Epidemiological and clinical features of imported malaria at the three main hospitals of the Friuli-Venezia Giulia Region, Italy.

BACKGROUND: Imported malaria cases continue to occur in non-endemic regions among travellers returning from tropical and subtropical countries. At particular risk of acquiring malaria is the group of travellers identified as immigrants who return to their home country with the specific intent of visiting friends or relatives (VFRs) and who commonly believe they are immune to malaria and fail to seek pre-travel advice. Our aim was to review the current trends of imported malaria in the three main hospitals of the Friuli-Venezia Giulia region (FVG), North Eastern Italy, focusing in particular on patient characteristics and laboratory findings. METHODS: In this retrospective study, we examined all malaria cases among patients admitted from January 2010 through December 2014 to the emergency department of the three main hospitals located in FVG. RESULTS: During the 5-year study period from 2010 to 2014, there were a total of 140 patients with a diagnosis of suspected malaria and who received microscopic confirmation of malaria. The most common species identified was P. falciparum, in 96 of 140 cases (69%), followed by P. vivax (13%), P. ovale (4%), P. malariae (4%), and mixed infection (4%). The most common reason for travel was VFRs (54%), followed by work (17%), and recent immigration (15%). Moreover, 78% of all patients took no chemoprophylaxis, 80 (79%) of whom were foreigners. Notably, the percentage of Italian travellers who took chemoprophylaxis was only 20% (8 of 39 Italian cases), and the regimen was appropriate in only four cases. Parasitaemia greater than 5% was observed in 11 cases (10%), all due to P. falciparum infection. CONCLUSIONS: We highlight that VFRs have the highest proportion of malaria morbidity and the importance of improving patient management in this category. These data are useful for establishing appropriate malaria prevention measures and recommendations for international travellers.

Evaluation of the new Sysmex UF-5000 fluorescence flow cytometry analyser for ruling out bacterial urinary tract infection and for prediction of Gram negative bacteria in urine cultures.

BACKGROUND: We evaluated the new flow cytometer UF-5000 with a blue semiconductant laser as a screening tool for ruling out urine samples negative for UTI and its ability to predict Gram negatives in culture. METHODS: Flow cytometry and microbiological analysis were performed on 2719 urine samples, sent to our microbiology laboratory with a request for urine culture. RESULTS: UF-5000 showed a very good performance in the screening process. Carryover and cross-contamination was negligible. 797 samples were culture positive at a cut-off of ≥105CFU/mL. ROC curve analysis for BACT count demonstrated AUC between 0.973, on 2714 samples, 0.959, on 1516 female samples, and 0.988 on 1198 male samples, respectively. At the cut-off of BACT ≥58/µL AND/OR YLC ≥150/µL, SE was 99.4%, SP 78.2%, PPV 65.4% and NPV 99.7%; false negatives were 0.6%, avoiding unnecessary cultures in 55.5% of specimens. "Gram Neg?" flag predicted Gram negatives in culture with a SE of 81.6% and SP of 93.3%. CONCLUSION: The new Sysmex UF-5000 showed high diagnostic accuracy in UTI-screening with a very low rate of false negatives. The instrument is capable of predicting Gram negatives with a good SE and a high agreement with the culture, even if this performance needs further evaluation.

Co-production of NDM-1 and OXA-232 by ST16 Klebsiella pneumoniae, Italy, 2016.

Carbapenem-resistant Klebsiella pneumoniae strains, New Delhi metallo-ß-lactamase-1 producers, are still rare in Italy, being endemic in Southeast Asiatic region. In October 2016, a multidrug-resistant K. pneumoniae was isolated from blood and urine of an Italian long-hospitalized patient with urosepsis without travel history abroad. To the best of our knowledge, this is the first report of bacteremia caused by an ST16 K. pneuomoniae New Delhi metallo-ß-lactamase-1 and OXA-232 co-producing carbapenemase, in Italy.

Technical note: Discard the specimen collection swab directly at point of care to improve extensive automated processing in clinical microbiology laboratories.

