Staphylococcus aureus with reduced susceptibility to vancomycin in healthcare settings.

Glycopeptide resistance in Staphylococcus aureus is a source of great concern because, especially in hospitals, this class of antibiotics, particularly vancomycin, is one of the main resources for combating infections caused by methicillin-resistant Staphylococcus aureus strains (MRSA). Reduced susceptibility to vancomycin (VISA) was first described in 1996 in Japan; since then, a phenotype with heterogeneous resistance to vancomycin (h-VISA) has emerged. H-VISA isolates are characterised by the presence of a resistant subpopulation, typically at a rate of 1 in 10(5) organisms, which constitutes the intermediate stage betweenfully vancomycin-susceptible S. aureus (VSSA) and VISA isolates. As VISA phenotypes are almost uniformly cross-resistant to teicoplanin, they are also called Glycopeptides-intermediate Staphylococcus aureus strains (GISA) and, in the case of heterogeneous resistance to glycopeptides, h-GISA. The overall prevalence of h-VISA is low, accounting for approximately 1.3% of all MRSA isolates tested. Mortality due to h-GISA infections is very high (about 70%), especially among patients hospitalised in high-risk departments, such as intensive care units (ICU). Given the great clinical relevance of strains that are heteroresistant to glycopeptides and the possible negative impact on treatment choices, it is important to draw up and implement infection control practices, including surveillance, the appropriate use of isolation precautions, staff training, hand hygiene, environmental cleansing and good antibiotic stewardship.

Improving environmental quality in an operating room: clinical outcomes and economic implications.

An experimental study was conducted in a hospital in Liguria (northern Italy) on two groups of patients with the same disease severity who were undergoing the same type of surgery (primary hemiarthroplasty). Our aim was to assessing the results of a quality-improvement scheme implemented in the operating room. The quality-improvement protocol involved analyzing a set of parameters concerning the operating team's behavior and environmental conditions that could be attributed to the operating team itself A program of training and sanitary education was carried to rectify any improper behavior of the operating staff Two hundred and six hip-joint replacement operations (primary hip hemiarthroplasty--ICD9-CM 81.51) all conducted in the same operating room were studied: 103 patients, i.e. operations performed before the quality-improvement scheme and 103 patients, i.e. operations performed after the quality improvement scheme; all were comparable in terms of type of surgery and severity. The scheme resulted in an improvement in both behavioral and environmental parameters and an 80% reduction in the level of microbial air contamination (p < 0.001). Patient outcomes improved in terms of average postoperative hospitalization time, the occurrence and duration of fever (> 37.5 degrees C) and microbiological contamination of surgical wounds. From an economic point of view, facility efficiency increased by 28.57%, average hospitalization time decreased (p < 0.001) and a theoretical increase of Euro 1,441,373.58 a year in revenues was achieved.

Operating theatre quality and prevention of surgical site infections.

Surgical site infections (SSI) account for 14% to 17% of all hospital-acquired infections and 38% of nosocomial infections in surgical patients. SSI remain a substantial cause of morbidity and death, possibly because of the larger numbers of elderly surgical patients or those with a variety of chronic and immunocompromising conditions, and emergence of antibiotic-resistant microorganisms. Factors causing surgical site infection are multifarious. Several studies have identified the main patient-related (endogenous risk factors) and procedure-related (external risk factors) factors that influence the risk of SSI. The rate of surgical wound infections is strongly influenced by operating theatre quality, too. A safe and salubrious operating theatre is an environment in which all sources of pollution and any micro-environmental alterations are kept strictly under control. This can be achieved only through careful planning, maintenance and periodic checks, as well as proper ongoing training for staff Many international scientific societies have produced guidelines regarding the environmental features of operating theatres (positive pressure, exchanges of filtered air per hour, air-conditioning systems with HEPA filters, etc.) and issued recommendations on healthcare-associated infection, including SSI, concerning surveillance methods, intervention to actively prevent SSI and approaches to monitoring the implementation of such strategies. Therefore, the prevention of SSI requires a multidisciplinary approach and the commitment of all concerned, including that of those who are responsible for the design, layout and functioning of operating theatres.

Investigation of organizational and hygiene features in dentistry: a pilot study.

