Stime dell'antibiotico-resistenza in Italia e in Europa occidentale nel 2019: un'analisi comparativa basata su MICROBE.

BACKGROUND: antimicrobial resistance (AMR) will cause 10 million deaths per year worldwide by 2050, with economic costs of up to 100 trillion dollars. Antibiotic resistance (ABR) constitutes the majority of this health threat. Globally, 1.27 million people died in 2019 as a direct result of ABR. One in 5 deaths occurred in children under five, and 6 bacterial pathogens accounted for more than 70% of ABR-associated deaths. OBJECTIVES: to compare ABR estimates in terms of death and disability-adjusted life-years (DALYs) in 2019 in Italy and in Western Europe (WE) by grading the infectious syndromes and the bacterial pathogens involved, with the aim to identify the most urgent healthcare needs in Italy. DESIGN: the estimates of the burden of ABR in 2019 in WE and Italy, extracted from the Measuring Infectious Causes and Resistance Outcomes for Burden Estimation (MICROBE) tool by the Institute for Health Metrics and Evaluation (IHME; Seattle, USA), reported deaths and DALYs associated with 33 bacterial pathogens across 12 infectious syndromes, as well as deaths and DALYs associated with and attributable to ABR for 23 bacteria and 86 pathogen-drug combinations. The comparison between WE and Italy was performed in steps. First, among the 12 groups of infectious syndromes from the Global Burden of Diseases (GBD) study 2019, the most impacting in terms of deaths and DALYs were ranked based on the magnitude of rates, and the corresponding ABR-associated burden was reported. Then, the burden of the leading pathogens (bacteria, viruses, fungi, and polymicrobial infections) for all infectious syndromes was compared between the two areas. Death and DALY rates associated with ABR were reported for each bacterium, together with the percentage of ABR-attributable burden. Although it is known that Italy is one of the WE countries with the largest share of elderly, crude rates were reported instead of age-standardized rates, in order to quantify the actual burden of ABR in the two areas. SETTING AND PARTICIPANTS: Italy and Western Europe. MAIN OUTCOMES MEASURES: death and DALYs rates per 100,000 inhabitants. RESULTS: the largest difference between ABR-associated death rates in the two areas was found for bloodstream infections (25.2 and 18.8 per 100,000 in Italy and WE, respectively), followed by peritoneal and abdominal infections (15.1 and 12.2 in Italy and WE, respectively). However, the percentages of deaths and DALYs attributable to ABR were always higher in Italy for all the infections considered. Regarding pathogens, Escherichia coli accounted for the greatest burden associated to ABR, in terms of both deaths and DALYs, in both areas. The highest ABR-attributable percentage of deaths was found for Acinetobacter baumannii (28.4% in WE and 31.9% in Italy), accounting also for the highest percentage of ABR-attributable DALYs (28.4% in WE and 31.7% in Italy). The pathogen-drug combination with the highest burden associated with AMR was Escherichia coli-Aminopenicillin, while the greatest AMR-attributable burden was found for Staphylococcus aureus-Methicillin (MRSA). On average, 55.4% of Escherichia coli was resistant to Aminopenicillin in WE, with Italy ranking third (67.6%). Nordic countries showed smaller values, with Sweden in last place (32.8%). The average percentage of MRSA in WE was 16%, with Italy exceeding it by more than 13 pointsConclusions: despite similar sepsis mortality rates in Italy and other WE countries, the proportion of ABR-associated and attributable deaths was higher in Italy. Targeted strategies aimed at reducing the circulation of bacteria and resistant microorganisms together with other interventions could lead to an overall reduction in deaths associated with ABR.

Factors Influencing the Healthcare Workers' Willingness to Receive the COVID-19 Booster Dose in Tuscany (Italy).

