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ABSTRACTThe decline in children’s vaccination coverage and the resurgence of preventable infectious diseases draw attention to parents’ vaccine hesitancy. Our study introduces two validated tools to independently assess vaccine hesitancy and health literacy among parents with school-age children. We developed a Vaccine Confidence Index (VCI) from 10 Likert items, exploring their relationships through exploratory and confirmatory factor analyses. We modified the IMETER (Italian medical term recognition test) to measure health literacy. We assessed the internal consistency of the modified IMETER and the 10 Likert items using Cronbach’s alpha test (α) and McDonald’s omega total coefficient (ω) with good results (ω = 0.92, α = 0.90; ω = 0.87, α = 0.82 respectively). We used these tools within a questionnaire conducted on 743 parents recruited from pediatric clinic waiting rooms in Italy, collecting demographic data, information sources on vaccines and vaccine-preventable diseases knowledge. The VCI resulting from factor analyses consisted of six items on a ten-point Likert scale, reflecting the ratio of positive to negative items. The survey revealed significant variations in the VCI according to individual features such as education, use of social networks, or Health institutions as sources of information. Multivariate logistic regression identified an association between vaccine intention and the VCI. Health literacy was functional for 91.2% of participants, but knowledge about vaccine-preventable diseases was generally low. The VCI showed no significant association with health literacy and vaccine-preventable diseases knowledge. The VCI and the modified IMETER effectively assess vaccination attitude and health literacy, offering valuable public health tools for tailoring vaccination campaigns to hesitant population subgroups.

Objective and Design.Legionellacontrol still remains a critical issue in healthcare settings where the preferred approach to health risk assessment and management is to develop a water safety plan. We report the experience of a university hospital, where a water safety plan has been applied since 2002, and the results obtained with the application of different methods for disinfecting hot water distribution systems in order to provide guidance for the management of water risk.Interventions.The disinfection procedures included continuous chlorination with chlorine dioxide (0.4–0.6 mg/L in recirculation loops) reinforced by endpoint filtration in critical areas and a water treatment based on monochloramine (2-3 mg/L). Real-time polymerase chain reaction and a new immunoseparation and adenosine triphosphate bioluminescence analysis were applied in environmental monitoring.Results.After 9 years, the integrated disinfection-filtration strategy significantly reduced positive sites by 55% and the mean count by 78% (P< .05); however, the high costs and the occurrence of a chlorine-tolerant clone belonging to Legionella pneumophilaST269 prompted us to test a new disinfectant. The shift to monochloramine allowed us to eliminate planktonic Legionellaand did not require additional endpoint filtration; however, nontuberculous mycobacteria were isolated more frequently as long as the monochloramine concentration was 2 mg/L; their cultivability was never regained by increasing the concentration up to 3 mg/L.Conclusions.Any disinfection method needs to be adjusted/fine-tuned in individual hospitals in order to maintain satisfactory results over time, and only a locally adapted evidence-based approach allows assessment of the efficacy and disadvantages of the control measures.

The role of methicillin-resistant Staphylococcus aureus(MRSA) colonization as a predictor of invasive disease in intensive care unit (ICU) patients was established many years ago. The role of mefhicillin-susceptible Staphylococcus aureus(MSSA) colonization is more debated, although in a recent report patients who were carriers of MRSA or MSSA at ICU admission were found to be at increased risk. Whether carriage at ICU admission involves a higher risk of invasive infection than carriage acquired during an ICU stay has not been established. We report the results of a study aimed at estimating the frequency of S. aureus(MRSA and MSSA) colonization at admission and at discharge in patients admitted to several ICUs in Italy and at estimating the relationship between colonization status and infection by S. aureus.

