Impact of COVID-19 on antimicrobial stewardship activities in Italy: a region-wide assessment.

BACKGROUND: In the region of Piedmont, in Northern Italy, formal monitoring of antimicrobial stewardship (AMS) programs has been in place since 2012. The objective of our study was to provide an updated assessment of AMS programs operating in our region, and to assess the impact of the COVID-19 pandemic on stewardship activities. METHODS: A retrospective observational study was conducted to investigate AMS programs implemented in acute-care trusts participating in a broader healthcare-associated infections and antimicrobial resistance (AMR) prevention and control program, promoted by the regional health department. Within this program, structure, process, and outcome indicators of AMS programs were investigated, using a previously developed scoring system. Differences between scores prior to (2019) and during the pandemic (2021) were assessed. Linear regression was used to assess whether the 5-year trends (2017-2021) in outcome measures in relation to structure and process scores were statistically significant. Compound annual growth rates (CAGR) for each outcome were calculated to illustrate changes in outcome rates over time. RESULTS: All public trusts in the Region (20) and a small number of private institutions (3) provided data for this study. A modest, non-significant improvement was found for 2021 structure, process, and total scores compared to respective 2019 scores. A significant improvement was found concerning the definition of a formal mission statement, whereas significantly less trusts included monitoring adherence to antimicrobial policy or treatment guidelines in their programs. Overall consumption of antibiotics for systemic use saw an increase in 2021, with 2021 recording the highest median overall consumption compared to all previous years considered in this study. Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) rates decreased over the 5-year period. Significant downwards trends in MRSA rates were identified for high-outlier structure and process groups. CONCLUSIONS: Results of this study suggest AMS programs in Piedmont were not set back following the pandemic. This outcome was possible thanks to well-established programs, coordinated within a regional framework. Continued efforts should be dedicated to supporting AMS programs and contrasting AMR, even when the focus is shifted towards other public health emergencies.

Level of implementation of multimodal strategies for infection prevention and control interventions and prevalence of healthcare-associated infections in Northern Italy.

BACKGROUND: In November 2022, Italy participated in the third edition of the European Centre for disease prevention and control (ECDC) point prevalence survey (PPS) of healthcare-associated infections (HAIs) in acute-care hospitals. A questionnaire based on the WHO infection prevention and control assessment framework (IPCAF) was included, which aims to investigate multimodal strategies for the implementation of IPC interventions. METHODS: A PPS was conducted using the ECDC PPS protocol version 6.0. The Regional health authority of the region of Piedmont, in north-western Italy, chose to enlist all public acute-care hospitals. Data were collected within one day per each ward, within 3 weeks in each hospital, at hospital, ward and patient level. A score between 0-1 or 0-2 was assigned to each of the 9 items in the IPCAF questionnaire, with 14 points representing the best possible score. HAI prevalence was calculated at the hospital-level as the percentage of patients with at least one HAI over all included patients. Relations between HAI prevalence, IPCAF score, and other hospital-level variables were assessed using Spearman's Rho coefficient. RESULTS: In total, 42 acute-care hospitals of the region of Piedmont were involved, with a total of 6865 included patients. All participant hospitals reported they employed multimodal strategies to implement IPC interventions. The median IPCAF overall score was 11/14 (interquartile range, IQR: 9.25-12). The multimodal strategy with the highest level of adherence was education and training, followed by communication and reminders. Strategies with the lowest level of adherence were safety climate and culture of change, and system change. Overall HAI prevalence was 8.06%. A weak to moderate inverse relation was found between IPCAF score and HAI prevalence (Spearman's Rho -0.340, p 0.034). No other significant correlation was found. CONCLUSIONS: This study found a high self-reported overall level of implementation of multimodal strategies for IPC in the region. Results of this study suggest the relevance of the multimodal approach and the validity of the IPCAF score in measuring IPC programs, in terms of effectiveness of preventing HAI transmission.

Impact of COVID-19 on healthcare associated infections and antimicrobial use in Italy, 2022.

