Impact of the COVID-19 pandemic on the Italian national viral hepatitis surveillance: an interrupted time series analysis, 2006-2022

OBJECTIVES

This study aimed to assess the impact of the COVID-19 pandemic on national surveillance of viral hepatitis in Italy.

STUDY DESIGN

Interrupted time series analysis.

METHODS

Using an interrupted time series analysis with a customised AutoRegressive Integrated Moving Average model on hepatitis cases reported to the Integrated Epidemiological System of Acute Viral Hepatitis from 2006 to 2022, we examined trends in incidence, time to diagnosis and time to epidemiological investigations for hepatitis A, hepatitis B and hepatitis C.

RESULTS

The quarterly incidence of hepatitis B (-0.251, P = 0.05) and hepatitis C (-0.243, P = 0.003) significantly decreased with the onset of the pandemic. Surveillance times for hepatitis B (5.496, P < 0.001) and hepatitis C (35.723, P < 0.001), measured as days lost per quarter, significantly increased 12 and 24 months after the pandemic's start. This aligns with a notable rise in quarterly incidence at 36 months for both (0.032, P = 0.030 for hepatitis B; 0.040, P < 0.001 for hepatitis C).

CONCLUSIONS

The decrease in reported cases could be due to an increase in infection prevention control and containment measures put in place in a pandemic context. However, a delay in the initiation of epidemiological investigations was observed, which could lead to a further increase in incidence in the future.

Evaluating the Trend of VRE carriages in Health Facilities: A Retrospective Study from 2019-2022

Background

Healthcare-associated infections (HAIs) and multidrug resistance (MDR) are a growing public health threat and pose a risk to patient safety in healthcare facilities. Vancomycin-resistant Enterococci (VRE) are responsible for nosocomial infections and have intrinsic and acquired resistance to many antibiotics, including glycopeptides. VRE carriage can remain undetected, increasing the risk of contact transmission. Identifying colonized patients is crucial for the implementation of preventive measures.

Aims

The aims of this study were to evaluate the trend of VRE carriage based on rectal swab results between 2019 and February 2022 in a large Italian trust and the percentage of patients with VRE colonization at the time of hospitalization.

Methods

This was a retrospective observational study based on results of rectal swabs performed for screening on admission between January 2019 and February 2022 in four hospitals part of a single trust in Turin, North-Western Italy. The study collected data on the date of specimen collection, type of specimen, isolated pathogen and the date of hospital admission. Descriptive analysis of data was performed, and duplicate samples were not considered.

Results

From January 2019 to February 2022 we collected 5025 rectal swabs performed in hospitals of the trust, of which 3037 were performed in 2019 (60%), 741 in 2020 (15%), 611 in 2021 (12%) and 636 in the first two months of 2022 (13%). VRE positivity was found in 162 (3%) rectal swabs, of which 2 cases in both 2019 (0.1%) and 2020 (0.3%), 95 in 2021 (15.5%) and 63 in the first two months of 2022 (9.9%). Furthermore, 52% (84/162) of positive rectal swabs were performed at admission, whereas the remaining 48% (78/162) of positive rectal swabs were performed after 48h.

Conclusions

This study found an increasing trend of VRE carriage in the study population during the SARS-CoV-2 pandemic, highlighting the importance of screening patients for VRE carriage to prevent worsening clinical conditions, environmental contamination, and prolonged hospitalization.

Seroprevalence of SARS-CoV-2 before/after case zero

Introduction

Italy was one of the first EU countries hit by the COVID-19 pandemic. Currently, Italy has reported 15.5 million cases of COVID-19 and 161000 deaths. Meanwhile, the vaccination campaign against COVID-19 began in Italy at the end of 2020, using mRNA and viral vector vaccines (immunizing people against Spike protein of SARS-CoV-2. The purpose of this study was to estimate, in a representative sample of the Italian population, the prevalence of antibodies against SARS-CoV2 in 2019 (before case zero, identified in Italy in February 2020) and in 2021, after 3 pandemic waves and a vaccination campaign.

Methods

During October / November 2019: 365 participants were selected in the Piedmontese population among those who went to a hospital for routine blood tests. The population was selected on the basis of age and gender to be representative of the Italian population. The same number of patients was selected in the first quarter of 2021, the inclusion and exclusion criteria remained the same. Sera were searched for spike protein of SARS-CoV-2 and, if positive, tested for anti-nucleocapsid antibodies.

Results

Our preliminary data show that half of the sample for both years is female. In the 2019 sample, i.e. before case zero was identified in Italy (Lombardy), five of the sera (4 males and one female) tested positive for anti-Spike,indicating a previous infection (vaccine didn't exist). In the 2021 sample, 152 males and 139 females tested positive for IgG anti-spike, for a total of 291. The prevalence therefore passed from 1.37% to 79.73%. As regards the search for ANti-Nantibodies, one male and one female tested positive in 2019; in 2021 9 males and 13 females.