BACKGROUND: The World Health Organization has defined vaccine hesitancy as behavior influenced by several factors, including trust in the vaccine itself or its provider or the perceived need for vaccination. The aim of this study was to investigate the factors influencing the willingness to receive the COVID-19 vaccine among the employees and healthcare professionals of the Central Tuscany Local Health Authority (CT-LHA) in Italy. METHODS: From July to October 2022, a cross-sectional study was conducted. An online questionnaire was administered to 7000 employees of the CT-LHA. The questionnaire analyzed the factors that influenced receiving the booster dose of the COVID-19 vaccine. The sample was stratified by gender, age, type of occupation (healthcare or non-healthcare workers), and seniority. Incomplete questionnaires were excluded. A chi-squared test was performed through STATA. The significance level was set at 95%. RESULTS: Of the questionnaires administered, 1885 (26.9%) questionnaires were eligible for the study. In the previous vaccination campaign, the healthcare workers (HCWs) considered the vaccine used by CT-LHA as safe, in contrast to non-healthcare workers (N-HCWs), who considered it less secure (p < 0.05). The HCWs showed a higher propensity for vaccine safety to receive the booster dose than N-HCWs. N-HCWs appeared to be less affected by an updated booster dose than HCWs (p < 0.05). CONCLUSIONS: The factors studied appear to influence HCWs differently from N-HCWs. Both HCWs and N-HCWs would choose an upgraded mRNA vaccine for the booster dose.

Does Vaccine Confidence Mediate the Relationship between Vaccine Literacy and Influenza Vaccination? Exploring Determinants of Vaccination among Staff Members of Nursing Homes in Tuscany, Italy, during the COVID-19 Pandemic.

BACKGROUND: Low coverage of influenza vaccination in nursing home (NH) staff may be attributed to factors such as vaccine confidence (VC) and vaccine literacy (VL). Our study aimed to evaluate the role of VL and VC in predicting the intention to get the influenza vaccine in a sample of employees of NHs in Tuscany, Italy. METHODS: Data from staff members in Tuscany were collected using an online questionnaire that examined influenza vaccination history, intentions, demographic information, health status, and VL. Statistical analyses explored the relationships between VC, VL, and vaccination intentions. RESULTS: The study included 1794 respondents, (86.3%) and assistants/aides (58.1%), with a median age of 46 years. The intention to get vaccinated was significantly higher among those with health risk conditions, and there was a positive association between VC and VL, specifically its interactive/critical component. The mediation analysis showed that VC completely mediated the relationship between VL and the intention to get vaccinated, with significant effects observed in different subgroups. CONCLUSIONS: VC is a key factor that mediates the effect of VL on vaccine intention. These results suggest that interventions aimed at improving VL alone may not be sufficient to increase vaccine uptake unless VC is also addressed.

Hospital admission and mortality rates for non-Covid diseases among residents of the long-term care facilities before and during the pandemic: a cohort study in two Italian regions.

Aim: Long-term-care facility residents are a vulnerable population who experienced reduced healthcare access during the pandemic. This study aimed to assess the indirect impact of the COVID-19 pandemic, in terms of hospitalisation and mortality rates, among this population in two Italian Regions, Tuscany and Apulia, during 2020 in comparison with the pre-pandemic period. Subject and methods: We conducted a retrospective cohort study on people residing in long-term-care facilities from 1 January 2018 to 31 December 2020 (baseline period: 1 January 2018-8 March 2020; pandemic period: and 9 March-31 December 2020). Hospitalisation rates were stratified by sex and major disease groups. Standardised weekly rates were estimated with a Poisson regression model. Only for Tuscany, mortality risk at 30 days after hospitalisation was calculated with the Kaplan-Meier estimator. Mortality risk ratios were calculated using Cox proportional regression models. Results: Nineteen thousand two hundred and fifty individuals spent at least 7 days in a long-term-care facility during the study period. The overall mean non-Covid hospital admission rate per 100 000 residents/week was 144.1 and 116.2 during the baseline and pandemic periods, with a decrease to 99.7 and 77.3 during the first (March-May) and second lockdown (November-December). Hospitalisation rates decreased for all major disease groups. Thirty-day mortality risk ratios for non-Covid conditions increased during the pandemic period (1.2, 1.1 to 1.4) compared with baseline. Conclusion: The pandemic resulted in worse non-COVID-related health outcomes for long-term-care facilities' residents. There is a need to prioritise these facilities in national pandemic preparedness plans and to ensure their full integration in national surveillance systems. Supplementary information: The online version contains supplementary material available at 10.1007/s10389-023-01925-1.