INTRODUCTION: In dentistry, as in surgery, there is a risk of cross-infection for both patients and staff The aim of this research was to evaluate procedures and behaviors enacted by dental staff which might engender a risk for themselves and their patients. METHODS: A questionnaire was administered to 106 dental workers in Genoa (Italy), both public and private. Whenever personal interviews were conducted, the facilities involved were also inspected and the activities of the dental staff were observed directly. RESULTS: This research highlighted some critical points in both structural and organizational features and in the management of infective hazards in the sample considered. In some cases, inadequacies were noted with regard to the prevention of cross-infections, such as the lack of disinfection of work surfaces and the handles of chair-set accessories. DISCUSSION AND CONCLUSIONS: The particular nature of dental work, in which aerosols of blood and saliva may be produced by rotating instruments, engenders a risk of infection. Application of the various preventive measures available can significantly reduce microbial contamination and the risk of occupational infection and cross-infections. Furthermore, improvement in the structural and organizational features of dental surgeries and the continuing education of health-care workers is indispensable to the control and prevention of infectious diseases.

Evaluation of contamination by blood aerosols produced during various healthcare procedures.

This study aimed to quantify the blood content of aerosols produced during dental, maxillofacial and autopsy procedures and to identify those activities which involve the greatest risk of infection due to exposure to blood-containing aerosols. A total of 132 air samples were taken in several dental cubicles, a maxillofacial operating theatre and an autopsy room. The concentration of haemoglobin (Hb) in the samples was quantified and, for each day of sampling, the concentration of blood/m(3) of air aspirated (muL blood/m(3) air) was calculated. Hb was detected in 38.64% of samples. The mean concentration of Hb in the samples was 0.10+/-0.19 microg Hb/m(3) of aspirated air, with a range of 0-0.72 microg Hb/m(3). No statistically significant differences in the concentration of blood aerosol per m(3) of aspirated air were noted among the three types of activity analysed (P>0.05). Although there is, as yet, no concrete proof of the risk of infection through blood-containing aerosols, minimising the production and dispersal of aerosols and spatters is strongly recommended.

Fungal contamination in hospital environments.

OBJECTIVES: To assess the degree of fungal contamination in hospital environments and to evaluate the ability of air conditioning systems to reduce such contamination. METHODS: We monitored airborne microbial concentrations in various environments in 10 hospitals equipped with air conditioning. Sampling was performed with a portable Surface Air System impactor with replicate organism detection and counting plates containing a fungus-selective medium. The total fungal concentration was determined 72-120 hours after sampling. The genera most involved in infection were identified by macroscopic and microscopic observation. RESULTS: The mean concentration of airborne fungi in the set of environments examined was 19 +/- 19 colony-forming units (cfu) per cubic meter. Analysis of the fungal concentration in the different types of environments revealed different levels of contamination: the lowest mean values (12 +/- 14 cfu/m(3)) were recorded in operating theaters, and the highest (45 +/- 37 cfu/m(3)) were recorded in kitchens. Analyses revealed statistically significant differences between median values for the various environments. The fungal genus most commonly encountered was Penicillium, which, in kitchens, displayed the highest mean airborne concentration (8 +/- 2.4 cfu/m(3)). The percentage (35%) of Aspergillus documented in the wards was higher than that in any of the other environments monitored. CONCLUSIONS: The fungal concentrations recorded in the present study are comparable to those recorded in other studies conducted in hospital environments and are considerably lower than those seen in other indoor environments that are not air conditioned. These findings demonstrate the effectiveness of air-handling systems in reducing fungal contamination.

[Occupational exposure to formaldehyde in three pathology departments]. / Esposizione professionale a formaldeide in alcuni reparti di anatomia patologica.

Although formaldehyde has recently been classified by the IARC as "carcinogenic in humans" (class 1), it is still widely used in pathology departments for the fixing and conservation of biological tissues. Its use therefore raises the question of occupational exposure. The present paper reports the results of an environmental monitoring campaign to evaluate pollution by formaldehyde in various areas of three pathology departments. Chemi-adsorbent cartridges able to adsorb airborne formaldehyde were used to detect the substance. Quantitative determination of the formaldehyde was carried out by means of liquid chromatography (HPLC). The concentrations of airborne formaldehyde in the areas monitored were fairly modest, being below the limits of indoor concentration proposed by the OSHA. In one of the three departments, however these limits were exceeded in 40% of the samples taken in the room used for the storage of containers. As yet, in spite of the recent class 1 classification by the IARC, no provisions have been made to ban the use of formaldehyde. It is therefore essential to draw up environmental monitoring programmes in order to evaluate occupational exposure and to assess the efficacy of any preventive measures adopted.

Factors affecting individual exposure to NO2 in Genoa (northern Italy).