Conclusions

The results of our study show that in 2019, before the first official case in Italy was highlighted, coronavirus was already circulating. The prevalence has risen exponentially, going from less than 2% to around 80%.

Key messages

• Covid-19 was circulating in Italy in 2019.

• Seroprevalence of anti-S in 2021 was about 20%.

Trends in mortality associated with surgical site infections: a cohort study in Italy, 2009-2019

Background

Surveillance programs have proven to be effective in reducing surgical site infection (SSI) rates. In 2008 Piedmont joined the Italian national surveillance system. The aim of this study was to evaluate mortality rates and trends associated with SSIs in Piedmont from 2009 to 2019 for the two most frequently performed surgical procedures, hip arthroplasty (HPRO) and colon surgery (COLO).

Methods

Data were collected through the national surveillance system, which includes 42 hospitals in Piedmont who participated in the surveillance program from 2009 to 2019. Procedure-specific SSI rates, overall mortality rates and case fatality rates (CFR) associated with SSIs were calculated, overall and per year. Trends were evaluated using the chi-squared test for trends. Analyses were performed using Epi Info v. 7.2.

Results

A total of 33438 surgical procedures (21645 HPRO, 11793 COLO) were monitored over the study period from the hospitals participating in the network. 1215 SSIs (293 HPRO, 922 COLO) were observed and 617 deaths were registered (222 HPRO, 395 COLO). For HPRO procedures, an overall SSI rate of 1.35% was found, with an overall mortality of 1.03% and a CFR of 3.75%. No significant trend was observed. Considering COLO interventions, an overall SSI rate of 7.82% was found, with an overall mortality of 3.35% and a CFR of 6.94%. There was a statistically significant downward trend in SSI and overall mortality rates (p = 0.046 and 0.005, respectively).

Conclusions

Considering HPRO, it is possible that the lack of significant trends could be due to the already low SSI and overall mortality rates, with the protective effect of surveillance having reached a plateau. Regarding COLO procedures, a significant reduction in SSI and overall mortality rates was observed during the study period. The reduction in mortality could be due to the decrease in SSI rates, however other factors not analysed in our study could have contributed.

Key messages

• This study brings further evidence to the protective effect of surveillance, attributable to an improvement in healthcare quality and patients’ safety.

• A significant decrease in COLO mortality rates was observed, which could be due to the decreasing trend in SSI rates.

Evaluating the pandemic’s impact on surgical site infections after abdominal surgery in Italy

Background

The COVID-19 pandemic led to important disruptions in surgical activity. The aim of this study was to evaluate the impact of COVID-19 on abdominal surgery outcomes in the region of Piedmont, in northern Italy.

Methods

Data were gathered from 42 hospitals participating in the regional surveillance network from 2018 to 2020. SSI, overall mortality and case fatality rates (CFR) were calculated, comparing 2020 to mean 2018-19 data. Chi-squared tests were used to assess both the differences among the proportion of urgent and oncological procedures (based on ICD-9-CM codes) and rates between the two periods. Subgroup analyses on 2020 data were carried out comparing urgent vs. elective and oncological vs. non-oncological procedures using chi-squared tests. Analyses were performed using SPSS v. 28.0.1.0.

Results

5407 procedures were recorded in 2018-19; 310 SSIs and 120 deaths were observed. The mean proportions of urgent and oncological operations were, respectively, 21.90% and 43.24%. In 2020, 1057 procedures were recorded, along with 44 SSIs and 29 deaths. 34.44% of procedures were urgent and 39.74% oncological. The mean 2018-2019 SSI rate was 5.73%, with an overall mortality of 2.22% and a CFR of 7.42%. The SSI rate in 2020 was 4.16%, with an overall mortality of 2.74% and a CFR of 9.09%. The proportion of urgent procedures significantly differed between the two periods (p < 0.001), as did the proportion of oncological procedures and SSI rates (both p = 0.05). Considering 2020, significant differences were found comparing overall mortality between urgent vs. elective procedures (4.95% vs. 1.59%, p = 0.002) and comparing SSI rates between oncological vs. non-oncological patients (3.57% vs. 2.20%, p = 0.02).

Conclusions

During the pandemic, patients undergoing surgical procedures significantly differed, reflecting public health decisions. Even though these differences did not reach statistical significance, overall mortality and CFR increased in 2020.

Key messages

Antimicrobial stewardship programs in Italy: structure, process and outcome indicators, 2017-2019

Background

The increasing spread of antimicrobial resistance (AMR) represents a global public health threat, and a significant challenge for healthcare delivery. Antimicrobial stewardship (AMS) programs have proven to be effective and cost-effective strategies for optimizing antimicrobial use. We aimed to assess key aspects of AMS programs implemented in acute-care trusts of the region of Piedmont, and to evaluate changes in antimicrobial usage against a score we attributed to structural and functional elements of AMS programs.

