Stime dell'antibiotico-resistenza in Italia e in Europa occidentale nel 2019: un'analisi comparativa basata su MICROBE.

BACKGROUND: antimicrobial resistance (AMR) will cause 10 million deaths per year worldwide by 2050, with economic costs of up to 100 trillion dollars. Antibiotic resistance (ABR) constitutes the majority of this health threat. Globally, 1.27 million people died in 2019 as a direct result of ABR. One in 5 deaths occurred in children under five, and 6 bacterial pathogens accounted for more than 70% of ABR-associated deaths. OBJECTIVES: to compare ABR estimates in terms of death and disability-adjusted life-years (DALYs) in 2019 in Italy and in Western Europe (WE) by grading the infectious syndromes and the bacterial pathogens involved, with the aim to identify the most urgent healthcare needs in Italy. DESIGN: the estimates of the burden of ABR in 2019 in WE and Italy, extracted from the Measuring Infectious Causes and Resistance Outcomes for Burden Estimation (MICROBE) tool by the Institute for Health Metrics and Evaluation (IHME; Seattle, USA), reported deaths and DALYs associated with 33 bacterial pathogens across 12 infectious syndromes, as well as deaths and DALYs associated with and attributable to ABR for 23 bacteria and 86 pathogen-drug combinations. The comparison between WE and Italy was performed in steps. First, among the 12 groups of infectious syndromes from the Global Burden of Diseases (GBD) study 2019, the most impacting in terms of deaths and DALYs were ranked based on the magnitude of rates, and the corresponding ABR-associated burden was reported. Then, the burden of the leading pathogens (bacteria, viruses, fungi, and polymicrobial infections) for all infectious syndromes was compared between the two areas. Death and DALY rates associated with ABR were reported for each bacterium, together with the percentage of ABR-attributable burden. Although it is known that Italy is one of the WE countries with the largest share of elderly, crude rates were reported instead of age-standardized rates, in order to quantify the actual burden of ABR in the two areas. SETTING AND PARTICIPANTS: Italy and Western Europe. MAIN OUTCOMES MEASURES: death and DALYs rates per 100,000 inhabitants. RESULTS: the largest difference between ABR-associated death rates in the two areas was found for bloodstream infections (25.2 and 18.8 per 100,000 in Italy and WE, respectively), followed by peritoneal and abdominal infections (15.1 and 12.2 in Italy and WE, respectively). However, the percentages of deaths and DALYs attributable to ABR were always higher in Italy for all the infections considered. Regarding pathogens, Escherichia coli accounted for the greatest burden associated to ABR, in terms of both deaths and DALYs, in both areas. The highest ABR-attributable percentage of deaths was found for Acinetobacter baumannii (28.4% in WE and 31.9% in Italy), accounting also for the highest percentage of ABR-attributable DALYs (28.4% in WE and 31.7% in Italy). The pathogen-drug combination with the highest burden associated with AMR was Escherichia coli-Aminopenicillin, while the greatest AMR-attributable burden was found for Staphylococcus aureus-Methicillin (MRSA). On average, 55.4% of Escherichia coli was resistant to Aminopenicillin in WE, with Italy ranking third (67.6%). Nordic countries showed smaller values, with Sweden in last place (32.8%). The average percentage of MRSA in WE was 16%, with Italy exceeding it by more than 13 pointsConclusions: despite similar sepsis mortality rates in Italy and other WE countries, the proportion of ABR-associated and attributable deaths was higher in Italy. Targeted strategies aimed at reducing the circulation of bacteria and resistant microorganisms together with other interventions could lead to an overall reduction in deaths associated with ABR.

Careggi Re-Engineered Discharge project: standardize discharge and improve care coordination between healthcare professionals.

