Air microbial sampling in operating theatres by active and passive methods: equation correlation from the GISIO-ISChIA study results and comparison with the EU GGMP recommendation, towards the definition of threshold values.

The aim of this study was to calculate the equation of correlation between the microbial air contamination values obtained by active sampling (colony-forming units per cubic metre, CFU/m3) and by passive sampling (Index of microbial air contamination, IMA), by using the data from the ISChIA study, and to compare the values obtained with the recommended limits defined by the EU Guidelines to Good Manufacturing Practice (EU GGMP), 2008, for clean areas used to manufacture sterile medicinal products. Air sampling was performed during 335 elective prosthesis procedures. Correlation between CFU/m3 and IMA values was evaluated using the Spearman test; p<0.05 was considered to indicate significance. This equation was used to calculate the IMA values corresponding to the CFU/m3 recommended threshold values by EU GGMP for the different Grades of microbial contamination. The following correlation equation was obtained: y = 1.86 + 0.12x, where "x" = cfu/m3 value and "y" = IMA value. The relationships between CFU/m3 and IMA values obtained from active and passive sampling during the ISChIA study showed to be in line to those suggested by the EU GGMP for pharmaceutical manufacturing for Grade C and D. This study shows that the EU GGMP relationship could be considered valid also for operating theatres. Both methods, active and passive samplings, can be used to evaluate microbial air quality and highlight critical situations; however, in particular during the activity, passive sampling estimating the risk posed by airborne microorganisms to the surgical wound, can be considered more relevant, and for its simplicity, economy and standardization, can be suggested for routine microbial monitoring.

Hospital acquired infections in COVID-19 patients in sub intensive care unit: analysis of two waves of admissions.

BACKGROUND AND AIM: The pandemic caused by SARS-COV-2 has increased Semi-Intensive Care Unit (SICU) admission, causing an increase in healthcare-associated infection (HAI). Mostly HAI reveals the same risk factors, but fewer studies have analyzed the possibility of multiple coinfections in these patients. The study aimed was to identify patterns of co-presence of different species describing at the same time the association between such patterns and patient demographics and, finally, comparing the patterns between the two cohorts of COVID-19 patients admitted at Policlinico during the first wave and the second one). METHODS: All the patients admitted to SICUs during two COVID-19 waves, from March to June 2020 months and from October to December 2020, were screened following the local infection control surveillance program; whoever manifested fever has undergone on microbiological culture to detect bacterial species. Statistical analysis was performed to observe the existence of microbiological patterns through DBSCAN method. RESULTS: 246 patients were investigated and 83 patients were considered in our study because they presented infection symptoms with a mean age of 67 years and 33.7% of female patients. During the first and second waves were found respectively 10 and 8 bacterial clusters with no difference regarding the most frequent species. CONCLUSIONS: The results show the importance of an analysis which considers the risk factors for the possibility of co- and superinfection (such as age and gender) to structure a good prognostic tool to predict which patients will encounter severe coinfections during hospitalization.

SPiNCAR: A systematic model to evaluate and guide actions for tackling AMR.

BACKGROUND: Italy records very alarming levels antimicrobial resistance (AMR), so a National Action Plan on Antimicrobial resistance (PNCAR) was developed, adopting the AMR European Union's recommendations based on the results of the ECDC site visit of January 2017. For achieving PNCAR objectives, it is necessary to support and harmonize the implementation of recommendations in all the different healthcare levels (regional authorities and local trusts), so the SPiNCAR project was launched to create a tool for reaching this goal. METHODS: We developed a framework based on a scientific literature and national and international guidelines. Firstly, we identified the major intervention areas for tackling AMR, then, for each area, we built a set of standards, both for regional authorities than for local trusts. Every standard is composed by a set of essential and additional criteria, which refer to a minimum or supplemental performance level respectively. The contents were firstly discussed by the project's team during face-to-face kick-off meetings, then confirmed with Delphi methodology and finally validated through a pilot study. RESULTS: The final framework consists of seven different areas that reflect the PNCAR structure: Governance, Surveillance and Monitoring, Appropriate Use of antimicrobials, Healthcare-associated Infections (HAIs) control and prevention, Education and Training, Alliance among Stakeholders, Implementation. The total number of standards for the regional framework was 34 with 264 criteria and for the local version 36 criteria with 279 standards. CONCLUSION: The ongoing use of this tool, developed on international evidences and recommendations that were tailored on the Italian specific context, allows monitoring the improvement achieved over time and plan the next steps.