INTRODUCTION: We aimed to assess the impact of COVID-19 on healthcare associated infection (HAI) transmission and antimicrobial use (AMU) prevalence during the later stages of the pandemic. METHODS: A point prevalence survey (PPS) was conducted among 325 acute-care hospitals of 19/21 regions of Italy, during November 2022. Non COVID-19 patients were matched to COVID-19 patients according to age, sex, and severity of underlying conditions. HAI and AMU prevalence were calculated as the percentage of patients with at least one HAI or prescribed at least one antimicrobial over all included patients, respectively. RESULTS: In total, 60403 patients were included, 1897 (3.14%) of which were classified as COVID-19 patients. Crude HAI prevalence was significantly higher among COVID-19 patients compared to non COVID-19 patients (9.54% vs. 8.01%, prevalence rate ratio, PRR 1.19, 95% confidence interval, CI 1.04-1.38, p<0.05), and remained higher in the matched sample, however statistical significance was not maintained: odds ratio (OR) 1.25 (95% CI 0.99 - 1.59, p 0.067). AMU prevalence was significantly higher among COVID-19 patients prior to matching (46.39% vs. 41.52%, PRR 1.21, 95% CI 1.11-1.32, p<0.001), and significantly lower after matching: OR 0.77 (95% CI 0.66-0.89, p < 0.001). CONCLUSIONS: COVID-19 patients could be at higher HAI risk due to underlying clinical conditions and to the intensity of healthcare needs. Further efforts should be dedicated to antimicrobial stewardship among COVID-19 patients.

Validation of the prevalence to incidence conversion method for healthcare associated infections in long-term care facilities.

INTRODUCTION: Residents of long-term care facilities (LTCFs) are a population at high risk of developing severe healthcare associated infections (HAIs). In the assessment of HAIs in acute-care hospitals, selection bias can occur due to cases being over-represented: patients developing HAIs usually have longer lengths of stays compared to controls, and therefore have an increased probability of being sampled in PPS, leading to an overestimation of HAI prevalence. Our hypothesis was that in LTCFs, the opposite may occur: residents developing HAIs either may have a greater chance of being transferred to acute-care facilities or of dying, and therefore could be under-represented in PPS, leading to an underestimation of HAI prevalence. Our aim was to test this hypothesis by comparing HAI rates obtained through longitudinal and cross-sectional studies. METHODS: Results from two studies conducted simultaneously in four LTCFs in Italy were compared: a longitudinal study promoted by the European Centre for Disease Prevention and Control (ECDC, HALT4 longitudinal study, H4LS), and a PPS. Prevalence was estimated from the PPS and converted into incidence per year using an adapted version of the Rhame and Sudderth formula proposed by the ECDC. Differences between incidence rates calculated from the PPS results and obtained from H4LS were investigated using the Byar method for rate ratio (RR). RESULTS: On the day of the PPS, HAI prevalence was 1.47% (95% confidence interval, CI 0.38-3.97), whereas the H4LS incidence rate was 3.53 per 1000 patient-days (PDs, 95% CI 2.99-4.08). Conversion of prevalence rates obtained through the PPS into incidence using the ECDC formula resulted in a rate of 0.86 per 1000 PDs (95% CI 0-2.68). Comparing the two rates, a RR of 0.24 (95% CI 0.03-2.03, p 0.1649) was found. CONCLUSIONS: This study did not find significant differences between HAI incidence estimates obtained from a longitudinal study and through conversion from PPS data. Results of this study support the validity of the ECDC method.

Hip prosthesis and colon surgery, a decade of surveillance on surgical site infections in Italy, a prospective cohort study: rates, trends, and disease burden in DALYs.

BACKGROUND: Surveillance programs are a key element of interventions aiming to reduce rates of surgical site infections (SSIs). The aim of this study was to evaluate rates and trends of SSIs following hip arthroplasty and colon surgery procedures in Piedmont, a region in North-western Italy, from 2010 to 2019. Further, we aimed to assess the burden of SSIs in terms of Disability-Adjusted Life-Years (DALYs). METHODS: A prospective cohort study was conducted among 42 hospitals participating in the surveillance system. Procedure-specific SSI rates were calculated and the 2010 - 2019 trend was evaluated using Spearman's Rho test. Patients were stratified according to age, sex and infection risk index according to life expectancy in order to calculate DALYs, using a modified version of the ECDC's BCoDE toolkit: disease models for both procedure types were adapted to incorporate long-term disability associated with SSIs. RESULTS: Overall, 20,356 hip arthroplasty and 11,011 colon surgery procedures were monitored over 10 years and were included in our analyses. Hip arthroplasty and colon surgery cumulative SSIs rates were 1.5% and 8% respectively. Using the Spearman's Rho test, we evaluated a significant downward trend from 2010 to 2019 for colon surgery interventions (Rs - 0.7, p < 0.05), while there was no difference for hip arthroplasty. (Rs - 0.04, p > 0.05). Regarding disease burden, a total of 955.3 (95%CI 837.7-1102.98) and 208.65 (95%CI 180.87-240.90) DALYs were calculated for SSIs following hip arthroplasty, whilst 76.58 (95%CI 67.15-90.71) and 38.62 (95% CI 33.09-45.36) DALYs for SSIs in colon surgery, in 2010 and 2019, respectively. CONCLUSIONS: The significant decrease both in terms of incidence and DALYs found in this study for colon surgery and the stability for hip arthroplasty support the role of surveillance networks in improving quality of care. Despite the smaller SSI rate, the burden associated with SSIs following hip arthroplasty was higher, which is important to consider in light of the aging population in Italy.

