Barriers to the implementation of antimicrobial stewardship programmes in long-term care facilities: a scoping review.

BACKGROUND: Long-term care facilities (LTCFs) present specific challenges for the implementation of antimicrobial stewardship (AMS) programmes. A growing body of literature is dedicated to AMS in LTCFs. OBJECTIVES: We aimed to summarize barriers to the implementation of full AMS programmes, i.e. a set of clinical practices, accompanied by recommended change strategies. METHODS: A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase and Cochrane Central. Studies addressing barriers to the implementation of full AMS programmes in LTCFs were included. Implementation barriers described in qualitative studies were identified and coded, and main themes were identified using a grounded theory approach. RESULTS: The electronic search revealed 3904 citations overall. Of these, 57 met the inclusion criteria. All selected studies were published after 2012, and the number of references per year progressively increased, reaching a peak in 2020. Thematic analysis of 13 qualitative studies identified three main themes: (A) LTCF organizational culture, comprising (A1) interprofessional tensions, (A2) education provided in silos, (A3) lack of motivation and (A4) resistance to change; (B) resources, comprising (B1) workload and staffing levels, (B2) diagnostics, (B3) information technology resources and (B4) funding; and (C) availability of and access to knowledge and skills, including (C1) surveillance data, (C2) infectious disease/AMS expertise and (C3) data analysis skills. CONCLUSIONS: Addressing inappropriate antibiotic prescribing in LTCFs through AMS programmes is an area of growing interest. Hopefully, this review could be helpful for intervention developers and implementers who want to build on the most recent evidence from the literature.

A cross-sectional study of SARS-CoV-2 seropositivity among healthcare workers and residents of long-term facilities in Italy, January 2021.

Long-term care facilities (LTCFs) are high-risk settings for SARS-CoV-2 infection. This study aimed to describe SARS-CoV-2 seropositivity among residents of LTCFs and health-care workers (HCWs). Subjects were recruited in January 2021 among unvaccinated HCWs of LTCFs and hospitals and residents of LTCFs in Northern Italy. Information concerning previous SARS-CoV-2 infections and a sample of peripheral blood were collected. Anti-S SARS-CoV-2 IgG antibodies were measured using the EUROIMMUN Anti-SARS-CoV-2 QuantiVac ELISA kit (EUROIMMUN Medizinische Labordiagnostika AG). For subjects with previous COVID-19 infection, gender, age, type of subject (HCW or resident), and time between last positive swab and blood draw were considered as possible determinants of two outcomes: the probability to obtain a positive serological result and antibody titer. Six hundred and fifty-eight subjects were enrolled. 56.1% of all subjects and 65% of residents presented positive results (overall median antibody titer: 31.0 RU/ml). Multivariable models identified a statistically significant 4% decrease in the estimated antibody level for each 30-day increase from the last positive swab. HCWs were associated with significant odds for seroreversion over time (OR: 0.926 for every 30 days, 95% CI: 0.860-0.998), contrary to residents (OR: 1.059, 95% CI: 0.919-1.22). Age and gender were not factors predicting seropositivity over time. Residents could have a higher probability of maintaining a seropositive status over time compared to HCWs.

Ugly but tasty: A systematic review of possible human and animal health risks related to entomophagy.

BACKGROUND: According to many recent studies, the use of insects as food seems to be convenient, sustainable, economical and healthy. The objective of this study is to analyze the possible effects of insect consumption on human and animal health. METHODS: A systematic review of the literature was performed using the PubMed, Scopus and CAB databases. RESULTS: Of the 6026 items initially retrieved, 70 were eligible for inclusion; 40 studies analyzed the use of insects in human foods or drugs, while 30 analyzed the use of insects in animal feed. In humans, the most commonly analyzed risks are nutrient malabsorption, growth alteration, chemical and microbiological contamination and allergy risk. Studies of animals focus on growth alteration, nutrient malabsorption and hematic and qualitative meat alteration. CONCLUSION: In recent years, researchers have shifted their focus from the possible use of edible insects in animal feed to their use as possible nutrient sources for humans. The results suggest that, if properly treated and preserved, products derived from insects are safe and efficient sources of nutrients for animals. Further studies are needed to evaluate the possible effects of prolonged insect consumption on human health.

The no correlation argument: can the morality of conscientious objection be empirically supported? the Italian case.