The first major vaccination campaign against smallpox in Lombardy: the mass vaccination campaign against coronavirus nothing new only terminology.

Terminology, technology, communication and organizational strategies are different but we tried to compare the mass vaccination campaign against smallpox with the one we are doing against coronavirus.

A Keyword Approach to Identify Adverse Events Within Narrative Documents From 4 Italian Institutions.

OBJECTIVES: Existing methods for measuring adverse events in hospitals intercept a restricted number of events. Text mining refers to a range of techniques to extract data from narrative sources. The goal of this study was to evaluate the performance of an automated approach for extracting adverse event keywords from within electronic health records. METHODS: The study involved 4 medical centers in the Region of Lombardy. A starting set of keywords was trained in an iterative process to develop queries for 7 adverse events, including those used by the Agency for Healthcare Research and Quality as patient safety indicators. We calculated positive predictive values of the 7 queries and performed an error analysis to detect reasons for false-positive cases of pulmonary embolism, deep vein thrombosis, and urinary tract infection. RESULTS: Overall, 397,233 records were collected (34,805 discharge summaries, 292,593 emergency department notes, and 69,835 operation reports). Positive predictive values were higher for postoperative wound dehiscence (83.83%) and urinary tract infection (73.07%), whereas they were lower for deep vein thrombosis (5.37%), pulmonary embolism (13.63%), and postoperative sepsis (12.28%). The most common reasons for false positives were reporting of past events (42.25%), negations (22.80%), and conditions suspected by physicians but not confirmed by a diagnostic test (11.25%). CONCLUSIONS: The results of our study demonstrated the feasibility of using an automated approach to detect multiple adverse events in several data sources. More sophisticated techniques, such as natural language processing, should be tested to evaluate the feasibility of using text mining as a routine method for monitoring adverse events in hospitals.

Are Epidemiological Estimates Able to Describe the Ability of Health Systems to Cope with COVID-19 Epidemic?

INTRODUCTION: The coronavirus disease 2019 (COVID-19) epidemic is an infectious disease which was declared a pandemic and hit countries worldwide from the beginning of the year 2020. Despite the emergency vigilance plans, health systems in all countries experienced a different ratio of lethality, amount of admissions to intensive care units and quarantine management of positive patients. The aim of this study is to investigate whether some epidemiological estimates could have been useful in understanding the capacity of the Italian Regional Health Services to manage the COVID-19 epidemic. METHODS: We have compared data between two different Italian regions in the Northern part of Italy (Lombardy and Veneto) and the national data to determine whether different health strategies might be significant in explaining dissimilar patterns of the COVID-19 epidemic in Italy. Data have been extracted from a public database and were available only in an aggregated form. RESULTS: The regions in question displayed two different health policies to face the COVID-19 epidemic: while Veneto's health service was largely territorially oriented, Lombardy's strategy was more hospital-centered. DISCUSSION: The key to facing epidemics like this one consists in identifying solutions outside of hospitals. This however requires there be well-trained general practitioners and enough healthcare personnel working outside hospitals.

CoViD-19, learning from the past: A wavelet and cross-correlation analysis of the epidemic dynamics looking to emergency calls and Twitter trends in Italian Lombardy region.

The first case of Coronavirus Disease 2019 in Italy was detected on February the 20th in Lombardy region. Since that date, Lombardy has been the most affected Italian region by the epidemic, and its healthcare system underwent a severe overload during the outbreak. From a public health point of view, therefore, it is fundamental to provide healthcare services with tools that can reveal possible new health system stress periods with a certain time anticipation, which is the main aim of the present study. Moreover, the sequence of law decrees to face the epidemic and the large amount of news generated in the population feelings of anxiety and suspicion. Considering this whole complex context, it is easily understandable how people "overcrowded" social media with messages dealing with the pandemic, and emergency numbers were overwhelmed by the calls. Thus, in order to find potential predictors of possible new health system overloads, we analysed data both from Twitter and emergency services comparing them to the daily infected time series at a regional level. Particularly, we performed a wavelet analysis in the time-frequency plane, to finely discriminate over time the anticipation capability of the considered potential predictors. In addition, a cross-correlation analysis has been performed to find a synthetic indicator of the time delay between the predictor and the infected time series. Our results show that Twitter data are more related to social and political dynamics, while the emergency calls trends can be further evaluated as a powerful tool to potentially forecast new stress periods. Since we analysed aggregated regional data, and taking into account also the huge geographical heterogeneity of the epidemic spread, a future perspective would be to conduct the same analysis on a more local basis.