Methods

AMS programs operating in acute-care trusts in the region of Piedmont were investigated via a survey addressing program characteristics, divided into structure and process quality indicators. All public health trusts of the region of Piedmont were invited to complete the survey. The indicators were selected based on core elements identified by international guidelines and were reviewed by a multi-disciplinary panel. Antimicrobial usage was expressed as defined daily doses, DDD per 1000 patient-days. The annual means for the years 2017-2019 were considered, as well as the percentage change between 2017 and 2019. Variables were investigated in relation to structure and process scores using Spearman correlation. Analyses were performed using SPSS v. 27.0 (SPSS Inc., Armonk, NY).

Results

In total, 25 AMS programs were surveyed. Higher scores were achieved for process rather than structure indicators. Improvements in total antimicrobial usage (-4%) were found between 2017 and 2019. A moderate correlation was found between structure score and percentage change in antimicrobial usage (Spearman’s ρ -0.603, p 0.006).

Conslusions

This study highlighted important areas for improvement, such as accountability, microbiological laboratory quality management and feedback. Repeated measurements of structure, process and outcome indicators will be important to guide continuing quality improvement efforts.

Key messages

• Results of this study support the effectiveness of AMS programs in reducing antimicrobial use.

• Important areas for improvement were identified. Improving the organization of AMS programs in particular should be prioritized.

Hand hygiene and HAI transmission in Piedmont, Italy: an observational study, 2017-2019

Background

Hand hygiene (HH) is one of the most important measures to prevent healthcare-associated infections (HAIs). Several indicators have been proposed to measure HH practices, including alcohol-based handrub consumption (AHC). The objective of this study was to evaluate whether AHC is associated with HAI transmission.

Methods

All 25 public hospitals/trusts of Piedmont, in Northern Italy, are required to provide data each year concerning HAIs and infection prevention and control (IPC) activities, as part of a mandatory regional indicator system. Data on AHC and HAIs were extracted from reports provided concerning the years 2017-2019. The mean annual AHC for each facility was expressed as liters per patient-day. The rate of hospital-wide Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) infections was calculated per 1000 patient-days (pd). Mean ventilation-associated infections (VAP) for 1000 days of ventilation (vd) and mean catheter-related bloodstream infections (CR-BSI) for 1000 days of catheterization (cd) were calculated for intensive care units (ICUs). Spearman's correlational analysis was conducted between AHC and HAIs: hospital-level, ICU-level.

Results

Hospital-level: mean AHC was 15.4 liters/pd; mean HAI rate was 39.6/1000 pd (MRSA) and 18.5/1000 pd (CRE). No significant correlation was found. ICU-level: mean AHC was 39.6 liters/pd; mean HAI rate was 1.7/1000 cd (CR-BSI) and 8.2/1000 vd (VAP). A moderate correlation was found between AHC and CR-BSI rate (Spearman's ρ -0.55, p 0.022). Concerning AHC and VAP, higher AHC was reported from facilities with lower VAP rates, however no significant correlation was found (Spearman's ρ -0.203, p 0.451).

Conclusions

Results of this study support the validity of AHC as an indicator of IPC practices in ICUs. The hospital-level analysis could have been affected by important differences in AHC among ward types.

Key messages

First assessment of covid-19 vaccine response in a population at risk

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), has led to a global pandemic. Currently, the diagnosis of COVID-19 is confirmed by detecting SARS-CoV-2 via RealTime-RT-PCR in rhino-pharyngeal swab. Serological test is required to evaluate a previous exposure to the virus, as well as antibody response. The aim of this multicentric study is to analyse the antibody response following COVID-19 vaccination in healthcare workers and guests of nursing homes, and to determine differences between subjects with or without a confirmed previous infection.

Methods

Our study included 657 subjects, recruited from guests and healthcare workers of nursing homes in the Piedmont region. 10 days after the completion of the vaccination cycle, a blood sample was taken from the subjects to measure IgG against SARS-CoV-2 spike protein. Serological testing was performed using an enzyme immunoassay kit (EUROIMMUN Anti-SARS-CoV-2 QuantiVac ELISA). We performed statistical analysis with R software.

Results

We recruited 657 subjects aged between 19 to 106. Among them, 404 had a previous infection and 253 didn't have a known previous infection. The serological examination resulted positive in 655 subjects and negative in 2 (X¯ IgG 1095 RU/ml). Samples with titer&gt; 1200 RU/ml will be further diluted to identify the titer and differences from the baseline situation.

Conclusions

This study analyses neutralizing antibodies, which should prevent the virus from binding to target cells via spike protein. According to literature, immunological response to vaccine presents a great variability of antibodies level in the study population. However, no significantly correlations were found between the available variables. Preliminary data show the presence of a very intense antibody response after active vaccine immunization both in subjects with previous infection and in the rest of the study population.

Key messages

Covid-19 vaccine response in a population at risk. Differences between subjects with or without a confirmed previous infection.

Preliminary assessment of COVID-19 serological situation in a high-risk cohort

Introduction

Studies on the duration of immune response in subjects with COVID-19 could facilitate understanding of how immunity develops and persists during the natural course of infection, as well as providing epidemiological information useful in public health decisions on the use of vaccines. The study aims to analyse antibody response in a cohort of subjects with high-risk of exposure to SARS-CoV-2 due to the long-term care facility environment.