The individual exposure to nitrogen dioxide (NO2) of 89 volunteers living in Genoa, a large port city of northern Italy, was investigated with personal passive diffusion tubes in February-March 2000. The data were related to NO2 concentration in the kitchen and bedroom as measured by static samplers. Volunteers included students, workers and housewives living in three areas of Genoa differing by street traffic and industrial plant location. The kitchen samples showed higher (47.00+/-16.5 microg/m3) NO2 concentrations than those from the bedroom (24.78+/-9.8 microg/m3); overall indoor NO2 concentrations were lower in the Eastern area of Genoa, where outdoor pollution is lower. Students were the volunteer group with the lowest exposure rate (24.9+/-7.8 microg/m3 vs. 44.3+/-10.1 microg/m3 for workers and 40.0+/-13.4 microg/m3 for housewives). This difference is related to the fact that students spend more time indoors, where pollution levels are lower. The main household characteristics which were shown to affect personal NO2 exposure were (a) the presence of a chimney equipped with an active aspiration device in the kitchen and (b) the heating system.

Increased urinary excretion of hydroxyproline in runners training in urban areas.

In this study, the authors investigated urinary excretion of hydroxyproline in 120 subjects to test the hypothesis that physical activity is associated with increased exposure to pollution derived from traffic exhaust. The study population comprised active noncompetitive runners (i.e., 21.1% trained < 2.5 hr/wk, 20% trained for 2.5-5.0 hr/wk, and 54.4% trained > 5 hr/wk) who lived in Genoa, an urban area of Northern Italy. The mean hydroxyproline value (24.39 +/- 8.38 standard deviation] mg/24 hr x m2) in a group of 69 runners who trained in tracks and streets located in downtown Genoa was higher (p < .05) than the mean value recorded in a group of 21 runners (13.33 +/- 2.51 mg/24 hr x m2) who trained mainly in a rural environment of Genoa. The difference was even greater (p < .01) when a third comparable group of 30 nonrunners was considered (mean = 12.54 +/- 3.41 [standard deviation] mg/24 hr x m2). In the urban environment, urinary levels of hydroxyproline were correlated significantly with intensity and frequency of running, but they were unrelated to smoking status.

Long-term decline of radiocesium concentration in seafood from the Ligurian sea (northern Italy) after Chernobyl.

The activity of 137Cs, 134Cs and 40K in tissues from fish, molluse and shellfish of the Ligurian sea was measured during 1987-1988. The mean annual concentrations in 1987 were 5.92 +/- 4.1 Bq/kg (wet tissue) for 137Cs and 2.7 +/- 1.5 Bq/kg for 134Cs and 2.46 +/- 1.82 and 0.33 +/- 0.57 Bq/kg respectively in 1988. The mean value of 40K activity was 138.6 +/- 22.1 Bq/kg. Contamination was significantly higher in the littoral area up to 1000 m from the coast (8.39 +/- 7.6 and 1.74 +/- 2.08 Bq/kg respectively versus 2.91 +/- 1.87 and 0.58 +/- 0.59 Bq/kg respectively in the open sea). The common octopus (Octopus vulgaris) had the highest radioactivity values and could be utilized as an indicator of radioactivity pollution. There were no significant differences regarding the trophic level, the seafood phylum, or the east and west Ligurian sea areas. Long-term reduction in the sea habitat was estimated at about 200 days for 137Cs and 110 days for 134Cs, reflecting differences in the physical half-life of these radionuclides. These values were lower than those found in terrestrial foodstuff and could have reflected dilution of the contaminants in the open sea. The effective dose equivalent for the Ligurian population of radiocesium originating from seafood was estimated at 1.3 microSv in 1987 and 0.5 microSv in 1988. These va ues represent 0.8 and 0.3% respectively of the annual dose (180 microSv/year) due to 40K intake with the diet.

Environmental and personal monitoring of exposure to urban noise and community response.

Noise exposure of a population sample living in a city in northern Italy (Genoa) was assessed by measuring the noise in the area as well as with personal sound detectors. Sampling was conducted during a standard day and covered a period of time spent out-of-doors, at work (service sector) and at home. Ambient noise at home and at work was assessed with sound-level meters, personal exposure levels were assessed with personal sound-level/dosimeters. Information regarding each environment was obtained with an interview including also a subjective judgement on traffic intensity and noise levels. The mean individual equivalent continuous sound level (Leq) of recorded noise was 74.5 dB(A) for 24 h and 63.9 dB(A) at night. A further distinction was made between noise exposure at home (Leq 74.4), work (Leq 74.0) and during city transfers (Leq 79.3). Leq values for individual hours, Leq daytime (Leq, d), Leq nighttime (Leq,n) and Leq day-night (Ldn) indices calculated in the different environments, i.e. at work, home and out-of-doors, are reported here. Individual noise levels have then been compared with environmental data and with subjective noise exposure judgement.