Sustainable Development Goals and 2030 Agenda: Awareness, Knowledge and Attitudes in Nine Italian Universities, 2019.

Sustainable Development Goals (SDGs) and 2030 Agenda represent global development programs. Education can widen the acknowledgement of their relevance and their applications. This survey aims to assess awareness, knowledge and attitudes towards SDGs and sustainability among first-year students in nine Italian Universities. A Likert scale-based online questionnaire of 70 items was compiled by students from March to July 2019. It examined knowledge and expectations referred to sustainable development concepts, indicators and documents/models accounting for sociodemographic variables. Statistical analyses performed were Chi-square test, Fisher's Exact test, Kendall's W correlation coefficient, univariate and multivariate analysis. The questionnaire was completed by 1676 students. A low percentage referred a good knowledge of SDGs and 2030 Agenda, most of them had never attended related educational activities previously. Better knowledge of SDGs and 2030 Agenda was observed in case of previous specific educational activities (p < 0.001). The expectation towards university guaranteeing an education on SDGs was high, both for personal wisdom and for usefulness in future professional context. A significant difference (p < 0.001) in such expectations was found, as healthcare students were less interested than colleagues of other areas. The results showed low knowledge but interest towards sustainable development. A scheduled implementation of academic initiatives should be considered.

COVID-19: What happened to the healthcare workers of a research and teaching hospital in Milan, Italy?

The paper wants to present the data of infection of the Health Care Workers of a research and teaching hospital in Milan, Italy. The majority (2554, 55.9%) of 4572 HCWs were tested for SARS-CoV-2 and 8.8% were found positive. Most of the tested workers were women, but we found higher relative frequency of positivity for men, even after adjustment for age, working area, and occupation. The higher frequency of positive tests in the medicine area is probably explained by the higher concentration in that area of COVID-19 patients. Conversely, the low frequency of positive HCWs in intensive care units is  probably explained by the diffuse and continuous use of PPD. Our results show that HCWs in a research and teaching hospital in the most hit Region in Italy had a similar pattern of infection as all other HCWs all over the world. The problem of SARS-CoV-2 infections among the hospital personnel HCWs should remind us  the concerns about hospital acquired infections both for patients and HCWs.

Hospital Acquired Infections in COVID-19 patients in sub intensive care unit.

The aim of this study is to assess the association among species of bacteria and to identify the presence of clusters of patients in sub intensive care unit with different profiles of infection, and to study the relationship between such profiles and patient demographics (gender, age), kind of investigations and  material used to detect the infection. The findings need to analyse a bigger amount of data in the same setting to make evident that it is constant the infection only with Escherichia coli and Staphylocossus epidemidis and a third case in which more bacteria are inlvolved.

COVID-19: new scenario old problems.

The short paper present the problem of hospital acquired infection in subintensive units og a research and teaching hospital.

Appropriateness of admission to rehabilitation: definition of a set of criteria and rules through the application of the Delphi method.

BACKGROUND: Controlling inappropriateness of care is an essential issue, especially in rehabilitation medicine. In fact, admitting a patient to a rehabilitation hospital or unit is a complex decision also due to the absence of shared and objective admission criteria. AIM: The aim was to define clinical admission criteria and rules in rehabilitation medicine. DESIGN: Survey based on the application of the Delphi method on a sample of rehabilitation medicine experts. SETTING: Administration of electronic online questionnaires concerning appropriateness of admission to intensive rehabilitation. POPULATION: Volunteer sample of 53 experts with the following inclusion criteria: being members of the Italian Society of Physical and Rehabilitation Medicine, having practical experience in the research field, agreeing to the confidentiality of the information and being skilled in both rehabilitation and healthcare organization. METHODS: A three-round Delphi survey was conducted according to international guidelines. The two initial rounds consisted of an electronic online questionnaire while in the third one a report of the results was provided to the participants. The experts had to score their agreement with each item in the questionnaires, based on either a Likert scale or a dichotomous statement. Consensus between the experts was assessed. RESULTS: A total of 53 health professionals completed the Delphi survey. 19 out of 20 Italian regions were represented. The first round consisted of 8 multiple-choice questions. The second round was designed according to the suggestions provided by the panelists in the previous one and consisted of a twelve items questionnaire. At the end of the survey, seven criteria of appropriateness of admission to rehabilitation were identified and five rules defining an appropriate admission to a rehabilitation facility were elaborated. CONCLUSIONS: This study represents an attempt to create a worthwhile and reliable tool for a more conscious clinical practice in admission to rehabilitation, based on a set of shared criteria and rules. CLINICAL REHABILITATION IMPACT: To increase appropriateness of admission to rehabilitation. Improving appropriateness in healthcare delivery must be a primary goal in order to improve healthcare quality, save money and ensure system sustainability.

