 65.2% of cases. Among wild ruminants, 90.9% of ELISA and HI positive samples showed a positive, >/=1:10 NT(80) titer. In conclusion, neutralization assays can be useful for the diagnosis and serosurveys of TBE.

A survey of Clostridium spiroforme antimicrobial susceptibility in rabbit breeding.

Rabbit meat breeding may be heavily affected by enterotoxaemia due to Clostridium spiroforme. Data on its antimicrobial susceptibility are insufficient, presumably because of difficulties in cultivating and identifying the pathogen. Our aim is therefore to provide this information to veterinary practitioners by focusing on a panel of therapeutics used in intensive rabbit units. Lincomycin was also checked in order to investigate the origin of resistance to macrolides. Minimal inhibitory concentrations (MICs) were determined with the agar dilution method according to the CLSI M11-A7 protocol (2007). MIC(50) and MIC(90) were, respectively, 64 and 64microg/ml for tiamulin, 32 and 32microg/ml for norfloxacin, 0.063 and 0.125microg/ml for amoxicillin, and 8 and 16microg/ml for doxycycline. MIC(50) and MIC(90) were 256microg/ml for sulphadimethoxine, spiramycin and lincomycin. Our results have shown that intrinsic or acquired antimicrobial resistances are diffuse in the C. spiroforme population and suggest focusing on prevention rather than on treatment of clostridial overgrowth, by reducing risk factors and using antimicrobials prudently.

Survey, characterization and antimicrobial susceptibility of Clostridium difficile from marine bivalve shellfish of North Adriatic Sea.

Clostridium difficile is a major cause of infectious diarrhea associated to healthcare settings. Community-acquired infections are increasingly reported in the last decade and exposure other than to symptomatic patients rather to contaminated foods or animals is feasible. Occurrence of C. difficile in shellfish raises concern because spores can survive the cooking temperatures given that shellfish is often consumed poorly cooked or raw. Aim of our study was to investigate whether shellfish represents a reservoir of C. difficile human PCR-ribotypes (RTs). 702 shellfish samples of farmed and wild bivalve mollusc species were collected over the 2015-2017 period in North Adriatic Italian Sea to investigate contamination with C. difficile and characterize the isolates in terms of genotypic variability and antimicrobial resistance profile. C. difficile was detected in 16.9% (CI: 14.1%-19.8%) samples: 11.6% mussels and 23.2% clams. Compared to mussels, clams were significantly associated with detection of C. difficile (OR = 2.4, P < 0.01). Overall 113 C. difficile isolates were genotyped and 75 (66.4%) were toxigenic. Fifty-three different RTs were identified. 40.7% C. difficile isolates were among the RTs most commonly involved in human infection in Europe. The profile of antimicrobial susceptibility was determined by E-test; microbiological resistance was frequent against clindamycin (17%), erythromycin (23%), rifampicin (8.8%) and moxifloxacin (10.6%). All isolates were susceptible to metronidazole and one showed MIC > ECOFF for vancomycin. C. difficile strains showed high variety in RTs, most of them already detected in other animals or known as highly virulent and epidemic in humans. These results prompt towards investigating on specific risk mitigation measures against C. difficile and are preliminary for any source attribution and risk assessment study.

Longitudinal study on antimicrobial consumption and resistance in rabbit farming.

