Strategies to control antibiotic resistance: results from a survey in Italian children's hospitals.

BACKGROUND: Antimicrobial stewardship programs and comprehensive infection control programs represent the main strategies to limit the emergence and transmission of multi-drug resistant bacteria in hospital settings. The purpose of this study was to describe strategies implemented in Italian children's hospitals for controlling antibiotic resistance. STUDY DESIGN: Cross sectional multicenter study. METHODS: Four tertiary care Italian children's hospitals were invited to participate in a survey aimed at collecting information on activities implemented as of December 2015 using a self-administered online questionnaire. The questionnaire was divided in three sections focalizing on: i) policies for prevention and control of hospital-acquired infection, ii) prevention and control of multi-drug resistant bacteria, and iii) antibiotic prescribing policies and Antimicrobial stewardship programs. Questionnaires were compiled between May and July 2016. RESULTS: All hospitals had multidisciplinary infection control committee, procedures on hand hygiene, isolation measures, disinfection/sterilization, waste disposal and prevention on infections associated to invasive procedures. All sites screened patients for multi-drug resistant bacteria colonization in selected units, and adopted contact precautions for colonized patients. Screening during hospitalization, or in case of infections in the same ward were not universally implemented. All hospitals had policies on surgical prophylaxis, while policies on medical prophylaxis and treatment of bacterial infections varied among sites. Two sites recommended to review the appropriateness of antibiotic prescribing after 48-72 hours and one recommended de-escalation therapy. CONCLUSIONS: This study highlighted several areas of improvement, such as actions for screening patients in case of occurrence of multi-drug resistant bacteria, antimicrobial stewardship programs and implementation of policies targeting antibiotic prescriptions for therapeutic purposes and medical prophylaxis.

CPAP by helmet for treatment of acute respiratory failure after pediatric liver transplantation.

ARF after pediatric liver transplantation accounts for high rate of morbidity and mortality associated with this procedure. The role of CPAP in postoperative period is still unknown. The aim of the study was to describe current practice and risk factors associated with the application of helmet CPAP. In this retrospective observational cohort study, 119 recipients were divided into two groups based on indication to CPAP after extubation. Perioperative variables were studied, and determinants of CPAP application were analyzed in a multivariate logistic model. Sixty patients (60/114) developed ARF and were included in the CPAP group. No differences were found between the two groups for primary disease, graft type, and blood product transfused. At multivariate analysis, weight <11 kg (OR = 2.9; 95% CI = 1.1-7.3; P = .026), PaO2 /FiO2 <380 before extubation (OR = 5.4; 95% CI = 2.1-13.6; P < .001), need of vasopressors (OR = 2.6; 95% CI = 1.1-6.4; P = .038), and positive fluid balance >148 mL/kg (OR = 4.0; 95% CI = 1.6-10.1; P = .004) were the main determinants of CPAP application. In the CPAP group, five patients (8.4%) needed reintubation. Pediatric liver recipients with lower weight, higher need of inotropes/vasopressors, higher positive fluid balance after surgery, and lower PaO2 /FiO2 before extubation were at higher odds of developing ARF needing CPAP application.

Incidence of surgical site infections in children: active surveillance in an Italian academic children's hospital.

BACKGROUND: Surgical Site Infections (SSIs) account for 16-34% of all health-care associated infections. This study aimed to assess the incidence rate of SSIs in children who underwent surgical procedures in an academic children's hospital in Italy. STUDY DESIGN: Prospective cohort study. METHODS: We actively followed-up 0-17 year old children at 30 days of surgical procedures without implants conducted during one index week per quarter, from the second quarter of 2014, to the first quarter of 2016 (8 index weeks in total). Follow up data were collected by telephone interview, or derived by clinical records if patients were still hospitalized. SSIs were defined according to case definitions of Centers for Diseases Control, Atlanta, USA. We calculated cumulative incidence of SSIs per 100 surgical procedures, by patient characteristics, procedure characteristics, and quarter. To investigate variables associated with SSIs, we compared characteristics of procedures with SSIs with those of procedures without SSIs. RESULTS: Over the study period, SSI incidence was 1.0% (19 cases/1,830 surgical procedures). SSI incidence was significantly lower after ear, nose and throat procedures compared to all other procedures, and significantly decreased over time. Duration of surgery was a risk factor for SSIs; patients with SSIs had a significantly longer total length of stay (LOS), due to a prolonged post-operative LOS. CONCLUSION: As reported in adults, this study confirms that SSIs are associated with longer hospitalizations in children. Active surveillance of SSIs is an important component of the overall strategy to reduce the incidence of these infections in children.