Implementation of a centralized, web-based surveillance for healthcare associated infections among residents of long-term care facilities in Italy.

Objective: The Italian National Action Plan to contrast AMR identified among its objectives the development and implementation of a national Healthcare-Associated Infection (HAI) surveillance system based on European Centre for Disease Prevention and Control (ECDC) indications, through point prevalence surveys (PPS) of HAIs and antibiotic use in acute-care hospitals and long-term care facilities (LTCFs). We aimed to assess feasibility and appropriateness of proposed tools for a national surveillance system of HAIs and antibiotic use in LTCFs. Study design: Point prevalence survey. Methods: A pilot PPS was conducted between May-June 2022, among 15 LTCFs of 7 Italian regions. Data were collected in a single day in each LTCF, at the LTCF, ward, and resident levels, using a web-based data collection tool developed ad hoc. Data collector teams of each facility were invited to complete a questionnaire investigating opinions on the proposed tools. Results: Among 1025 included residents, the prevalence of residents with at least one HAI was 2.5% (95% CI 1.7%-3.7%) considering all HAIs and 2.2% (95% CI 1.3%-3%) without considering SARS-CoV-2 infections. The prevalence of antimicrobial use was 3% (95% CI 0.2%-4.3%). Overall, most respondents were satisfied with the web-based software, training and protocol, even though some difficulties were reported. Conclusions: A national surveillance network was established, which will facilitate future surveillance efforts. Further studies are necessary to evaluate the impact of the pandemic on HAI transmission and antibiotic use in LTCFs.

Editorial for the Special Issue "Antibiotic Prescribing and Antimicrobial Resistance Patterns in Pediatric Patients".

Antibiotic overuse is among the most important factors contributing to the growing problem of antimicrobial resistance (AMR) [...].

Mortality and Case Fatality Rates Associated With Surgical Site Infections: A Retrospective Surveillance Study.

Background: Surgical site infections (SSIs) have been associated with increases in terms of costs, hospital stay, morbidity, and mortality. We aimed to assess trends in SSIs monitored through 10 years of surveillance activities in our region, and to describe mortality attributable to SSIs in the two most frequently monitored surgical procedures: colorectal surgery and hip arthroplasty. Methods: A retrospective cohort study was conducted among the 42 hospitals participating in the surveillance network of our region in northern Italy. All colorectal and hip arthroplasty procedures performed between January 1st, 2010, and December 31st, 2019, and monitored through the surveillance system were included in the study. Surgical site infection rates, overall mortality, case fatality rates (CFR), and mortality attributable to SSIs were evaluated overall and by year of participation in the surveillance program. Results: In total, 11,417 colon surgery and 20,804 hip arthroplasty procedures were included. Among colon surgery procedures, SSI rates decreased from 9.21% in 2010 to 5.7% in 2019. A significant decreasing trend was found for overall mortality (p = 0.008), which progressively decreased from 4.96% in 2010 to 2.96% in 2019. Among hip arthroplasty procedures, no significant trend emerged for SSI and mortality rates. Considering the 10-year period, the CFR was 6.62% and 3.7% for SSIs after colon surgery and hip arthroplasty procedures, respectively. Conclusions: The impact of SSIs on the clinical outcomes of patients undergoing surgery highlights the importance of SSI surveillance.

Cost-Effectiveness of Short Course of Ceftazidime/Avibactam for K. pneumoniae-KPC Bloodstream Infections in Italy.