Methods

We recruited 657 subjects between guests and healthcare workers from Piedmontese nursing homes. IgG directed against the S1 domain of SARS-CoV-2 spike protein were assayed on serum. We used EUROIMMUN kit, which exploits ELISA method. Reference values are (RU/mL): positive ≥ 11; borderline 8 ≤ value &lt; 11; negative &lt; 8.

Results

Among the 657 subjects, we examined 494 health workers and 163 guests. The average age was 56.2. In relation to COVID-19, 402 subjects had a previous infection, 255 had not. About serology: positive 369; negative 261; borderline 27. The mean of the IgG values was 35.68 RU/mL. Swabs/serology: 77.36% with previous infection were positive to serology, 18.66% negative; of all subjects who were always negative to swabs, 72.94% were negative, 22.74% positive. Moreover, the mean time elapsed from positive swab to serology test was 144.08 days.

Conclusions

Preliminary results show that the antibody response is present and persistent in the study population, even a long time after the infection. According to literature, antibody persistence has great variability in our population, as no statistically significant correlations were found between antibody titer and other variables such as time elapsed since infection. The examined sample, belonging to high-risk category (long-term care facilities), is most likely to present repeated exposure to SARS-CoV-2, highlighted by the seropositivity of never infected subjects. These findings might help policy makers better address resources regarding vaccines.

Key messages

Antibody response is present and persistent in the study population, even a long time after the infection. Antibody persistence has great variability in our population, as no statistically significant correlations were found between antibody titer and other variables such as time elapsed since infection.

Hospital-level risk factors for healthcare-associated infections: insight from the Italian PPS Study

Background

In 2016-2017, a Point Prevalence Survey (PPS) was conducted by the European Centre for Disease Prevention and Control (ECDC) in 29 European countries to investigate healthcare-associated infections (HAIs) and antimicrobial use. The aim of this study was to identify significant determinants of HAIs at a hospital level according to Italian data.

Methods

Among variables considered by the ECDC Protocol for the PPS, those with most plausible relationship with HAI occurrence according to the literature were a priori selected. Hence, conceptual causal models were built for each reference variable, by adjusting for an established set of confounders (geographical region, hospital type and number of beds), and also considering the possible interaction of the number of blood cultures per 100 patient-days (a proxy of how thoroughly HAIs are searched). Direct effects were estimated in the form of risk ratios through multivariable log-binomial regression models.

Results

Data were available for 135 Italian hospitals participating in the survey. Factors with significant impact on HAIs resulted to be: percentage of single rooms (RR = 0.91 for every 5% increase, p = 0.013), presence of a plan for infection prevention and control (IPC, RR = 0.51, p = 0.007), routine production of an IPC report (RR = 0.50, p = 0.001), adoption of measures for HAI prevention (RR = 0.21, p = 0.002) and antimicrobial stewardship (RR = 0.50, p = 0.015). The interaction of the number of blood cultures was significant for the effect of IPC report (p = 0.038), number of measures for HAI prevention (p = 0.037) and antimicrobial stewardship (p = 0.02).

Conclusions

The results confirm the importance of HAI prevention and antimicrobial stewardship as means of lowering the occurrence of HAIs. Therefore, investigating, testing and correctly reporting the onset and evolution of HAIs is paramount to ensure better understanding of the phenomenon and to provide useful insights to create a safer background for clinical practice.

Key messages

Adopting preventive measures and antimicrobial stewardship is crucial in lowering the occurrence of HAIs and ensuring safer care. Investigating, testing and correctly reporting the onset and evolution of HAIs is paramount to ensure better understanding of the phenomenon and to enable effective HAI prevention.

Burden of healthcare-associated infections in Italy: incidence, attributable mortality and disability-adjusted life years (DALYs) from a nationwide study, 2016

BACKGROUND

Healthcare-associated infections (HAIs) are an increasing public health threat. Measuring disease burden in disability-adjusted life-years (DALYs) allows the combination of morbidity and mortality into one figure, as it represents the summation of years lived with disability and years of life lost.

AIM

To evaluate the incidence, attributable deaths and burden of the most significant HAIs in Italy.

METHODS

Prevalence data from the study sample of the 2016 national Point Prevalence Survey of HAIs in acute-care settings were used to estimate the incidence of five HAIs. The methodology from the Burden of Communicable Diseases in Europe (BCoDE)-project was employed for DALY calculations, adapting the disease models to the Italian population.

FINDINGS

We estimated a total of 641,065 (95% uncertainty interval, UI 585,543.00-699,207.90) new yearly cases of HAIs and 29,375 (95% UI 23,705.97-35,905.80) deaths in Italy in 2016. The total annual DALYs were estimated to be 424,657.45 (95% UI 346,240.35-513,357.28), corresponding to 702.53 DALYs (95% UI 575.22-844.66) per 100,000 general population. Bloodstream infections accounted for the majority of total DALYs (59%), healthcare-associated pneumonia for 29%, surgical site infections for 9%, CDI for 2% and urinary tract infections accounted for less than 1% of total DALYs.