Epidemiology of pertussis in Italy: disease trends over the last century.

We reviewed the epidemiology of pertussis in Italy over the last 125 years to identify disease trends and factors that could have influenced these trends. We described mortality rates (1888-2012), case fatality rates (1925-2012), cumulative incidence rates (1925-2013) and age-specific incidence rates (1974-2013). We compared data from routine surveillance with data from a paediatric sentinel surveillance system to estimate under-notification. Pertussis mortality decreased from 42.5 per 100,000 population in 1890 to no reported pertussis-related death after 2002. Incidence decreased from 86.3 per 100,000 in 1927 to 1 per 100,000 after 2008. Vaccine coverage increased from 32.8% in 1993 to about 96% after 2006. As for under-notification, mean sentinel/routine surveillance incidence ratio increased with age (from 1.8 in <1 year-olds to 12.9 in 10-14 year-olds). Pertussis mortality decreased before the introduction of immunisation. Incidence has decreased only after the introduction of pertussis vaccine and in particular after the achievement of a high immunisation coverage with acellular vaccines. Routine surveillance does not show an increase in cumulative incidence nor in ≥ 15 year-olds as reported by other countries. Underrecognition because of atypical presentation and the infrequent use of laboratory tests may be responsible for under-notification, and therefore affect incidence reports and management of immunisation programmes.

Trend of healthcare-associated infections in children: annual prevalence surveys in a research hospital in Italy, 2007-2010.

BACKGROUND: Annual prevalence surveys of healthcare-associated infections (HAIs) between 2007 and 2010 were conducted in the largest tertiary care children's hospital in Italy. During this period, actions to improve HAI prevention were implemented, including strengthened isolation measures; adoption of care bundles for invasive procedures; hand hygiene promotion using the World Health Organization multimodal strategy; and promotion of appropriate antimicrobial use. AIM: To determine the impact of these measures on HAI rates. METHODS: A total of 1506 patients were surveyed. Information on patient demographics, mechanical ventilation, central line and urinary catheterization in the preceding 48 h, and surgery in the previous 30 days were abstracted from medical charts. The type and date of onset of HAIs, and microbiological data were recorded. Univariate and multivariate logistic analysis were used to evaluate changes in HAI rates over time, and the influence of ward type and patient characteristics. FINDINGS: There were significant (P < 0.001) reductions in the prevalence of patients developing HAI (from 7.6% to 4.3%) and in the prevalence of total HAIs (from 8.6 to 4.3 per 100 patients). Factors independently associated with increased HAI risk were hospitalization in intensive care ward, length of stay >30 days, presence of invasive device, and age 6-11 years. CONCLUSION: This HAI prevention strategy was influential in decreasing infections among hospitalized children. Repeated prevalence surveys are an effective tool for monitoring HAI frequency, increasing awareness among the healthcare personnel, and contributing to the establishment of effective infection control.

Immunization coverage and timeliness of vaccination in Italian children with chronic diseases.

Since children with chronic diseases represent a primary target for immunization strategies, it is important that their immunization coverage and timeliness of vaccines is optimal. We performed a study to measure immunization coverage and timeliness of vaccines in children with type 1 diabetes, HIV infection, Down syndrome, cystic fibrosis, and neurological diseases. A total of 275 children aged 6 months-18 years were included in the study. Coverage for diphtheria-tetanus-pertussis (DTP), polio (Pol), and hepatitis B (HBV) vaccines approximated 85% at 24 months, while measles-mumps-rubella (MMR) coverage was 62%. Immunization coverage for seasonal influenza was 59%. The analysis of timeliness revealed that there was heterogeneity among children with different chronic diseases. A proportional hazard model showed that children with HIV infection had the longest time to complete three doses of DTP, Pol, and HBV, and those with neurological diseases received the first dose of MMR later than the other categories. Causes of missing or delayed vaccination mostly included a concurrent acute disease. Children with chronic diseases should be strictly monitored for routine and recommended vaccinations, and health care providers and families should be properly informed to avoid false contraindications.

Prolonged in-hospital exposure to an infant with active pulmonary tuberculosis.

Active pulmonary tuberculosis was diagnosed in a 4-month-old infant 16 days after hospitalization; 186 exposed individuals were traced and one conversion detected. Although the risk of tuberculosis transmission in paediatric hospitals is low, paediatricians in low-incidence countries should maintain a high level of alert for timely identification of cases.

