Since 2013, an ongoing global outbreak of among patients who underwent open-chest surgery has been recognized with all cases linked to contamination of a specific brand of heater-cooler device (HCD). Nine cases were diagnosed with disseminated infectionin our hospital. Following the first cases HCD was changed with different technology assuring no release of contaminated particles. The potentially at-risk population was managed throughout a multidisciplinary task force.


In November 2018, following an infected patient’ death, a huge impact on public opinion was registered following mass media publicity of the case. A task force was built up to face the concern of the population: apress release [https://context.reverso.net/traduzione/inglese-italiano/press+release]and an official note were publicly released addressing risk factors and critical symptoms and a call center was activated. The notice was transmitted to general practitioners too. People complaining symptoms suggestive for infection, primarily screened by an expert group through telephone interview, were addressed to an infectious consultation.


The official note was delivered to 2181 potentially at risk patients chosen by cardio surgery registry and 567 of them called back the call center and were interviewed. 66 patients were judged to need infectious specialist consultation: 12 were submitted to further microbiological analysis and 4 required hospitalization. No new cases of infectious were detected.


The public health task force promptly activated granted safety measures for the population; furthermore HCD will soon be settled in separated place out from operating room.

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