BACKGROUND: The hospital discharge process plays a key role in patient care. Careggi Re-Engineered Discharge (CaRED) aimed at establishing a meaningful relationship among general practitioners (GPs) and patients, throughout the discharge process. OBJECTIVE: The aim is to describe the activities and results in the period 2014-17 of the CaRED. METHODS: CaRED is a restructured discharge protocol, which foresees a different, more direct form of communication between hospital and GPs, enabled by an ad hoc electronic medical record. The 30-day hospital readmission rate and/or accesses to the emergency department were evaluated as proxy for effective communication. A pre-post survey was launched to assess the GPs' perceived quality, and patient and family satisfaction. RESULTS: A total of 1549 hospitalizations were included, respectively, 717 in the pre and 832 in the post-intervention period. The 30-day hospital readmission rate decreased significantly in the post-intervention period (14.4% vs. 19.4%, χ2(1) = 8.03, P < 0.05).Eighty-two and 52 GPs participated, respectively, in the pre- and post-survey. In the post-phase the percentage of GPs declaring the discharge letter facilitated the communication on the admission causes (χ2(1) = 0.56, P = 0.03) and on what to do if conditions change (χ2(31) = 19.0, P < 0.01) significantly increased, as well as the perception of an easier contact with the hospitalist (χ2(3) = 19.6, P < 0.01).Two-hundred-eighty and 282 patients were enrolled in the pre- and post-survey. The level of understanding of key parts of the discharge letter (reason for hospitalization, post-discharge therapy, follow-up examinations and how to contact the hospital ward) improved significantly (P < 0.01). CONCLUSIONS: CaRED significantly improved the discharge process and became a benchmark for local improvements in communication patterns with GPs.

Strategia vaccinale in un contesto incerto e in costante evoluzione.

Politics is facing the need to make important decisions about anti-COVID-19 vaccination campaign in uncertain and changing contexts. With reference to the time frame between the administration of the first and second dose, the scientific evidence is still weak and comes from different contexts. New ways to collect and synthesize expert knowledge and opinions are needed with the direct involvement of the citizens in order to explain the uncertainties and maintain trust in institutions and their decisions.

Prolonged outbreak of New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE), Tuscany, Italy, 2018 to 2019.

In Tuscany, Italy, New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE) have increased since November 2018. Between November 2018 and October 2019, 1,645 samples were NDM-CRE-positive: 1,270 (77.2%) cases of intestinal carriage, 129 (7.8%) bloodstream infections and 246 (14.9%) infections/colonisations at other sites. Klebsiella pneumoniae were prevalent (1,495; 90.9%), with ST147/NDM-1 the dominant clone. Delayed outbreak identification and response resulted in sustained NDM-CRE transmission in the North-West area of Tuscany, but successfully contained spread within the region.

The risk of over-diagnosis in serological testing. Implications for communications strategies.

BACKGROUND: since the beginning of the COVID-19 pandemic, the importance of developing a serological test has emerged and a debate on test accuracy and reliability become an issue widely discussed in the media. The importance of communication during this pandemic has been strongly underlined by public health experts, epidemiologists, media expert, psychologists, sociologists. In the case of serological tests, there are several aspects that have to be considered: why we perform the test, what population is tested, which are the parameters conditioning the results and their interpretation. OBJECTIVES: to show how to quantify the uncertainty related to the validity of the serological test with respect to its predictive value and in particular the positive predictive value. METHODS: the evaluation of a qualitative diagnostic test includes four distinct assessments: accuracy, empirical evidence, practical importance, and prevalence of the pathology. Accuracy is measured by the sensitivity and specificity of the test; empirical evidence is quantified by the likelihood ratio, respectively for a positive and negative test result; the practical importance of the result of a diagnostic test is assessed by the positive or negative predictive value. Prevalence of COVID-19 is substantial uncertainty and it is possible to estimate the apparent prevalence starting from the results obtained with a diagnostic test. RESULTS: at the moment, the knowledge about the accuracy of serological tests is limited and little attention is paid to confidence interval on point estimates. In terms of practical importance of testing at individual level, while negative predictive values are high whatever the level of sensitivity of the test, the interpretation of a positive results is very cumbersome. Positive predictive values above 90% can be reached only by tests with specificity above 99% at the expected prevalence rate of 5%. There is a linear relationship between apparent - testing positive - prevalence and real prevalence. The apparent prevalence in the context of serological test for COVID-19 is always larger than real prevalence. The level of specificity is crucial. CONCLUSIONS: the main applications of the serological test in the epidemic contest are: to study the seroprevalence of the virus antibodies in the general population; to screen the healthcare workers for the early identification of contagious subjects' health care settings and to screen the general population in order to identify new incident cases. In the first two cases, seroprevalence study and screening of a high-risk population, the consequences of the uncertainty associated to the statistics are already accounted for in the first situation, or are overcome by repeating the screening on the healthcare workers, and using the molecular test to verify the presence of the virus in those tested positive. The case of screening of general population is more complex and of major interest for the implication it may have on individual behaviours and on the implementation of public health interventions by the political decision makers. A positive result has, per se, no practical value for individuals since the probability of being really infected by the virus is low. The uncertainty associated with the different estimates (sensitivity, specificity and disease prevalence) play a double role: it is a key factor in defining the informative content of the test result and it might guide the individual actions and the public policy decisions.

