Bassetti denuncia cosa sta accadendo in Italia. Matteo Bassetti, come sempre, non le manda a dire. Direttore della Clinica Malattie infettive dell’IRCCS San Martino di Genova e ordinario della stessa materia all’Università del capoluogo ligure, è – dallo scorso mese di marzo – in prima linea nella battaglia contro il Covid-19. Ecco le sue parole in una lunga intervista rilasciata a Il Giornale:
Ma non si è mai lasciato sopraffare dal panico “da pandemia”, e dal suo reparto, dove nonostante i ricoveri siano in grande crescita la mortalità è sempre molto bassa, risponde volentieri alle nostre domande, mettendo però immediatamente in chiaro un concetto: «Non parlerò dei miei colleghi, sono stanco di polemiche e di inutili contrapposizioni tra “ottimismo” e “pessimismo”, tra chi lavora meglio e chi peggio. Io penso solo a curare i miei pazienti e a fare il mio lavoro. Con realismo».
Bassetti denuncia cosa sta succedendo in Italia
E il realismo oggi cosa ci dice?
«Ci dice che questa è un’infezione che si può gestire, dalla quale si guarisce, e che a oggi ha una letalità di circa lo 0,5%. Una percentuale che è più alta rispetto all’influenza stagionale, ma molto più bassa rispetto a molte altre malattie infettive. Quindi, il problema di questa infezione non è la letalità ma la contagiosità e la contemporaneità dei casi: il numero di morti di Covid-19 di oggi e il numero di morti per infezioni respiratorie e influenza non saranno molto differenti. Però nel caso del Covid, proprio per il fatto che i casi si verificano tutti in pochissimo tempo, c’è un impatto importante sulle strutture ospedaliere che rischia di mandarle al collasso. E su questo influisce la paura, il panico che viene inopinatamente trasmesso alle persone, ormai in ogni occasione. Ma il panico, in medicina, è il peggior ostacolo verso la risoluzione dei problemi, e il peggior consigliere che possa esistere: sia del medico che del paziente».
Cosa intende dire?
«Che se il 30/35% di accessi al pronto soccorso è composto da persone asintomatiche o paucisintomatiche, vuol dire che il comportamento – sia individuale che collettivo – è già pesantemente alterato dal panico. Se una persona ha 38 di febbre, deve stare a casa, non correre al Pronto Soccorso. Perché il problema è proprio quello, la gestione ospedaliera. Se consideriamo che ci sono aree del Paese – pensiamo a Milano, ma anche alla stessa Genova – che al momento hanno una prevalenza del 10/15% o forse più, che vuol dire che 15-20 persone su 100 potrebbero essere positive al SarsCov-2, si capisce bene come mai e poi mai si potranno gestire, negli ospedali, tutte queste persone. Bisogna evitare di fomentare il terrore, se si vuole mantenere saldo il sistema».
Però magari molte persone corrono subito all’ospedale perché nella prima fase i malati erano di fatto abbandonati a casa, e spesso arrivavano in ospedale quando ormai il danno era irreparabile, non pensa?
«Certamente, questo può essere il messaggio che è arrivato alla gente. Ma non sempre è stato così. E proprio su questo dobbiamo fare un ulteriore sforzo di informazione e di chiarezza improntata al realismo: spiegare cosa succede nei reparti. Spiegare il fatto che abbiamo adesso protocolli di cura sperimentati, che all’inizio non avevamo. Nella prima fase di questa ondata il sistema sanitario è stato colpito in maniera così improvvisa e inaspettata che per molti giorni e molte settimane si è proceduto per tentativi. Adesso non è più così».
Quali sono i protocolli che utilizzate?
«Utilizziamo l’antivirale remdesivir quando c’è insufficienza respiratoria, e quando l’esordio dei sintomi è avvenuto da meno di 10 giorni: questo perché prendere il remdesivir ha un senso solo quando siamo nella fase “viremica”. Poi abbiamo il cortisone, che oggi è la base del trattamento per i quadri più impegnativi di Covid-19, e poi abbiamo l’eparina, sia in profilassi che in terapia. In caso di polmonite grave, usiamo anche gli antibiotici».
Molti farmaci che usavate nella prima fase sono stati abbandonati, per quale motivo?