COVID 19 and Spanish flu pandemics: All it changes, nothing changes.

The Corona Virus 19 (COVID 19) epidemic is an infectious disease which was declared as a pandemic and hit all the Countries, all over the world, from the beginning of the year 2020. There are many similarities between the COVID 19 epidemic and the Spanish flu epidemic. We considered some preventive measures which do not change in the two epidemics.

Leadership in Public Health: Opportunities for Young Generations Within Scientific Associations and the Experience of the "Academy of Young Leaders".

This paper outlines the characteristics of scientific leadership and the role of Scientific Associations with their specific activities. The recent activities of the Lombard Academy of Public Health are subsequently described, including the creation, in 2019, of the Academy of young leaders in public health. Comparing to other sectors, scientific leadership dynamics take into consideration different aspects. Besides awards (Nobel Prize or several other) and prestigious affiliations, eventual indicators might be academic roles, fundraising abilities, relevant positions among scientific associations, editors of prestigious journals or editorial series and, more recently, high bibliometric indicators. The peculiar topics of public health encompass interactions with institutions, authorities, politicians, involved in different levels in health policies. Recently, in Italy, the Ministry of Health has identified parameters to be accreditated as a scientific and technical association. The role of SItI (Italian Society of Hygiene), EUPHA, ASPHER, and WFPHA appears relevant in PH, in national and international contexts, with Italian praiseworthy members constantly achieving leading roles. Considering that few training opportunities aimed to improve research and leadership skills are available, Accademia Lombarda di Sanità Pubblica (ALSP) designed the AYLPH (Academy of Young Leaders in Public Health) program. AYLPH program is a 1-year training to shape leadership skills among young professionals. A set of didactic, theoretical and practical methods was offered and evaluated.

Azole-resistant Aspergillus fumigatus in the Italian environment.

OBJECTIVES: Azole resistance in Aspergillus fumigatus environmental and clinical isolates is recognised as an emerging problem worldwide. Development of azole resistance may be environmentally driven because of the massive use of azole fungicides in agriculture. The mechanism of azole resistance is mostly related to mutations in the cyp51A gene. METHODS: A. fumigatus azole resistance in the environment was previously documented in northern Italy. This study extended the research in the agricultural environment also in central and southern Italy and investigated differences in the Italian geographical areas and in the different types of crops. RESULTS: A total of 177 samples (173 soil samples and 4 Dutch bulbs) collected in the period 2014-20117 in 14 Italian regions were analysed. Itraconazole-resistant A. fumigatus isolates grew in 16.9% of the screened samples. Differences were observed in soil samples from the three Italian geographic areas: 12.5% in the north, 15.2% in the centre and 24.1% in the south. Resistant isolates were from different cultivations, treated or officially not treated with azole fungicides. Sequencing of the cyp51A gene confirmed that resistance was mainly associated with the TR34/L98H mutation (29/30 isolates); 1 isolate showed the G54E mutation. CONCLUSIONS: The risk for patients to acquire multi-azole-resistant strains from the environment could have a serious impact on the management of life-threatening invasive infections. The azole resistance rate of 16.9% found in Italy requires suitable monitoring of antifungal susceptibility of clinical isolates.

Control and prevention measures for legionellosis in hospitals: A cross-sectional survey in Italy.