[Good practices for the surveillance and control of antimicrobial resistance]. / Buone pratiche per la sorveglianza e il controllo dell'antibiotico-resistenza.

Italy is one of the European Countries with the highest level of antimicrobial consumption, both in the community and in hospital settings, and with the highest prevalence of antimicrobial resistant microorganisms. In 2015, the Project "Good practices for the surveillance and control of antimicrobial resistance" was funded by the Italian National Centre for Disease Prevention and Control (CCM): the aim was to promote integrated actions at national level to control antimicrobial resistance, favouring the transfer of existing good practices. The principal objectives of the project were: to describe the Italian scenario of good practices based on literature review; to improve the capacity of surveillance, through achieving consensus on a core set of indicators, including paediatrics, and through the strengthening of the national surveillance system of antimicrobial resistance coordinated by the Italian National Institute of Health; to define tools useful for priority setting; to evaluate the efficacy of intervention programme aimed at promoting the appropriate use of antibiotics among children for upper respiratory tract infections in the community; to set up training programmes on the prudent use of antibiotics in veterinary medicine. Seven regions were enrolled in the project (Emilia-Romagna with the role of programme coordinator, Campania, Calabria, Lazio, Lombardy, Piedmont, Tuscany) and the Italian National Health Institute. The project allowed to document: the scarce spread of control practices at national level (out of 277 studies reviewed, only 6.1% of the cases were targeted to evaluating the effectiveness of intervention programmes); a significant variability among regions both in relation to antimicrobial consumption and antimicrobial resistance prevalence, with a worrying spread in some regions of several antimicrobial resistant organisms responsible for "critical" infections with great potential health impact; the effectiveness of an intervention aimed at promoting appropriate use of antibiotics in frequent infections for children in the community, such as pharingotonsillitis and acute otitis media (35% reduction of antimicrobial consumption between 2010 and 2017 in Emilia-Romagna; an inversion of the ratio amoxicillin/amoxicillin-clavulanate); the need for new indicators to monitor antimicrobial consumption in hospital paediatric wards and of a new national system for timely identification of new antimicrobial resistance profiles; a positive evaluation of the training programme for veterinary physicians. In conclusion, the project has contributed to identify the most critical areas for antimicrobial resistance control and to select appropriate solutions, potentially transferable to the national level.

Patient mobility for cardiac problems: a risk-adjusted analysis in Italy.

BACKGROUND: The Italian National Health System was revised in the last 20 years, introducing new elements such as efficacy, efficiency and competitiveness. Devolution to regional authorities has created a quasi-market system where patients can choose the hospital in which to be treated. Patient mobility therefore becomes an indicator of perceived hospital quality and of financial flows between the regions of Italy. Previous studies analyzed patient mobility in general or by specific disease/diagnosis-related groups but there is a lack of research on the influence of severity of patient condition. The aim of the study was to describe patient mobility, crude and stratified by disease severity, in cardiac surgery units of three health areas (HAs) in Tuscany (Italy). METHODS: In this retrospective observational study, data was gathered from hospital discharge records obtained from the Tuscan Regional Health Agency, Italy. The three HAs (HA1, HA2, HA3) recorded 25,017 planned hospitalizations in cardiac surgery units in the period 2001-2007. Patients were stratified in four All Patient Refined Diagnosis Related Group (APR-DRG) severity levels. Gandy's nomogram was used to describe how HAs met health care demand and their capacity to attract patients. Cuzick's test was used to identify significant differences in time trends. RESULTS: Raw data showed that the HAs met their own local health care demand. Stratifying by APR-DRG severity, it emerged that capacity to meet local demand remained unchanged for zero-to-minor severity levels, but one HA was less able to meet demand for moderate severity levels or to attract patients from other HAs and Regions of Italy. In fact, HA3 showed a decrease in admissions of local residents. CONCLUSIONS: The study highlights important differences between the three HAs that were only revealed by severity stratification: unlike HA3, HA1 and HA2 seemed able to deal with local demand, even after severity stratification. Planners and researchers can benefit from risk stratification data, which provides more elements for correct comparisons and interventions. In the context of patient mobility, the present study is a step in that direction.

