Multimodal surveillance of healthcare associated infections in an intensive care unit of a large teaching hospital

BACKGROUND: Healthcare-associated infections (HAIs), or nosocomial infections, represent a significant burden in terms of mortality, morbidity, length of stay and costs for patients hospitalized in intensive care units (ICUs). Surveillance systems are recommended by national and international institutions to gather data on HAIs in order to develop and evaluate interventions that reduce the risk of HAIs. STUDY DESIGN: Here we describe the methodology and the results of the surveillance system implemented in the ICU of the Policlinico Umberto I, a large teaching hospital in Rome, from April 2016 to October 2018. METHODS: The multimodal infection surveillance system integrates four different approaches: i) active surveillance of inpatients; ii) environmental microbiological surveillance; iii) surveillance of isolated microorganisms; and iv) behavioral surveillance of healthcare personnel. Data were collected on catheter-related bloodstream infections, ventilation-associated pneumonia, catheter-associated urinary tract infections and primary bloodstream infections that developed in patients after 48 h in the ICU. For environmental surveillance 14 points were selected for sampling (i.e. bed edges, medication carts, PC keyboards, sink faucets). The system of active surveillance of HAIs also included surveillance of microorganisms, consisting of the molecular genotyping of bacterial isolates by pulsed-field gel electrophoresis (PFGE). From 1 November 2016, monitoring of compliance with guidelines for hand hygiene (HH) and proper glove or gown use by healthcare personnel was included in the surveillance system. After the first six months (baseline phase), a multimodal intervention to improve adherence to guidelines by healthcare personnel was conducted with the ICU staff. RESULTS: Overall, 773 patients were included in the active surveillance. The overall incidence rate of device-related HAIs was 14.1 (95% CI: 12.2-16.3) per 1000 patient-days. The monthly device-related HAI incident rate showed a decreasing trend over time, with peaks of incidence becoming progressively lower. The most common bacterial isolates were Klebsiella pneumoniae (20.7%), Acinetobacter baumannii (17.2%), Pseudomonas aeruginosa (13.4%) and Staphylococcus aureus (5.4%). Acinetobacter baumannii and Klebsiella pneumoniae showed the highest proportion of isolates with a multidrug-resistant profile. A total of 819 environmental samples were collected, from which 305 bacterial isolates were retrieved. The most frequent bacterial isolates were Acinetobacter baumannii (27.2%), Staphylococcus aureus (12.1%), Enterococcus faecalis (11.1%), Klebsiella pneumoniae (5.2%) and Pseudomonas aeruginosa (4.7%). All Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae environmental isolates were at least multidrug-resistant. Genotyping showed a limited number of major PFGE patterns for both clinical and environmental isolates of Klebsiella pneumoniae and Acinetobacter baumannii. Behavioral compliance rates significantly improved from baseline to post-intervention phase. CONCLUSIONS: By integrating information gathered from active surveillance, environmental microbiological surveillance, surveillance of bacterial isolates and behavioral surveillance of healthcare personnel, the multimodal infection surveillance system returned a precise and detailed view of the infectious risk and microbial ecology of the ICU.

Fresh vegetables and ready-to eat salads: phenotypic characterization of moulds and molecular characterization of yeasts.

This study was performed to characterize and quantify mould and yeast isolates in fresh vegetables (FV) and ready to eat salads (RTES). During 2007, a random set of 194 samples, including 56 samples of FV and 138 samples of RTES, were analyzed for a total of 388 mycological determinations. Yeasts and moulds identification was carried out on 18/56 whole FV and 42/138 RTES. Yeasts were the predominant organisms in the FV (mean values: 6.20 log cfu g-1-8.00 log cfu g-) while moulds showed lower mean values (4.70 log cfu g-l-6.79 log cfu g-l). After processing, FV samples showed a statistically significant decreases (p-value <0.001) in the contamination of fungi. Most of the species identified were found both in the FV and RTES samples. Many of moulds species isolated belong to toxigenic genera Penicillium, Stachybotrys, Phoma, Fusarium indicating a potential mycotoxin production and a potential risk for consumers.

The evaluation of the microbial safety of fresh ready-to-eat vegetables produced by different technologies in Italy.