CONCLUSION

Results of this study suggest HAIs have a substantial burden in Italy. Reducing the burden of HAIs through infection prevention and control efforts is an achievable goal. This study provides data that could be used to guide policy-makers in the implementation of these measures.

Data quality assessment and subsampling strategies to correct distributional bias in prevalence studies

Background

Healthcare-associated infections (HAIs) represent a major Public Health issue. Hospital-based prevalence studies are a common tool of HAI surveillance, but data quality problems and non-representativeness can undermine their reliability.

Methods

This study proposes three algorithms that, given a convenience sample and variables relevant for the outcome of the study, select a subsample with specific distributional characteristics, boosting either representativeness (Probability and Distance procedures) or risk factors’ balance (Uniformity procedure). A “Quality Score” (QS) was also developed to grade sampled units according to data completeness and reliability.

The methodologies were evaluated through bootstrapping on a convenience sample of 135 hospitals collected during the 2016 Italian Point Prevalence Survey (PPS) on HAIs.

Results

The QS highlighted wide variations in data quality among hospitals (median QS 52.9 points, range 7.98–628, lower meaning better quality), with most problems ascribable to ward and hospital-related data reporting. Both Distance and Probability procedures produced subsamples with lower distributional bias (Log-likelihood score increased from 7.3 to 29 points). The Uniformity procedure increased the homogeneity of the sample characteristics (e.g., − 58.4% in geographical variability).

The procedures selected hospitals with higher data quality, especially the Probability procedure (lower QS in 100% of bootstrap simulations). The Distance procedure produced lower HAI prevalence estimates (6.98% compared to 7.44% in the convenience sample), more in line with the European median.

Conclusions

The QS and the subsampling procedures proposed in this study could represent effective tools to improve the quality of prevalence studies, decreasing the biases that can arise due to non-probabilistic sample collection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01277-y.

Burden of Healthcare-Associated Infections in Italy: Disability-Adjusted Life Years

Background

Healthcare-Associated Infections (HAIs) significantly increase adverse clinical outcomes and healthcare costs. In 2016 Italy participated in the second European Centre for Disease Prevention and Control (ECDC) Point Prevalence Survey (PPS) of HAIs and antimicrobial use in acute care hospitals. The aim of this study was to estimate the burden of the 5 most common HAIs in Italy, by evaluating incidence, attributable deaths, Years of Life Lost (YLL), Years Lived with Disability (YLD) and Disability-Adjusted Life-Years (DALYs).

Methods

National PPS data were used to establish sex- and age-specific incidence of Healthcare-associated Pneumonia (HAP), HA Urinary tract infections (HA UTI), HA Bloodstream Infections (HA BSI) excluding neonatal BSI, Surgical Site Infections (SSI), HA Clostridium Difficile infections (HA CDI). Patients' life expectancy was adjusted according to the severity of underlying conditions using the McCabe score. Following the methodology from the Burden of Communicable Diseases in Europe (BCoDE)-project, an adapted version of the disease models of the BCoDE toolkit was used.

Results

An overall yearly incidence of 643434 new cases of HAI in Italy was estimated. The aggregate burden of the 5 HAIs was 426411.98 DALYs (86731.03 YLD + 339680.96 YLL), corresponding to 702.53 DALYs per 100000 total population. HA BSI and HAP had the highest burden with respectively 253868.22? and 126038.26 DALYs. The population strata with the highest burden were the ones with McCabe Score 1 for every considered HAI. The age groups with the highest burden were 70-74 for male and 45-49 for female patients. In total, 56% of DALYs were attributable to men and 44% to women.

Conclusions

This nation-wide study found a significant burden of disease due to HAIs in Italy. Results of this study could be used to guide policy-makers in the implementation of measures aiming to reduce the impact of HAIs.

Key messages

This study estimated the burden of 5 HAIs in Italy was 426411.98 DALYs (86731.03 YLD + 339680.96 YLL according to 2016 PPS data. Considering the significant burden of HAIs found in this study, infection prevention and control measures should be a Public Health priority in Italy.

Meta-analysis of the efficacy of ertapenem in preventing SSIs after elective colorectal surgery

Background

The efficacy of standard surgical antimicrobial prophylaxis (SAP) regimens in preventing surgical site infections (SSIs) after colorectal surgery is declining, along with rising rates of intestinal colonization with antimicrobial resistant (AMR) Enterobacteriaceae and Bacteroides spp. Ertapenem has been approved by the FDA and EMA for SAP in this context, however it has not been used extensively for this indication out of concern for increasing carbapenem-resistance rates. A limited number of studies have investigated the efficacy of ertapenem in preventing SSIs after colorectal surgery, comparing ertapenem with different agents or combinations of agents.