[Equity of access to percutaneous transluminal coronary angioplasty (PTCA) among patients with acute myocardial infarction in Tuscany Region (Central Italy), 2001-2008]. / Equità nell'accesso all'angioplastica coronarica transluminale percutanea (ACTP) nei pazienti con infarto miocardico acuto in Toscana, 2001-2008.

OBJECTIVE: assessing the equity in the access to the percutaneous transluminal coronary angioplasty (PTCA) and in its time trend among patients with ST-elevation acute myocardial infarction. DESIGN: observational study based on regional administrative data: Hospital Discharge Registry, Health Registry, and 2001 Census data. Two indexes were used as deprivation measure: deprivation status at small area level (as proxy of the individual deprivation) and deprivation status at Local Health Agency level. The residence in a mountain municipality was used as extra measure of contextual deprivation. SETTING AND PARTICIPANTS: patients with first emergency hospital admission for acute myocardial infarction (AMI) with ST-elevation, resident in Tuscany Region (Central Italy) and hospitalized during the period 2001-2008. MAIN OUTCOME MEASURES: relative risk (RR) of the PTCA utilization. RESULTS: multivariate analysis by multilevel multiple logistic regression showed a significant lower PTCA utilization in females (RR: 0.91, p <0.0001), in patients with high deprivation status at Local Health Agency level (RR: 0.71, p <0.0001), in residents in a mountain municipality (RR: 0.90, p <0.0001), and in patients with comorbidity (RR: 0.98, p =0.006; RR: 0.87, p <0.0001; RR: 0.69, p <0.0001 for Charlson comorbidity index equal to 1, 2, ≥3, respectively). The PTCA utilization over time has grown significantly (p <0.0001), from 26.6% in 2001 to 57.4% in 2008. This increase was more pronounced in patients with high deprivation status at Local Health Agency level (RR: 4.01, p <0.0001 for year 2008 vs. 2001), with consequent reduction of the initial differential with respect to patients with low deprivation status at Local Health Agency level (RR: 0.40, p <0.0001 in 2001 and RR: 0.93, p =0.114 in 2008). However, the differential associated with gender and residence in a mountain municipality persisted over time. DISCUSSION: In Tuscany during the period 2001-2008 a significant reduction of the differential in the PTCA utilization associated with the deprivation status at Local Health Agency level was observed. This finding could be explained by the diffusion and organization of suitable invasive cardiology units in the region, the organizational models of care, the different propensity to the PTCA utilization by the referral hospitals.

Does Vaccine Confidence Mediate the Relationship between Vaccine Literacy and Influenza Vaccination? Exploring Determinants of Vaccination among Staff Members of Nursing Homes in Tuscany, Italy, during the COVID-19 Pandemic.

BACKGROUND: Low coverage of influenza vaccination in nursing home (NH) staff may be attributed to factors such as vaccine confidence (VC) and vaccine literacy (VL). Our study aimed to evaluate the role of VL and VC in predicting the intention to get the influenza vaccine in a sample of employees of NHs in Tuscany, Italy. METHODS: Data from staff members in Tuscany were collected using an online questionnaire that examined influenza vaccination history, intentions, demographic information, health status, and VL. Statistical analyses explored the relationships between VC, VL, and vaccination intentions. RESULTS: The study included 1794 respondents, (86.3%) and assistants/aides (58.1%), with a median age of 46 years. The intention to get vaccinated was significantly higher among those with health risk conditions, and there was a positive association between VC and VL, specifically its interactive/critical component. The mediation analysis showed that VC completely mediated the relationship between VL and the intention to get vaccinated, with significant effects observed in different subgroups. CONCLUSIONS: VC is a key factor that mediates the effect of VL on vaccine intention. These results suggest that interventions aimed at improving VL alone may not be sufficient to increase vaccine uptake unless VC is also addressed.