[Measles and its secondary pulmonary complications: prevention is better than treatment]. / Il morbillo e le sue complicanze polmonari secondarie: prevenire è meglio che curare.

Recent measles outbreaks observed in North America and in several European countries, including Italy, raised the attention about the risks linked to this infection and the need of implementing and maintaining adequate preventive strategies. Measles may cause several respiratory complications such as chronic obstructive lung disease, pneumonia, with subsequent development of chronic suppurative lung disease, giant cells pneumonia or progressive respiratory insufficiency. The current preventive strategies aim to improve vaccination coverage rates with 2 doses of measles-mumps and rubella vaccine, and to catch up individuals who have not been previously vaccinated. The present review analyses pulmonary complications of measles and measles preventive strategies. Elimination of measles is a feasible goal. Since measles complications are preventable by vaccination, improvement in vaccination coverage is highly desirable.

Point prevalence study of antibiotic use in a paediatric hospital in Italy.

A survey aimed to describe the prevalence of antibiotic use in hospitalised children was conducted in June 2007, in Bambino Gesù Children's Hospital in Rome which has the highest annual number of inpatients among paediatric hospitals in Italy. Data were collected by reviewing medical charts of all patients hospitalised for >48 hours. A total of 412 hospitalised children were evaluated; their median age was 42.3 months, and 55.6% were males. Antibiotics were prescribed to 181 of the 412 patients (43.9%). The prevalence was lowest (37.7%) in medical wards, higher (51.1%) in intensive care units and highest (52.2%) in surgical wards. Of the patients treated with antibiotics in surgical wards, 71% received the treatment as prophylaxis. The most frequently prescribed antibiotics were ceftazidime and the combination of amoxicillin and clavulanic acid. The observed prevalence of antibiotic use was within the range recently reported from other paediatric hospitals in Europe; however, it is advisable to collect data from all over the country in order to identify priority areas and design interventions. These results also highlight the need to implement guidelines for surgical prophylaxis in children, and to further investigate reasons for prescription of parenteral antibiotic therapy in paediatric hospitals.

[Survey on computerized immunization registries in Italy]. / Indagine conoscitiva sulle anagrafi vaccinali informatizzate in Italia.

Computerized immunization registries are essential for conducting and monitoring vaccination programs. In fact, they enable to improve vaccine offering to target population, generating needed-immunization lists and assessing levels of vaccination coverage. In 2007, a national survey on immunization registries was conducted in Italy. In February 2007, all the 21 Regional Health Authorities (RHAs) completed and returned an ad hoc questionnaire. In June 2007, RHAs were further contacted by telephone in order to verify and update the information provided in questionnaires. In 9 Italian Regions (42.8%), vaccination registries are computerized in all Local Health Units (LHUs). In five of these Regions, all LHUs use the same software, while in the remaining four Regions, different softwares are in use. In six additional Regions (28.6%), only some LHUs use computerized immunization registries (range 61.5%-95%). In the remaining 6 Regions (28.6%), which are all in Southern Italy, there are no computerised immunization registries at all. In total, computerised immunization registries cover 126/180 Italian LHUs (70%); in 76/126 (60%) of these LUHs, immunization registries are linked with population registries. This survey shows the need to improve the implementation of computerised immunization registries in Italy, especially in Southern Regions.

The epidemiology of mumps in Italy.

In Italy, although vaccination has been recommended for a number of years, vaccination coverage for mumps is still sub-optimal. The objective of the present study was to evaluate the seroprevalence of mumps antibodies in the Italian population, stratified by age, gender and geographical area. The proportion of individuals positive for mumps antibodies remained stable in the age classes 0-11 months and 1 year (25.4% and 30.8%, respectively) and showed a continuous increase after the second year of life. The percentage of susceptible individuals was higher than 20% in persons 2-14 years of age and exceeded 10% in persons 15-39 years of age. No statistically significant differences were observed by gender or geographical area. Comparison between these results and the data obtained from a 1996 survey showed a statistically significant increase in seroprevalence in the age class 2-4 years. No changes were observed in the other age-groups. The results of this study confirm that the efforts made in recent years to improve vaccination coverage within the second year of life should be strengthened.

Scenarios of diffusion and control of an influenza pandemic in Italy.

