Residency in LTCFs increases the likelihood of colonization with multidrug resistant Gram-negative bacteria (MDR-GNB). We assessed the prevalence and risk factors for enteric colonization by ...III-generation cephalosporins-resistant and carbapenem-resistant (CR) GNB in a large group of LTCFs in a high endemic setting. We also assessed the prevalence and risk factors for
colonization.
A point prevalence survey with rectal screening (RS) was conducted in 27 LTCFs in north Italy. Epidemiological and clinical variables on the survey day, history of hospitalization and surgery within one year, and antibiotics within three months, were collected. The presence of III-generation cephalosporin resistant and CR GNB was assessed using a selective culture on chromogenic medium and PCR for carbapenemase detection. The presence of
was assessed using ELISA for GDH and RT-PCR to identify toxigenic strains. Multi-variable analyses were performed using two-level logistic regression models.
In the study period 1947 RSs were performed. The prevalence of colonization by at least one GNB resistant to III-generation cephalosporin was 51% (
65%,
14% of isolates). The prevalence of colonization by CR GNB was 6%. 6% of all isolates (1150 strains) resulted in a carbapenem-resistant
, and 3% in a carbapenem-resistant
. KPC was the most frequent carbapenemase (73%) identified by PCR, followed by VIM (23%). The prevalence of colonization by
was 11.7%. The presence of a medical device (OR 2.67) and previous antibiotic use (OR 1.48) were significantly associated with III-generation cephalosporin resistant GNB colonization. The presence of a medical device (OR 2.67) and previous hospitalization (OR 1.80) were significantly associated with CR GNB. The presence of a medical device (OR 2.30) was significantly associated with
colonization. Main previously used antibiotic classes were fluoroquinolones (32% of previously treated subjects), III-generation cephalosporins (21%), and penicillins (19%).
Antimicrobial stewardship in LTCFs is a critical issue, being previous antibiotic treatment a risk factor for colonization by MDR-GNB. The prevalence of colonization by III-generation cephalosporin and CR GNB among LTCF residents also underlines the importance to adhere to hand hygiene indications, infection prevention and control measures, and environmental hygiene protocols, more achievable than rigorous contact precautions in this type of social setting.
IMPORTANCE: The coronavirus disease 2019 (COVID-19) pandemic is threatening billions of people worldwide. Tocilizumab has shown promising results in retrospective studies in patients with COVID-19 ...pneumonia with a good safety profile. OBJECTIVE: To evaluate the effect of early tocilizumab administration vs standard therapy in preventing clinical worsening in patients hospitalized with COVID-19 pneumonia. DESIGN, SETTING, AND PARTICIPANTS: Prospective, open-label, randomized clinical trial that randomized patients hospitalized between March 31 and June 11, 2020, with COVID-19 pneumonia to receive tocilizumab or standard of care in 24 hospitals in Italy. Cases of COVID-19 were confirmed by polymerase chain reaction method with nasopharyngeal swab. Eligibility criteria included COVID-19 pneumonia documented by radiologic imaging, partial pressure of arterial oxygen to fraction of inspired oxygen (Pao2/Fio2) ratio between 200 and 300 mm Hg, and an inflammatory phenotype defined by fever and elevated C-reactive protein. INTERVENTIONS: Patients in the experimental arm received intravenous tocilizumab within 8 hours from randomization (8 mg/kg up to a maximum of 800 mg), followed by a second dose after 12 hours. Patients in the control arm received supportive care following the protocols of each clinical center until clinical worsening and then could receive tocilizumab as a rescue therapy. MAIN OUTCOME AND MEASURES: The primary composite outcome was defined as entry into the intensive care unit with invasive mechanical ventilation, death from all causes, or clinical aggravation documented by the finding of a Pao2/Fio2 ratio less than 150 mm Hg, whichever came first. RESULTS: A total of 126 patients were randomized (60 to the tocilizumab group; 66 to the control group). The median (interquartile range) age was 60.0 (53.0-72.0) years, and the majority of patients were male (77 of 126, 61.1%). Three patients withdrew from the study, leaving 123 patients available for the intention-to-treat analyses. Seventeen patients of 60 (28.3%) in the tocilizumab arm and 17 of 63 (27.0%) in the standard care group showed clinical worsening within 14 days since randomization (rate ratio, 1.05; 95% CI, 0.59-1.86). Two patients in the experimental group and 1 in the control group died before 30 days from randomization, and 6 and 5 patients were intubated in the 2 groups, respectively. The trial was prematurely interrupted after an interim analysis for futility. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of hospitalized adult patients with COVID-19 pneumonia and Pao2/Fio2 ratio between 200 and 300 mm Hg who received tocilizumab, no benefit on disease progression was observed compared with standard care. Further blinded, placebo-controlled randomized clinical trials are needed to confirm the results and to evaluate possible applications of tocilizumab in different stages of the disease. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04346355; EudraCT Identifier: 2020-001386-37