Hospital admission and mortality rates for non-Covid diseases among residents of the long-term care facilities before and during the pandemic: a cohort study in two Italian regions.

Aim: Long-term-care facility residents are a vulnerable population who experienced reduced healthcare access during the pandemic. This study aimed to assess the indirect impact of the COVID-19 pandemic, in terms of hospitalisation and mortality rates, among this population in two Italian Regions, Tuscany and Apulia, during 2020 in comparison with the pre-pandemic period. Subject and methods: We conducted a retrospective cohort study on people residing in long-term-care facilities from 1 January 2018 to 31 December 2020 (baseline period: 1 January 2018-8 March 2020; pandemic period: and 9 March-31 December 2020). Hospitalisation rates were stratified by sex and major disease groups. Standardised weekly rates were estimated with a Poisson regression model. Only for Tuscany, mortality risk at 30 days after hospitalisation was calculated with the Kaplan-Meier estimator. Mortality risk ratios were calculated using Cox proportional regression models. Results: Nineteen thousand two hundred and fifty individuals spent at least 7 days in a long-term-care facility during the study period. The overall mean non-Covid hospital admission rate per 100 000 residents/week was 144.1 and 116.2 during the baseline and pandemic periods, with a decrease to 99.7 and 77.3 during the first (March-May) and second lockdown (November-December). Hospitalisation rates decreased for all major disease groups. Thirty-day mortality risk ratios for non-Covid conditions increased during the pandemic period (1.2, 1.1 to 1.4) compared with baseline. Conclusion: The pandemic resulted in worse non-COVID-related health outcomes for long-term-care facilities' residents. There is a need to prioritise these facilities in national pandemic preparedness plans and to ensure their full integration in national surveillance systems. Supplementary information: The online version contains supplementary material available at 10.1007/s10389-023-01925-1.

Early Warning Systems for Emerging Profiles of Antimicrobial Resistance in Italy: A National Survey.

Antimicrobial resistance (AMR) national surveillance systems in Italy lack alert systems for timely detection of emerging profiles of AMR with potential relevance to public health. Furthermore, the existence of early warning systems (EWS) at subnational level is unclear. This study aims at mapping and characterizing EWS for microbiological threats available at regional level in Italy, focusing on emerging AMR, and at outlining potential barriers and facilitators to their development/implementation. To this end, a three-section, web-based survey was developed and administered to all Italian regional AMR representatives from June to August 2022. Twenty out of twenty-one regions and autonomous provinces (95.2%) responded to the survey. Among these, nine (45%) reported the implementation of EWS for microbiological threats at regional level, three (15%) reported that EWS are in the process of being developed, and eight (40%) reported that EWS are not currently available. EWS characteristics varied widely among the identified systems concerning both AMR profiles reported and data flow: the microorganisms most frequently included were extensively drug-resistant (XDR) Enterobacterales, with the lack of a dedicated regional IT platform reported in most cases. The results of this study depict a highly heterogeneous scenario and suggest that more efforts aimed at strengthening national AMR surveillance systems are needed.

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.

Automated detection of hospital outbreaks of multi-drug resistant pathogens in one Italian region.

BACKGROUND: Automated tools for antimicrobial resistance surveillance are critical for improving detection of drug-resistant organisms and informing prevention and control interventions. In this study, the WHONET-SaTScan software was used at a multihospital level in Tuscany, Italy, to identify case clusters consistent with hospital outbreaks caused by drug-resistant pathogens. METHODS: Antimicrobial resistance surveillance data from all Tuscany hospitals between January 2018 and December 2020 were analyzed using WHONET. The SaTScan package was used to detect case clusters applying a simulated prospective approach and the space-time permutation algorithm. Clusters were identified using resistance profiles and two distinct spatial variables: single medical services ('service') or groups of related services ('metaservice'). RESULTS: Data from eight bacterial pathogens were provided from 49 hospitals for 312,779 isolates from 158,809 patients. Single service-based analysis detected 693 hospital clusters, while metaservice-based analysis identified 635. There was no evidence for a difference between the two methods in terms of cluster length, cluster size, recurrence intervals, number of alerts, distribution across years or hospitals. Among clusters involving multiple services identified by both analyses, metaservice-detected clusters were usually larger and more statistically significant. CONCLUSIONS: WHONET-SaTScan proved to be a valuable multi-facility cluster detection tool that can be implemented for real-time surveillance.

