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Background: Management of recurrent urinary tract infection (rUTI) is still challenging. A better understanding of the natural history of rUTI could help us reduce antibiotic use and improve antibiotic stewardship. Objective: To describe the effect of risk identification, stratification, and counseling on the natural course of the disease in women with rUTI. Design, setting, and participants: A total of 373 women affected by recurrent cystitis were enrolled in this longitudinal cohort study between December 2014 and December 2019. A systematic and standardized identification of risk factors was performed. Intervention: As intervention, risk factors were treated or removed where possible. Patients with nonremovable risk factors were included in the control group. All patients were scheduled for follow-up visits every 6 mo. Outcome measurements and statistical analysis: The main outcome measures were the rate of symptomatic recurrences and improvement in questionnaire results from baseline to the end of the follow-up period. Reduction of antibiotic usage was regarded as a secondary outcome measure. Results and Limitations: Finally, 353 women were analyzed: 196 in the study group and 157 in the control group. At the end of the follow-up period, a statistically significant reduction in the symptomatic recurrence rate was found between the two groups (0.9 ± 0.2 and 2.6 ± 0.5; p < 0.001), as well as in quality of life and anxiety according to mean questionnaire results: quality of life (0.88 ± 0.06 and 0.63 ± 0.09; p < 0.001) and Spielberger State-Trait Anxiety Inventory-Form Y (32.7 ± 9.3 and 47.5 ± 14.3; p < 0.001). The use of antibiotics was significantly lower in the study group: 4410 versus 9821 (p < 0.001). A limitation to consider is the lack of a randomized design for the active approach in the high-risk group. Conclusions: Identification, counseling, and removal of risk factors, where possible, are able to change the natural history of rUTI, by reducing the number of symptomatic episodes and antibiotic use and improving quality of life. Patient summary: In this report, we analyzed a large cohort of women affected by recurrent urinary tract infections and followed for a long time period. We found that risk factor identification and counseling may change the natural history of recurrent urinary tract infections, concluding that this approach is able to reduce the number of symptomatic episodes, reduce antibiotic usage, and improve patients’ quality of life.

Neonatal sepsis is a systemic condition characterized by haemodynamic changes and other clinical manifestations due to a presence of pathogenic microorganisms (bacteria, viruses, or fungi) in nor- mally sterile fluid that occurs in an infant younger than 90 days old. Neonatal sepsis may be divided into two types: early-onset neonatal sepsis (EOS) and late-onset neonatal sepsis (LOS). Gram-posi- tive microorganisms are the etiological agents in 62% of EOS, and in 43% of the total the identified microorganism is GBS. Gram-negative microorganisms comprise 37% of the etiological agents of EOS, of which 29% are caused by Escherichia coli. ESBL-producing Enterobacteriaceae represent a major worldwide threat among drug-resistant bacteria in both hospital and community settings. ESBLs are often located on large plasmids that also harbour genes resistant to other antimicrobial classes, resulting in multidrug-resistant isolates. Plasmid-encoded ESBLs of the CTX-M-type are increasingly reported worldwide in Gram-negative rods and now account for most of the ESBLs found in Enterobacteriaceae. We present one case of EOS by Multi Drug Resistant (MDR) and ESBL producing E. coli (CTX-M gene) in a neonate born to a mother recently immigrated from Africa. Maternal blood culture grew the same bacteria.

Background: Trentino is an Italian province with a tourism-based economy, bordering the regions of Lombardy and Veneto, where the two earliest and largest outbreaks of COVID-19 occurred in Italy. The earliest cases in Trentino were reported in the first week of March 2020, with most of the cases occurring in the winter sport areas in the Dolomites mountain range. The number of reported cases decreased over the summer months and was followed by a second wave in the autumn and winter of 2020. Methods: we performed high-coverage Oxford Nanopore sequencing of 253 positive SARS-CoV-2 swabs collected in Trentino between March and December 2020. Results: in this work, we analyzed genome sequences to trace the routes through which the virus entered the area, and assessed whether the autumnal resurgence could be attributed to lineages persisting undetected during summer, or as a consequence of new introductions. Conclusions: Comparing the draft genomes analyzed with a large selection of European sequences retrieved from GISAID we found that multiple introductions of the virus occurred at the early stage of the epidemics; the two epidemic waves were unrelated; the second wave was due to reintroductions of the virus in summer when traveling restrictions were uplifted.