BACKGROUND: The legitimacy of conscientious objection to abortion continues to fuel heated debate in Italy. In two recent decisions, the European Committee for Social Rights underlined that conscientious objection places safe, legal, and accessible care and services out of reach for most Italian women and that the measures that Italy has adopted to guarantee free access to abortion services are inadequate. Nevertheless, the Ministry of Health states that current Italian legislation, if appropriately applied, accommodates both the right to conscientious objection and the right to voluntary abortion. MAIN BODY: One empirical argument used to demonstrate that conscientious objection does not create barriers to abortion is the "no correlation" argument, which the Italian Committee for Bioethics employed to demonstrate that no association exists between conscientious objection and waiting times for voluntary abortion in Italy and to support the weak form of conventional comprise adopted by the Italian legislation to balance the conflict between women' autonomy and healthcare professionals' moral integrity. Conversely, we showed how the "no correlation" argument fails to demonstrate the absence of a relationship between the number of conscientious objectors and waiting times for voluntary abortion, and that the limitations of the "no correlation" argument itself demonstrate how it is still difficult to describe the real effect of conscientious objection on the access to abortion services and to evaluate the suitability of conventional compromise to effectively balance conflicting moral principles. CONCLUSION: Further studies are needed to better describe the relationship between conscientious objection and waiting times for voluntary abortion. If new evidence would show that the increasing proportion of objectors does undermine the efficacy of the Italian law and the right of a woman to freely obtain a voluntary abortion, new ways will need to be found to address the conflict between moral principles and restrict the protection accorded to the principle of moral integrity. This would inevitably imply the need to constrain and to redefine the terms and conditions for claiming conscientious objection.

Appropriate use of antimicrobial prophylaxis: an observational study in 21 surgical wards.

BACKGROUND: Surveillance of Surgical Site Infections (SSI) in 2010 found 39 % compliance with hospital guidelines in Piedmont (Italy). The aim of the study was to estimate the appropriate use of antimicrobial prophylaxis and compliance with hospitals guidelines in surgical wards. METHODS: This survey study took place in 21 surgery wards of 4 public hospitals. Forms were completed by public health resident doctors together with a medical ward referent and infection control nurses. 15 consecutive surgical procedures were randomly chosen from each ward. A total of 320 cases were analyzed. The study period was from July 2012 to January 2013. Data were collected using a survey form. A final score variable from 0 to 4 was given to each case. The results were compared with hospital and international guidelines. Data were analyzed using Epi-Info software. RESULTS: Of the 320 cases collected, 63 were excluded; of the remaining 257 cases, 56.4 % of the procedures were appropriate (score 4), 15.2 % were acceptable and 28.4 % were not acceptable. The study found an unjustified continuation of antimicrobial prophylaxis in 17.1 % of the 257 cases, an unjustified re-start of antimicrobial therapy in 9.7 % and a re-dosing omission in 7.8 %. CONCLUSIONS: The study demonstrated critical problems in antimicrobial prophylaxis management in surgical wards due to a lack of compliance between hospitals and national guidelines, a shortage of specific and updated recommendations for some surgical interventions and incorrect local specific procedures. Coordination between local and national recommendations, strengthening of evidence based decisions and continuous sharing of policy updates are needed.

Conscientious objection and waiting time for voluntary abortion in Italy.

OBJECTIVES: This study sought to determine whether a correlation exists in Italy between conscience-based refusal by physicians to perform an abortion and waiting times for elective abortion. METHODS: Data on the number of objectors and of elective abortions performed within different time intervals were retrieved from annual Italian ministerial reports. Spearman's correlation coefficients were calculated between an indicator of the increase in workload for non-objectors when conscientious objection is exercised by physicians refusing to provide an abortion and the proportion of women whose request for an abortion was met within 14 days, or later, in 13 regions in Italy. RESULTS: An inverse correlation emerged between the workload for non-objectors and the proportion of abortions performed within 14 days of the request in seven regions (statistically significant in Emilia-Romagna and Tuscany). There was a direct correlation between increased workload and the proportion of abortions performed later than 21 days in nine regions. The same trends were highlighted at national level. CONCLUSIONS: Our results suggest that when data spanning at least more than a decade are available, a trend toward an inverse correlation can be noted between the workloads for non-objectors and timely access to elective abortion. This holds organisational and ethical implications.