The health impact of antimicrobial resistance (AMR) has not been included in the Global Burden of Disease (GBD) report, as reliable data have been lacking. AMR burden estimates have been derived from ...models combining incidence and/or prevalence data from national and/or international surveillance systems and mortality estimates from clinical studies. Depending on utilized empirical data, statistical methodology and applied endpoints, the validity and reliability of results can differ substantially.
We assessed comprehensiveness, and internal and external validity of studies estimating the clinical impact of infections caused by the priority antibiotic resistant pathogens monitored by the WHO Global Antimicrobial Resistance Surveillance System.
Ovid MEDLINE, January 1950 to March 2019, In-Process and other non-indexed citations were searched.
Studies reporting mortality, length of hospital stay, duration of the disease until remission and/or death, complications, hospital re-admissions, and follow-up beyond hospital discharge were eligible.
The literature was searched according to the Cochrane recommendations and reported according to Preferred Reporting Items for Systematic Reviews.
Two-hundred and eighty-six studies out of 3529 were eligible. Studies derived mainly from high-income countries (215, 75%) and relied on data from retrospective (226, 79%), single-centre (201, 70%), cohort studies (243, 85%). The health impact was mostly limited to all-cause mortality (128, 45%) with heterogeneity in timing of assessment; attributable length of hospital stay was seldom adjusted for pre-infection admission time and a few studies had enough follow-up for assessing long-term sequelae. Overall, adjustment for confounding has shown a substantial improvement. Data on health state definitions and duration of diseases are generally lacking, precluding calculation of disability-adjusted life years, critical for application of the GBD study methodology.
Efforts to improve harmonization, representativeness, quality of AMR surveillance data and cohort studies to determine AMR attributable mortality and morbidity are urgently required. Policy makers need accurate and detailed burden estimates to inform prioritization of resource allocation, and to select the most effective intervention strategies to halt the AMR crisis.
•Antimicrobial stewardship (AS) is a key intervention for controlling antimicrobial resistance; however, there is no clear evidence on which AS strategy has the best effectiveness and ...sustainability•This study reports the results of a quasi-experimental study assessing the effect of a new AS model in reducing antimicrobial consumption in the internal medicine area•The intervention was associated with a sustained reduction in antimicrobial consumption, mortality and length of hospital stay in the intervention wards•A non-significant trend towards reduced Clostridioides difficile infections and multidrug-resistant Gram-negative bacteraemia was also recorded in the intervention wards•A more comprehensive analysis, including different hospital settings, is needed to further extend the generalisability of the results
Antibiotic stewardship (AS) is a cornerstone of the fight against antimicrobial resistance; however, evidence on the best practice to improve antibiotic prescription in various hospital settings is still scarce. This study aimed to measure the efficacy of a non-restrictive AS intervention in the internal medicine area of a tertiary-care hospital across a 3-year period.
The intervention comprised a 3-month ‘intensive phase’ based on education and guidelines provision, followed by 9 months of audits and feedback activities. The primary outcome was the overall antibiotic consumption measured as days of therapy (DOTs) and defined daily doses (DDDs). Secondary outcomes were carbapenem and fluoroquinolone consumption, all-cause in-hospital mortality, length of stay, incidence of Clostridioides difficile and carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSIs). All outcomes were measured in the intervention wards comparing the pre-phase with the post-phase using an interrupted time-series model.
