Strategies to control antibiotic resistance: results from a survey in Italian children's hospitals.

BACKGROUND: Antimicrobial stewardship programs and comprehensive infection control programs represent the main strategies to limit the emergence and transmission of multi-drug resistant bacteria in hospital settings. The purpose of this study was to describe strategies implemented in Italian children's hospitals for controlling antibiotic resistance. STUDY DESIGN: Cross sectional multicenter study. METHODS: Four tertiary care Italian children's hospitals were invited to participate in a survey aimed at collecting information on activities implemented as of December 2015 using a self-administered online questionnaire. The questionnaire was divided in three sections focalizing on: i) policies for prevention and control of hospital-acquired infection, ii) prevention and control of multi-drug resistant bacteria, and iii) antibiotic prescribing policies and Antimicrobial stewardship programs. Questionnaires were compiled between May and July 2016. RESULTS: All hospitals had multidisciplinary infection control committee, procedures on hand hygiene, isolation measures, disinfection/sterilization, waste disposal and prevention on infections associated to invasive procedures. All sites screened patients for multi-drug resistant bacteria colonization in selected units, and adopted contact precautions for colonized patients. Screening during hospitalization, or in case of infections in the same ward were not universally implemented. All hospitals had policies on surgical prophylaxis, while policies on medical prophylaxis and treatment of bacterial infections varied among sites. Two sites recommended to review the appropriateness of antibiotic prescribing after 48-72 hours and one recommended de-escalation therapy. CONCLUSIONS: This study highlighted several areas of improvement, such as actions for screening patients in case of occurrence of multi-drug resistant bacteria, antimicrobial stewardship programs and implementation of policies targeting antibiotic prescriptions for therapeutic purposes and medical prophylaxis.

Hospital statistics for antibiotics: defined versus prescribed daily dose.

PURPOSE: Defined daily doses (DDD) are widely used as a unit to measure drug use in hospital and community settings. However, discrepancies exist between DDD and actual prescribed daily dose (PDD). The present study aims at estimating an alternative PDD (PDD-proxy) to calculate rates of systemic antibiotic consumption and to compare these results with those obtained using DDD. METHODS: The study considered a 9-year period (2004-2012) and included the 17 Health Trusts (HTs) in the Emilia-Romagna Region, Italy. Drugs under study were antibacterials for systemic use (group J01). Data were obtained from the database for hospital drug prescription of Emilia-Romagna Region. The PDD-proxy was estimated by averaging the doses of antibiotic prescriptions from a point prevalence survey for healthcare-associated infections and antimicrobial use, conducted in Emilia-Romagna hospitals in 2012. RESULTS: Significant discrepancies between DDD and PDD were observed, especially for some antibiotics, resulting in DDD rates that were systematically higher than PDD-proxy rates. In 2012, HT median rates of antibiotic consumption were 90 DDD/100 bed days and 70 PDD-proxy/100 bed-days. However, PDD-proxy and DDD rates showed comparable trends within HTs, although some HTs ranked differently when one or the other measure was used. Interquartile ranges of DDD rates were systematically wider than those of PDD-proxy rates in most years in the period of interest. CONCLUSIONS: Comparison of HT antibiotic consumption using DDDs may artificially increase observed differences and affect the true HT ranking. Therefore, an additional unit of measurement is useful for in-depth analysis at the local level.

The Italian national surgical site infection surveillance programme and its positive impact, 2009 to 2011.

Programmes surveying surgical site infection (SSI) have been implemented throughout the world and are associated with a reduction in SSI rates. We report data on non-prosthetic surgery from the Italian SSI surveillance programme for the period 2009 to 2011. Participation in the programme was voluntary. We evaluated the occurrence of SSI, based on protocols from the European Centre for Disease Prevention and Control, within 30 days of surgery. Demographic data, risk factors, type of surgery and presence of SSI were recorded. The National Coordinating Centre analysed the pooled data. On 355 surgical wards 60,460 operations were recorded, with the number of surveyed intervention doubling over the study period. SSI was observed in 1,628 cases (2,6%) and 60% of SSI were diagnosed through 30-days post discharge surveillance. Operations performed in hospitals with at least two years of surveillance showed a 29% lower risk of SSI. Longer intervention duration, American Society of Anesthesiologists' (ASA) score of at least three, and pre-surgery hospital stay of at least two days were associated with increased risk of SSI, while videoscopic procedures had reduced SSI rates. Implementation of a national surveillance programme was helpful in reducing SSI rates and should be prioritised in all healthcare systems.

Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.

Starting in 2010, there was a sharp increase in infections caused by Klebsiella pneumoniae resistant to carbapenems in the Emilia-Romagna region in Italy. A region-wide intervention to control the spread of carbapenemase-producing K. pneumoniae (CPKP) in Emilia-Romagna was carried out, based on a regional guideline issued in July 2011. The infection control measures recommended to the Health Trusts (HTs) were: phenotypic confirmation of carbapenemase production, active surveillance of asymptomatic carriers and contact isolation precautions for carriers. A specific surveillance system was activated and the implementation of control measures in HTs was followed up. A significant linear increase of incident CPKP cases over time (p<0.001) was observed at regional level in Emilia-Romagna in the pre-intervention period, while the number of cases remained stable after the launch of the intervention (p=0.48). Considering the patients hospitalised in five HTs that provided detailed data on incident cases, a downward trend was observed in incidence after the release of the regional guidelines (from 32 to 15 cases per 100,000 hospital patient days). The spread of CPKP in Emilia-Romagna was contained by a centrally-coordinated intervention. A further reduction in CPKP rates might be achieved by increased compliance with guidelines and specific activities of antibiotic stewardship.

Comparison of two HIV testing strategies in primary care centres: indicator-condition-guided testing vs. testing of those with non-indicator conditions.

OBJECTIVES: The aim of the study was to compare prospectively indicator-condition (IC)-guided testing versus testing of those with non-indicator conditions (NICs) in four primary care centres (PCCs) in Barcelona, Spain. METHODS: From October 2009 to February 2011, patients aged from 18 to 65 years old who attended a PCC for a new herpes zoster infection, seborrhoeic eczema, mononucleosis syndrome or leucopenia/thrombopenia were included in the IC group, and one in every 10 randomly selected patients consulting for other reasons were included in the NIC group. A proportion of patients in each group were offered an HIV test; those who agreed to be tested were given a rapid finger-stick HIV test (€6 per test). Epidemiological and clinical data were collected and analysed. RESULTS: During the study period, 775 patients attended with one of the four selected ICs, while 66,043 patients presented with an NIC. HIV screening was offered to 89 patients with ICs (offer rate 11.5%), of whom 85 agreed to and completed testing (94.4 and 100% acceptance and completion rates, respectively). In the NIC group, an HIV test was offered to 344 persons (offer rate 5.2%), of whom 313 accepted (90.9%) and 304 completed (97.1%) testing. HIV tests were positive in four persons [prevalence 4.7%; 95% confidence interval (CI) 1.3-11.6%] in the IC group and in one person in the NIC group (prevalence 0.3%; 95% CI 0.01-1.82%; P < 0.009). If every eligible person had taken an HIV test, we would have spent €4650 in the IC group and €396,258 in the NIC group, and an estimated 36 (95% CI 25-49) and 198 persons (95% CI 171-227), respectively, would have been diagnosed with HIV infection. The estimated cost per new HIV diagnosis would have been €129 (95% CI €107-153) in the IC group and €2001 (95% CI €1913-2088) in the NIC group. CONCLUSIONS: Although the number of patients included in the study was small and the results should be treated with caution, IC-guided HIV testing, based on four selected ICs, in PCCs seems to be a more feasible and less expensive strategy to improve diagnosis of HIV infection in Spain than a nontargeted HIV testing strategy.

Infections and antimicrobial resistance in long term care facilities: a national prevalence study.