Automated detection of hospital outbreaks of multi-drug resistant pathogens in one Italian region.

BACKGROUND: Automated tools for antimicrobial resistance surveillance are critical for improving detection of drug-resistant organisms and informing prevention and control interventions. In this study, the WHONET-SaTScan software was used at a multihospital level in Tuscany, Italy, to identify case clusters consistent with hospital outbreaks caused by drug-resistant pathogens. METHODS: Antimicrobial resistance surveillance data from all Tuscany hospitals between January 2018 and December 2020 were analyzed using WHONET. The SaTScan package was used to detect case clusters applying a simulated prospective approach and the space-time permutation algorithm. Clusters were identified using resistance profiles and two distinct spatial variables: single medical services ('service') or groups of related services ('metaservice'). RESULTS: Data from eight bacterial pathogens were provided from 49 hospitals for 312,779 isolates from 158,809 patients. Single service-based analysis detected 693 hospital clusters, while metaservice-based analysis identified 635. There was no evidence for a difference between the two methods in terms of cluster length, cluster size, recurrence intervals, number of alerts, distribution across years or hospitals. Among clusters involving multiple services identified by both analyses, metaservice-detected clusters were usually larger and more statistically significant. CONCLUSIONS: WHONET-SaTScan proved to be a valuable multi-facility cluster detection tool that can be implemented for real-time surveillance.

The indirect impact of COVID-19 pandemic on the utilization of the emergency medical services during the first pandemic wave: A system-wide study of Tuscany Region, Italy.

BACKGROUND: Utilization of Emergency Medical Services (EMS) declined during COVID-19 pandemic, but most of the studies analyzed components of the EMS system individually. The study aimed to evaluate the indirect impact of COVID-19 pandemic on the utilization of all the components of the EMS system of Tuscany Region (Italy) during the first pandemic wave. METHODS: Administrative data from the health care system of Tuscany were used. Changes in utilization for out-of-hospital emergency calls and emergency vehicle dispatched, emergency department (ED) visits, and patients being admitted from the ED to an inpatient hospital bed (hospitalizations from ED) during the first pandemic wave were analyzed in relation with corresponding periods of the previous two years. Percentage changes and 95%CI were calculated with Poisson models. Standardized Ratios were calculated to evaluate changes in in-hospital mortality and hospitalizations requiring ICU. RESULTS: Significant declines were observed in the utilization of all the EMS considered starting from the week in which the first case of COVID-19 was diagnosed in Italy till the end of the first pandemic wave. During the epidemic peak, the maximum decreases were observed: -33% for the emergency calls, -45% for the dispatch of emergency vehicles, -71% for ED admissions. Furthermore, a decline of 37% for hospitalizations from ED was recorded. Significant decreases in ED admissions for life threatening medical conditions were observed: acute cerebrovascular disease (-36%, 95% CI: -43, -29), acute myocardial infarction (-42%, 95% CI: -52, -31) and renal failure (-42%, 95% CI: -52, -31). No significant differences were found between the observed and the expected in-hospital mortality and hospitalizations requiring ICU during the epidemic peak. CONCLUSION: All the components of the EMS showed large declines in their utilization during COVID-19 pandemic; furthermore, major reductions were observed for admissions for time-dependent and life-threatening conditions. Efforts should be made to ensure access to safe and high-quality emergency care during pandemic.

Vaccine Literacy and Source of Information about Vaccination among Staff of Nursing Homes: A Cross-Sectional Survey Conducted in Tuscany (Italy).