We compared, in terms of microorganisms recovery, the discard of specimen collection swab, after swirling into its medium, directly at point of care, with its placing into the medium and vortexing on arrival in the laboratory. Our results show that these two procedures are overlapped in terms of bacterial recovery.

Recurrent skin infection associated with nasal carriage of Panton-Valentine leukocidin-positive methicillin-susceptible Staphylococcus aureus closely related to the EMRSA-15 clone.

We report the case of a soldier with recurrent skin infection associated with nasal carriage of a Panton-Valentine leukocidin (PVL)-producing methicillin-susceptible Staphylococcus aureus (MSSA), closely related to the EMRSA-15 clone. MSSA isolates causing infection not requiring hospitalization usually go unnoticed; however, their typing may be useful to understand the global distribution of successful staphylococcal lineages related to epidemic clones. PVL-positive MSSA strains might serve as reservoirs from which virulent methicillin-resistant strains may evolve and spread.

Liquid based microbiological transport systems: conformity assessment of two commercial devices.

We compared two types of liquid-based microbiology devices for microorganism viability according to standardized quantitative elution method CLSI M40-A2. The eSwab® met CLSI acceptance criteria of viability maintenance for all microorganisms tested. The Σ-Transwab® failed to meet CLSI acceptance criteria for Peptostreptococcus anaerobius, Prevotella melaninogenica, Fusobacterium nucleatum and Haemophilus influenzae.

Direct molecular detection of pathogens in blood as specific rule-in diagnostic biomarker in patients with presumed sepsis: our experience on a heterogeneous cohort of patients with signs of infective systemic inflammatory response syndrome.

The practical value of blood cultures in the diagnosis of sepsis is impaired by a delay in the turnaround time to result and by the fact that blood culture positive can be found for only about 30% of these patients. Conventional laboratory signs of sepsis and acute phase protein biomarkers are sensitive and easy to use, but often also very nonspecific. Molecular diagnostic reflects currently the most promising avenue to decrease time to result and to influence decision making for antibiotic therapy in the septic host. In this study, we wish to highlight the impact of the LightCycler SeptiFast, a multipathogen probe-based real-time polymerase chain reaction, in the rapid etiological diagnosis of sepsis in patients with clinical and laboratory signs of bloodstream infections. We have evaluated prospectively 830 adult patients with suspected bloodstream infection and at least two criteria of systemic inflammatory response syndrome. In more than 50% of critically ill patients strongly suspected of having sepsis, we arrived to an etiological diagnosis only by the molecular method in a median time of 15 h, with specificity and predictive positive values of 96% and 94%, respectively. We highlight the role of DNAemia as time-critical, high-specificity, etiological, non-culture-based rule-in diagnostic biomarker in patients with presumed sepsis.

When should adenoviral non-gonococcal urethritis be suspected? Two case reports.

The impact of Adenovirus as agent of non-gonococcal urethritis (NGU) is still poorly documented in the literature. We describe two cases showing that adenoviral infection should be reasonably hypothesized in men with dysuria and scant urethral discharge in addition to meatus inflammation and/or edema (meatitis) or conjunctivitis. Case 1: a 55-year-old man came to our observation in July 2012 referring a 5-day-history of intense dysuria and scant mucoid urethral discharge. Physical examination revealed the urethral discharge referred, but also modest meatitis and an intense conjunctival hyperemia on his right eye. Adenoviral infection was investigated and Adenovirus DNA (type 37) was detected in both the urethral and conjunctival swabs. Case 2: a 43-year-old man with intense dysuria, started 4-5 days earlier, came to our attention with his wife in August 2012. Scant urethral mucoid secretions, severe meatal inflammation of the male patient were revealed during physical examination. His wife instead complained of a 2-day history of intense burning eyes. Adenoviral infection was investigated and Adenovirus DNA (type 37) was positive both in the male urethral swab and in his wife's conjunctival swab. Adenovirus seems to cause a distinct and recognisable clinical syndrome in men presenting with urethritis. Studies on the prevalence and role of Adenovirus as a causative agent of urethritis are limited. Moreover, as rapid advanced molecular microbiology is now available, we believe that extending the search to Adenovirus in sexually active men with dysuria, scant discharge in addition to meatitis or conjunctivitis, should be a useful approach improving our understanding about adenoviral NGU, and especially avoiding or stopping unnecessary empirical antibiotic therapy.