BACKGROUND: A point prevalence survey (PPS) was conducted in Italy in 2010, as part of the first European PPS in Long Term Care Facilities (LTCFs), conducted within the HALT Project. METHODS: The PPS was aimed at estimating the prevalence of infections, antimicrobial resistance, and antibiotic use and to assess the status of infections control programs in this setting. RESULTS: Ninety two LTCFs, located in 11 different Italian regions, participated to the study: 9391 residents were enrolled, 9285 of whom were eligible according to the study criteria. The prevalence of residents with signs/symptoms of infection was 6.5% (606 residents); 438 residents were on antimicrobial treatment (4.7%) and 526 had signs/symptoms (5.7%) but in 324 residents only (3.5/100 residents) the infection satisfied the modified McGeer criteria and was considered confirmed. The most frequent infection site was the respiratory tract (1.27/100 residents). Mostly of the antibiotics were prescribed for respiratory tract infections (42.8% of the antibiotics) and for urinary tract infections (26.6%). The most frequently prescribed classes were quinolones, followed by penicillin plus beta-lactamase inhibitor and 3rd generation cephalosporins. Few infection had a microbiological confirmation, but among the 143 isolated microorganisms 24% were multidrug resistant. CONCLUSIONS: The burden of infections and antimicrobial resistance in LTCFs is significant and infection control and surveillance program are urgently needed.

Prevalence of infections in long-term care facilities: how to read it?

PURPOSE: Prevalence surveys are mostly used in European countries for infection surveillance in long-term care facilities (LTCFs). The purpose of this paper is to document the prevalence of infections in LTCFs and to identify and discuss the potential sources of variation in the overall prevalence of infections. METHODS: Six repeated prevalence surveys were carried out over a period of 3 years in 11 LTCFs in the Emilia-Romagna region, involving a mean of 812 residents in each survey. In one facility, continuous surveillance was also conducted. McGeer's infection criteria were used. Observers undertook a 1-day training course and on-field training. RESULTS: The average prevalence of infected residents was 11.5/100 residents: respiratory tract infections were the most common (5.7/100 residents), followed by urinary tract infections (2.6%), skin infections (1.9%), and ocular infections (1.4%). In a multivariate model, the prevalence significantly varied by season (p < 0.001) and residents' case-mix index (CMI, p < 0.001). In individual homes, the case mix varied from 0.91 to 1.1 and the observed prevalence varied from 6.6 to 40.4%. One facility set up and maintained continuous surveillance: three clusters of lower respiratory tract infection were identified in 1.5 years by a temporal scan test. Cases belonging to one outbreak only were captured by the prevalence surveys conducted in the same periods. CONCLUSIONS: The prevalence of infections in LTCFs needs to be interpreted cautiously, given the effects of seasonality and case-mix variation. Repeated prevalence surveys may be a good start in individual facilities, but the identification of outbreaks requires a continuous surveillance system.

Use of health databases to deal with underreporting of surgical site infections due to suboptimal post-discharge follow-up.

This study describes a combined surveillance of surgical site infection implemented in an Italian region, which relies on integration of the specific surveillance (SIChER) with other sources and the targeted review of a small proportion of cases. Additional information on post-surgical follow-up was obtained from hospital discharge, microbiology laboratory and emergency department databases. Based on these data, 76 patients were reclassified as possible cases and revised by the health trust representatives. Eventually 45 new cases were confirmed, leading to an increase in the infection ratio from 1.13% to 1.45%. The proposed method appears to be accurate and sustainable over time.

A Novel Tool for the Early Identification of Frailty in Elderly People: The Application in Primary Care Settings.