The indirect impact of COVID-19 pandemic on the utilization of the emergency medical services during the first pandemic wave: A system-wide study of Tuscany Region, Italy.

BACKGROUND: Utilization of Emergency Medical Services (EMS) declined during COVID-19 pandemic, but most of the studies analyzed components of the EMS system individually. The study aimed to evaluate the indirect impact of COVID-19 pandemic on the utilization of all the components of the EMS system of Tuscany Region (Italy) during the first pandemic wave. METHODS: Administrative data from the health care system of Tuscany were used. Changes in utilization for out-of-hospital emergency calls and emergency vehicle dispatched, emergency department (ED) visits, and patients being admitted from the ED to an inpatient hospital bed (hospitalizations from ED) during the first pandemic wave were analyzed in relation with corresponding periods of the previous two years. Percentage changes and 95%CI were calculated with Poisson models. Standardized Ratios were calculated to evaluate changes in in-hospital mortality and hospitalizations requiring ICU. RESULTS: Significant declines were observed in the utilization of all the EMS considered starting from the week in which the first case of COVID-19 was diagnosed in Italy till the end of the first pandemic wave. During the epidemic peak, the maximum decreases were observed: -33% for the emergency calls, -45% for the dispatch of emergency vehicles, -71% for ED admissions. Furthermore, a decline of 37% for hospitalizations from ED was recorded. Significant decreases in ED admissions for life threatening medical conditions were observed: acute cerebrovascular disease (-36%, 95% CI: -43, -29), acute myocardial infarction (-42%, 95% CI: -52, -31) and renal failure (-42%, 95% CI: -52, -31). No significant differences were found between the observed and the expected in-hospital mortality and hospitalizations requiring ICU during the epidemic peak. CONCLUSION: All the components of the EMS showed large declines in their utilization during COVID-19 pandemic; furthermore, major reductions were observed for admissions for time-dependent and life-threatening conditions. Efforts should be made to ensure access to safe and high-quality emergency care during pandemic.

Orthopaedic Implant-Associated Staphylococcal Infections: A Critical Reappraisal of Unmet Clinical Needs Associated with the Implementation of the Best Antibiotic Choice.

Infections associated with orthopaedic implants represent a major health concern characterized by a remarkable incidence of morbidity and mortality. The wide variety of clinical scenarios encountered in the heterogeneous world of infections associated with orthopaedic implants makes the implementation of an optimal and standardized antimicrobial treatment challenging. Antibiotic bone penetration, anti-biofilm activity, long-term safety, and drug choice/dosage regimens favouring outpatient management (i.e., long-acting or oral agents) play a major role in regards to the chronic evolution of these infections. The aim of this multidisciplinary opinion article is to summarize evidence supporting the use of the different anti-staphylococcal agents in terms of microbiological and pharmacological optimization according to bone penetration, anti-biofilm activity, long-term safety, and feasibility for outpatient regimens, and to provide a useful guide for clinicians in the management of patients affected by staphylococcal infections associated with orthopaedic implants Novel long-acting lipoglycopeptides, and particularly dalbavancin, alone or in combination with rifampicin, could represent the best antibiotic choice according to real-world evidence and pharmacokinetic/pharmacodynamic properties. The implementation of a multidisciplinary taskforce and close cooperation between microbiologists and clinicians is crucial for providing the best care in this scenario.

Indirect impact of the COVID-19 pandemic and its containment measures on social inequalities in hospital utilisation in Italy.

