Microbiological surveillance post-reprocessing of flexible endoscopes used in digestive endoscopy: a national study.

INTRODUCTION: Microbiological surveillance of endoscopes is a safety measure for verifying the quality of reprocessing procedures and identifying contaminated devices, but duodenoscope-related outbreaks are still reported. AIM: To assess the effectiveness of duodenoscope reprocessing procedures in Italy. METHODS: Between December 2019 and April 2020, data obtained from microbiological surveillance post-reprocessing in 15 Italian endoscopy units were collected. Sampling was carried out after reprocessing or during storage in a cabinet. In keeping with international guidelines and the Italian position paper, the micro-organisms were classified as high-concern organisms (HCOs) and low-concern organisms (LCOs). FINDINGS: In total, 144 samples were collected from 51 duodenoscopes. Of these, 36.81% were contaminated: 22.92% were contaminated with HCOs and 13.89% were contaminated with LCOs [2.08% with an LCO load of 11-100 colony-forming units (CFU)/device and 0.69% with an LCO load of >100 CFU/device]. The contamination rate was 27.5% in samples collected after reprocessing, 40% in samples collected during storage in a cabinet that was compliant with EN 16442:2015 (C-I), and 100% in samples collected during storage in a cabinet that was not compliant with EN 16442:2015 (NC-I). The respective HCO rates were 15.00%, 27.27% and 66.67%. Correlation between LCO contamination and storage time was demonstrated (Spearman's rho=0.3701; P=0.0026). The Olympus duodenoscope TJFQ180V demonstrated the lowest rate of contamination (29.82%), although the contamination rate was 100% for duodenoscopes stored in an NC-I cabinet. CONCLUSION: Microbiological surveillance, along with strict adherence to reprocessing protocols, may help to detect endoscope contamination at an early stage, and reduce the risk of duodenoscope-associated infections.

Procedures in endoscope reprocessing and monitoring: an Italian survey.

BACKGROUND: The high diffusion of endoscopes worldwide and the need for effective reprocessing methods requested the development of guidelines and implementation of surveillance procedures at local level. STUDY DESIGN: In order to collect data on everyday's practice and adherence to available guidelines, endoscopy units from different public institutions were surveyed using a dedicated questionnaire. METHODS: Between July and November 2015 a survey was carried in 12 main hospitals from 10 different Italian regions, involving 22 endoscopy units. The state of the art of national and international guidelines was investigated to compare the protocols adopted at local level. RESULTS: In all the surveyed hospitals, the reprocessing activity is based on pre-established protocols in adherence with principal guidelines. Enzymatic detergents, which are recommended by the international guidelines, are used in 55.6% of units and peracetic acid is currently the most widely used chemical disinfectant. Discrepancies were observed in the application of periodic quality controls. CONCLUSION: Updated guidelines are generally applied in reprocessing practice. Quality controls may represent a critical issue to improve effectiveness and surveillance. The whole of acquired data can promote a positive trend towards the application of best practices.

A Clostridium difficile outbreak in an Italian hospital: the efficacy of the multi-disciplinary and multifaceted approach.

INTRODUCTION: We described an outbreak of C. difficile that occurred in the Internal Medicine department of an Italian hospital and assessed the efficacy of the measures adopted to manage the outbreak. METHODS: The outbreak involved 15 patients and was identified by means of continuous integrated microbiological surveillance, starting with laboratory data (alert organism surveillance). Diarrheal fecal samples from patients with suspected infection by C. difficile underwent rapid membrane immuno-enzymatic testing, which detects both the presence of the glutamate dehydrogenase antigen and the presence of the A and B toxins. Extensive microbiological sampling was carried out both before and after sanitation of the environment, in order to assess the efficacy of the sanitation procedure. RESULTS: The outbreak lasted one and a half month, during which time the Committee for the Prevention of Hospital Infections ordered the implementation of multiple interventions, which enabled the outbreak to be controlled and the occurrence of new cases to be progressively prevented. The strategies adopted mainly involved patient isolation, reinforcement of proper hand hygiene techniques, antimicrobial stewardship and environmental decontamination by means of chlorine-based products. Moreover, the multifaceted management of the outbreak involved numerous sessions of instruction/training for nursing staff and socio-sanitary operatives during the outbreak. Sampling of environmental surfaces enabled two sites contaminated by C. difficile to be identified. CONCLUSIONS: Joint planning of multiple infection control practices, together with effective communication and collaboration between the Hospital Infections Committee and the ward involved proved to be successful in controlling the outbreak.