BACKGROUND: Frailty is a pre-disability condition in older persons providing a challenge to Health-Care Systems. Systematic reviews highlight the absence of a gold-standard for its identification. However, an approach based on initial screening by the General Practitioner (GP) seems particularly useful. On these premises, a 9-item Sunfrail Checklist (SC), was developed by a multidisciplinary group, in the context of European Sunfrail Project, and tested in the Community. OBJECTIVES: - to measure the concordance between the judgments of frailty (criterion-validity): the one formulated by the GP, using the SC, and the one subsequently expressed by a Comprehensive Geriatric Assessment Team (CGA-Team); - to determine the construct-validity through the correspondence between some checklist items related to the 3 domains (physical, cognitive and social) and the three tools used by the CGA-Team; - to measure the instrument's performance in terms of positive predictive value (PPV) and negative predictive value (NPV). DESIGN: Cross-sectional study, with a final sample-size of 95 subjects. SETTING: Two Community-Health Centers of Parma, Italy. PARTICIPANTS: Subjects aged 75 years old or more, with no disability and living in the community. MEASUREMENTS: We compared the screening capacity of the GP using the SC to that one of CGA-Team based on three tests: 4-meter Gait-Speed, Mini-Mental State Examination and Loneliness Scale. RESULTS: 95 subjects (51 women), with a mean age of 81±4 years were enrolled. According to GPs 34 subjects were frail; the CGA-Team expressed a frailty judgment on 26 subjects. The criterion-validity presented a Cohen's k of 0.353. Construct-validity was also low, with a maximum contingency-coefficient of 0.19. The analysis showed a PPV of 58.1% and a NPV equal to 84.6%. CONCLUSIONS: Our data showed a low agreement between the judgements of GP performed by SC and CGA-Team. However, the good NPV suggests the applicability of SC for screening activities in primary-care.

National hand hygiene campaigns in Europe, 2000-2009.

Hand hygiene represents the single most effective way to prevent healthcare-associated infections. The World Health Organization, as part of its First Global Patient Safety Challenge, recommends implementation of multi-faceted strategies to increase compliance with hand hygiene. A questionnaire was sent by the European Centre for Disease Prevention and Control to 30 European countries, regarding the availability and organisation of their national hand hygiene campaigns. All countries responded. Thirteen countries had organised at least one national campaign during the period 2000-2009 and three countries were in the process of organising a national campaign. Although the remaining countries did not have a national campaign, several reported regional and local hand hygiene activities or educational resources on national websites.

Colonization and infection due to carbapenemase-producing Enterobacteriaceae in liver and lung transplant recipients and donor-derived transmission: a prospective cohort study conducted in Italy.

OBJECTIVES: A prospective cohort study was conducted in Italy in order to describe the microbiologic aspects of colonization/infection by carbapenemase-producing Enterobacteriaceae (CPE) in donors and recipients of lung and liver transplants and the possible CPE transmission from donors to recipients. METHODS: Between 15 January 2014 and 14 January 2015, all recipients of solid organ transplants (SOT) at ten lung and eight liver transplantation centres and the corresponding donors were enrolled. Screening cultures to detect CPE were performed in donors, and screening and clinical cultures in recipients with a 28-day microbiologic follow-up after receipt of SOT. Detection of carbapenemase genes by PCR, genotyping by multilocus sequence typing, and pulsed-field gel electrophoresis and whole-genome sequencing were performed. RESULTS: Of 588 screened donors, 3.4% were colonized with CPE. Of the liver first transplant recipients (n = 521), 2.5% were colonized before receipt of SOT and 5% acquired CPE during follow-up. CPE colonization was higher in lung first transplant recipients (n = 111, 2.7% before SOT and 14.4% after SOT). CPE infections occurred in 1.9% and 5.3% of liver or lung recipients, respectively. CPE isolates were mostly Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae belonging to CG258. Three events of donor-recipient CPE transmission, confirmed by whole-genome sequencing and/or pulsed-field gel electrophoresis, occurred in lung recipients: two involving K. pneumoniae sequence type 512 and one Verona integron-encoded metallo-ß-lactamase (VIM)-producing Enterobacter aerogenes. CONCLUSIONS: This study showed a low risk of donor-recipient CPE transmission, indicating that donor CPE colonization does not necessarily represent a contraindication for donation unless colonization regards the organ to be transplanted. Donor and recipient screening remains essential to prevent CPE transmission and cross-infection in transplantation centres.

Emergence of ciprofloxacin resistance in Escherichia coli isolates from outpatient urine samples.