BACKGROUND: The pandemic may undermine the equity of access to and utilisation of health services for conditions other than COVID-19. The objective of the study is to evaluate the indirect impact of COVID-19 and lockdown measures on sociodemographic inequalities in healthcare utilisation in seven Italian areas. METHODS: In this multicentre retrospective study, we evaluated whether COVID-19 modified the association between educational level or deprivation and indicators of hospital utilisation and quality of care. We also assessed variations in gradients by sex and age class. We estimated age-standardised rates and prevalence and their relative per cent changes comparing pandemic (2020) and pre-pandemic (2018-2019) periods, and the Relative Index of Inequalities (RIIs) fitting multivariable Poisson models with an interaction between socioeconomic position and period. RESULTS: Compared with 2018-2019, hospital utilisation and, to a lesser extent, timeliness of procedures indicators fell during the first months of 2020. Larger declines were registered among women, the elderly and the low educated resulting in a shrinkage (or widening if RII <1) of the educational gradients for most of the indicators. Timeliness of procedures indicators did not show any educational gradient neither before nor during the pandemic. Inequalities by deprivation were nuanced and did not substantially change in 2020. CONCLUSIONS: The socially patterned reduction of hospital utilisation may lead to a potential exacerbation of health inequalities among groups who were already vulnerable before the pandemic. The healthcare service can contribute to contrast health disparities worsened by COVID-19 through more efficient communication and locally appropriate interventions.

Resistome and virulome accretion in an NDM-1-producing ST147 sublineage of Klebsiella pneumoniae associated with an outbreak in Tuscany, Italy: a genotypic and phenotypic characterisation.

BACKGROUND: Carbapenemase-producing Enterobacterales (CPE), particularly those producing metallo-ß-lactamases, are among the most challenging antibiotic-resistant pathogens, causing outbreaks of difficult-to-treat nosocomial infections worldwide. Since November 2018, an outbreak of New Delhi metallo-ß-lactamases-positive CPE (NDM-CPE) has emerged in Tuscany, Italy. In this study, we aimed to investigate the NDM-CPE associated with the outbreak and characterise the responsible Klebsiella pneumoniae clone. METHODS: We used whole-genome sequencing and bioinformatic analysis to characterise NDM-CPE isolates that caused bloodstream infections in 53 patients at 11 hospitals in Tuscany and that were collected between Jan 1, 2018, and July 5, 2019 (ie, the early phase of the outbreak and preceding months). The CPE isolates characterised in this study were isolated and identified at the species level and as NDM producers by six diagnostic microbiology laboratories that serve the 11 hospitals. We used comparative genomic analysis, antimicrobial susceptibility testing, plasmid conjugal transfer assays, evaluation of virulence potential in the Galleria mellonella infection model, and serum bactericidal assays to further characterise the clone causing the outbreak. FINDINGS: The outbreak was sustained by an ST147 K pneumoniae producing NDM-1, which had a complex resistome that mediated resistance to most antimicrobials (except cefiderocol, the aztreonam-avibactam combination, colistin, and fosfomycin). The clone belonged to a sublineage of probably recent evolution, occurred by the sequential acquisition of an integrative and conjugative element encoding the yersiniabactin siderophore, an FIB(pQil)-type multiresistance plasmid carrying blaNDM-1, and a transferable chimeric plasmid, derived from virulence elements of hypervirulent K pneumoniae, carrying several resistance and virulence determinants. Infection of G mellonella larvae revealed a variable virulence potential. The behaviour in serum bactericidal assays was different from typical hypervirulent K pneumoniae strains, with variable grades of serum resistance apparently associated with mutations in specific chromosomal loci (csrD, pal, and ramR). INTERPRETATION: This description of a sublineage of ST147 K pneumoniae with a complex resistome and virulome that is capable of sustaining a large regional outbreak adds to existing research on the evolutionary trajectories within high-risk clones of K pneumoniae. Global surveillance programmes are warranted to track the dissemination of these lineages, and to prevent and control their spread. FUNDING: Italian Ministry of Health and Department of Experimental and Clinical Medicine, University of Florence.

Vaccine Literacy and Source of Information about Vaccination among Staff of Nursing Homes: A Cross-Sectional Survey Conducted in Tuscany (Italy).