Operating room environment and surgical site infections in arthroplasty procedures.

BACKGROUND: The rate of surgical site infections (SSI) is strongly influenced by operating room quality, which is determined by the structural features of the facility and its systems and by the management and behavior of healthcare workers. The aim of the present study was to assess microbial contamination in the operating room during hip- and knee-replacement procedures, the behavior of operating room staff and the incidence of SSI through postdischarge surveillance. METHODS: Microbial contamination was evaluated by active and passive sampling at rest and in operating conditions. Organizational and behavioral characteristics were collected through observational assessment. The incidence of SSI was evaluated in 255 patients, and follow-up examinations were carried out 30 and 365 days after the procedure. RESULTS: The mean values of the airborne and sedimenting microbial loads were 12.90 CFU/m3 and 0.02 CFU/cm2/h, respectively. With regard to outcome, the infection rate proved to be 0.89% and was associated with knee-replacement procedures. The microorganism responsible for this superficial infection was Staphylococcus aureus. CONCLUSIONS: Clinical outcomes proved to be satisfactory, owing to the limited microbial load (in both at-rest and operating conditions), the appropriate behavior of the staff, compliance with the guidelines on preoperative antibiotic prophylaxis, and efficient management of the ventilation system.

Epidemiology and biomolecular characterization of carbapenem-resistant klebsiella pneumoniae in an Italian hospital.

OBJECTIVE: To describe the occurrence of CRKP infections in a tertiary care hospital and to analyse the allelic profiles of the clinical strains involved and the most frequent carbapenemases. DESIGN: The study analyzed cases of infection due to CRKP in the period 2013-2014; 147 cases were recorded, most of which (82.31%) were in-hospital infections. SETTING: A hospital in northern Italy. METHODS: We retrospectively collected: data on patient characteristics and the microbiological characteristics of CRKP. Isolates from 72 of the in-hospital cases underwent molecular typing (MLST); in addition, in each isolate, a procedure for the detection of the blaKPC gene was carried out. RESULTS: The in-hospital death rate was 24.0% in 2013 and 37.5% in 2014. However, the difference between these two values did not prove statistically significant (P > .05). Analysis of mortality revealed that bloodstream infections were more frequently associated with death than other infections (χ2 = 14.57, P < .001). The age-adjusted Cox proportional hazard model revealed that the patients with bacteremia due to CRKP had a 3-fold higher risk of death (HR 3.11; 95% CI 1.66 - 5.84, P< .001) than those with infections of other sites. MLST revealed that the prevalent allelic profile was ST 512 (79.62%); the most frequent carbapenemase was KPC-3 (83.8%). CONCLUSIONS: Our results are in line with those of recent studies, which have shown that the spread of CRKP in Italy is a matter of concern and that further efforts have to be made to prevent the potential dissemination of carbapenemase-producing clones of K. pneumoniae, whenever possible.

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.

Multidrug-resistant Acinetobacter baumannii outbreak: an investigation of the possible routes of transmission.

OBJECTIVES: To establish the possible sources and routes of transmission of a multidrug-resistant Acinetobacter baumannii outbreak involving 22 patients. STUDY DESIGN: Descriptive, retrospective study. METHODS: An environmental investigation was undertaken, monitoring surfaces, air and water. Reconstruction of the spread of the infection took several factors into account such as intrahospital movements of patients and healthcare personnel, hospitalization of patients in the same ward and in chronologically compatible periods, and length of stay. A. baumannii clinical samples were typed using the Multilocus Sequence Typing scheme. RESULTS: The outbreak originated from a patient admitted to the sub-intensive care unit, and the infection subsequently spread to other wards. The allelic profile proved to be the same for all the clinical isolates. Environmental monitoring yielded negative results for A. baumannii. CONCLUSIONS: The results suggest that this epidemic spread through cross-transmission involving healthcare workers.