Blood lead levels in shopkeepers and car traffic pollution in Liguria, Italy.

A study was conducted into the exposure to atmospheric pollution caused by car traffic by measuring blood lead (PbB) levels in a sample of 657 adult individuals (shopkeepers) all living in Liguria. The mean level of blood lead in all examined individuals was 9.39 micrograms dl-1 (0.45 mumol per liter; C.I. 95%: 9.06-9.75 micrograms dl-1; 0.44-0.47 mumol per liter) with a range between 2.0 and 46.03 micrograms dl-1 (0.10-2.22 mumol per liter). The average Pb values in individuals working in streets with high and very high traffic was 8.30 micrograms dl-1 (0.40 mumol per liter; C.I. 95%: 7.41-9.31 micrograms dl-1; 0.36-0.45 mumol per liter) and 9.98 micrograms dl-1 (0.48 mumol per liter; C.I. 95%: 9.62-10.37 micrograms dl-1; 0.46-0.50 mumol per liter), respectively. These average blood lead levels were statistically greater than the average PbB values of those working in low traffic streets (7.06 micrograms dl-1; 0.34 mumol per liter; C.I. 95%: 6.22-7.94 micrograms dl-1; 0.30-0.38 mumol per liter). The percentile distribution (50th, 90th and 98th P) for all subgroups surveyed has always proved to be below the maximum limits specified by EC Directive No. 77/312.

Increased blood lead levels in runners training in urban areas.

In an attempt to examine the hypothesis of whether physical activity causes increased uptake of lead in humans, blood lead levels were measured in 231 individuals. Included in the study were subjects who lived in Northern Italy and who practiced noncompetitive running in urban areas or along the countryside. The mean values (1.25 +/- 0.27 mumol/l) measured in a group of 28 runners who trained at tracks and on roads of a large town, characterized by heavy traffic and high atmospheric lead levels, were slightly higher than those recorded in a group of 10 runners of the same town who trained mostly in a rural environment (0.99 +/- 0.29 mumol/l) and, with a striking and significant difference, in a comparable group of 182 nonrunners (0.46 +/- 0.22 mumol/l). These background figures were similar to those found in 11 runners who lived in a smaller, less polluted urban area who trained in country roads (0.40 +/- 0.11 mumol/l). Blood lead levels were correlated significantly with the intensity and frequency of the running practice and were unrelated to smoking habits.

[Determination of cesium in human placenta 3 years after Chernobyl]. / Determinazione del cesio in placente umane tre anni dopo Chernobyl.

Three years after the nuclear reactor accident in Chernobyl, 80 human placentae were tested to determine concentrations of cesium 134 and cesium 137 radionuclides. The activities of radionuclides were measured using a low-back ground gamma-ray spectrometry system. Human placentae were obtained from normal and at term pregnancies in women who lived in rural areas of northern-Italy and north-west of Yugoslavia and who in particular used locally grown vegetables and meats. According to the data of other Authors, the low cesium isotopes 134 and 137 levels detected (inferior to 2 Bq/kg) in human placentae suggest that, in the observed geographic areas, the fetal risk following the reactor accident in Chernobyl was negligible.

[Possible correlations between urinary cadmium and fetal growth retardation in pregnant women who smoke]. / Possibili correlazioni tra cadmio urinario e ritardato accrescimento fetale in gestanti fumatrici.

The results of a study on Ligurian women at the third day of puerperium are presented. The data obtained from the analysis of urinary cadmium levels in puerperae are related to their smoking habits and to the newborn weight. We found that women who smoked during pregnancy run the risk of giving birth to small-weight children one-and-a-half times higher than women who didn't smoke; moreover, cadmium levels in the urine of the women who smoked are higher too. The cadmium levels in urine on average are higher in women who gave birth to small-weight children, independently of smoke habits. We didn't find a significant relationship between cadmium levels in urine and newborn weight.

Amniotic fluid prolactin and fetal lung maturity.

Prolactin concentration and palmitic acid/stearic acid ratio were measured in 92 samples of amniotic fluid at various gestational ages. There was no correlation between prolactin concentration and palmitic acid/stearic acid ratio, when this ratio was greater than 5, that is when there was an obvious indication that fetal pulmonary maturation was complete. On the contrary there was a statistically significant negative correlation between prolactin levels and palmitic acid/stearic acid ratio when this ratio was lower than 5 (incomplete fetal pulmonary maturation).