Efficient wide-scale testing for SARS-CoV-2 is crucial for monitoring the incidence of the infection in the community. The gold standard for COVID-19 diagnosis is the molecular analysis of epithelial secretions from the upper respiratory system captured by nasopharyngeal (NP) swabs, which requires the intervention of trained personnel. Given the ease of collection, saliva has been proposed as a possible substitute to support testing at the population level. Here we describe the set-up of a laboratory, in an academic context, for the high-throughput screening of SARS-CoV-2 in the saliva from the community. A novel saliva collection device was designed to favour the safe and correct acquisition of the sample as well as the processivity of the downstream molecular analysis. To test the performance of the system,1025 paired saliva and nasopharyngeal samples were collected from individuals recruited at a public drive through testing facility and analysed in parallel. An overall moderate concordance (68%) between the two tests was found, with evidence that neither test can diagnose the infection in 100% of the cases. While the two tests performed equally well in symptomatic individuals, their discordance was mainly restricted to samples from convalescent individuals. The saliva test was at least as effective as NP swabs in asymptomatic individuals recruited for contact tracing. Our study, therefore, indicates that saliva testing can be a reliable tool for wide-scale COVID-19 screening in the community.

The study analysed the trend of toxoplasmosis infection in pregnancy by using antenatal serological screening and the incidence of the congenital condition in newborns in the province of Trento, Italy. Data from pregnant women who gave birth at local maternity units between 2009 and 2018 were obtained. The serological test results were collected from birth attendance certificates (BACs), the main - and mandatory - source of information used to monitor pregnancies, births and neonatal health in Italy. The BAC used in the province of Trento acquires the results of serological tests for a vast range of infections in pregnancy. The data collected from the BACs were integrated with those provided by the Hospital Information System (HIS), which was also used to collect data on the trimester in which the seroconversion occurred. A total of 45,492 pregnant women were analysed, of whom 24% were foreigners. The average coverage of serological screening in pregnancy was 99.7%. Mean overall prevalence of Toxoplasma gondii infection was 21.7% (95% CI: 21.3-22.1): in Italians the prevalence was 17.9% (95% CI: 17.5-18.30) and in foreign nationals 32.7% (95% CI: 32.26-33.13). The mean annual seroconversion rate was 0.35% (95% CI: 3.0-4.2) of susceptible women and 0.27% (95% CI: 2.2-3.4) of all pregnant women who were screened. The seroconversion rate was higher amongst foreign women (0.32%, 95% CI: 3.0-3.6) than Italian women (0.24%, 95% CI: 2.1-2.8). In all, 91.0% of seroconverted women were treated during pregnancy in accordance with the anti-toxoplasma protocol. Five cases of congenital infection were identified (2 amongst Italians and 3 amongst foreign women), amounting to an overall transmission rate of 4.0% (2.3% in Italians and 8.8% in foreigners). Transmission risk ranged from 0.0% in the first trimester to 19% in the third. The incidence of congenital toxoplasmosis, over the entire study period, was 0.012% live births (0.011% in Italians and 0.016% in foreigners). Data collection on infections in pregnancy through BAC allows area-based assessment. Although the quality of the data recorded in the BAC can be considered satisfactory, it was also necessary to access other information sources. The screening coverage was very high. The prevalence of toxoplasmosis infection was found to be higher in foreign mothers than in Italians, as well as seroconversion. The extent of serological screening and the high treatment rate helped to keep the risk of infection transmission to the foetus low and to achieve a very low rate of congenital infection.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), became a pandemic in early 2020. Lateral flow immunoassays for antibody testing have been viewed as a cheap and rapidly deployable method for determining previous infection with SARS-CoV-2; however, these assays have shown unacceptably low sensitivity. We report on nine lateral flow immunoassays currently available and compare their titer sensitivity in serum to a best-practice enzyme-linked immunosorbent assay (ELISA) and viral neutralization assay. For a small group of PCR-positive, we found two lateral flow immunoassay devices with titer sensitivity roughly equal to the ELISA; these devices were positive for all PCR-positive patients harboring SARS-CoV-2 neutralizing antibodies. One of these devices was deployed in Northern Italy to test its sensitivity and specificity in a real-world clinical setting. Using the device with fingerstick blood on a cohort of 27 hospitalized PCR-positive patients and seven hospitalized controls, ROC curve analysis gave AUC values of 0.7646 for IgG. For comparison, this assay was also tested with saliva from the same patient population and showed reduced discrimination between cases and controls with AUC values of 0.6841 for IgG. Furthermore, during viral neutralization testing, one patient was discovered to harbor autoantibodies to ACE2, with implications for how immune responses are profiled. We show here through a proof-of-concept study that these lateral flow devices can be as analytically sensitive as ELISAs and adopted into hospital protocols; however, additional improvements to these devices remain necessary before their clinical deployment.