Reliable indicators of antimicrobial consumption (AMC) measured with harmonised data and supported by indicators for antimicrobial resistance (AMR) at herd level are necessary to target antimicrobial misuse in food-producing animals. AMC data in 2010-2015 in 32 Italian industrial rabbit holdings weighted with semester production and standardised with animal daily doses (ADDs) were collected. Herd-level AMR against eight antimicrobials was assessed in Escherichia coli, Enterococcus faecalis and Enterococcus hirae collected in 2014-2015. Escherichia coli were assessed for mcr-1 and mcr-2 genes. To produce 1 kg of live rabbit, a mean of 71.8 ADDs was used. Overall AMC reduced over time (P < 0.05) owing to lowering consumption of tetracyclines (P < 0.05) and colistin (P < 0.01), but consumption of quinolones (P < 0.05), bacitracin (P < 0.01) and sulfonamides (P = 0.017) increased. All except one indicator E. coli were wild-type for cefotaxime, whereas 97% displayed reduced susceptibility to tetracyclines, 89% to trimethoprim, 63% to enrofloxacin, 24% to chloramphenicol and 21% to colistin. mcr-1 was detected in 50/320 E. coli isolates from 15/32 holdings; mcr-2 was not detected in 58 isolates with colistin MIC ≥ 2 mg/L. All 305 enterococci were wild-type for ampicillin, ciprofloxacin and vancomycin and displayed reduced tetracycline susceptibility. The mean antimicrobial resistance index (ARI) was 0.5 for E. coli and 0.3 for enterococci. ARI was significantly correlated with AMC at herd level for enterococci (P = 0.008) but not E. coli where high ARI levels were found in a few holdings with low AMC.

Molecular characterization and antimicrobial susceptibility of Clostridium difficile isolated from rabbits raised for meat production.

Clostridium difficile is an important cause of enteric disease in humans and animals. Recent studies demonstrated a genetic overlap between C. difficile isolated from animals and humans suggesting animals as possible reservoir for human pathogenic strains. This study was a preliminary investigation on the occurrence of C. difficile in rabbits raised in industrial holdings for food production and aimed to characterise isolates and estimate their antimicrobial susceptibility. C. difficile isolates were characterized by toxin profiles, toxinotyping and PCR-ribotyping. The MICs of six antibiotics were determined using E-test. Between 2007 and 2013, 285 industrial holdings (representing 40% of the national census) submitted rabbits to our laboratory for diagnostic purposes, among these holdings, groups of three to five post-weaned rabbits were sampled once by convenience. 1279 samples of caecal content were collected. The overall isolation rate of C. difficile from the enteric specimen was 3% (38/1279), with no difference among animals affected or not by enteric disorders. Among isolates 66% (25/38) were toxigenic. Sixteen different PCR-ribotypes (RTs) were identified. Among the toxigenic strains RT-014/020, RT-078 and RT-012 were found in at least three rabbit holdings. According to the ECOFF threshold, 82% (31/38) C. difficile isolates displayed a reduced susceptibility to at least one and 18% (7/38) to three tested antimicrobials. Rabbits are colonized by heterogeneous C. difficile ribotypes many of which are commonly isolated in humans. One third of isolates displayed a reduced susceptibility to MTZ, the first choice antimicrobial for human CDI treatment. According to our findings rabbits are a potential source of C. difficile for humans.

First reporting of methicillin-resistant Staphylococcus aureus (MRSA) ST398 in an industrial rabbit holding and in farm-related people.

Livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) has been described in food-producing animals and farm or slaughterhouse workers involved in the primary industrial production of swine, bovine and poultry. This communication describes the first case of LA-MRSA (ST398, spa types t034 and t5210) occurring in rabbits raised intensively for meat production and involving farm workers or their family members. In 2012-2013, in a study involving 40 rabbit industrial holdings in Italy, one farm was found to have rabbits colonized or infected with MRSA. Four farm workers and one of their relatives were found to be carrying MRSA. In this case holding, rabbits, people and the holding environment were further investigated and followed up by a second sampling five months later. MRSA was found in 48% (11/23) and 25% (15/59) of the rabbits carrying S. aureus at first and second samplings, respectively. Five months after first detection, some farm workers or family members were still MRSA carriers. Surface samples (2/10) and air samples (2/3) were contaminated with MRSA. Air samples yielded MRSA counts of 5 and 15CFU/m(3). MRSA from rabbits and people collected at first sampling were spa types t034 and t5210 belonging to ST398. The MRSA isolates from rabbits and persons tested at second sampling were t034 and t5210, but spa types t1190 and t2970 were also detected in MRSA isolates from rabbits. Tracing the epidemiological pattern earlier may prevent further spread of LA-MRSA in these food producing animals.