A total of 145 337 patient days (PDs) and 14 159 admissions were included in the analysis. The intervention was associated with reduced DOTs*1000PDs (–162.2/P = 0.005) and DDDs*1000PDs (–183.6/P ≤ 0.001). A sustained decrease in ward-related antibiotic consumption was also detected during the post-intervention phase and in the carbapenem/fluoroquinolone classes. The intervention was associated with an immediate reduction in length of stay (–1.72 days/P < 0.001) and all-cause mortality (–3.71 deaths*100 admissions/P = 0.002), with a decreasing trend over time. Rates of Clostridioides difficile infections and CRE-BSIs were not significantly impacted by the intervention.
The AS intervention was effective and safe in decreasing antibiotic consumption and length of stay in the internal medicine area. Enabling prescribers to judicious use of antimicrobials through active participation in AS initiatives is key to reach sustained results over time.
Abstract Objectives Escherichia coli can cause infections in the urinary tract and in normally sterile body sites leading to invasive E. coli disease (IED), including bacteraemia and sepsis, with ...older populations at increased risk. We aimed to estimate the theoretical coverage rate by the ExPEC4V and 9V vaccine candidates. In addition, we aimed at better understanding the diversity of E. coli isolates, including their genetic and phenotypic antimicrobial resistance (AMR), sequence types (STs), O-serotypes and the bacterial population structure. Methods Blood and urine culture E. coli isolates (n = 304) were collected from hospitalized patients ≥60 years (n = 238) with IED during a multicentric, observational study across three continents. All isolates were tested for antimicrobial susceptibility, O-serotyped, whole-genome sequenced and bioinformatically analysed. Results A large diversity of STs and of O-serotypes were identified across all centres, with O25b-ST131, O6-ST73 and O1-ST95 being the most prevalent types. A total of 45.4% and 64.7% of all isolates were found to have an O-serotype covered by the ExPEC4V and ExPEC9V vaccine candidates, respectively. The overall frequency of MDR was 37.4% and ST131 was predominant among MDR isolates. Low in-patient genetic variability was observed in cases where multiple isolates were collected from the same patient. Conclusions Our results highlight the predominance of MDR O25b-ST131 E. coli isolates across diverse geographic areas. These findings provide further baseline data on the theoretical coverage of novel vaccines targeting E. coli associated with IED in older adults and their associated AMR levels.
Background
Clinical data characterizing invasive
Escherichia coli
disease (IED) are limited. We assessed the clinical presentation of IED and antimicrobial resistance (AMR) patterns of causative
E. ...coli
isolates in older adults.
Methods
EXPECT-2 (NCT04117113) was a prospective, observational, multinational, hospital-based study conducted in patients with IED aged ≥ 60 years. IED was determined by the microbiological confirmation of
E. coli
from blood; or by the microbiological confirmation of
E. coli
from urine or an otherwise sterile body site in the presence of requisite criteria of systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), or quick SOFA (qSOFA). The primary outcomes were the clinical presentation of IED and AMR rates of
E. coli
isolates to clinically relevant antibiotics. Complications and in-hospital mortality were assessed through 28 days following IED diagnosis.
Results
Of 240 enrolled patients, 80.4% had bacteremic and 19.6% had non-bacteremic IED. One-half of infections (50.4%) were community-acquired. The most common source of infection was the urinary tract (62.9%). Of 240 patients, 65.8% fulfilled ≥ 2 SIRS criteria, and 60.4% had a total SOFA score of ≥ 2. Investigator-diagnosed sepsis and septic shock were reported in 72.1% and 10.0% of patients, respectively. The most common complication was kidney dysfunction (12.9%). The overall in-hospital mortality was 4.6%. Of 299
E. coli
isolates tested, the resistance rates were: 30.4% for trimethoprim-sulfamethoxazole, 24.1% for ciprofloxacin, 22.1% for levofloxacin, 16.4% for ceftriaxone, 5.7% for cefepime, and 4.3% for ceftazidime.