This study investigated the association between prescription of fluoroquinolones and emergence of ciprofloxacin resistance among Escherichia coli isolates in the urine of outpatients from whom a ciprofloxacin-sensitive E. coli strain had been isolated previously. Patients were identified and followed using the healthcare databases of Emilia-Romagna Region, Italy. The outcome of interest was the first isolation from urine of an E. coli strain resistant to ciprofloxacin. Prescription of fluoroquinolones during the previous 6 months was associated independently with the emergence of ciprofloxacin resistance; the strength of the association varied according to individual fluoroquinolone agents.

Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control.

BACKGROUND: Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are "at-risk" may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E).The purpose of this guidance is to raise awareness and identify the "at-risk" patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE. METHODS: The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients "at-risk" for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for "at-risk" patients upon admission to healthcare settings. RESULTS: Individuals with the following profile are "at-risk" for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE.Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for "at-risk" patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures. CONCLUSIONS: Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here.This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources.

Colonization by multidrug-resistant organisms in long-term care facilities in Italy: a point-prevalence study.

OBJECTIVES: To determine prevalence and risk factors for colonization by multidrug-resistant organisms (MDROs) in long-term care facility (LTCF) residents in Italy. Genotypes of MDRO isolates were investigated. METHODS: A point-prevalence study was conducted at 12 LTCFs located in four Italian cities (2 February to 14 March 2015). Rectal swabs, faeces and nasal/auxiliary swabs were cultured for extended-spectrum ß-lactamase (ESBL)- and/or carbapenemase-producing Enterobacteriaceae, Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) respectively. Antimicrobial susceptibility testing, detection of ESBL and/or carbapenemase genes and molecular typing of MDROs were performed. Risk factors for colonization were determined by univariate and multivariate analysis. RESULTS: A total of 489 LTCF residents aged ≥65 years were enrolled. The prevalence of colonization by ESBL-producing Enterobacteriaceae, MRSA and C. difficile was 57.3% (279/487), 17.2% (84/487) and 5.1% (21/409) respectively. Carriage rate of carbapenemase-producing Enterobacteriaceae was 1% (5/487). Being bedridden was a common independent risk factor for colonization by all MDROs, although risk factors specific for each MDRO were identified. ESBL-producing Escherichia coli carriage was associated with the sequence type (ST) 131-H30 subclone, but other minor STs predominated in individual LTCF or in LTCFs located in the same city, suggesting a role for intrafacility or local transmission. Similarly, MRSA from LTCF residents belonged to the same spa types/ST clones (t008/ST8 and t032/ST22) commonly found in Italian acute-care hospitals, but infrequent spa types were recovered in individual LTCFs. The prevalent C. difficile PCR ribotypes were 356/607 and 018, both common in Italian acute-care hospitals. CONCLUSIONS: MDRO colonization is common among residents in Italian LTCFs.

Seroprevalence of five neglected parasitic diseases among immigrants accessing five infectious and tropical diseases units in Italy: a cross-sectional study.

OBJECTIVE: This multicentre cross-sectional study aims to estimate the prevalence of five neglected tropical diseases (Chagas disease, filariasis, schistosomiasis, strongyloidiasis and toxocariasis) among immigrants accessing health care facilities in five Italian cities (Bologna, Brescia, Florence, Rome, Verona). METHODS: Individuals underwent a different set of serological tests, according to country of origin and presence of eosinophilia. Seropositive patients were treated and further followed up. RESULTS: A total of 930 adult immigrants were enrolled: 477 men (51.3%), 445 women (47.9%), eight transgender (0.8%); median age was 37.81 years (range 18-80 years). Most of them had come from the African continent (405/930, 43.5%), the rest from East Europe, South America and Asia, and 9.6% (89/930) were diagnosed with at least one of the infections under study. Seroprevalence of each specific infection varied from 3.9% (7/180) for Chagas disease to 9.7% (11/113) for toxocariasis. Seropositive people were more likely to be 35-40 years old and male, and to come from South East Asia, sub-Saharan Africa or South America. CONCLUSIONS: The results of our study confirm that neglected tropical diseases represent a substantial health problem among immigrants and highlight the need to address this emerging public health issue.

Delay in the treatment of pulmonary TB in a changing demographic scenario.