Methicillin-resistant Staphylococcus aureus infection rate after implementation of an antibiotic care bundle based on results of rapid molecular screening.

AIM: Colonization with methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for subsequent invasive MRSA infection, particularly in patients admitted to critical areas. We conducted a surveillance among patients admitted to our Intensive Care Unit (ICU) to determine whether the implementation of a specific MRSA antibiotic care bundle (ACB) based on rapid molecular screening for MRSA and de-colonization, reduced the total MRSA infection rate. MATERIALS AND METHODS: A total of 431 and 577 nasal swabs were obtained from ICU patients at admission from April 2009 through December 2010 (pre-ACB period) and, after the bundle implementation, from January 2011 through December 2012 (post-ACB period), respectively. Nasal swabs were analyzed by the rapid molecular test Xpert MRSA. All patients were followed-up during their whole ICU stay to determine whether they developed MRSA infection. RESULTS: Overall, 31 out of 431 (7.1%) patients were colonized with MRSA at admission during the pre-ACB period and 49 out of 577 (8.4%) were colonized with MRSA during the post-ACB period. The rate of MRSA infection in ICU significantly declined from 2% in pre-ACB to 0.3% in post-ACB, with a total decrease of 100% in two consecutive semesters between July 2011 and July 2012 (p<0.001). CONCLUSION: The analysis demonstrated a significant decline in MRSA infections following the introduction of active rapid molecular surveillance and the specific ACB at our ICU and in the risk associated with MRSA bacteremia.

[In vitro activity of Eucalyptus smithii and Juniperus communis essential oils against bacterial biofilms and efficacy perspectives of complementary inhalation therapy in chronic and recurrent upper respiratory tract infections]. / Attività in vitro degli oli essenziali di Eucalyptus smithii e Juniperus communis su biofilms batterici e prospettive di efficacia nella terapia complementare inalatoria delle infezioni croniche e recidivanti delle via aeree superiori.

Staphylococcus aureus and Pseudomonas aeruginosa have a high propensity to develop biofilms that are resistant to antimicrobial agents. Eucalyptus smithii and Juniperus communis essential oils are credited with a series of traditional therapeutical properties, including mucolytic effect. As S. aureus and P. aeruginosa biofilms are known to be important factors underlying their virulence and pathogenicity, the aim of this study was to investigate whether E. smithii and J. communis essential oils can interfere with biofilm formation as well as acting on mature biofilms. Tests of two S. aureus and P. aeruginosa clinical strains and two ATCC strains (S. aureus ATCC 25923 and P. aeruginosa ATCC 27853) showed that both E. smithii and J. communis essential oils interfere with the starting phases of biofilm production, as well as with mature biofilms. The results of this study reveal new relevant perspectives for a complementary inhalatory treatment of chronic and/or recurrent upper respiratory tract infections.

[Experimental evaluation of the Sysmex UF-1000i for ruling out non-gonococcal urethritis]. / Utilizzo sperimentale di Sysmex UF-1000i nello screening di uretrite non gonococcica.

Acute nongonococcal urethritis (NGU) is one of the commonest sexually transmitted infections affecting men and women. The diagnosis of NGU has traditionally required microscopic evidence of urethritis. However, a significant proportion of patients with urethral symptoms do not have microscopic evidence of urethritis. The purpose of the present study was to evaluate the analytical performance of the UF1000i, a recently introduced fluorescence flow cytometer intended for urinalysis purposes which provides new analytical features that seem particularly suitable for microbiological diagnostics, for ruling out NGU or predicting the presence of infection. The Sysmex UF1000i is a flow cytometry analyzer capable of quantifying a lot of particles, including bacteria (BACT) and white blood cells (WBCs). To evaluate the analytical performance of the UF1000i as a method for ruling out NGU, we examined 200 urethral smear samples, collected in a new liquid transport medium (Copan), and compared the UF1000i results with standard culture/molecular and microscopic Gram stain results. With instrument cut-off values of 200 BACT x 10^6/L and 500 WBCs x 10^6/L, we obtained a sensitivity of 84%, a specificity of 82%, and a high negative predictive value (96%). Culture/molecular detection of pathogens remains the gold standard technique for the diagnosis of NGU. However, the Sysmex UF1000i is capable of improving the efficiency of NGU presumptive diagnosis, providing results in a few minutes, with a high negative predictive value and high values of sensitivity.