Rubella, syphilis, toxoplasmosis, cytomegalovirus (CMV), hepatitis B (HBV) and C (HCV), HIV, and Group B Streptococcus (GBS) infections may have very severe outcomes during pregnancy, and for this reason, monitoring of infections in pregnant women is a requirement of prenatal assistance.To describe coverage and outcome of the screening for rubella, syphilis, toxoplasmosis, CMV, HBV, HCV, HIV, and Group B Streptococcus in pregnancy in the Autonomous Province of Trento, Northern Italy (538,600 inhabitants).We analysed the coverage and outcome of the above-mentioned screenings among women who delivered in the hospitals of the Province of Trento between 2007 and 2014 (N = 38,712). Screenings were grouped according to characteristics such as recommendation by national and local guidelines, scheduling of the tests, operating methods, and charge. We also estimated odds ratios (ORs) for missing screening for selected infections through multiple logistic regression.Estimated uptake of antenatal screening was 99.7% for rubella, 99.3% for syphilis, 99.7% for toxoplasmosis, 98.1% for HIV infection, 99.0% for HBV, 98.9% for HCV, 94.0% for GBS infection, and 75.4% for CMV infection. The overall prevalence of immunity was 94.1% for rubella, 24.2% for toxoplasmosis, and 64.2% for CMV. The rate of seroconversion in pregnant women was 0.02% for rubella, 0.29% for toxoplasmosis, and 0.75% for CMV. The overall prevalence of infection was 0.94% for HBV, 0.53% for HCV, 22.3% for GBS, 0.29% for syphilis, and 0.13% for HIV. We found a significant positive association for all screening tests, between lack of testing and late first medical examination in pregnancy (ORs ranging from 1.20 to 1.66 for the first medical visit in the second trimester and ORs ranging from 1.60 to 5.88 for the first medical visit in third trimester, compared to early medical visit in the first trimester). Compared to Italian citizenship, foreign citizenship of the mother was also positively associated with absence of screening (ORs ranging from 1.30 to 1.53). A significant inverse association was observed for calendar year of delivery (ORs ranging from 0.71 to 0.97, for 1 year increment). Less educated mothers and pluriparae were also at higher risks of not being tested. Analysis of the association with mother age showed different heterogeneous effects.Our study indicates that the attention to screening and detecting infected cases is growing over the time. In addition, care delivered during pregnancy has a leading role in determining coverage of the examinations. Immigrant, pluriparous and less educated women need particular attention.