Methods

A systematic review was conducted following the PRISMA checklist. PubMed, Embase and Cochrane databases were searched for studies measuring the efficacy of ertapenem in preventing SSIs following elective colorectal procedures. Studies were considered eligible if they reported extractable data on the proportion of SSIs and/or on the proportion of AMR pathogens isolated from SSIs. Data from all ertapenem study arms were extracted. A random effects meta-analysis was performed to estimate the overall proportion of SSI.

Results

Of 1109 identified studies, 5 met the inclusion criteria and were included in the meta-analysis, totalling 3176 participants. The pooled proportion of SSI was 0.10 (95% CI 0.05-0.18; I2=96%; τ2=0.6323; p ≤ 0.01). Only one study reported data on carbapenem resistance: out of 124 isolates from 30 patients, 1 gram negative carbapenem-resistant isolate was identified.

Conclusions

The pooled proportion of SSI using ertapenem as SAP found in this study is in line with the proportion of SSI using standard SAP found by a recent meta-analysis (Gandra, 2019). According to this analysis, the benefit of ertapenem does not outweigh the risk of further promoting AMR, although results should be interpreted with caution due to the high heterogeneity among included studies.

Key messages

According to this study, the efficacy of ertapenem in preventing surgical site infections after elective colorectal surgery is comparable to the efficacy of standard surgical antibiotic prophylaxis. The emergence of carbapenem resistance after surgical prophylaxis with ertapenem should be further investigated through longer term studies before widespread use for this indication.

Hand hygiene: are WHO Framework scores consistent with hand rub consumption data? A regional study

Background

Hand hygiene represents one of the most effective measures to prevent infection transmission in healthcare facilities and may reduce healthcare-associated infections by up to 15-30%. In Piedmont (a region in North-West Italy), hand hygiene compliance is routinely monitored through the WHO Hand Hygiene Self-Assessment Framework (HHSAF) and each hospital is also required to provide data about alcohol-based hand rub (ABHR) consumption as part of the regional performance indicator surveillance system. The aim of this study is to assess whether these two systems yield consistent results, i.e. whether numerical data matches the self-reported status of hand hygiene compliance.

Methods

For the years 2015-2018, data on ABHR consumption (in millilitres per patient-day, ml/PD) were collected annually at a facility level (40 hospitals) and then aggregated according to the corresponding local health unit/hospital unit, whereas the HHSAF scores were collected at a health/hospital unit level (18 units). The analysis was performed through logistic regression, by taking the WHO HHSAF score (continuous variable) as predictor and ABHR consumption as response variable, dichotomously considered as “low” or “high” (respectively below or above the 20 ml/PD threshold commonly accepted for good practice in hand hygiene).

Results

This study found that a high level of ABHR consumption is more likely to be observed in hospitals/health units with higher HHSAF scores, with a 1.14-fold increase in the odds for every 10-point increase in the HHSAF score. Despite the limited number of observations due to data aggregation, the result reached borderline statistical significance (p = 0.05).

Conclusions

The ABHR consumption surveillance provides feedback heading in the same direction as the results of the HHSAF, therefore the two surveillance systems are consistent. These findings provide further support for the validity of the HHSAF score as a reasonable predictor of hand hygiene compliance.

Key messages

The WHO Hand Hygiene Self-Assessment Framework score is a reliable predictor of hand hygiene compliance, as a high hand rub consumption is more likely to occur in hospitals with higher HHSAF score. Surveillance through the WHO HHSAF should be encouraged, along with alcohol-based hand rub (ABHR) measurement, and these results should be used to guide action plans to promote hand hygiene.

Effectiveness of Oncology Network model in pancreas cancer surgery in Piedmont, IT: a survival study

Background

The Oncology Network of Piedmont and Aosta Valley (North-West Italy) was started in 2000 and fully established in 2010 as a regional organisational model offering multidisciplinary care by experienced reference centres for cancer diagnosis and surgical treatment. In particular, the San Giovanni Bosco Hospital in Turin is the regional reference centre for pancreatic cancer since 2015 (50-70 oncologic surgery operations performed annually). The aim of study is to assess the effectiveness of this model for pancreatic cancer surgery by comparing survival outcomes before and after the adoption of the Oncology Network model.

Methods

The study included 178 patients, aged 37-84, who underwent duodenocephalo- or total pancreatectomy for ductal cancer in the years 2007-2019. Clinical data were retrieved from surgical records, whereas the vital status was ascertained through an application connected to the Regional Registry Office. The Kaplan-Meier method was used to estimate survival and the log-rank test was then used to compare survival rates between the two groups (before vs. after 2015). Cox's regression was employed to assess the difference between the groups, also adjusting for age, sex and ASA score.

Results

The median survival for included patients was 19 months. No significant differences were found between patients of the two groups (before vs. after 2015), neither considering all patients (p = 0.4) nor for any single ASA or age category (p-values ranging from 0.1 to 0.6). The multivariate Cox model accounting for ASA, age and sex confirmed absence of significant survival differences between the two groups.