Burden of herpes zoster-associated chronic pain in Italian patients aged 50 years and over (2009-2010): a GP-based prospective cohort study.

BACKGROUND: Post-herpetic neuralgia (PHN) is the most common complication in herpes zoster (HZ) patients. METHODS: We performed a longitudinal, prospective study in 108 general practices throughout Italy to assess how many immunocompetent patients aged ≥50 years with newly diagnosed HZ develop HZ-associated pain, its duration and management over 6-months. HZ-associated pain was assessed by a direct question to the patient and by self-assessment of the worst pain felt in the previous two weeks on a visual analogue scale (VAS), a score ≥3 was taken as pain. PHN was defined as pain reported during the study period persisting for ≥3 months. Quality of life (QoL) was measured using the SF-12 questionnaire. RESULTS: At enrolment, 370 of the 413 patients (89.6%) reported HZ-associated pain which was still present in 20.6% and 9.2% of patients after three and six months, respectively, despite many patients receiving recommended anti-viral therapy. The overall QoL scores were lower than those in healthy Italians of similar age; scores for patients with HZ-associated pain were lower. The presence of >50 vesicles and VAS score ≥3 at enrolment, and being male were significantly associated with PHN at three months. CONCLUSIONS: These results suggest that HZ and PHN represent an important burden of disease in the elderly. There is a need for interventions that can prevent and reduce the burden of HZ to help improve the quality of life of the elderly. These data may be useful as baseline epidemiology data for the assessment of the impact of the VZV vaccine in Italy, after its implementation.

[Point prevalence survey of health care associated infections and antimicrobial use in Piedmont Region long-term care facilities according to ECDC protocol]. / Prevalenza delle infezioni correlate all'assistenza e dell'uso di antibiotici nelle residenze sanitarie assistite della Regione Piemonte secondo il protocollo ECDC.

OBJECTIVE: Aim of this study is to examine the prevalence data from different types of long-term care facilities (LTCFs); we also analyzed similarities and differences between them and national data. DESIGN: «Healthcare-Associated Infections and Antimicrobial Use in European Long-Term Care Facilities Project¼ (HALT2) is a prevalence survey of health care associated infections and antimicrobial use in European long-term care facilities. The study protocol is developed, funded and promoted by the ECDC (European Centre for Disease Prevention and Control). SETTING AND PARTICIPANTS: Data were collected on a single day from long term care facilities (LTCFs) defined as facilities in which residents need constant supervision (24 hours). Two types of questionnaires had to be completed. MAIN OUTCOME MEASURES: Point prevalence of healthcare-associated infections (HAI) and antimicrobial use (AU). RESULTS: 63 LTCFs in Piedmont Region participated in the HALT-2 point prevalence survey; 3,984 residents met the eligibility criteria. The crude prevalence of residents with at least one HAI was 3% in LTCF and 10% in CA/DP facilities. The crude prevalence of residents receiving at least one antimicrobial agent was 4%; this percentage rose to 17.4 % in CA/DP facilities. CONCLUSIONS: Data from Piedmont Region are similar to national data; differences are highlighted in different types of LTCFs. The results show the need to improve antimicrobial stewardship and to define protocols in each type of facilities in order to standardize the appropriateness and patient management.

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.

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.

Surgical reorganization during the COVID-19 pandemic and impact on case-mix and surgical site infections: A multicenter cohort study in Italy.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic led to major disruptions in surgical activity, particularly in the first year (2020). The objective of this study was to assess the impact of surgical reorganization on surgical outcomes in Northern Italy in 2020 and 2021. METHODS: A retrospective cohort study was conducted among 30 hospitals participating in the surveillance system for surgical site infections (SSIs). Abdominal surgery procedures performed between 2018 and 2021 were considered. Predicted SSI rates for 2020 and 2021 were estimated based on 2018-2019 data and compared with observed rates. Independent predictors for SSI were investigated using logistic regression, including procedure year. RESULTS: 7605 procedures were included. Significant differences in case-mix were found comparing the three time periods. Observed SSI rates among all patients in 2020 were significantly lower than expected based on 2018-2019 SSI rates (p 0.0465). Patients undergoing procedures other than cancer surgery in 2020 had significantly lower odds for SSI (odds ratio, OR 0.52, 95 % confidence interval, CI 0.3-0.89, p 0.018) and patients undergoing surgery in 2021 had significantly higher odds for SSI (OR 1.49, 95 % CI 1.07-2.09, p 0.019) compared to 2018-2019. CONCLUSIONS: Enhanced infection prevention and control (IPC) measures could explain the reduced SSI risk during the first pandemic year. IPC practices should continue to be reinforced beyond the pandemic context.