Conclusions
The clinical profile of identified IED cases was characterized by high rates of sepsis. IED was associated with high rates of AMR to clinically relevant antibiotics. The identification of IED can be optimized by using a combination of clinical criteria (SIRS, SOFA, or qSOFA) and culture results.
We report the first Italian case of Mycobacterium chimaera disseminated infection in a patient with a history of cardiac surgery. The patient was initially diagnosed with sarcoidosis and started on ...immunosuppressive therapy. Ten months later she developed a vertebral osteomyelitis: M. chimaera was isolated from bone specimen. A review of the literature shows that M. chimaera infection occurs specifically in this population of patients, due to contamination of heater-cooler units used during cardiosurgery. Devices responsible for the transmission were produced by Sorin Group Deutschland. Mycobacterium chimaera infection should be included in the differential diagnosis for patients undergoing cardiac surgery.
The work consists of two overlapping generations models of three periods each, one containing a pay-as-you-go pension system and the other a capitalisation pension system. In the first period agents ...don't work and have to decide how much to invest in training, borrowing from the generation working at that time. Training is risky and its result is known in the following period, when the accumulated human capital becomes productive and enters the production function. In the final third period agents are retired. Human capital deriving from investments in training follows a simple stochastic process. The two models are analytically solved in the two endogenous variables: the rate of growth of investments in human capital and the stock of real capital per unit of efficient work. What kind of effects can the structure of pensions have on decisions of agents to have or not to have risky training when young? Contrarily to commonly accepted theoretical position, many scenarios come out in which a pay-as-you-go system conducted in financial equilibrium can generate higher rate of growth, never violating compatibility between incomes belonging to the young and the old generation.
The paper provides a detailed description of the legal and regulatory framework that governs Italian pharmacies and the retail distribution of pharmaceuticals, as well as the government’s recent ...attempts to reform and modernize the system. The picture to emerge is a clear example of an over-regulated market closed to competition; in fact, while the declared intention is to protect the public health and citizens, the regulatory machinery appears designed precisely to favor the interests of incumbent pharmacies and pharmacists. In conclusion, the paper proposes some policy guidelines, also based on the considerations, suggestions and provisions that both the Italian Antitrust and the European Commission have been developing over the past few years.
