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Between April 1, 2017 and July 1, 2020, “91 Citrobacter koseri positive subjects were identified” and of these “a total of 9 patients developed invasive disease” and 4 died. Going back to 2015, the number of children infected with the bacterium increases to 100: 98 between neonatal and pediatric intensive care and two more in pediatrics. These are the data of the Inspection Commission commissioned by the Governor of Veneto Luca Zaia on the medical-sanitary situation at the Hospital for Women and Children of Borgo Trento, in Verona.
The map
The Commission has just presented its report: 52 pages describing the underestimation, poor hygiene care, for example, not respecting the sterilization protocols for the hands of medical and nursing staff, but also of parents present in the rooms under accusation. There is talk of the bacteria in the jet-breaking filters of the taps (therefore in the water) and in the bottles (both on the external and internal surface). The lack of communication with the institutional bodies that should have been aware of the ongoing epidemic is described. From the documentation that the Commission has compiled and analyzed, it appears that after the interruption of controls by Covid, “the resumption of screening demonstrates how high circulation of the bacteria persists among newborns hospitalized in neonatal intensive care.” In the first 5 months of 2020, 33.6% of newborns were affected and, in some moments, according to the minutes, the affectation involved 75% of hospitalized subjects ”. Another passage: “There is evidence of a lack of communication of the events in the Veneto Region and Azienda Zero (the health administrative center of Veneto)” contrary to what “established by regional and national directives”. No one has released information “about epidemic events” from the hospital. Nothing “until the email from the Risk Manager on June 22nd. It is emphasized that this communication is after the establishment of this Commission “.
“Hygiene products below standards”
On the other hand, it is unknown what information and what communication methods were made to the families of the infants involved. Again: “In neonatal and pediatric intensive care, the products used in alcoholic solution were below the minimum standards of the WHO”, standards to be considered “insufficient given the type of patients managed”. The Commissioners hypothesize the transmission of citrobacter also through the use of “tap water”. They explain that “for the hygienic care of the child, the use of pre-washed tap water with an antibacterial filter is foreseen, but the analysis of the reports shows that the antibacterial filters were only installed in July 2020.” Such a set of understatements that the report ends with words about “a substantial lack of infectious culture.”
September 1, 2020 (change September 1, 2020 | 19:01)
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