To predict the spread of a pandemic strain of influenza virus in Italy and the impact of control measures, we developed a susceptible-exposed, but not yet infectious-infectious-recovered, and no longer susceptible (SEIR) deterministic model with a stochastic simulation component. We modelled the impact of control measures such as vaccination, antiviral prophylaxis and social distancing measures. In the absence of control measures, the epidemic peak would be reached about 4 months after the importation of the first cases in Italy, and the epidemic would last about 7 months. When combined, the control measures would reduce the cumulative attack rate to about 4.2%, at best, although this would require an extremely high number of treated individuals. In accordance with international findings, our results highlight the need to respond to a pandemic with a combination of control measures.

An Easter outbreak of Salmonella Typhimurium DT 104A associated with traditional pork salami in Italy.

Salmonella enterica is a common cause of gastrointestinal illness in Italy. S. Typhimurium accounts for approximately 40% of isolates, and most of these strains belong to the phage type DT104. We describe the investigation of an outbreak of S. Typhimurium DT104A, a subtype never observed before in Italy, which occurred in Rome during spring 2004.We conducted a matched case control study between 24 July and 9 September 2004. Controls were matched for age and area of residence. Each case had between one and four controls. Odds of exposure to potential risk factors and vehicles for the outbreak were compared between cases and controls. A multivariate analysis was conducted to estimate adjusted Odds Ratios.Sixty-three cases of S. Typhimurium DT 104A infection with onset between 1 April and 5 May 2004 were identified. Sixty-one were residents of Rome and two were residents of a neighbouring region. Twenty-six cases (43%) were enrolled in the study. Their median age was 7.5 years. Fourteen of 26 cases and 16 of 62 controls had eaten pork salami (OR= 25.5; 95% CI 1.6- 416.8). No food samples were available for testing. In northern Italy, two months prior to the outbreak, the veterinary surveillance system identified the first isolation of S. Typhimurium DT104A in a pig isolate. Both human and pig isolates showed indistinguishable PFGE patterns. It was not possible to trace the pig after the sample was taken at slaughter. The epidemiological evidence on the implication of pork salami in this outbreak suggests that pork products can also be a vehicle for salmonella in Italy and underlines the importance of good manufacturing practices for ready-to-eat foods. This investigation highlights the value of laboratory-based surveillance in identifying community-wide outbreaks of uncommon pathogens. It also underlines the need to improve surveillance timeliness, for promptly detecting outbreaks, undergoing field investigation, and implementing control measures. Moreover, our study shows the usefulness of integrated human and animal surveillance in tracing the possible source of infection.

[Rubella epidemiology in Italy in years 1998-2004]. / Epidemiologia della rosolia in Italia negli anni 1998-2004.

In November 2003 the National Plan for the elimination of measles and congenital rubella was approved, with the aim of reducing and maintaining the incidence of congenital rubella syndrome (CRS) at less than 1 case per 100,000 live births by 2007. In order to describe the epidemiology of rubella in Italy, we conducted a serosurvey and evaluated incidence and vaccination coverage data available for the period 1998-2004. In the years considered, national mean coverage of measles-mumps-rubella vaccination within the second year of life, even though still below the 95% threshold, has progressively increased reaching 87%. In addition, previously existing differences in coverage among regions have diminished. In the same period the incidence of rubella has decreased, with a historic minimum of 461 cases notified in 2004. The cyclic pattern typical of rubella persists, but with a prolongation of the interepidemic period and an increased mean age of acquisition of the infection. Although the proportion of immune individuals has increased, the percentage of women of childbearing age susceptible to rubella remains high (11% in the 15-19 year age group and 8% in the 20-39 year age group) and CRS cases continue to occur. Despite the clear results achieved through the implementation of vaccination strategies in children within the second year of life, a continued strong public health commitment is required to increase the proportion of vaccinated individuals and absolute priority must be given to immunising women of childbearing age.

Rubella seroprofile of the Italian population: an 8-year comparison.

The objective of this study is to evaluate how increasing MMR infant vaccination coverage in recent years has modified the epidemiology of rubella in Italy. A cross-sectional population-based seroprevalence study of rubella antibodies was conducted on 3094 sera, in 2004, and results were compared with data obtained by the same method in 1996. The overall proportion of rubella-seropositive individuals was found to be significantly higher in 2004 with respect to 1996 (84.6% vs. 77.4%). However, an increase in seropositivity was observed only in the 1-19 years age groups. Recent increases in childhood MMR vaccination coverage, therefore, have not had an impact on seroprevalence in women of childbearing age, over 5% of whom remain susceptible to rubella. Preconception screening and postpartum vaccination of susceptible women are fundamental if the WHO target of less than one case of congenital rubella syndrome per 100,000 live births is to be attained.