Recently, Escherichia coli producing extended-spectrum β-lactamases (ESBLs) have become a serious public-health problem, and food-producing animals (FPAs) have been suggested as a potential reservoir/source. This study aimed to compare ESBL-producing E. coli isolates from different sources. ESBL-producing E. coli isolates were collected from humans (n = 480) and FPAs (n = 445) in Italy (2016–2017). Isolates were screened for the presence of ESBL and carbapenemase genes and were classified according to phylogenetic group and MLST genotyping. The genes mcr-1 to -5 were searched for in colistin-resistant isolates. CTX-M was the most frequent ESBL type both in human and animal isolates. CTX-M-15 prevailed in humans (75.0%) and cattle (51.1%) but not in poultry (36.6%). CTX-M-1 was common (58.3%) in pigs. SHV-type and CMY-2-like were found in FPAs, especially in poultry (17.0% and 29.9%, respectively). Additionally, 29 isolates were mcr-1 carriers (3 from humans and 26 from FPAs). No carbapenemase genes were detected. Human isolates mostly belonged to phylogroup B2 (76.5%). Animal isolates were distributed among groups A (35.7%), B1 (26.1%) and C (12.4%). Few animal isolates (almost all from poultry) were classified into group B2 (4.3%). Most human isolates (83.4%) belonged to the pandemic ST131 clone and frequently carried CTX-M-15 (75.9%). ST131 was rarely detected in FPAs (three isolates from poultry). Nineteen STs were shared in both sources, with ST10, ST410 and ST69 being more frequently detected. Potential exchange of ESBL genes from animals to humans is feasible, underlying the need for strict monitoring based on a ‘One Health’ approach.

Background Enterovirus infections can cause a variety of illnesses, ranging from asymptomatic infections to severe illness and death. Aim To support polio eradication activities, in February 2019, the WHO Regional Reference Laboratory for polio in Italy, at the National Institute of Public Health (Istituto Superiore di Sanita), promoted an investigation on non-polio enterovirus laboratory capacity, with the support of the Italian Ministry of Health. The aim was to collect data on the assays used routinely for diagnostic purposes and to characterize enterovirus outbreaks strains by sequence analysis of the Viral Protein 1 region. Methods A questionnaire was administered to public health laboratories through all Italian Regions for 2018 and subsequently, an electronic form for lab-confirmed enterovirus infection reported from February 2019 to January 2020, including patients clinical characteristics, and laboratory data was distributed through 25 laboratories participating the survey. Results Overall, a homogenous laboratory capacity for enterovirus infection diagnosis was found and 21,000 diagnostic tests were retrospectively reported in 2018. Then, in 2019, two outbreaks of Echovirus 30 were identified and confirmed by molecular analyses. Conclusion These results underline the need monitor the circulation of non-polio enterovirus to ascertain the real burden of the disease in the country.

In February 2017 a case of Hemolytic-Uremic Syndrome (HUS) was reported to the National Registry of HUS in an adult living in Northern Italy. Stool specimens from the patient and his family contacts were collected and the analyses led to the isolation of a Locus of Enterocyte Effacement (LEE)-negative Shiga toxin 2 (Stx2)-producing Escherichia coli. The epidemiological investigations performed brought to collect fecal samples from the animals reared in a farm held by the case’s family and a mixture of bovine and swine feces proved positive for Shiga toxin-producing E. coli (STEC) and yielded the isolation of a LEE-negative stx2-positive E. coli strain. Further characterization by whole genome sequencing led to identify the isolates as two identical O2:H27 hybrid Enterotoxigenic Shiga toxin-producing E. coli (ETEC-STEC). Sequencing of a high molecular weight plasmid present in the human isolate disclosed a peculiar plasmid harboring virulence genes characteristic for both pathotypes, including the enterohemolysin-coding gene and sta1, encoding the heat stable enterotoxin. Moreover, a complete fae locus encoding the ETEC F4 fimbriae could be identified, including a novel variant of faeG gene responsible for the production of the main structural subunit of the fimbriae. This novel faeG showed great diversity in the nucleotidic sequence when compared with the reference genes encoding the swine F4 allelic variants, whereas at the amino acid sequence level the predicted protein sequence showed some similarity with FaeG from E. coli strains of bovine origin. Further investigation on the plasmid region harboring the newly identified faeG allelic variant allowed to identify similar plasmids in NCBI sequence database, as part of the genome of other previously uncharacterized ETEC-STEC strains of bovine origin, suggesting that the novel F4-like fimbriae may play a role in bovine host specificity.