An antibiotic care bundle approach based on results of rapid molecular screening for nasal carriage of methicillin-resistant Staphylococcus aureus in the intensive care unit.

The potential role of active methicillin-resistant Staphylococcus aureus (MRSA) surveillance in the intensive care unit (ICU), has been recently proposed as a guide for antibiotic treatment in patients suspected of being infected with MRSA by using an antibiotic care bundle (ACB) approach. A group of 376 consecutive ICU patients were prospectively screened for nasal carriage of MRSA using a real-time polymerase chain reaction test. The study group consisted of 244 (64.9%) males and (35.1%) females, with a median age of 64 (range 17-95 years). Overall, 26 (6.9%) patients were positive for MRSA, while 350 (93.1%) were MRSA-negative. No difference was observed in gender and age between groups. During ICU stay, 9 (2.4%) patients developed generalized MRSA infection, of whom 8 out of 26 (30.8%) were MRSA-carriers and one out of the 350 (0.3%) was MRSA-negative. Thus, a strong relationship between MRSA infection and MRSA carriage (relative risk=107.7, 95% confidence interval=14.0-828.5, p<0.0001) was found. Subsequently, in our ICU, we developed and introduced a new ACB approach based on rapid nasal screening results for improving the management of critically ill patients. The use of anti-MRSA agents should be re-evaluated daily on the basis of clinical and laboratory features, with positive cultures from sterile site or signs of active infection supporting prolongation of empirical treatment. On the contrary, MRSA-negative clinical cultures support a de-escalation strategy. In conclusion, the early identification of MRSA-carriers using a rapid molecular screening is safe and accurate, allowing MRSA-positive patients, who will more likely develop MRSA infections, to be detected.

[Impact of recent advances in molecular techniques on diagnosing lower respiratory tract infections (LRTIs)]. / L'impatto dei recenti progressi delle tecniche molecolari nella diagnosi delle infezioni delle basse vie respiratorie (LRTI).

At present there is still a great deficit in the routine aetiological diagnosis of lower respiratory tract infections (LRTIs): in most studies more than 50% of cases have no aetiological diagnosis, resulting in prescribing unnecessary or inappropriate antibiotics. A wide variety of diagnostic procedures and techniques are applied to detect the aetiological pathogens of LRTIs. Traditional diagnostic culture methods lack sensitivity, are not feasible in many contexts, and focus only on a few of the large number of aetiological agents. Molecular methods are revolutionizing the diagnostic procedures for managing patients with LRTIs, resulting from a combination of improved sensitivity and specificity, a potential for automatisation and the production of very rapid results.

Molecular diagnosis of Staphylococcus aureus prosthetic aortic graft infection: a case report.

INTRODUCTION: Aortic graft infection is a widely debated topic in the literature, it represents about 1% of post-surgical complications and is associated with a high complication and mortality rate. In most cases, such infections are treated empirically because patients are already under antibiotic coverage so as not to allow isolation of the pathogen. The literature in this regard is very attentive to new molecular diagnostic possibilities, and especially the operating of such complications in a precise diagnostic algorithm and management of the patient. REPORT: We present the case of a 62-year-old patient with abdominal aortic aneurysms (AAA) treated in 2004 by endovascular repair of abdominal aortic aneurysms (EVAR). In 2009, a type II endoleak (the most frequent complication in this kind of surgery) was treated by CT-guided direct puncture and embolization of aneurysm, due to progressive enlargement of the aortic aneurism sac during annual follow-up. After nine days the patient was hospitalized for septic fever. DISCUSSION: When traditional culture does not allow microbiological diagnosis, molecular tests may permit results to be obtained that can change the effective therapeutic intervention, with a decisive impact on patient outcome.