Objective.Healthcare-associated infections (HAIs) are an important cause of morbidity and mortality worldwide. During the period from 2002 through 2004, a group of Italian hospitals was recruited to conduct HAI point-prevalence surveys.Design.Three point-prevalence surveys.Methods.A total of 9,609 patients were surveyed.Results.The overall frequency of HAI was 6.7% (645 infections among the 9,609 surveyed patients). The most frequent HAIs were lower respiratory tract infections, which accounted for 35.8% (231 of 645 HAIs) of all HAIs, followed by urinary tract infections (152 [23.6%] of 645 HAIs), bloodstream infections (90 [14.0%] of 645 HAIs), and surgical site infections (79 [12.2%] of 645 HAIs). In both multivariate and univariate analysis, invasive procedures, duration of stay, chemotherapy, trauma, coma, and the location of the hospital were all factors statistically significantly associated with the occurrence of an HAL Enterobacteriaceae were the most common isolates recovered in medical and surgical wards, whereas gram-negative aerobic bacilli were the most common isolates recovered in intensive care units. Approximately one-half of all of the patients surveyed were receiving antibiotics at the time of our study; the most used antibiotic classes were fluoroquinolones in medical wards, cephalosporins in surgical wards, and penicillins and glycopeptides in intensive care units.Conclusion.Our study emphasizes the need for implementing further HAI surveillance to provide the National Health System with proper tools to prevent and manage infection in hospitalized patients.

A survey in eight European countries, including 13 hospitals, of vancomycin-resistant enterococci (VRE) in at-risk hospital wards (such as the ICU and the haematology ward) was performed in 2001, and the in vitro susceptibility of the isolates ramoplanin and other drugs was tested. A total of 1314 non-duplicate clinical enterococcal isolates were collected, and 38 (2.9&percnt;) were vancomycin resistant: 27 Enterococcus faecium and 11 Enterococcus faecalis; 35 VanA and three VanB phenotypes. Rates of VRE among clinical enterococcal isolates varied between 0 and 1.7&percnt; for the participating countries, except the UK (10.4&percnt;) and Italy (19.6&percnt;). One hundred and twenty-three (3.5&percnt;) VRE were found among 3499 stool samples tested for the presence of these organisms: 111 (3.2&percnt;) E. faecium and 12 (0.3&percnt;) E. faecalis; 114 (3.3&percnt;) VanA and nine (0.3&percnt;) VanB phenotypes. Rates of intestinal colonization with VRE varied between 0 and 1.2&percnt; for the participating countries, except Italy (7.5&percnt;) and the UK (32.6&percnt;). In vitro susceptibility testing showed that the Italian and UK VRE are multi-resistant (including resistance to ampicillin and high-level resistance to gentamicin and streptomycin), and that ramoplanin was active against all strains of VRE, with an MIC90 of 0.5 mg/L for clinical isolates. Pulsed-field gel electrophoresis showed that the high prevalence of VRE in the Italian and UK centres was related to the monoclonal emergence and spread of three centre-specific clones. This survey suggests that in some centres in Europe, a similar situation may be encountered to that in the USA (monoclonal spread of multi-resistant VRE in at-risk wards).

The emergence of multiple resistance to β-lactam antimicrobial agents is a major problem in the treatment of patients infected with Enterobacteriaceae that characteristically produce inducible β-lactamases. Inducible and ‘derepressed’ AmpC β-lactamases are produced by Enterobacterspp., Citrobacter freundii, Serratia marcescens, Morganella morganiiand Providenciaspp. Resistance to broad-spectrum β-lactams has emerged in 16-44% of these strains from infections treated with one of the newer cephalosporins, even in combination with other antimicrobials. Multiply resistant organisms have spread widely both locally, within hospitals, and nationally. This trend has been shown to correlate closely with the extent of usage of some third-generation cephalosporins. These resistant strains, especially Enterobacterspp., are more regularly isolated from seriously ill patients (especially from respiratory sources), or in intensive care units and pose one of the greatest challenges to contemporary chemotherapy of infections in hospitalized patients. Zwitterionic fourth-generation cephalosporins combine the properties of rapid bacterial outer membrane penetration with high stability to AmpC β-lactamase with good affinity for the penicillin-binding proteins to achieve in vitro activity against AmpC-producing organisms, including the majority of strains highly resistant to ceftazidime and other earlier generation cephalosporins. These features have contributed to their clinical success in the therapy of infections caused by Enterobacterspp. with and without resistance to third-generation compounds. Other alternative agents for chemotherapy of infections due to AmpC β-lactamase-producing strains (inducible or derepressed expression) should also be considered e.g. carbapenems, aminoglycosides and fluoroquinolones.