BACKGROUND: Evidence has shown that short courses of antibiotic therapy are at least as effective as long courses with better clinical outcomes. CAZ/AVI has demonstrated its clinical efficacy in treating K. pneumoniae-KPC infections. METHODS: We conducted an analysis based on the real-life data of our ten years retrospective cohort to assess the cost-effectiveness and cost-utility of a short course of CAZ/AVI plus source control compared to a long course plus source control. A Markov model was structured. Patient transition between health states was modeled, each transition has a probability, and each state has a cost and a utility. Incremental cost-effectiveness ratios (ICERs) were obtained by dividing the difference in costs by the difference in utilities between the two courses. Input parameter uncertainty was investigated through sensitivity analysis. We launched 1000 Monte Carlo simulations by iteratively perturbing variables within estimated variation ranges, obtaining an ICER result for each simulation. RESULTS: In the first model (old appropriate treatment), a short course of treatment was associated with reduced costs per patient per year of €4818.60 and reduced effects (0.10 QALYs), compared to a long course. In the CAZ/AVI model, the short course was associated with increased costs of €1297.9 and with increased effects (0.04 QALYs), resulting in an ICER of €32,317.82 per QALY gained, below the WTP threshold of €40,000. CONCLUSIONS: Our findings highlight additional evidence regarding the cost-effectiveness of CAZ/AVI for policy-makers. We outline that CAZ/AVI could be cost-effective compared to old appropriate antibiotic therapies for KPC-Kp BSI.

Confirmation of presumptive Legionella colonies on culture media according to ISO 11731:2017: principles, problems, and practice.

AIMS: The ISO 11731 norm, published in 2017, describes a method to identify and enumerate Legionella based exclusively on the confirmation of presumptive colonies by subculturing them on BCYE and BCYE-cys agar (BCYE agar without L-cysteine). METHODS AND RESULTS: Despite this recommendation, our laboratory has kept confirming all presumptive Legionella colonies by combining the subculture method with the latex agglutination and polymerase chain reaction (PCR) assays. Here, we show that the ISO 11731:2017 method adequately performs in our laboratory according to ISO 13843:2017. We compared the performance of the ISO method in detecting Legionella in typical and atypical colonies (n = 7156) from health care facilities (HCFs) water samples to that of our combined protocol, and we found a 2.1% false positive rate (FPR), underscoring the importance of combining agglutination test and PCR with subculture to achieve optimal confirmation. Lastly, we estimated the water system disinfection cost for HCFs (n = 7), which due to false positive results, would display Legionella values exceeding the threshold of risk acceptance established by the Italian guidelines. CONCLUSIONS: Overall, this large-scale study indicates that the ISO 11731:2017 confirmation method is error-prone, leading to significant FPRs, and higher costs for HCFs due to remedial actions on their water systems.

Hand Hygiene and Antimicrobial Resistance in the COVID-19 Era: An Observational Study.

Hand hygiene (HH) is one of the most important infection prevention and control strategies at the hospital level. The aim of this study was to evaluate the potential COVID-19 pandemic impact on HH practices and rate of healthcare-associated infections. Data on alcohol-based handrub consumption (AHC) and antimicrobial resistance across 27 Italian hospitals over the period 2017-2021 were considered. Data on Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteria (CRE) were extracted from the antimicrobial resistance regional surveillance system. A significant increase was highlighted, with a peak in 2020 and a partial fall in 2021 for AHC (p < 0.001). The decrease in MRSA rates in 2021 compared to 2017-2019 was significant (p = 0.013). A significant Spearman's correlation between AHC and CRE rates was found (Spearman's ρ -0.646, p = 0.032). This study supports the importance of AHC monitoring and showed that improving AHC was an attainable goal in the COVID-19 era. However, other strategies are needed to maintain the high levels of AHC attained during the pandemic, in order to avoid a progressive drop that has already begun in 2021. Furthermore, our results support the inverse relationship between AHC and infection rates and antimicrobial-resistant bacteria.

Cost-Effectiveness of Targeted Prophylaxis among Allogenic Stem Cell Transplant Recipients.