Risk assessment, environmental monitoring, and the disinfection of water systems are the key elements in preventing legionellosis risk. The Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine, and Public Health and the Italian Multidisciplinary Society for the Prevention of Health Care-Associated Infections carried out a national cross-sectional survey to investigate the measures taken to prevent and control legionellosis in Italian hospitals. A multiple-choice questionnaire was developed, comprising 71 questions regarding hospital location, general characteristics, clinical and environmental surveillance, and control and preventive measures for legionellosis in 2015. Overall, 739 hospitals were enrolled from February to June 2017, and 178 anonymous questionnaires were correctly completed and evaluated (response rate: 24.1%). The survey was conducted using the SurveyMonkey® platform, and the data were analyzed using Stata 12 software. Of the participating hospitals, 63.2% reported at least one case of legionellosis, of which 28.2% were of proven nosocomial origin. The highest case numbers were reported in the Northern Italy, in hospitals with a pavilion structure or cooling towers, and in hospitals with higher numbers of beds, wards and operating theaters. Laboratory diagnosis was performed using urinary antigen testing alone (31.9%), both urinary antigen testing and single antibody titer (17.8%), or with seroconversion also added (21.5%). Culture-based or molecular investigations were performed in 28.8% and 22.1% of the clinical specimens, respectively. The water systems were routinely tested for Legionella in 97.4% of the hospitals, 62% of which detected a positive result (> 1000 cfu/L). Legionella pneumophila serogroup 2-15 was the most frequently isolated species (58.4%). The most common control measures were the disinfection of the water system (73.7%), mostly through thermal shock (37.4%) and chlorine dioxide (34.4%), and the replacement (69.7%) or cleaning (70.4%) of faucets and showerheads. A dedicated multidisciplinary team was present in 52.8% of the hospitals, and 73% of the hospitals performed risk assessment. Targeted training courses were organized in 36.5% of the hospitals, involving nurses (30.7%), physicians (28.8%), biologists (21.5%), technicians (26.4%), and cleaners (11%). Control and prevention measures for legionellosis are present in Italian hospitals, but some critical aspects should be improved. More appropriate risk assessment is necessary, especially in large facilities with a high number of hospitalizations. Moreover, more sensitive diagnostic tests should be used, and dedicated training courses should be implemented.

Antibiotic resistance: Italian awareness survey 2016.

Antimicrobial resistance has become a public health priority worldwide. The WHO conducted a survey concerning the personal use of antibiotics, knowledge of appropriate use and awareness of the issue of resistance. A similar survey was conducted in Italy involving 666 young university students and 131 seniors attending courses of the University of the third age. Antibiotics seem to be taken with moderate frequency and appropriately: 30% of respondents took them in the past six months and 94% took these drugs only prescribed by a doctor, in the correct dose and for the proper duration. Notable confusion concerning the conditions treatable with antibiotics was detected (only 30% indicated gonorrhea, and 30-40% believed that antibiotics should be employed for fever, cold, and flu), while 94% of participants seemed aware of the problem of antibiotic resistance. Most of the respondents identified the behaviors that can reduce the phenomenon of resistance (regular handwashing and use of antibiotics only when prescribed and needed). The results of our survey, that involved people of high level of instruction and living in urban areas of northern regions, cannot be extended to all the Italian population. However, they provide valid elements to promote initiatives aimed to a more aware use of antibiotics.

Preventable proportion of intubation-associated pneumonia: Role of adherence to a care bundle.

OBJECTIVE: The aim of the present study was to estimate the preventable proportion of Intubation-Associated Pneumonia (IAP) in the Intensive Care Units (ICUs) participating in the Italian Nosocomial Infections Surveillance in ICUs (SPIN-UTI) network, taking into account differences in intrinsic patients' risk factors, and additionally considering the compliance with the European bundle for IAP prevention. METHODS: A prospective patient-based survey was conducted and all patients staying in ICU for more than 2 days were enrolled in the surveillance. Compliance with the bundle was assessed using a questionnaire for each intubated patient. A twofold analysis by the parametric g-formula was used to compute the number of infections to be expected if the infection incidence in all ICUs could be reduced to that one of the top-tenth-percentile-ranked ICUs and to that one of the ICU with the highest compliance to all five bundle components. RESULTS: A total of 1,840 patients and of 17 ICUs were included in the first analysis showing a preventable proportion of 44% of IAP. In a second analysis on a subset of data, considering compliance with the European bundle, a preventable proportion of 40% of IAP was shown. A significant negative trend of IAP incidences was observed with increasing number of bundle components performed (p<0.001) and a strong negative correlation between these two factors was shown (r = -0.882; p = 0.048). CONCLUSIONS: The g-formula controlled for time-varying factors is a valuable approach for estimating the preventable proportion of IAP and the impact of interventions, based entirely on an observed population in a real-world setting. However, both the study design that cannot definitively prove a causative relationship between bundle compliance and IAP risk, and the small number of patients included in the care bundle compliance analysis, may represent limits of the study and further and larger studies should be conducted.