Correction to: J Transl Med (2020) 18:405 https://doi.org/10.1186/s12967-020-02573-9 Following publication of the original article 1 the authors identified that the collaborators of the TOCIVID-19 ...investigators, Italy were only available in the supplementary file. The original article has been updated so that the collaborators are correctly acknowledged. For clarity, all collaborators are listed in this correction article. Acknowledgement List of participating centres and Co-Investigators TOCIVID-19 Investigators * Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli—Clinical Trials Unit: Francesco Perrone, Maria Carmela Piccirillo, Clorinda Schettino, Adriano Gravina, Piera Gargiulo, Claudia Cardone, Laura Arenare; Melanoma And Cancer Immunotherapy And Developmental Therapeutics Unit: Paolo Antonio Ascierto, Maria Grazia Vitale, Claudia Trojaniello, Marco Palla; Direction: Attilio Antonio Montano Bianchi, Gerardo Botti, Gianfranco De Feo, Leonardo Miscio. * Università degli Studi della Campania Luigi Vanvitelli, Dipartimento di Salute Mentale e Medicina Preventiva; Ciro Gallo, Paolo Chiodini. * IRCCS Policlinico San Donato—Milano: Laurenzia Ferraris, Massimiliano M. Marrocco-Trischitta, Marco Froldi, Lorenzo Menicanti, Maria Teresa Cuppone, Giulia Gobbo, Chiara Baldessari, Vincenzo Valenti, Serenella Castelvecchio, Federica Poli, Francesca Giacomazzi, Rosangela Piccinni, Maria Laura Annnunziata, Andrea Biondi, Cecilia Bussolari, Manuel Mazzoleni, Andrea Giachi, Annalisa Filtz, Arianna Manini, Enrico Poletti, Federico Masserini, Francesco Conforti, Gianfranco Gaudiano, Vittoria Favero, Alice Moroni, Tommaso Viva, Fabiana Fancoli, Davide Ferrari, Dario Niro, Marco Resta, Andrea Ballotta, Marco Dei Poli, Marco Ranucci. * ASST Papa Giovanni XXIII—Bergamo: Diego Ripamonti, Francesca Binda, Alessandra Tebaldi, Giuseppe Gritti, Luisa Pasulo, Leonardo Gaglio, Roberto Del Fabbro, Leonardo Alborghetti. * ASST Monza—Monza: Paolo Bonfanti, Nicola Squillace, Giulia Giustinetti, Paola Columpsi, Marina Cazzaniga, Serena Capici, Luca Sala, Riccardo Di Sciacca, Giacomo Mosca, Maria Rosa Pirozzi. * ASST degli Spedali Civili di Brescia e Università di Brescia—Brescia: Francesco Castelli, Maria Lorenza Muiesan, Franco Franceschini, Aldo Roccaro, Massimo Salvetti, Anna Paini, Luciano Corda, Chiara Ricci, Lina Tomasoni, Paola Nasta, Silvia Lorenzotti, Silvia Odolini, Emanuele Focà, Eugenia Quiros Roldan, Marco Metra, Stefano Magrini, Paolo Borghetti, Nicola Latronico, Simone Piva, Matteo Filippini, Gabriele Tomasoni, Francesco Zuccalà, Sergio Cattaneo, Francesco Scolari, Nicola Bossini, Mario Gaggiotti, Martina Properzi. * Ospedale Santa Maria Goretti—Latina: Miriam Lichtner, Emanuela Del Giudice, Raffaella Marocco, Anna Carraro, Cosmo Del Borgo, Raffaella Marocco, Valeria Belvisi, Tiziana Tieghi, Margherita De Masi, Paola Zuccalà, Paolo Fabietti, Angelo Vetica, Vito Sante Mercurio, Anna Carraro, Laura Fondaco, Blerta Kertusha, Ambrogio Curtolo, Emanuela Del Giudice, Riccardo Lubrano, Maria Gioconda Zotti, Antonella Puorto, Marcello Ciuffreda, Antonella Sarni, Gabriella Monteforte, Domenico Romeo, Emanuela Viola, Carla Damiani, Antonietta Barone, Barbara Mantovani, Daniela Di Sanzo, Vincenzo Gentili, Massimo Carletti, Massimo Aiuti, Andrea Gallo, Piero Giuseppe Meliante, Salvatore Martellucci, Oliviero Riggio, Vincenzo Cardinale, Lorenzo Ridola, Maria Consiglia Bragazzi, Stefania Gioia, Emiliano Valenzi, Camilla Graziosi, Niccolò Bina, Martina Fasolo, Silvano Ricci, Maria Teresa