Conclusions

Despite increased case complexity, due to the extension of surgery indication to more critical patients, the Oncology Network model allowed achieving an overall survival in pancreatic cancer surgery that is consistent with international literature and not inferior to survival outcomes previously reached in patients more strictly selected.

Key messages

This study found survival after pancreatic cancer surgery was similar before and after the center entered an Oncological Network, which led to include patients with an increased severity in case-mix. Promoting the implementation of Oncology Networks should be a public health priority as it allows to improve health outcomes and quality of care.

Appropriateness of antibiotics for medical prophylaxis: evaluation of data from the Italian PPS-2

Background

Antibiotics (AB) are administered for medical prophylaxis (MP) to prevent infectious complications. The second national point prevalence survey (PPS) of healthcare-associated infections and AB use was conducted in Italy in 2016-2017. The survey found MP accounted for nearly 25% of all registered ABs, more than twice the EU/EEA proportion. The aim of this study was to evaluate how many ABs were administered for MP and how frequently general indications were followed.

Methods

Data from the PPS were used to evaluate the prevalence of indications for MP over the total number of ABs, the proportion - among these indications - of those justified by a motivation in the patients' charts, and the prevalence of ABs considered appropriate for MP. The evaluation was made in 12 hospitals out of 14 participating in the PPS in Piedmont, chosen on the basis of patient traceability. According to national guidelines, the indications for MP that were considered appropriate in this study were: Trimethoprim/sulfamethoxazole for P. carinii pneumonia, Rifaximin for diverticulitis, Penicillin for Streptococcal infections and for splenectomized patients, and Rifampin for TB infections.

Results

1844 AB prescriptions were registered among 1334 traceable inpatients in Piedmont. The prevalence of indications for MP was 16.2% and 253 ABs (84.6%) were prescribed with a motivation. Only 3% of ABs registered as MP were appropriate for this indication: Bactrim 2%, Rifaximin 0.3%, Penicillin 0.2% and Rifampin 0.4%.

Conclusions

This study found an extremely high rate of inappropriate ABs for MP, that will be further investigated through qualitative analysis of medical records to evaluate whether a misunderstanding of the PPS protocol occurred and empirical therapy was confused with MP. Nevertheless, this study highlighted the need for interventions to improve prescribing appropriateness for MP.

Key messages

This study found that only 2.98% of ABs registered as MP among traceable patients in Piedmont were appropriate for this indication. 15.38% of prescriptions for MP were not justified by a motivation. Interventions to improve prescribing appropriateness for MP could lead to a considerable reduction in inappropriate use of ABs, which is crucial in a country facing hyperendemic levels of AMR.

The Bundle approach to reduce SSI rate of colon surgery, Piedmont (Italy): experience of 2012-2017

Background

According to ECDC, Surgical Site Infections (SSI) are the second most frequent type of Healthcare Associated Infections (HAI) in Europe and in USA, and 9.5% of colon surgical procedures develop SSI. SSIs are associated with prolonged hospital stay, higher costs burden and higher attributable morbidity and mortality. Interventional programs can reduce the risk of SSI. Care bundles are a complex of EBM-based interventions on a specific population and setting, in order to improve clinical outcomes. A bundle is successful only if all its items are properly applied, through the ‘all-or-none’ method. Application of a bundle does not exclude other good clinical practices.

Methods

Data from 37 hospitals participating in the Regional SSI surveillance of Piedmont (Italy) were collected from 2012 to 2017. In hospitals applying the bundle, 4 bundle items had to be used in all the procedures: Temperature control, preoperative shower, trichotomy, antimicrobial prophylaxis. 6909 patients undergoing colon surgery were followed for 30 post-operative days to detect SSI events (According to ECDC 2016 Protocol). For some procedures, compliance to Bundle item application was ≤ 75%.

Results

6909 procedures were assessed: 3631 with no bundle application and 3278 with bundle application; in particular 974 were compliant to all bundle items (100%), while 2304 were compliant to 3 items or less (≤ 75%). We report a SSI risk of 11.20% for surgical procedures performed without bundle application; this risk decreases to 5.63% (OR: 0.49, 95% CI: 0,36-0,67; p &lt; 0.001) when compliance to bundle is 100%. When compliance to bundle is ≤ 75% instead of 100%, SSI risk raises to 8.47% (OR: 1.49, 95% CI: 1.07-2.04; p = 0.002).

Conclusions

Care bundle, if properly applied, is associated to statistically significant reduction of SSI rate (51%) for colon surgical procedures. Bundle programs should be encouraged and improved in hospitals to reduce healthcare costs and burden of HAIs.

Key messages

The use of the 4-item Surgical Care Bundle is associated to statistically significant reduction (51%) of SSI rate for colon surgical procedures. Surgical Care Bundle programs should be recommended and improved in every hospital to reduce healthcare costs and burden of HAIs.

Compulsory vaccination policies: a systematic review about knowledge, attitudes and believes

Background

Vaccine hesitancy is a considerable issue in European Countries and leads to low coverage rates. Consequently, the implementation of national immunization programmes including the introduction of compulsory vaccination are required. It is interesting to determine citizens’ knowledge, attitudes and believes about vaccination policies, in order to more effectively define vaccination programs.