La sepsi e un’infezione sistemica che nella medicina moderna risulta essere sempre piu frequente e con un alto tasso di mortalita, soprattutto nei reparti di terapia intensiva, nonostante i progressi compiuti nella diagnosi e nel trattamento di tali infezioni. Una rapida ed accurata identificazione dei vari agenti patogeni isolati dal sangue e molto importante per un tempestivo intervento terapeutico; la somministrazione di una terapia antibiotica mirata e decisiva per ottenere una prognosi favorevole. Attualmente l’esame di laboratorio gold standard per la diagnosi di sepsi e l’emocoltura in quanto permette di determinare l’agente eziologico e la sua sensibilita agli antibiotici, informazioni utili al clinico per realizzare una terapia mirata. Il gold standard nella diagnosi delle infezioni ematiche purtroppo pero permette di ottenere tutte le informazioni necessarie non prima di 36–96 ore, dopo che i flaconi di emocoltura sono pervenuti in laboratorio. Lo scopo di questo studio e stato valutare e confrontare, con il metodo tradizionale, due diversi metodi molecolari rapidi: un microarray (Verigene ® Nanosphere, Inc., USA) ed un film-array (Film-Array ® BioFire Diagnostics Inc., USA). Le due metodiche molecolari sono in grado, all’interno del loro pannello di microrganismi, di identificare il patogeno presente in un campione di emocoltura positiva e suoi determinanti di antibioticoresistenza. Sono state analizzate in parallelo con le due metodiche molecolari microarray e film array un totale di 42 emocolture risultate positive nel sistema di monitoraggio continuo, comparando i risultati definitivi di identificazione e suscettibilita antibiotica generati per ogni campione dalle due tecniche molecolari e valutando la concordanza di questi risultati con il profilo di identificazione microbica e di antibiotico sensibilita ottenuti con il sistema utilizzato in routine MicroScan WalkAway ® Siemens (Siemens Healthcare). Alla segnalazione di positivita delle emocolture incubate nel sistema BD BACTEC™ FX (Becton Dickinson) un’aliquota di campione del flacone positivo e stata sottoposta alle indagini microbiologiche tradizionali (esame microscopico dopo colorazione di Gram, colture su piastra, identificazione degli isolati ed antibiogramma) ed in parallelo ai test diagnostici molecolari, microarray (Verigene ® Nanosphere, Inc., USA) e film-array (FilmArray ® BioFire Diagnostics Inc., USA). Su un totale di 42 emocolture positive corrispondenti a 42 casi clinici differenti, il test molecolare Verigene ® e stato in grado di identificare 44 agenti eziologici di sepsi (94%), mentre le metodiche tradizionali (coltura in piastra, identificazione biochimica, tipizzazione sierologica) ne hanno rilevati 47. L’analisi di emocolture positive per infezioni polimicrobiche miste (5 casi) ha determinato il numero maggiore di patogeni identificati dal sistema molecolare e dalla metodica tradizionale rispetto ai campioni effettivamente processati, ma e stata sempre rilevata una perfetta concordanza tra i risultati ottenuti con il test molecolare e quelli generati da piastra e da antibiogramma definitivo per quanto riguarda le resistenze associate ai patogeni identificati. Sono stati rilevate 9 positivita per il gene di resistenza mecA, tutte associate a Staphylococci coagulasi negativi, come confermato dagli antibiogrammi diretti allestiti in piastra (100%). Non e stata invece rilevata alcuna positivita per i geni vanA/vanB e KPC e gli antibiogrammi preliminari eseguiti per tutti i campioni analizzati hanno fornito il medesimo risultato. Lo strumento Film-Array ® e stato in grado di fornire risultati di identificazione microbica in 40 emocolture positive su 42 analizzate, mostrando una sensibilita del 95%. In soli due campioni analizzati il test molecolare non e stato in grado di rilevare alcun target batterico. In questo studio e emerso che entrambi i metodi molecolari sono potenzialmente utili nel fornire una diagnosi di sepsi in tempi piu rapidi rispetto al metodo di coltura tradizionale dopo la segnalazione di positivita del flacone da parte del sistema a monitoraggio continuo per emocolture. Sono stati sviluppati diversi metodi per ridurre il turnaround time per l’identificazione degli agenti patogeni; la riduzione dei tempi di indagine puo essere ottenuta utilizzando metodiche molecolari che possono essere eseguite sulle emocolture positive o direttamente su campioni di sangue. Le nuove tecniche di diagnostica molecolare consentono al clinico di intraprendere precocemente una terapia antibiotica piu mirata rispetto a quella a largo spettro e quindi fornire un notevole vantaggio nella gestione dei pazienti settici. L’opportunita di impostare il prima possibile una terapia mirata ed efficace rende possibile il contenimento e la riduzione di ceppi microbici multiresistenti ed inoltre permette una drastica diminuzione della spesa sanitaria associata a trattamenti terapeutici inappropriati con conseguenti tempi di degenza prolungati.