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.

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.

The epidemiology of domestic injurious falls in a community dwelling elderly population: an outgrowing economic burden.

In Italy, more than 3 million people annually sustain a domestic injury; the elderly experience it the most. From a healthcare perspective, elderly falls are a major clinical issue with an outgrowing socioeconomic burden. The aim of the study was to evaluate the epidemiology of injurious falls in a community dwelling population, admitted to the emergency room (ER) because of a domestic injury, to assess the socioeconomic burden. Seventy-four hospitalized patients among 227 were examined. Falls represented the main cause of admittance to the ER; the average cost for fall-related hospitalization was of €5479.09.

Environmental monitoring programme in the cell therapy facility of a research centre: preliminary investigation.

INTRODUCTION: Recent discoveries in cell therapy research present new opportunities for cellular products to be used to treat severe, and as yet incurable, diseases. It is therefore essential to implement a quality control programme in order to ensure that safe cells and tissues are provided. METHODS: In a preliminary phase of the setting up of a the cellfactory, monitoring was carried out monthly over a 6-month period in one out of three cell therapy laboratories and filter rooms in order to evaluate the microbial contamination of air and surfaces and the presence of airborne particulates. RESULTS: The mean total bacterial and fungal loads measured in the air in the centre of the filter room were 20.7 +/1 28.9 colony-forming units (cfu)/m3 and 9.2 +/- 15.4 cfu/m3, respectively, and 5.2 +/- 4.1 cfu/m3 and 6.8 +/- 13.4 cfu/m3, respectively, in the laboratory. The mean fungal load values recorded on the surfaces sampled in the laboratory were in 6 out of 18 cases higher than the reference values (5 cfu/plate). As to the results of particulate monitoring, with regard to the 0.5 microm particles, about 83% of the samples revealed values below the limit of 350.000 particles per cubic metre. CONCLUSIONS: In this set-up phase, monitoring was able to pick out structural and organisational flaws acceptable in a laboratory compliant with Good Manufacturing Practices class C (Annex 1), but not in a class B facility. Thanks to this preliminary monitoring phase, and by correcting these flaws, the clean room facility could achieve compliance to class B.

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.

Nitrous oxide pollution in operating theatres in relation to the type of leakage and the number of efficacious air exchanges per hour.

INTRODUCTION: As occupational exposure to anaesthetic gases is one of the main risks for operating theatre staff an environmental monitoring campaign was conducted in order to evaluate the degree of pollution by nitrous oxide (N2O) in the operating theatres of some hospital facilities in Liguria. METHODS: Any leaks (systemic and/or managerial) of anaesthetic gas and the number of efficacious air exchanges per hour supplied by air-conditioning systems were evaluated by means of an IR spectrometer, which was wired to a computer for data collection and analysis. The concentration of nitrous oxide in the centre of each operating theatre was measured by means of chemo-adsorbent cartridges analysed by gas chromatography. RESULTS: In 76.0% of the operating theatres examined a mean environmental concentration of N2O below the legal limits was recorded. The highest mean concentrations were generally associated with the presence of systemic leaks. Supplying an adequate number of efficacious air exchanges per hour enabled environmental concentrations of anaesthetic gas to be kept within acceptable levels. DISCUSSION AND CONCLUSIONS: Training personnel in the correct management of the operating theatre and of anaesthesia equipment, and ensuring the availability of an adequate air-conditioning system enable the risk of exposure to nitrous oxide to be minimised. This can be achieved through a concerted effort on the part of all involved, in accordance with the concept of ongoing improvement in healthcare services.