AIMS: The study was performed to evaluate the safety of whole and RTE vegetables and to investigate the effectiveness of different preventive strategies for the quality assurance of RTE vegetables collected from three Italian production systems. Producer 1, applied a strict system in compliance with GAP- GMP - HACCP, Producer 2 used chlorine disinfection at a second washing step, and Producer 3 using a physical microbial stabilization. METHODS: During the period 2005-2007, a total of 964 samples including whole vegetables and RTE salads, collected from three different producers in central Italy, were analysed to quantify the aerobic mesophilic count (AMC) and Escherichia coli, and for the presence of Salmonella spp, Listeria monocytogenes, E. coli O157:H7, hepatitis A virus and Norovirus (NoV). RESULTS: None of the whole vegetable samples were positive for L. monocytogenes, E. coli O157:H7, HAV and NoV; however, a low prevalence of Salmonella was found. No pathogens were detected with cultural methods in any of the RTE vegetables analysed, only two RTE samples were positive for L. monocytogenes with PCR, but were not confirmed by the cultural method. The median values of AMC in RTE vegetables measured 24 h after packaging were statistically different among the 3 producers (5·4 × 10(6), 1·5 × 10(7) and 3·7 × 10(7) CFU g(-1), respectively; P=0·011). The lowest level was detected in Producer 1. CONCLUSION: The products that were processed applying rigorously GAP, GMP and HACCP showed a better microbiological quality than those processed with chemical or physical stabilization. STUDY SIGNIFICANCE AND IMPACT: The results of the study evidenced the efficacy of GAP, GMP and HACCP in improving microbiological quality of whole and RTE vegetables.

[Health care reforms in Italy: towards an health system with national rights and local responsibilities]. / Dalla "riforma-ter" alle modifiche al titolo V della parte seconda della Costituzione: verso un sistema sanitario nazionale nelle garanzie e regionale nelle responsabilità.

The aim of the article is to describe the new Italian National Health Service outlined by the third health care reform ("riforma-ter"), the fiscal federalism and the modifications to the title V of the second part of the Constitution. The authors examine the present "performance" of the Italian National Health Service in terms of health status of the population, perceived quality of care and health care expenditure, analyzing the international and national context in which the new reforms were developed. The most significant changes in health care programming, organization and functioning of the system, financing of the National Health Service and medical education are described. The authors conclude outlining research priorities to be addressed.

Phenotypic detection of nosocomial mecA-positive coagulase-negative staphylococci from neonates.

Over a 3-year period, we screened antimicrobial resistance genotype (mecA-positive or -negative) in clinically significant coagulase-negative staphylococci isolated from patients residing in our neonatal intensive care unit. For the 152 study strains, the accuracy of standard methods (agar dilution MIC, disc diffusion and agar screen tests) in detecting oxacillin resistance during 48 h of incubation was evaluated. Using mecA gene PCR and Southern blot hybridization as the gold standard, the differential in MICs of additional antibiotics selected for their relevant clinical use in our setting was also compared with mecA status of the isolates. The frequency of mecA was 48.6% among study strains. When applying the previous (1998) and most current (1999) NCCLS interpretive criteria, the specificities of oxacillin agar dilution MICs in detecting the 78 mecA-negative isolates were 100 and 89.7%, respectively, at 24 h, and 100 and 80.7%, respectively, at 48 h. In this respect, the sensitivities of oxacillin agar dilution MICs in detecting the 74 mecA-positive strains were 75.6 and 97.2%, respectively, at 24 h, and 86.4 and 100%, respectively, at 48 h. When applying the previous and most current NCCLS zone size interpretive criteria, oxacillin zone diameters were in false-susceptible error for 13.5 and 8.1%, respectively, of the 74 mecA-positive strains tested at 24 h, and for 6.7 and 2.7%, respectively, at 48 h. Accordingly, when the 78 mecA-negative strains were considered, oxacillin zone diameters were in false-resistant error for 2.5 and 8.9%, respectively, at 24 h, and for 8.9 and 15.3%, respectively, at 48 h. The oxacillin salt agar screen assay accurately identified all mecA-negative strains at both 24 and 48 h. However, 26 (35.1%) and 7 (9.4%) of the mecA-positive strains were misinterpreted as susceptible by the agar screen test at 24 and 48 h, respectively. Using the presence of mecA as the reference standard for interpreting oxacillin susceptibility results, strains lacking mecA were more likely to be susceptible to ampicillin, ceftazidime, gentamicin, netilmicin and rifampicin than were mecA-positive strains. Vancomycin was the only antibiotic tested for which all strains, regardless of mecA status, remained susceptible.