Antimicrobial stewardship programs in acute-care hospitals: A multicenter assessment of structure, process, and outcome indicators in Italy and Spain.

BACKGROUND: Antimicrobial stewardship (AMS) programs have been differently implemented across Europe. This study primarily aimed to compare AMS in two European regions. Secondarily, the study explored the COVID-19 pandemic impact on surrogate outcome indicators of AMS. METHODS: A retrospective observational study was conducted in Piedmont (Italy) and Catalonia (Spain). AMS programs were compared through structure and process indicators in 2021. Changes in surrogate outcome indicators (antimicrobial usage; alcohol-based sanitizer consumption; antimicrobial resistance, AMR) from 2017 to 2021 described the pandemic impact. RESULTS: Seventy-eight facilities provided structure and process indicators. Catalonia showed better structure scores (p < 0.001) and less dispersion in both indicators. The greatest areas to improve were accountability (Piedmont) and diversification of strategies (Catalonia). Overall, the regions reported consistent changes in outcome indicators. Antimicrobial usage decreased in 2020, returning to near-pre-pandemic levels in 2021. Alcohol-based sanitizer consumption surged in 2020, then dipped remaining above pre-pandemic levels. AMR trends were minimally affected. CONCLUSIONS: The centralized approach of Catalonia ensured consistent attainment of quality objectives across all facilities, but it may limit facility-specific strategies. In Piedmont, accountability remain one of the most critical factors as in previous years. The pandemic did not substantially disrupt surrogate outcome measures of AMS. However, the data on AMR suggest that maintaining vigilance against this issue remains paramount.

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.

Prevalence of human papillomavirus in young Italian women with normal cytology: how should we adapt the national vaccination policy?

BACKGROUND: Human Papillomavirus (HPV) is the most common sexually transmitted infection. In Italy, HPV vaccination is now offered free of charge to 12-year-old females. However, some regional health authorities have extended free vaccination to other age-groups, especially to girls under 18 years of age. We conducted a multicentre epidemiological study to ascertain the prevalence of different genotypes of HPV in young Italian women with normal cytology, with the aim of evaluating the possibility of extending vaccination to older females. METHODS: The study was performed in 2010. Women aged 16-26 years with normal cytology were studied. Cervical samples were analyzed to identify the presence of HPV by PCR amplification of a segment of ORF L1 (450 bp). All positive HPV-DNA samples underwent viral genotype analysis by means of a restriction fragment length polymorphism assay. RESULTS: Positivity for at least one HPV genotype was found in 18.2% of the 566 women recruited: 48.1% in the 16-17 age-class, 15.4 in the 18-20 age-class, 21.9% in the 21-23 age-class, and 15.5% in the 24-26 age-class; 10.1% of women were infected by at least one high-risk HPV genotype. HPV-16 was the most prevalent genotype. Only 4 (0.7%), 4 (0.7%) and 3 (0.5%) women were infected by HPV-18, HPV-6 and HPV-11, respectively. Of the HPV-DNA-positive women, 64.1% presented only one viral genotype, while 24.3% had multiple infections. The HPV genotypes most often involved in multiple infections were high-risk. A high prevalence was noted in the first years of sexual activity (48.1% of HPV-DNA-positive women aged 16-17 years); HPV prevalence subsequently declined and stabilized.The estimate of cumulative proportions of young women free from any HPV infection at each age was evaluated; 93.3% and 97.1% of 26 year-old women proved free from HPV-16 and/or HPV-18 and from HPV-6 and/or HPV-11, respectively. CONCLUSIONS: Our findings confirm the crucial importance of conducting studies on women without cytological damage, in order to optimise and up-date preventive interventions against HPV infection, and suggest that vaccinating 26-year-old females at the time of their first pap-test is to be recommend, though this issue should be further explored.

A retrospective analysis of the costs and management of genital warts in Italy.