Bloodstream infections (BSI) are life-threatening complications for onco-hematologic patients. Fluoroquinolones prophylaxis (FQP) was recommended for patients with neutropenia. Later, it was correlated with increased resistance rates among this population and its role became debated. While the role of FQ prophylaxis is still being studied, its cost-effectiveness is also unknown. The objective of this study was to evaluate the costs and effects associated with two alternative strategies (FQP vs. no prophylaxis) for patients with hematological malignancies undergoing allogenic stem cell transplant (HSCT). A decision-tree model was built integrating retrospectively collected data from a single transplant center, part of a tertiary teaching hospital in Northern Italy. Probabilities, costs and effects were considered in the assessment of the two alternative strategies. Probabilities of colonization, BSIs, extended-spectrum beta lactamase (ESBL) and Klebsiella pneumoniae carbapenemase (KPC) BSIs and mortality associated with infection, as well as median duration of length of stay (LOS) were calculated based on data collected between 2013 and 2021. The center applied the strategy of FQP between 2013 and 2016, and of no prophylaxis between 2016 and 2021. Data on 326 patients were collected during the considered time period. Overall, the rates of colonization, BSI, KPC/ESBL BSI, and mortality were 6.8% (95% confidence interval (CI) 2.7-13.5), 42% (9.9-81.4) and 20.72 (16.67-25.26), respectively. A mean bed-day cost of 132€ was estimated. Considering no prophylaxis vs. prophylaxis, the difference in costs ranged between additional 33.61 and 80.59€ per patient, whereas the difference in effects ranged between 0.11 and 0.03 life-years (LYs) lost (around 40 and 11 days). Given the small differences in terms of costs and effects between the two strategies, no prophylaxis seems an appropriate choice. Furthermore, this analysis did not consider the broader effect on hospital ecology of multiple doses of FQP, which could provide further support for the strategy of no prophylaxis. Our results suggest that the necessity for FQP in onco-hematologic setting should be determined based on local antibiotic resistance patterns.

Antibody responses to BNT162b2 SARS-CoV-2 mRNA vaccine among healthcare workers and residents of long-term care facilities: A cohort study in Northern Italy.

Background and Aims: Long-term care facilities (LTCFs) have been severely impacted by COVID-19, with a disproportionate amount of SARS-CoV-2 infections and related deaths occurring among residents. Methods: This study is part of an ongoing multicenter, prospective cohort study conducted among healthcare workers (HCWs) and residents of 13 LTCFs in Northern Italy designed to evaluate SARS-CoV-2 specific immunoglobulin class G (IgG) titers before and following vaccination with Pfizer/BNT162b2 SARS-CoV-2 mRNA vaccine (two doses of vaccine, 21 days apart). Serum samples were obtained from participants (t0) before vaccination, and (t1) 2 weeks after and analyzed to determine anti-S1 IgG antibodies. Results: Five hundred and thirty-four participants were enrolled (404 subjects participated in both blood draws). Seropositivity was 50.19% at t0 and 99% at t1, with a significant difference in IgG titers. A higher proportion of residents were seropositive at t0 compared with HCWs, with significantly higher IgG titers among residents at both t0 and t1. Pre-existing immunity also had a significant effect on postvaccination IgG titers. However, a significant difference in titers at t1 between HCWs and residents considering only participants seropositive at t0 was found, with higher median titers among previously seropositive residents. Conclusion: Findings of this study provide scientific evidence endorsing the policy of universal vaccination in LTCFs.

The Italian policy of mandating SARS-CoV-2 vaccination for healthcare workers: Analysis of the policy processes and preliminary outcomes.

BACKGROUND: Italy experienced the first outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Europe, and was among the most hardly hit European countries. Growing evidence suggests healthcare workers (HCWs) are at increased risk of SARS-CoV-2 infection. Infection in HCWs can lead to cross-transmission and increase community transmission. Italy was the first country in Europe to introduce mandatory vaccinations against SARS-CoV-2 for HCWs, on April 1, 2021. AIM: To describe the policy processes and preliminary results of the introduction of compulsory vaccination against SARS-CoV-2 for HCWs in Italy. RESULTS AND CONCLUSION: In Italy, the adoption of the policy was possible in the context of the public health and economic crisis resulting from the pandemic, with support from the scientific community and among favorable political conditions. Preliminary data suggest the policy has so far had a positive impact on increasing vaccine uptake and lowering infection rates among HCWs. Hopefully, the lack of serious vaccine-related adverse events and the growing evidence on vaccine effectiveness will progressively strengthen vaccine confidence among HCWs. In the context of a global pandemic, the Italian experience could provide insight for policymakers in other countries considering similar policies. Further, the ethical, legal, and policy challenges raised by the current public health emergency could be used to inform future pandemic preparedness plans.