Vaccine literacy (VL) mediates the transfer of information and facilitates vaccination acceptance. The aims of this study are to validate the HLVa-IT (Health Literacy Vaccinale degli adulti in Italiano­Vaccine health literacy for adults in Italian language) for the staff of nursing homes (NHs), to measure VL in such a peculiar target group, and to assess its relationship with the sources used to obtain information about vaccines and vaccinations. A survey has been conducted in a sample of Tuscan NHs using an online questionnaire. Eight-hundred and fifty-three questionnaires were analyzed. Two dimensions of the HLVa-IT appeared (functional and interactive/communicative/critical VL). The HLVa-IT interactive/communicative/critical subscale score was slightly higher than the functional subscale, although with no statistical significance. General practitioners (GPs) or other professionals have been reported as the main source of information by most of the respondents (66.1%). The HLVa-IT total score was significantly higher among those who have declared to use official vaccination campaigns (mean score: 3.25 ± 0.49; p < 0.001), GPs or other health professionals (3.26 ± 0.47; p < 0.001), and search engines (3.27 ± 0.48; p = 0.040) as the main sources of information. In conclusion, the HLVa-IT could be reliable test to investigate VL for staff of NHs, and also to highlight criticalities related to information sources.

Validity of "Sepsis-3" criteria in identifying patients with community-onset sepsis in Internal Medicine wards; a prospective, multicenter study.

BACKGROUND: Few data are available on the validity of "Sepsis-3" criteria in identifying patients with sepsis in internal medicine wards (IMWs). Real-life data about this topic and on the prevalence of sepsis in IMWs could be useful for improving hospital organization. OBJECTIVES: To assess the validity of "Sepsis-3" criteria in identifying patients with community-onset sepsis in IMWs. Secondary objectives: to evaluate the prevalence of these patients in IMWs and to compare "Sepsis-3" and "Sepsis-1" criteria. METHODS: Multicenter, prospective, observational, cohort study, carried out in 22 IMWs of Tuscany (Italy). All patients admitted to each of the study centers over a period of 21-31 days were evaluated within 48 hours; those with clinical signs of infection were enrolled. The main outcome was in-hospital mortality. RESULTS: 2,839 patients were evaluated and 938 (33%) met the inclusion criteria. Patients with sepsis diagnosed according to "Sepsis-3" were 522, representing 55.6% of patients with infection and 18.4% of all patients hospitalized; they were older than those without sepsis (79.4±12.5 vs 74.6±15.2 years, p<0.001). In-hospital mortality was significantly higher in patients with sepsis compared to others (13.8% vs 4.6%; p<0.001). "Sepsis-3" criteria showed greater predictive validity for in-hospital mortality than "Sepsis-1" criteria (AUROC=0.71; 95%CI, 0.66-0.77 vs 0.60; 95%CI 0.54-0.66; p=0.0038). CONCLUSIONS: "Sepsis-3" criteria are able to identify patients with community-onset sepsis in IMWs, whose prevalence and in-hospital mortality are remarkably high. Medical departments should adapt their organization to the needs for care of these complex patients.

Indirect impact of Covid-19 on hospital care pathways in Italy.

Earlier in 2020, seven Italian regions, which cover 62% of the Italian population, set up the Mimico-19 network to monitor the side effects of the restrictive measures against Covid-19 on volumes and quality of care. To this aim, we retrospectively analysed hospital discharges data, computing twelve indicators of volume and performance in three clinical areas: cardiology, oncology, and orthopaedics. Weekly indicators for the period January-July 2020 were compared with the corresponding average for 2018-2019; comparisons were performed within 3 sub-periods: pre-lockdown, lockdown, and post-lockdown. The weekly trend of hospitalisations for ST-segment elevation myocardial infarction (STEMI) showed a 40% reduction, but the proportion of STEMI patients with a primary PTCA did not significantly change from previous years. Malignant neoplasms surgery volumes differed substantially by site, with a limited reduction for lung cancer (< 20%) and greater declines (30-40%) for breast and prostate cancers. The percentage of timely surgery for femoral neck in the elderly remained constantly higher than the previous 2 years whereas hip and knee replacements fell dramatically. Hospitalisations have generally decreased, but the capacity of a timely and effective response in time-dependent pathways of care was not jeopardized throughout the period. General trends did not show important differences across regions, regardless of the different burden of Covid-19. Preventive and primary care services should adopt a pro-active approach, moving towards the identification of at-risk conditions that were neglected during the pandemic and timely addressing patients to the secondary care system.