BACKGROUND: In Italy the prevalence of genital warts in women (15-64 years) is approximately 0.6% with an incidence of 0.4% per year. Treatments for GW are usually long, with moderate success and high costs. The aim of the study was to evaluate the diagnostic-therapeutic pathway, duration and setting of treatment, costs of episodes of condyloma in a population attending a regional STI clinic in Piedmont. METHODS: This was a retrospective observational study conducted using medical records of outpatients who first visited the STI Clinic of San Lazzaro Dermatological Hospital in 2008. The patients' medical histories were analysed for episodes that occurred and were cleared in 18 months following the initial visit. Data on screening methods for STIs, type of diagnosis for condyloma, treatment type, treatment setting, and anatomic lesion site were obtained from medical records. The costs were calculated for each episode. RESULTS: A total of 450 episodes were analysed (297 men,153 women). The most frequently affected anatomic site was the genital area (74%) in both genders. With regard to treatment setting, 78.44% of patients received outpatient treatment at the STI clinic, 4% were treated at home, and 0.22% were hospitalised; 11.11% were treated in multiple settings. The mean number of treatments per episode was 2.03; although many patients received only 1 treatment (n = 207, 46%), exspecially cryotherapy or diathermy coagulation (64.73% versus 28.02% of episodes, respectively). The mean episode duration was 80.74 days. The mean cost (in 2011 euros) for an episode was €158.46 ± 257.77; the mean costs were €79.13 ± 57.40 for diagnosis and €79.33 ± 233.60 for treatment. The mean cost for treatment in a STI-Clinic setting was €111.39 ± 76.72, that for home treatment was €160.88 ± 95.69, and that for hospital care was €2825.94. CONCLUSIONS: The treatment of and associated costs for genital warts are significant. Several factors affect the cost, and internal STI clinic protocols, such as the 6 month window used to consider a recurrence or new diagnosis, create bias. Nonetheless, our findings how costs similar to those reported in the international literature and should be considered when deciding on which HPV vaccination programs should be provided by the public health system.

Rome Consensus Conference - statement; human papilloma virus diseases in males.

BACKGROUND: Human Papillomavirus (HPV) is a very resistant, ubiquitous virus that can survive in the environment without a host. The decision to analyse HPV-related diseases in males was due to the broad dissemination of the virus, and, above all, by the need to stress the importance of primary and secondary prevention measures (currently available for women exclusively). The objective of the Consensus Conference was to make evidence-based recommendations that were designed to facilitate the adoption of a standard approach in clinical practice in Italy. METHODS: The Sponsoring Panel put a series of questions to the members of the Scientific Committee who prepared a summary of the currently available information, relevant for each question, after the review and grading of the existing scientific literature. The summaries were presented to a Jury, also called multidisciplinary Consensus Panel, who drafted a series of recommendations. RESULTS: The prevalence of HPV in males ranges between 1.3-72.9%;. The prevalence curve in males is much higher than that in females and does not tend to decline with age. Women appear to have a higher probability of acquiring HPV genotypes associated with a high oncogenic risk, whereas in males the probability of acquiring low- or high-risk genotypes is similar. The HPV-related diseases that affect males are anogenital warts and cancers of the penis, anus and oropharynx. The quadrivalent vaccine against HPV has proved to be effective in preventing external genital lesions in males aged 16-26 years in 90.4%; (95%; CI: 69.2-98.1) of cases. It has also proved to be effective in preventing precancerous anal lesions in 77.5%; (95%; CI: 39.6-93.3) of cases in a per-protocol analysis and in 91.7%; (95%; CI: 44.6-99.8) of cases in a post-hoc analysis. Early ecological studies demonstrate reduction of genital warts in vaccinated females and some herd immunity in males when vaccine coverage is high, although males who have sex with males gained no benefit at all. Males with an immunodeficiency disease are at greater risk of developing disease. Infertility seems to be caused by HPV in some cases. Studies demonstrate vaccination to both genders can be more efficacious and social equity matters are to be taken into consideration. CONCLUSIONS: The Jury made Recommendations based on the scientific evidence presented by the Scientific Committee. Accordingly, for prevention purposes and social fairness and equality, as both sexes are affected by the disease, the vaccination of 12-year-old males against HPV should be recommended in order to guaranty protection to everyone. Aspects related to healthcare policy and economic sustainability, are to be discussed by respective public system representatives. More campaigns to raise awareness through all institutional channels are needed, not only regarding anogenital warts, but for HPV-related diseases in general in males in accordance to new scientific evidences.

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) [...].