Hand hygiene monitoring: Comparison between app and paper forms for direct observation.

Healthcare-associated infections (HAIs) are a global public health threat. Italy is one of the countries with the highest prevalence of HAI. Hand hygiene (HH) is a pillar of infection prevention and control. Monitoring HH is necessary to improve HH compliance, and direct observation is considered the gold standard. Transcription and analysis of data collected during direct observation of HH compliance with the WHO paper form are time-consuming. We collected, during a 9-day observation period, HH opportunities and compliance both with a smartphone application (SpeedyAudit) and with the WHO paper form. Then, we investigated the difference in the required time for data transcription and analysis between the WHO paper form and the use of the app. The difference in the required time for data transcription and analysis was significant with a mean time of 2 s using the app and about 14-54 min/day using paper form (p = .004) while no significant difference was found in measured compliance rates between the two data collecting methods. HH monitoring with an app is time-saving, and the app we used was easy to use.

Antimicrobial stewardship experiences in acute-care hospitals of Northern Italy: Assessment of structure, process and outcome indicators, 2017-2019.

BACKGROUND: Antimicrobial stewardship (AMS) programs are effective strategies for optimizing antimicrobial use. We aimed to assess AMS programs implemented in acute-care trusts of the region of Piedmont, Northern Italy. METHODS: AMS programs were investigated via a survey addressing structure, process and outcome indicators. For outcome indicators, annual means for the years 2017-2019 were considered, as well as the percentage change between 2017 and 2019. Outcome indicators were investigated in relation to structure and process scores using Spearman correlation. RESULTS: In total, 25 AMS programs were surveyed. Higher scores were achieved for process over structure indicators. Improvements in alcohol-based handrub usage (+30%), total antimicrobial usage (-4%), and percentages of methicillin-resistant Staphylococcus aureus and carbapenem-resistant Enterobacteriaceae over invasive isolates (respectively -16 and -23%) were found between 2017 and 2019. Significant correlations were found between structure score and percentage change in total antimicrobial usage and carbapenem-resistant Enterobacteriaceae over invasive isolates (Spearman's ρ -0.603, P .006 and ρ -0.433, P .044 respectively). DISCUSSION: This study identified areas for improvement: accountability, microbiological laboratory quality management and feedback to clinicians. Improving the organization of AMS programs in particular should be prioritized. CONCLUSION: Repeated measurements of structure and process indicators will be important to guide continuing quality improvement efforts.

Serological Responses up to 9 Months following COVID-19 mRNA Vaccination in Residents and Health-Care Workers of Long-Term Care Facilities: A Multicenter Prospective Cohort Study in Northern Italy.

Long-term care facilities (LTCFs) were severely affected by COVID-19, in particular in Northern Italy. We aimed to assess antibody responses among residents and healthcare workers (HCWs) of 13 LTCFs through serum samples collected at three time points: prior to, two weeks, and 9 months after receiving Pfizer/BNT162b2 SARS-CoV-2 mRNA vaccine (respectively t0, t1, and t2). IgG antibodies targeted towards the S1 domain of the spike protein were measured, and results were expressed in binding antibody units (BAU/mL). Friedman's average rank test was performed to compare antibody titres between the three time points. Two logistic regression models were built to identify independent predictors of (1) developing and (2) maintaining a significant antibody response to vaccination, using a previously identified threshold. In total, 534 subjects were enrolled (371 HCWs and 163 residents). The antibody titres at t1 were the highest; at t2, the IgG titres significantly decreased, remaining however 10 times higher compared to titres at t0. Previous infection was the only significant predictor of developing and maintaining a response over threshold in both models. Results of this study provided further insights on the humoral response elicited by vaccination, and on host factors determining variations in its magnitude and kinetics.

Hand Hygiene Practices during the COVID-19 Pandemic in Northern Italy: Assessment of Compliance Rates Measured by Direct Observation and Alcohol-Based Handrub Usage.