Gioacchini, Antonella Lucci, Luisella Corso, Daniela Tornese, Parni Nijhawan, Francesco Equitani, Carmine Cosentino, Marcello Palladino, Frida Leonetti, Gaetano Leto, Camillo Gnessi, Giuseppe Campagna, Roberto Cesareo, Francesca Marrocco, Giuseppe Straface, Alessandra Mecozzi, Lidia Cerbo, Valentina Isgrò, Sergio Parrocchia, Giuseppe Visconti, Giorgio Casati. * AOU di Parma—Parma: Carlo Calzetti, Alarico Ariani, Lorenzo Donghi. * AOUI di Verona—Verona: Nicola Duccio Salerno, Evelina Tacconelli, Marco Bertoldi, Paolo Cattaneo, Lorenza Lambertenghi, Leonardo Motta, Luca Omega. * Humanitas Gavazzeni—Bergamo: Giovanni Albano. * AORN Dei Colli—Napoli: Roberto Parrella, Fiorentino Fraganza, Luigi Atripaldi, Vincenzo Montesarchio, Francesco Scarano, Annunziata De Rosa, Amalia Buglione, Sabrina Lavoretano, Gianfranco Gaglione, Mario De Marco, Vincenzo Sangiovanni, Francesco Maria Fusco, Rosaria Viglietti, Elio Manzillo, Carolina Rescigno, Raffaella Pisapia, Giulia Plamieri, Alberto Maraolo, Giosuè Calabria, Mario Catalano, Giuseppe Fiorentino, Anna Annunziata, Giorgio Polistina, Pasquale Imitazione, Mariano Mollica, Vincenzo Esposito, Maurizio D’Abraccio, Rodolfo Punzi, Vincenzo Bianco, Costanza Sbreglia. * Azienda Ospedaliera Umberto I—Siracusa: Rosa Fontana Del Vecchio, Alessandro Bordonali, Antonina Franco. * Arcispedale Santa Maria Nuova IRCCS—Reggio Emilia: Carlo Salvarani, Marco Massari, Giovanni Dolci, Pierpaolo Salsi, Matteo Fontana. * ASST di Cremona—Cremona: Giuseppe Virzì, Calderone Ornella, Alfredo Molteni. * Azienda Ospedaliera San Salvatore—Pesaro: Silvia Gennarini, Umberto Gnudi, Maria Anastasia Ricci, Giancarlo Titolo, Giulio Mensi, Pietro Vuotto, Beatrice Gasperini, Mauro Mancini, Zeno Pasquini. * Ospedale Bassini—Cinisello Balsamo: Paolo Spanu, Stefano Clementi, Simona Pierini, Daniela Bokor, Daniela Gori, Morena Ciofetti, Marina Caimi, Laura Bettazzi, Elisabetta Allevi, Silvia Furiani, Chiara Capitanio, Bernardino Mastropasqua, Claudio Fara, Grazia Pulitanò, Jun Sebastian Matsuno, Francesca Della Porta, Viola Dolfini, Nebiat Balei Beyene. * ASST Degli Spedali Civili Di Brescia—Brescia: Michela Bezzi, Mauro Novali. * AOU di Bologna—Bologna: Pierluigi Viale, Sara Tedeschi, Renato Pascale. * Policlinico S. Matteo—Pavia: Raffaele Bruno, Alessandro Di Filippo, Michele Sachs, Tiberio Oggionni, Michele Di Stefano, Caterina Mengoli. * Ospedale di Conegliano—Conegliano: Cesarina Facchini, De Nardo Daniele. * Azienda Ospedaliera San Salvatore—Pesaro: Gabriele Frausini, Luciano Mucci, Silvia Tedesco, Rita Girolimetti, Elena Manfredini, Anna Maria Di Carlo, Emma Espinosa, Donatella Dennetta. * AOU di Parma—Parma: Andrea Ticinesi, Tiziana Meschi, Antonio Nouvenne. * Azienda Ospedaliera Ordine Mauriziano—Torino: Norbiato Claudio, Francesco Vitale, Marta Saracco. * Ospedale Guglielmo Da Saliceto—Piacenza: Mauro Codeluppi, Elisa Fronti, Patrizia Ferrante. * Ospedale di Fermo—Fermo: Giorgio Amadio Nespola. * AOU di Perugia—Perugia: Daniela Francisci, Andrea Tosti. * Casa Sollievo Della Sofferenza—San Giovanni Rotondo: Cristiano Matteo Carbonelli, Antonio Greco, Maria Giulia Tinti. * Fondazione Poliambulanza Istituto Ospedaliero—Brescia: Roberto Stellini, Camilla Appiani, Piera Reghenzi. * Ospedale