Vaccine literacy (VL) mediates the transfer of information and facilitates vaccination acceptance. The aims of this study are to validate the HLVa-IT (Health Literacy Vaccinale degli adulti in Italiano­Vaccine health literacy for adults in Italian language) for the staff of nursing homes (NHs), to measure VL in such a peculiar target group, and to assess its relationship with the sources used to obtain information about vaccines and vaccinations. A survey has been conducted in a sample of Tuscan NHs using an online questionnaire. Eight-hundred and fifty-three questionnaires were analyzed. Two dimensions of the HLVa-IT appeared (functional and interactive/communicative/critical VL). The HLVa-IT interactive/communicative/critical subscale score was slightly higher than the functional subscale, although with no statistical significance. General practitioners (GPs) or other professionals have been reported as the main source of information by most of the respondents (66.1%). The HLVa-IT total score was significantly higher among those who have declared to use official vaccination campaigns (mean score: 3.25 ± 0.49; p < 0.001), GPs or other health professionals (3.26 ± 0.47; p < 0.001), and search engines (3.27 ± 0.48; p = 0.040) as the main sources of information. In conclusion, the HLVa-IT could be reliable test to investigate VL for staff of NHs, and also to highlight criticalities related to information sources.

Orthopaedic Implant-Associated Staphylococcal Infections: A Critical Reappraisal of Unmet Clinical Needs Associated with the Implementation of the Best Antibiotic Choice.

Infections associated with orthopaedic implants represent a major health concern characterized by a remarkable incidence of morbidity and mortality. The wide variety of clinical scenarios encountered in the heterogeneous world of infections associated with orthopaedic implants makes the implementation of an optimal and standardized antimicrobial treatment challenging. Antibiotic bone penetration, anti-biofilm activity, long-term safety, and drug choice/dosage regimens favouring outpatient management (i.e., long-acting or oral agents) play a major role in regards to the chronic evolution of these infections. The aim of this multidisciplinary opinion article is to summarize evidence supporting the use of the different anti-staphylococcal agents in terms of microbiological and pharmacological optimization according to bone penetration, anti-biofilm activity, long-term safety, and feasibility for outpatient regimens, and to provide a useful guide for clinicians in the management of patients affected by staphylococcal infections associated with orthopaedic implants Novel long-acting lipoglycopeptides, and particularly dalbavancin, alone or in combination with rifampicin, could represent the best antibiotic choice according to real-world evidence and pharmacokinetic/pharmacodynamic properties. The implementation of a multidisciplinary taskforce and close cooperation between microbiologists and clinicians is crucial for providing the best care in this scenario.

The indirect impact of COVID-19 large-scale containment measures on the incidence of community-acquired pneumonia in older people: a region-wide population-based study in Tuscany, Italy.

OBJECTIVE: To evaluate the indirect effect of COVID-19 large-scale containment measures on the incidence of community-acquired pneumonia (CAP) in older people during the first epidemic wave of COVID-19 in Tuscany, Italy. METHODS: A population-based study was carried out on data from the Tuscany healthcare system. The outcome measures were: hospitalization rate for CAP, severity of CAP hospitalizations, and outpatient consumption of antibacterials for CAP in people aged 65 and older. Outcomes were compared between corresponding periods in 2020 (week 1 to 27) and previous years. RESULTS: Compared with the average of the corresponding periods in the previous 3 years, significant reductions in weekly hospitalization rates for CAP were observed from the week in which the national containment measures were imposed (week 10) until the end of the first COVID-19 wave in July (week 27). There was also a significant decrease in outpatient consumption in all antibacterial classes for CAP. CONCLUSIONS: The implementation of large-scale COVID-19 containment measures likely reduced the incidence of CAP in older people during the first wave of the COVID-19 pandemic in Tuscany, Italy. Considering this indirect impact of pandemic containment measures on respiratory tract infections may improve the planning of health services during a pandemic in the future.

Resistance Patterns from Urine Cultures in Children Aged 0 to 6 Years: Implications for Empirical Antibiotic Choice.