Hand hygiene (HH) is among the most effective measures for reducing the transmission of healthcare-associated infections and SARS-CoV-2. We aimed to assess HH practices among healthcare workers (HCWs) of three hub hospitals in Northern Italy during the COVID-19 pandemic, by assessing HH compliance measured by direct observation and alcohol-based handrub usage. An observational study was conducted over a period of three months, between February and April 2021. HH compliance audits were conducted using the WHO My 5 Moments for HH approach. Multivariable logistic regression was used to evaluate independent predictors of HH compliance: ward type, HCW category and HH indication. Spearman correlation was used to investigate the relationship between HH compliance and alcohol-based handrub consumption. In total, 2880 HH opportunities were observed, with an overall compliance of 68%. Significant differences were found in compliance rates across ward types, HCW categories and HH indications. The mean alcohol-based handrub usage among included wards was 41.63 mL/PD. No correlation was identified between compliance rates and alcohol-based handrub consumption (ρ 0.023, p 0.943). This study provided a snapshot of HH practices in a pandemic context, which could be useful as a reference for future studies.

A New Culture Method for the Detection of Non-Tuberculous Mycobacteria in Water Samples from Heater-Cooler Units and Extracorporeal Membrane Oxygenation Machines.

The isolation of non-tuberculous mycobacteria (NTM) from cultures is particularly laborious due to the potential overgrowth of coexisting non-acid fast bacilli. To reduce the overgrowth of these non-mycobacterial organisms, a decontamination step with NaOH or cetylpyridinium chloride is highly recommended before plating the samples on the culture medium. However, due to their toxicity, decontamination solutions tend to decrease NTM recovery from clinical and environmental samples. Here, we tested an alternative method for NTM recovery based on the use of NTM Elite agar, a selective medium that does not require a decontamination step. Using NTM Elite agar, we were able to detect non-tuberculous mycobacteria in 27.7% (30/108) of water samples analyzed. The average time to NTM detection was 18 days, but some strains required longer to grow, perhaps due to the stressful environmental conditions (periodical disinfection of devices). NTM Elite agar's effectiveness in inhibiting background flora was proven by the isolation of NTM from samples with and without background flora, showing no statistically significant differences in detection rates for different total viable counts of background flora (p = 0.4989). In conclusion, our findings indicate that effective NTM recovery from HCU- and ECMO-derived water samples can be achieved via filtration and direct culture of the filters on NTM Elite agar. This simple procedure can speed up laboratory work and provide an improved method, successfully resulting in low contamination and high detection rate, in addition to being less time-consuming. Its sensitivity and lack of a decontamination step make this protocol particularly useful for monitoring the effectiveness of device disinfection in hospital settings, even in the presence of low NTM loads. Reading timeframes should probably be extended to 7 weeks (i.e., well beyond the standard 4 weeks advised by the manufacturer), in order to isolate even the slow-growing mycobacteria. However, an extended incubation period is not necessary for exclusion of M. chimaera contamination of the devices, as M. chimaera isolation times do not generally exceed 3 weeks.

An Overview of Strategies to Improve Vaccination Compliance before and during the COVID-19 Pandemic.

The debate on vaccination mandate was fuelled over the past two years by the COVID-19 pandemic. This study aimed at overviewing vaccination strategies and corresponding vaccine coverages for childhood vaccinations before the pandemic and for SARS-CoV-2 in high-income countries. A qualitative comparison was also performed between the two contexts: unlike for childhood vaccinations, only one European country (Austria) imposed generalised COVID-19 mandates, most countries preferring targeted mandates for higher-risk categories (Italy, Greece) or workers in key public services (Finland, Australia, New Zealand, UK, Germany). Many countries (Norway, Sweden, Netherlands, Portugal, Spain) confirmed their traditional voluntary vaccination approach also for COVID-19, while others (Slovenia and Hungary), historically relying on compulsory vaccination strategies, surprisingly opted for voluntary SARS-CoV-2 vaccination, with unsatisfactory results in terms of immunisation rates. However, no tangible relationship was generally found between vaccination policies and immunisation coverages: data show that, unlike some countries with mandates, countries where vaccinations are merely recommended could achieve higher coverages, even beyond the recommended 95% threshold. The COVID-19 experience has enriched pre-existent vaccination strategy debates by adding interesting elements concerning attitudes towards vaccines in a novel and unexplored context. Interpreting the available results by considering the different cultural contexts and vaccine hesitancy determinants can help to better understand the complexity of the relationship between policies and achieved coverages.