Morgagni-Pierantoni—Forlì: Venerino Poletti, Claudia Ravaglia. * Ospedale Area Aretina Nord—Arezzo: Danilo Tacconi, Costanza Malcontenti. * AOU “Maggiore della Carità”—Novara: Pier Paolo Sainaghi, Raffaella Landi, Veronica Vassia, Eleonora Rizzi, Mattia Bellan, Antonella Rossati, Luigi Castello * Policlinico Umberto I—Roma: Claudio Maria Mastroianni, Gianluca Russo. * Presidio Ospedaliero di Jesolo—Jesolo: Toffoletto Fabio, Francesco Saverio Serino, Lucio Brollo, Elena Momesso, Maria Luisa Turati. * ASST Santi Paolo e Carlo—Milano: Antonella D'arminio Monforte, Giulia Marchetti. * Ospedale Civile di Guastalla—Guastalla: Fabrizio Boni, Elisabetta Teopompi, Chiara Trenti, Luca Boracchia, Enrica Minelli, Matteo Fontana, Giulia Ghidoni, Anaflorina Matei, Andrea Caruso. * AO Ospedali Riuniti Villa Sofia e Cervello—Palermo: Giuseppe Arcoleo, Gaetana Camarda, Filippo Catalano, Mario Spatafora. * Ospedale Sacra Famiglia, Fatebenefratelli—Erba: Donato Bettega. * AOU Policlinico Tor Vergata—Roma: Massimo Andreoni, Elisabetta Teti, Loredana Sarmati, Andrea Di Lorenzo, Mariagrazia Celeste. * Ospedali Riuniti Padova Sud—Padova: Fabio Baratto, Jacopo Monticelli, Pietro Criveller. * Ospedale San Paolo—Savona: Antonini Andrea, Anselmo, Riccio. * ASST Spedali Civili Di Brescia—Brescia: Maurizio Castellano, Carlo Cappelli, Federica Corvini, Barbara Zanini. * ASST Spedali Civili Di Brescia, Presidio Ospedaliero Gardone—Brescia: Massimo Crippa, Maurizio Ronconi, Raffaella Costa, Silvia Casella, Loretta Brentana. * Ospedale Civile e Ospedale Dell'Angelo—Mestre: Livio Bernardi, Andrea Frascati, Sandro Panese, Fabio Presotto, Lucio Michieletto, Cristina Bernardi. * Ospedale Santa Maria Delle Croci—Ravenna: Maurizio Fusar. * Presidio Ospedaliero di Cesena—Cesena: Vanni Agnoletti, Martina Farina, Russo. * AOU Careggi—Firenze: Federico Lavorini, Roberta Ginanni. * Istituto Nazionale Malattie Infettive INMI L. Spallanzani, IRCCS—Roma: Fabrizio Palmieri, Silvia Mosti. * Casa Di Cura Beato Palazzolo—Bergamo: Angelo Amaglio, Alessandra Cattaneo. * Istituto Clinico S. Ambrogio Spa—Milano: Silvia Cirri, Andrea Montisci, Chiara Gallazzi, Daniele Cosseta, Barabara Baronio, Lorenzo Rampa. * AO Sant’Anna e San Sebastiano—Caserta: Paolo Maggi, Vincenzo Messina. * Arcispedale Santa Maria Nuova IRCCS—Reggio Emilia: Emanuele Alberto Negri, Chiara Trenti. * Ospedale Generale Provinciale—Macerata: Marialma Berlendis, Maria Cecilia Sabatti. * Azienda Ospedaliera S. Maria—Terni: Michele Palumbo. * ASST Ovest Milanese—Milano: Antonino Mazzone, Paola Faggioli. * Ospedale Bellaria—Bologna: Linda Bussini, Giacomo Fornaro, Francesca Volpato. * Ospedale Maria Vittoria—Torino: Daniele Imperiale, Emilpaolo Manno, Enrico Ferreri, Domenico Martelli, Andrea Verhovez, Silvia Giorgis, Luciana Faccio, Rachele Delli Quadri, Cristina Negro. * Ospedale Giovanni Bosco—Torino: Marcella Converso, Francesca Bosco. * ASST Desenzano Del Garda—Gavardo: Silvia Amadasi, Paolo Prandini, Silvia Cocchi. * Azienda ULSS 6—Vicenza: Vinicio Manfrin, Veronica Del Punta. * PO Sant’Elia—Caltanissetta: Giovanni Mazzola, Giuseppe Sportato. * Ospedale Ca’ Foncello—Treviso: Micaela Romagnoli. * Ospedale Infermi—Rimini: Francesco Cristini
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