PURPOSE: Urinary tract infection (UTI) is a frequent disorder of childhood, caused mainly by Gram negative Enterobacterales. The aim of this study is to evaluate etiology and antimicrobial susceptibility patterns of bacterial isolates in urine cultures of children under the age of 6 and to analyze the relationship between previous hospitalization or antibiotic prescriptions and antimicrobial resistance rates. PATIENTS AND METHODS: A retrospective study on positive urine cultures from 13 public laboratories in Tuscany, Italy was conducted. Data were obtained by reviewing records of the "Microbiological and Antibiotic-Resistance Surveillance System" (SMART) in Tuscany, Italy. A total of 2944 positive urine cultures were collected from 2445 children. RESULTS: Escherichia coli represented the majority of isolates (54,2%), followed by Enterococcus faecalis (12,3%), Proteus mirabilis (10,3%) and Klebsiella pneumoniae (6,6%). Isolated uropathogens showed high resistance rates to amoxicillin-clavulanate (>25%), particularly in children under one year of age or hospitalized within the 12 months before the sample collection. High susceptibility rates were reported of aminoglycosides, cephalosporins and quinolones (>90%). Previous antibiotic prescriptions by general pediatricians did not increase resistance rates. CONCLUSION: Our results show a rate of amoxicillin-clavulanate resistance of 25%. Higher resistance rates were reported in children under one year of age and with previous hospitalization. Hence, amoxicillin-clavulanate should be used carefully in young children and those with severe symptoms.

Reduction of Emergency Calls and Hospitalizations for Cardiac Causes: Effects of Covid-19 Pandemic and Lockdown in Tuscany Region.

Introduction: Containment measures were established to flatten the curve of COVID-19 contagion in order to avoid a crash of the healthcare system. However, these measures influenced the rate of hospitalization of cardiac patients. In this study, we aimed to analyse the impact of COVID-19 and the effects of lockdown measures on hospital admissions and alerts of emergency medical system (EMS) for cardiac causes in the Tuscany region. Methods: An observational, retrospective analysis from Italian Tuscany region was conducted. We evaluated consecutive patients contacting EMS or admitted to the 39 Emergency Departments (EDs) in Tuscany for cardiac causes in the first trimester of 2020. Data were compared with the same period in 2018/19. Results: The alerts of EMS for cardiac causes significantly decrease in 2020 and the highest difference between 2018/19 and 2020 was found immediately after national lockdown (Δ = -47.4%, p < 0.001). The number of admissions for chest pain in the EDs also decreased, with a maximum difference of -67.6% (p < 0.001) vs. 2018/19. The number of hospital accesses for acute coronary syndromes, atrial fibrillation, and heart failure in the EDs significantly decreased in 2020 as compared to 2018/19 (maximum Δ = -58.9%, p < 0.001; maximum Δ = -63.0%, p < 0.001; maximum Δ = -72.7%, p < 0.001, respectively). Conclusions: A significant decrease in the contacts to EMS for cardiac causes and in cardiac diagnoses was observed during the first trimester of 2020. Fear of contagion has likely played a relevant role. The lesson learnt from first wave of COVID-19 pandemic suggests that appropriate public information strategies and re-education of people are essential.

Promoting Influenza Vaccination among Staff of Nursing Homes According to Behavioral Insights: Analyzing the Choice Architecture during a Nudge-Based Intervention.

(1) Background: Influenza vaccination uptake in nursing home (NH) workers is uncommon. The aim of this study was to understand the choice architecture of influenza vaccination acceptance or refusal among them and to promote vaccination acceptance using the nudge approach. (2) Methods: In autumn 2019, a nudge intervention with a contextual qualitative analysis of choice architecture of vaccination was performed among the staff of eight Tuscan NHs. In summer 2020, a cross-sectional study including the staff of 111 NHs (8 in the nudge, 103 in the comparison group) was conducted to assess the impact of the nudge intervention in promoting vaccination uptake. (3) Results: Macro-categories of motivations for vaccination uptake that emerged from the qualitative analysis were risk perception, value dimension, and trust, while those regarding refusal were risk perception, distrust, value dimension, and reasons related to one's health. Considering the cross-sectional study, influenza vaccination uptake in the 2018-2019 season was similar in the two groups (23.6% vs. 22.2% respectively, in the nudge and comparison group), but significantly different in the 2019-2020 season: 28% in the nudge vs. 20% in the comparison group. Also, the intention to get the vaccine in the 2020-2021 season was significantly different in the two groups: 37.9% in the nudge and 30.8% in the comparison group. (4) Conclusions: Nudge interventions-simple, fast, low cost-could be effective in promoting vaccination acceptance among NH workers and the analysis of choice architecture could be useful in improving tailored, new nudge interventions aimed at modifying irrational biased and cognitive errors.