Methods

The present study systematically reviewed published studies evaluating attitudes towards mandatory vaccination programs. PubMed and Scopus scientific databases were searched and 4,198 results were returned, of these 29 met the inclusion criteria. PRISMA statements were followed.

Results

Twenty-two studies assessed attitudes towards mandatory vaccination programs in general, while 9 papers focused specifically on the Human Papilloma Virus (HPV) vaccine. Most of the studies were performed in Europe and North America. According to the assessed studies, the majority of the population seems to be in favour of compulsory vaccinations, from 53% to 97% for different vaccination programs. More resistance has been recorded for the HPV vaccination: the percentage of agreement for mandatory HPV vaccinations ranged from 27% to 63.5%. Furthermore, some studies investigated healthcare workers’ attitudes towards childhood and adult vaccinations. They pointed out that the general population is generally more in favour of mandatory vaccination policies than healthcare workers. The studies highlighted that the support to mandatory policies increased after their implementations.

Conclusions

The results presented in this review could be an important starting point to further understand the issue of vaccine hesitancy and support the implementation of effective vaccination strategies in Europe.

Key messages

Mandatory vaccination policies are generally well accepted among general population. More resistance is recorded for specific vaccination (HPV) or among specific population (healthcare workers).

The conventional protocol vs. a protocol including illumination with a fabric-based biophotonic device (the Phosistos protocol) in photodynamic therapy for actinic keratosis: a randomized, controlled, noninferiority clinical study

BACKGROUND

Topical photodynamic therapy (PDT) using methyl aminolaevulinate is a noninvasive treatment option suitable to treat clinical and subclinical actinic keratosis (AK) over a large area (field cancerization). The most widely used, conventional protocol in Europe includes illumination with a red-light lamp. This illumination commonly causes pain, and patients often cannot complete the treatment.

OBJECTIVES

The aims of this paper are twofold. The first aim is to introduce a novel protocol, the Phosistos protocol (P-PDT), which includes illumination with a fabric-based biophotonic device. The second and major aim is to assess the noninferiority, in terms of efficacy for PDT of AK, of P-PDT compared with the conventional protocol (C-PDT).

METHODS

A randomized, controlled, multicentre, intraindividual clinical study was conducted. Forty-six patients with grade I-II AK of the forehead and scalp were treated with P-PDT on one area (280 AK lesions) and with C-PDT on the contralateral area (280 AK lesions). The primary end point was the lesion complete response (CR) rate at 3 months, with an absolute noninferiority margin of -10%. Secondary end points included pain scores, incidence of adverse effects and cosmetic outcome.

RESULTS

Three months following treatment, the lesion CR rate of P-PDT was noninferior to that of C-PDT (79·3% vs. 80·7%, respectively; absolute difference -1·6%; one-sided 95% confidence interval -4·5% to infinity). The noninferiority of P-PDT to C-PDT in terms of the lesion CR rate remained at the 6-month follow-up (94·2% vs. 94·9%, respectively; absolute difference -0·6%; one-sided 95% confidence interval -2·7% to infinity). Moreover, the pain score at the end of illumination was significantly lower for P-PDT than for C-PDT (mean ± SD 0·3 ± 0·6 vs. 7·4 ± 2·3; P < 0·001).

CONCLUSIONS

P-PDT is noninferior to C-PDT in terms of efficacy for treating AK of the forehead and scalp and resulted in much lower pain scores and fewer adverse effects. What's already known about this topic? Topical photodynamic therapy using methyl aminolaevulinate is effective for treating actinic keratosis. In Europe, the conventional protocol involves illumination with a red-light lamp. Unfortunately, pain is often experienced by patients undergoing this protocol. An alternative protocol that uses daylight illumination has recently been shown to be as effective as the conventional protocol while being nearly painless. However, this alternative protocol can be conducted only in suitable weather conditions. What does this study add? The Phosistos protocol is demonstrated to be as effective as the conventional protocol, nearly as painless as the daylight protocols and suitable year round for treatment of actinic keratosis.

Knowledge, attitudes and beliefs towards compulsory vaccination: a systematic review

Currently, many countries are dealing with groups refusing available recommended vaccinations. Despite several studies having demonstrated the efficacy of mandatory vaccinations in ensuring herd immunity, opposition is widespread. The aim of our study was to systematically review published studies evaluating attitudes towards mandatory vaccination programs. PubMed and Scopus scientific databases were searched and 4,198 results were returned, of these 29 met the inclusion criteria. Twenty-two studies assessed attitudes towards mandatory vaccination programs in general, while 9 papers focused specifically on the Human Papilloma Virus (HPV) vaccine. Most of the studies were performed in Europe and North America. According to the assessed studies, the majority of the population seems to be in favour of compulsory vaccinations, although attitudes differed among studies. The results presented in this review could be an important starting point to further understand the issue of vaccine hesitancy and support the implementation of effective vaccination strategies.