Alterations in the luminal microflora and increased intestinal translocation have been reported to occur following experimental and clinical small bowel transplantation (SBT). Selective intestinal decontamination (SID) has been used to prevent luminal overgrowth and bacterial translocation. Despite the wide use of SID in clinical SBT, there are no data supporting its usefulness in this situation. Thus, the aim of this investigation was to examine the effects of cyclosporine A (CsA) and SID upon bacterial overgrowth and translocation in a swine model of SBT. Nineteen Large White female pigs weighing 30 ± 2 kg underwent a total orthotopic SBT and were randomly allocated to one of the following experimental groups as follows: Group 1 (No. 8) CSA 25 mg/kg body weight (b.w.)/day administered subcutaneously and Cefazolin 2 g/day im. Group 2 (No. 6) received the identical immunosuppression but the Cefazolin 2 g/day im was discontinued on the 5th Postoperative Day (pod) and switched to a SID regimen consisting of Vancomycin, 1 g, Nystatin, 500,000 IU, Colistin, 1,500,000 IU, and Tobramycin, 100 mg, given through a gastrostomy tube. Group 3 (No. 5) received no immunosuppression but antibiotic consisting of Cefazolin 2 g im/day. Group 4 (No. 7) underwent a small bowel autotransplantation. Group 4 received SID as in group 2 but no immunosuppression was given. Finally, 17 normal animals were sham-operated and were used as normal controls (N group). The animals in groups 1, 2, and 4 were sacrificed on the 29th pod. Those in group 3 were sacrificed on the 7th pod. Samples from graft, native bowel, liver, kidney, skin, and lungs were processed for histologic evaluation. Moreover, samples from the graft (proximal, middle, and distal) and adjacent mesenteric lymph nodes were harvested aseptically and cultured for both aerobes as well as for anaerobes. Significant increases in the number of aerobes and anaerobes were found in the proximal graft of all groups studied compared to the normal controls. The rate of intestinal translocation was 19% in the normal controls and increased to 88, 83, 100, and 100% in groups 1, 2, 3, and 4, respectively. Based upon these data, it can be concluded that SID is no better than a parenteral antibiotic regimen at preventing bacterial overgrowth following SBT. Moreover, neither therapy reduces the high rate of bacterial translocation to mesenteric nodes seen in arrivals following experimental SBT.

RESISTANCE to various antibiotics is common in the anaerobic gut bacterium Bacteroides fragilis. A transferable plasmid coding for resistance to antibiotics of the lincosamide/macrol-ide/synergistin groups has been found1,2and transfer is most probably a conjugative process. This supports the observation of the recent emergence of resistance to antibiotics in these groups and its rapid spread in certain areas (ref. 3 and our unpublished data). However, in the case of tetracycline resistance the limited genetic and physical data were at variance with the epidemiological data. Although tetracycline resistance is common in B. fragilis4(at present 60% of strains isolated in the USA5and 30% of those isolated in France (our unpublished results) are resistant) intraspecies transfer of tetracycline resistance could not be demonstrated6. We report here that transfer of tetracycline resistance between B. fragilisstrains is easily achieved if the donor bacteria are grown in the presence of tetracycline before mating. This suggests that tetracycline resistance is borne on a transferable plasmid whose conjugative transfer requires activation of the tetracycline resistance gene. This is supported by our finding that the transfer of tetracycline resistance is either inducible or constitutive, depending on whether tetracycline resistance itself is respectively inducible by tetracycline or constitutive.