Health Literacy, Vaccine Confidence and Influenza Vaccination Uptake among Nursing Home Staff: A Cross-Sectional Study Conducted in Tuscany.

The aim of this cross-sectional study is to address whether health literacy (HL) and vaccine confidence are related with influenza vaccination uptake among staff of nursing homes (NHs). It was conducted in Tuscany (Italy) in autumn 2018, including the staff of 28 NHs. A questionnaire was used to collect individual data regarding influenza vaccination in 2016-2017 and 2017-2018 seasons; the intention to be vaccinated in 2018-2019; as well as demographic, educational, and health information. It included also the Italian Medical Term Recognition (IMETER) test to measure HL and eight Likert-type statements to calculate a Vaccine Confidence Index (VCI). The number of employees that fulfilled the questionnaire was 710. The percentage of influenza vaccination uptake was low: only 9.6% got vaccinated in 2016-2017 and 2017-2018 and intended to vaccinate in 2018-2019. The VCI score and the IMETER-adjusted scores were weakly correlated (Rho = 0.156). At the multinomial logistic regression analysis, the VCI was a positive predictor of vaccination uptake. In conclusion, vaccine confidence is the strongest predictor of influenza vaccination uptake among the staff of NHs. The development of an adequate vaccine literacy measurement tool could be useful to understand whether skills could be related to vaccine confidence.

Health-Literate Healthcare Organizations and Quality of Care in Hospitals: A Cross-Sectional Study Conducted in Tuscany.

The concept of Health-Literate Healthcare Organization (HLHO) concerns the strategies by which healthcare organizations make it easier for people to navigate, understand, and use information and services to take care of their health. The aims of this study were to validate the HLHO-10 questionnaire in the Italian language; to measure the degree of implementation of the 10 attributes of HLHOs in a sample of hospitals placed in Tuscany; and to assess the association between the degree of implementation of the 10 attributes of HLHOs and the perceived quality of care. This was a cross-sectional study where data were collected using a self-administered questionnaire including three sections: a descriptive section, a section focused on the perceived quality, and the Italian version of the HLHO-10 questionnaire. A total amount of 405 healthcare managers answered the questionnaire (54.9%). The analysis shows that the HLHO score is significantly associated with the type of hospitals: accredited private hospitals have higher HLHO scores. Moreover, the perceived quality increases with the increasing of the HLHO score, with the highest coefficient for local public hospitals. In conclusion, Organizational Health Literacy culture should be an integral element for the management to improve the quality of care.

Prolonged outbreak of New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE), Tuscany, Italy, 2018 to 2019.

In Tuscany, Italy, New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacterales (NDM-CRE) have increased since November 2018. Between November 2018 and October 2019, 1,645 samples were NDM-CRE-positive: 1,270 (77.2%) cases of intestinal carriage, 129 (7.8%) bloodstream infections and 246 (14.9%) infections/colonisations at other sites. Klebsiella pneumoniae were prevalent (1,495; 90.9%), with ST147/NDM-1 the dominant clone. Delayed outbreak identification and response resulted in sustained NDM-CRE transmission in the North-West area of Tuscany, but successfully contained spread within the region.

Health Literacy as a Shared Capacity: Does the Health Literacy of a Country Influence the Health Disparities among Immigrants?

Health literacy (HL) is an individual ability as well as a distributed resource available within an individual's social network. We performed an explorative study assessing the role of HL as the country-level ecological variable in predicting the health disparities among immigrants. Country-level HL data were obtained from the publicly available first European Health Literacy Survey reports. Individual-level data on citizenship, perceived health status, body mass index, smoking habits, physical activity and attendance at breast and cervical cancer screening were extracted from the European Health Interview Survey of Eurostat. Data from both sources were obtained for Austria, Bulgaria, Greece, Poland and Spain. The country-specific odds ratio (OR) for the association between the participants' citizenship and other individual health-relevant characteristics was pooled into summary OR using random-effects models. Meta-regression was used to explore whether the HL of a country could explain part of the between-countries heterogeneity. Results: For the perceived health status, nutritional status and attendance at cervical cancer screening, the lower was the country-level HL (as ecological variable), the higher were the health inequalities relating to citizenship. The results of our exploratory research suggest that improving the population HL may help mitigate health inequalities between residents and migrants.