Evaluation of the Sysmex UF1000i flow cytometer for ruling out bacterial urinary tract infection.

BACKGROUND: Urine culture is one of the most frequently requested tests in microbiology, and it represents the gold standard for the diagnosis of UTIs. Considering the high prevalence of negative results and the long TAT of the culture test, the use of a rapid and reliable screening method is becoming more and more important, as it reduces the workload, the TAT of negative results, and above all, unnecessary antibiotic prescription. METHODS: The Sysmex UF1000i is a new urine flow cytometry analyzer capable of quantifying urinary particles, including BACT, WBCs, and YLCs. To evaluate the analytical performance of the UF1000i as a method for ruling out UTIs, we examined 1349 urine samples and compared the UF1000i results with standard urine culture results. RESULTS: With instrument cut-off values of 170BACTx10(6)/L and 150WBCsx10(6)/L, we obtained a sensitivity of 98.8%, a specificity of 76.5%, a NPV of 99.5%, and four false negative results (1.2%), avoiding the culture of 57.1% of samples. CONCLUSION: The Sysmex UF1000i was capable of improving the efficiency of a routine microbiology laboratory by processing 100samples/h and providing negative results in a few minutes, thus reducing unnecessary testing with an acceptable number of false negative results. In addition, the preliminary evaluation of B_FSC and B_FLH parameters from bacteria histograms seems to be useful for the distinction of bacterial strains detected (Gram-negatives versus Gram-positives). In fact when B_FSC was less than 30 ch, it allowed the distinction of Gram-negative bacteria in 97% of the samples.

Molecular identification of bloodstream pathogens in patients presenting to the emergency department with suspected sepsis.

The rapid detection of pathogens in blood is critical for a favorable outcome of patients with suspected sepsis. Although blood culture (BC) is considered the criterion standard for diagnosis of bloodstream infection, it often takes several days to detect the causative organism. In this study, we compared BC with a commercially available multiplex real-time polymerase chain reaction (PCR) assay to detect bacteria and fungi in blood samples from 144 patients admitted to the emergency department with suspected sepsis. Of 144 blood samples examined, 91 (63%) were negative by both methods and 53 (37%) were positive by at least one of the two methods. In 30 among all positive cases (56.6%),both methods identified the same organisms, in 13 cases (24.5%), BC identified organisms not detected by real-time PCR,and in 10 cases (18.9%), SeptiFast PCR assay gave positive results, whereas the BC was negative. In this study, we wished to compare SeptiFast results obtained by standard procedures, but future clinical studies are necessary to define SeptiFast PCR as support for BC in the early diagnosis of severe bloodstream infections.

Aeromonas hydrophila ecthyma gangrenosum without bacteraemia in a diabetic man: the first case report in Italy.

Ecthyma gangrenosum is a well recognized cutaneous manifestation of severe, invasive infection by Pseudomonas aeruginosa usually in immunocompromised and critically ill patients. This type of infection is usually fatal. Aeromonas infection is infrequently reported as the cause of ecthyma gangrenosum. Here we show the first case described in Italy of Aeromonas hydrophila ecthyma gangrenosum in the lower extremities in an immunocompetent diabetic without bacteraemia. A 63-year-old obese diabetic male was admitted with an ulcer on his left leg, oedema, pain and fever. Throughout his hospitalization blood cultures remained sterile, but a culture of A. hydrophila was isolated following punctures from typical leg pseudomonal-ecthyma gangrenosum lesions developed after admission. The patient, questioned again, stated that a few days before he had worked in a well near his house without taking precautions. We conclude that early diagnosis and suitable antibiotic therapy are important for the management of ecthyma gangrenosum. The typical presentation of soft tissue infection of A. hydrophila should mimic a Gram-positive infection, which may result in a delay in administration of appropriate antibiotics. Moreover, A. hydrophila should be considered a possible agent for non-pseudomonal ecthyma gangrenosum in a diabetic man with negative blood cultures, in presence of anamnestical risk factors.