The diagnosis of invasive aspergillosis is notoriously difficult. The standard culture-based methods have shown considerable limitations in performance. For this reason, non-culture methods have been increasingly employed for the diagnosis of invasive aspergillosis, and, among them, the methods based on Real-Time polymerase chain reaction (RT-PCR). In this study we assess the contribution in lowering diagnosis errors provided by the RT-PCR method when run alongside other methods. We analyzed 23 biological samples, 14 serum samples, and 9 bronchoalveolar lavage samples (BAL) from 10 immunocompromised patients who were selected according to EORTC/MSG criteria (European Organization for Research and Treatment of Cancer/Mycoses Study Group). On the serum sample we searched the galactomannan (GM) (Platelia Aspergillus®) and the fungal genome (MycAssayTMAspergillus); the BAL samples were subjected also to the culture tests. In 11 serum samples the results showed concordance between GM and RT–PCR tests, while in 3 samples we report discordance: 2 results were GM positive and RT-PCR negative, and 1 results GM negative and RT-PCR indeterminate. In 5 BAL samples the results showed concordance between the two methods, while 4 were GM positive and RT-PCR negative. The data, although still preliminary, suggest an increased accuracy in the diagnosis of suspected invasive aspergillosis when employing both RT-PCR and GM tests given that the RT-PCR test eliminates the false positive results of the GM test. The PCR methods require, however, further applications of this type of diagnostic because of the severe limit given by the lack of standardization.

A comparative electron microscopic analysis of weakly beta-haemolytic spirochaetes related to human and animal intestinal spirochaetosis was done in order to search for the presence of inducible bacteriophages associated with these spirochaetes. Bacteriophages were detected at the electron microscope after experimental induction with mitomycin C in 4 strains of weakly beta-haemolytic spirochaetes related to human intestinal spirochaetosis, in Serpulina pilosicoli strain P43/6/78, the causative agent of swine intestinal spirochaetosis, in a spirochaetal strain related to avian intestinal spirochaetosis, and in Serpulina hyodysenteriae, strain P18A, the causative agent of swine dysentery, which was comparatively analysed as control. All phage-particles observed in both human and animal intestinal spirochaetes were morphologically similar with an isometric head of 45 nm diameter and a tail 63-70 nm long and 7-12 nm width. The presence of morphologically similar phages in all the haemolytic intestinal spirochaetes of human and animal origin analysed in this study opens some important questions, about the genetic relationship of phages present in pathogenic intestinal spirochaetes, their host range, and the possibility of natural gene transfer among pathogenic haemolytic intestinal spirochaetes of human and animal origin.