Use of Electronic Administrative Databases to Measure Quality Indicators of Breast Cancer Care: Experience of Five Regional Oncology Networks in Italy.

PURPOSE: Assuring quality of care, while maintaining sustainability, in complex conditions such as breast cancer (BC) is an important challenge for health systems. Here, we describe a methodology to define a set of quality indicators, assess their computability from administrative data, and apply them to a large cohort of BC cases. MATERIALS AND METHODS: Clinical professionals from the Italian Regional Oncology Networks identified 46 clinically relevant indicators of BC care; 22 were potentially computable using administrative data. Incident cases of BC diagnosed in 2016 in five Italian regions were identified using administrative databases from regional repositories. Each indicator was calculated through record linkage of anonymized individual data. RESULTS: A total of 15,342 incident BC cases were identified. Nine indicators were actually computable from administrative data (two structure and seven process indicators). Although most indicators were consistent with guidelines, for one indicator (blood tumor markers in the year after surgery, 44.2% to 64.5%; benchmark ≤ 20%), deviation was evident throughout the five regions, highlighting systematic overlooking of clinical recommendations. Two indicators (radiotherapy within 4 months after surgery if no adjuvant chemotherapy; 42% to 83.8%; benchmark ≥ 90%; and mammography 6 to 18 months after surgery, 55.1% to 72.6%; benchmark ≥ 90%) showed great regional variability and were lower than expected, possibly as result of an underestimation in indicator calculation by administrative data. CONCLUSION: Despite highlighting some limitations in the use of administrative data to measure health care performance, this study shows that evaluating the quality of BC care at a population level is possible and potentially useful for guiding quality improvement interventions.

[Good practices for the surveillance and control of antimicrobial resistance]. / Buone pratiche per la sorveglianza e il controllo dell'antibiotico-resistenza.

Italy is one of the European Countries with the highest level of antimicrobial consumption, both in the community and in hospital settings, and with the highest prevalence of antimicrobial resistant microorganisms. In 2015, the Project "Good practices for the surveillance and control of antimicrobial resistance" was funded by the Italian National Centre for Disease Prevention and Control (CCM): the aim was to promote integrated actions at national level to control antimicrobial resistance, favouring the transfer of existing good practices. The principal objectives of the project were: to describe the Italian scenario of good practices based on literature review; to improve the capacity of surveillance, through achieving consensus on a core set of indicators, including paediatrics, and through the strengthening of the national surveillance system of antimicrobial resistance coordinated by the Italian National Institute of Health; to define tools useful for priority setting; to evaluate the efficacy of intervention programme aimed at promoting the appropriate use of antibiotics among children for upper respiratory tract infections in the community; to set up training programmes on the prudent use of antibiotics in veterinary medicine. Seven regions were enrolled in the project (Emilia-Romagna with the role of programme coordinator, Campania, Calabria, Lazio, Lombardy, Piedmont, Tuscany) and the Italian National Health Institute. The project allowed to document: the scarce spread of control practices at national level (out of 277 studies reviewed, only 6.1% of the cases were targeted to evaluating the effectiveness of intervention programmes); a significant variability among regions both in relation to antimicrobial consumption and antimicrobial resistance prevalence, with a worrying spread in some regions of several antimicrobial resistant organisms responsible for "critical" infections with great potential health impact; the effectiveness of an intervention aimed at promoting appropriate use of antibiotics in frequent infections for children in the community, such as pharingotonsillitis and acute otitis media (35% reduction of antimicrobial consumption between 2010 and 2017 in Emilia-Romagna; an inversion of the ratio amoxicillin/amoxicillin-clavulanate); the need for new indicators to monitor antimicrobial consumption in hospital paediatric wards and of a new national system for timely identification of new antimicrobial resistance profiles; a positive evaluation of the training programme for veterinary physicians. In conclusion, the project has contributed to identify the most critical areas for antimicrobial resistance control and to select appropriate solutions, potentially transferable to the national level.