OBJECTIVE: To quantify patient and health care delays in the treatment of pulmonary tuberculosis (PTB) in Emilia-Romagna region, Italy, and to study the association between migration status and delay. DESIGN: All patients with symptomatic PTB, aged >15 years, who were notified in Emilia-Romagna during 2003 and were alive at time of data collection, were included. An individual form was completed for each notified patient by the local health authority officer in charge of surveillance data. RESULTS: Median patient delay, health care delay and total delay were 7, 36 and 65 days, respectively. Recent migrants (stay in Italy < or = 3 years) had the longest patient delay (16 days), while Italian patients had the longest health care delay (60 days). Migration status was independently associated with both patient and health care delay, although the direction of association changed according to which delay was considered. CONCLUSION: Public health interventions aiming to reduce delay in treatment of PTB should improve the access of recent migrants to health care and increase suspicion of TB among Italian patients. Studies on delays in treatment of TB should investigate patient delay and health care delay as distinct outcomes.

Barriers to effective tuberculosis control: a qualitative study.

SETTING: Emilia Romagna region, Italy. OBJECTIVE: To explore chest and infectious disease physicians' views of barriers to effective tuberculosis (TB) control and possible solutions. DESIGN: A series of nine focus groups including a total of 49 physicians. RESULTS: Three categories of barriers to effective TB control were identified: 1) uncertainty about appropriate clinical practice in the treatment of specific sub-groups of patients, such as the elderly or immigrants; 2) organisational factors, such as the availability of diagnostic services and of sufficient resources; and 3) multiple barriers to a viable and effective TB control programme in a country with a low prevalence of TB. CONCLUSIONS: The lack of integration and coordination of health services, as well as the scarcity of dedicated TB nurses, were perceived by the participants as crucial barriers to effective TB control. As a result of this study, a regional programme was started with the goals of quantifying the need for TB nurses and developing a better network for required health services. Qualitative studies such as this can be useful in improving TB control in a low-prevalence TB country, to identify problems and increase the participation of key professionals.

Persistence of anti-chikungunya virus-specific antibodies in a cohort of patients followed from the acute phase of infection after the 2007 outbreak in Italy.

Chikungunya is a mosquito-borne infection of humans, and its diffusion has increased worldwide. In 2007 an outbreak occurred in Italy. In this study, the antibody response of 133 patients followed up starting from the acute phase of infection was investigated. Antibody titres were periodically scored up to 1 year since the infection: 82.7% of the IgM antibody disappeared within 12 months, and the IgG response lasted longer than 12 months. Nevertheless, the IgG mean titre was lower in 95.5% of patients at the end of follow-up, thus suggesting a decrease within a relatively short period.

Evaluation of carbapenem-resistant Enterobacteriaceae in an Italian setting: report from the trench.

The spread of carbapenem resistant Enterobacteriaceae (CRE) has recently become a matter of concern in public health, mainly due to the wide distribution of carbapenemase genes. Italy is a country considered endemic for the spread of blaKPC Klebsiella pneumoniae (KP). The aim of this study was to depict the epidemiological trend of CRE in one Italian hospital over a long period (3 years surveillance, from May 2011 to April 2014). Based on defined MIC cut-off for specific carbapenems, 164 strains isolated from 146 different patients were analyzed both phenotypically and genotypically to establish the resistance genes. Molecular typing was performed using the RAPD technique. 77 strains were demonstrated to harbor the blaKPC gene (73 KP, 4 Escherichia coli - EC), 51 strains the blaVIM gene (44 KP, 3 EC, 2 Enterobacter cloacae and 2 Klebsiella oxytoca), 8 the blaNDM gene (3 KP, 4 EC and one Providencia stuartii), 3 the blaOXA-48 gene (2 KP, 1 EC), whereas 25 out of the 164 isolates (of different genera and species) had a negative multiplex-PCR amplification for all the targets tested. 39 out of the 164 strains analyzed (23.8%) revealed discrepancies between the MICs obtained with automated instrument and gradient MICs of more than two logs of difference; the broth microdilution provided a better agreement with the results obtained with the gradient MIC. The use of RAPD allowed to distinguish different clusters, closely related, both for blaKPC and for blaVIM KP.