Epidemiology and biomolecular characterization of carbapenem-resistant klebsiella pneumoniae in an Italian hospital.

OBJECTIVE: To describe the occurrence of CRKP infections in a tertiary care hospital and to analyse the allelic profiles of the clinical strains involved and the most frequent carbapenemases. DESIGN: The study analyzed cases of infection due to CRKP in the period 2013-2014; 147 cases were recorded, most of which (82.31%) were in-hospital infections. SETTING: A hospital in northern Italy. METHODS: We retrospectively collected: data on patient characteristics and the microbiological characteristics of CRKP. Isolates from 72 of the in-hospital cases underwent molecular typing (MLST); in addition, in each isolate, a procedure for the detection of the blaKPC gene was carried out. RESULTS: The in-hospital death rate was 24.0% in 2013 and 37.5% in 2014. However, the difference between these two values did not prove statistically significant (P > .05). Analysis of mortality revealed that bloodstream infections were more frequently associated with death than other infections (χ2 = 14.57, P < .001). The age-adjusted Cox proportional hazard model revealed that the patients with bacteremia due to CRKP had a 3-fold higher risk of death (HR 3.11; 95% CI 1.66 - 5.84, P< .001) than those with infections of other sites. MLST revealed that the prevalent allelic profile was ST 512 (79.62%); the most frequent carbapenemase was KPC-3 (83.8%). CONCLUSIONS: Our results are in line with those of recent studies, which have shown that the spread of CRKP in Italy is a matter of concern and that further efforts have to be made to prevent the potential dissemination of carbapenemase-producing clones of K. pneumoniae, whenever possible.

A Clostridium difficile outbreak in an Italian hospital: the efficacy of the multi-disciplinary and multifaceted approach.

INTRODUCTION: We described an outbreak of C. difficile that occurred in the Internal Medicine department of an Italian hospital and assessed the efficacy of the measures adopted to manage the outbreak. METHODS: The outbreak involved 15 patients and was identified by means of continuous integrated microbiological surveillance, starting with laboratory data (alert organism surveillance). Diarrheal fecal samples from patients with suspected infection by C. difficile underwent rapid membrane immuno-enzymatic testing, which detects both the presence of the glutamate dehydrogenase antigen and the presence of the A and B toxins. Extensive microbiological sampling was carried out both before and after sanitation of the environment, in order to assess the efficacy of the sanitation procedure. RESULTS: The outbreak lasted one and a half month, during which time the Committee for the Prevention of Hospital Infections ordered the implementation of multiple interventions, which enabled the outbreak to be controlled and the occurrence of new cases to be progressively prevented. The strategies adopted mainly involved patient isolation, reinforcement of proper hand hygiene techniques, antimicrobial stewardship and environmental decontamination by means of chlorine-based products. Moreover, the multifaceted management of the outbreak involved numerous sessions of instruction/training for nursing staff and socio-sanitary operatives during the outbreak. Sampling of environmental surfaces enabled two sites contaminated by C. difficile to be identified. CONCLUSIONS: Joint planning of multiple infection control practices, together with effective communication and collaboration between the Hospital Infections Committee and the ward involved proved to be successful in controlling the outbreak.

Urokinase thrombolytic therapy of pulmonary embolism in neurosurgically treated patients.

Pulmonary embolism (PE) is a severe complication in neurosurgery. The best treatment of PE is thrombolytic therapy, but the presence of either intracranial neoplasm or recent neurosurgical procedures is considered a major contraindication to this therapy. We have used urokinase thrombolytic therapy in nine of our patients with severe PE that occurred from 7 to 34 days after a neurosurgical operation. All patients survived. No intracranial hemorrhage occurred. We also advocate thrombolytic therapy for severe PE in patients who were recently operated on by neurosurgical procedure.

[MIPS: multicenter Italian pneumonia study. Results of an observational, prospective and multicenter study on the clinical approach to community-acquired pneumonia]. / MIPS: multicenter Italian pneumonia study. Risultati di uno studio osservazionale, prospettico e multicentrico sulla gestione clinica delle polmoniti acquisite in comunita.

In a survey of 25 Divisions of Internal Medicine and Pneumology throughout Italy, our study aimed to ascertain the diagnostic and therapeutic pathway, the gravity in accordance with Fine's score (PSI), the median hospital length of stay and mortality rate among patients consecutively hospitalized for community-acquired pneumonia (CAP), from January 1 to March 31, 2002. Overall 407 patients were evaluated, with a mean age of 69 years; the following Fine's scores: 28% less than 70, 21.4% between 71 and 90, 31.25% between 91 and 130, 19.4% more than130. A single chest radiography was performed in 27.2% of the patients, two chest radiographs in 55.2% of the patients, more than two chest radiographs in 13.2% of the patients. A CT scan of the thorax was performed in 20.1% of the patients; arterial blood gas tensions were measured in 73.4% of the patients. Antibiotics were used as follows: beta-lactams in 46.5% of the patients, fluoroquinolones in 30% of the patients, macrolides in 13.2% of the patients, glycopeptides in 2.2% of the patients, others in 2.9% of the patients. Mean hospital stay was 11 days; the 30-day in-hospital mortality was 9.6%. This study showed that a large number of patients with low-risk CAP were unnecessarily hospitalized.

[Wegener granulomatosis: a clinical case with parossistic positional vertigo due to involvement of the lateral semicircular canal]. / Su un caso di granulomatosi di Wegener esordita con vertigine parossistica posizionale da interessamento del canale semicircolare laterale.

The ear is involved in more than 20% of all cases of Wegener Granulomatosis (W.G.): such involvement takes place either through direct proliferation of the necrotic-granulomatosis tissue in the middle ear, or is a consequence of perieustachian tube infiltration from the rhinopharnyx. The inner ear is affected later and it is not clear as to exactly how. The present paper deals with the case of a 63-year-old woman who had a year been suffering from bilateral ear pain, and persistent otorrhea with typical signs of purulent chronic middle-ear otitis. During the course of the illness the patient complained of atypical paroxymal positional vertigo, compatible with cupulolithiasis of the semi-circular horizontal canal (as per E.N.G. recording). Transoral biopsy of the rhinopharynx and of the left nasal fossa revealed histopathological signs compatible with W.G.. In the light of post-mortem temporal bone studies performed by Friemann and Blatt on W.G. patients the present case could lead to further studies regarding the advancement of this pathological process within the middle and inner ears and the etiopathogenetic mechanisms involved. In particular, during the course of W.G., the appearance of benign paroxymal positional vertigo through cupulolithiasis of the semicircular horizontal canal may be justified: a) by the progressive involvement of the posterior labyrinth structures affecting the semicircular canals prior to the lateral canal and running on to the posterior canal; b) by the discovery of proteiform material in the labyrinthine fluids.

Rheumatoid arthritis with monoclonal IgE rheumatoid factor.

We studied a patient with rheumatoid arthritis (RA) and a high titer of IgE that could be attributed to a mono or oligoclonal expansion of IgE+ B lymphocytes. These IgE had no specificity for known allergens but bound to a panel of self (including Fc fragment of IgG) and exogenous antigens, displaying properties typical of polyspecific antibodies. We concluded that (1) RA can be associated with increased amounts of polyspecific IgE antibodies; (2) clonal excess populations of B cells are not a unique feature of malignant lymphoma, but may occur in autoimmune diseases in the form of a benign oligoclonal B cell proliferation.

Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure; the OSCUR study. Oucome dello Scompenso Cardiaco in relazione all'Utilizzo delle Risore.

AIMS: This study was designed to identify potential specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for congestive heart failure in departments of cardiology or internal medicine. METHODS AND RESULTS: From 1 July to 31 December 1998, we prospectively recorded epidemiological and clinical data from patients with congestive heart failure consecutively admitted to 11 departments of cardiology and 12 departments of internal medicine in Liguria, a northern area of Italy. The overall study population included 749 patients; 22% were treated by cardiologists and 78% by internists (P<0.0001). Patients managed by cardiologists were more likely to undergo echocardiography (92% vs 37%), Holter monitoring (25% vs 3%) and exercise stress testing (20% vs 0.5%) than those managed by internists (P=0.001). At discharge, patients treated by cardiologists were more likely to be prescribed beta-blockers (41% to 4%) and ACE inhibitors (100% to 74%) than those treated by internists (P<0.0001), and the latter medication at higher dosages by cardiologists than internists. In addition, patients followed by cardiologists were younger (70+/-9 to 79+/-1 years;P<0.0001), more likely to be male (61% to 50%;P=0.011) and to have coronary artery disease (57% to 45%;P<0.006) than those followed by internists. Conversely, patients followed by internists were more likely to have diabetes, chronic obstructive pulmonary disease, atrial fibrillation and renal failure (P<0.03). In the overall study population, 53 patients (7%) died during hospitalization. Patients treated by cardiologists had a mortality not significantly different from that of patients treated by internists (10% and 6%, respectively;P=0.067), although congestive heart failure was more severe on admission in patients treated by cardiologists. CONCLUSION: Cardiologists follow published guidelines for congestive heart failure more strictly than internists, but treat a smaller number of patients who are younger, have more severe congestive heart failure and fewer co-morbidities than those managed by internists.