«Perché strada facendo ci siamo resi conto che non servivano. Nell’ordine, possiamo dire di aver perso per strada per primo il tocilizumab, farmaco usato per l’artrite reumatoide che usavamo insieme al cortisone: i benefici, però, probabilmente provenivano più dal cortisone che dal tocilizumab e quindi è stato abbandonato e si usa solo all’interno di studi clinici. Abbiamo perso l’idrossiclorochina, che utilizzavamo inizialmente e che poi è stata sconsigliata per via degli effetti collaterali, e abbiamo anche perso gli antiretrovirali, quindi i farmaci contro l’HIV. Ma io vedo oggi, in reparto, risultati molto diversi rispetto a marzo. Le cure precoci, l’uso del cortisone, dare la giusta quantità di ossigeno, ci porta risultati molto incoraggianti. È evidente che conoscere una malattia e i suoi risvolti permette di curare molto meglio. Per questo è inutile, anzi dannoso farsi prendere dal panico. E poi c’è un’altra componente fondamentale, sulla quale al San Martino abbiamo sempre puntato e che ci ha permesso di diventare un modello…»
Può spiegarcela?
«La multi disciplinarietà, il cercare di gestire questa malattia con tante teste che lavorano insieme. C’è l’infettivologo, il rianimatore, il cardiologo, il pneumologo, il fisioterapista respiratorio, gli infermieri, gli operatori socio sanitari. il nostro segreto è di avere creato un gruppo dove non c’è un capo e gli altri ubbidiscono, ma dove siamo tutti uguali e importanti allo stesso modo. Lo sviluppo dei protocolli è fatto, inevitabilmente, di multidisciplinarietà: quindi io che sono infettivologo posso stabilire quale sia l’antivirale da usare, ma non posso valutare quando mettere un casco, o un tubo o una maschera di Venturi. Quando è bene nel protocollo usare l’eparina, quanta darne. La costruzione di un modello multidisciplinare è strategica, ed è proprio per questo che alcuni ospedali hanno visto declinare progressivamente le curve di letalità».
I risultati sono visibili anche su altri fattori, come la durata del ricovero, per esempio?
«Certamente, anzi gli altri fattori sono anche più utili, perché nella gestione del Covid è sbagliato prendere come unico parametro la mortalità, perché questa è legata a troppi fattori. Se hai molti ricoveri di ultraottantenni, è ovvio che purtroppo la mortalità salirà perché è legata alle condizioni di base. Dobbiamo quindi andare a esaminare indicatori come la quantità di tromboembolie polmonari, la durata dei ricoveri, fattori che magari all’osservatore non esperto sembrano poco importanti ma che invece sono fondamentali per migliorare i protocolli. Durata della ventilazione, dell’ospedalizzazione, giorni di antibiotico, velocità di dimissione. Su tutto questo abbiamo un modello che funziona, e l’abbiamo perché da subito abbiamo condiviso i percorsi e la gestione del malato».
Speranze dai nuovi farmaci in via di sperimentazione, e dalla ricerca portata avanti in tutto il mondo?
«Innanzitutto c’è ancora da capire quanto potrà servire il plasma iperimmune, perché ad oggi non ci sono evidenze solide per poter dire se usarlo o meno. Quando saranno pubblicati gli studi randomizzati potremmo avere chiare indicazioni. E poi, sì, grandi speranze perché aspettiamo gli anticorpi monoclonali, che apriranno la strada alla sconfitta del Covid-19. Io ho visto dei dati iniziali straordinari, e se saranno approvati potranno cambiare il paradigma del trattamento di questa infezione. Avremo gente che arriva al pronto soccorso, riceve una dose e dopo due giorni non ha più sintomi. Questo è il futuro.Poi ci sono 3 o 4 linee di ricerca su altri antivirali, oltre il remdesivir. La ricerca farmacologica è molto combattiva».
Lei ha parlato spesso degli “errori” commessi durante la prima fase: tra questi c’è anche l’aver fatto troppe previsioni?
«Sicuramente, e qui ricadiamo nell’argomento “realismo” di cui parlavo prima, che vuol dire spiegare le cose come stanno, e non prevedere il futuro. Tanti di noi, e io stesso abbiamo fatto previsioni, in passato, e sono state più le volte in cui abbiamo sbagliato di quelle che abbiamo azzeccato. Ricordo che qualcuno di noi ha detto che a giugno avremmo avuto 150.000 persone in terapia intensiva (nel picco massimo ne abbiamo avute 4800) chi ha detto che sarebbe arrivata una seconda ondata simile alla spagnola, con 50.000 morti, chi invece ha detto che non sarebbe mai arrivata la seconda ondata. Tutte previsioni che lasciano il tempo che trovano, dato che siamo di fronte a una malattia nuova. Fare previsioni equivale a lanciare una monetina».
In un post odierno, lei ha scritto che tra questi “errori” della prima fase di lotta al Covid-19 c’è anche quello di aver usato troppo e male gli antibiotici: è davvero così?
«Purtroppo sì. E questo è anche l’argomento di un editoriale che ho scritto assieme a due colleghi per la più prestigiosa rivista al mondo dedicata alla terapia intensiva, “Intensive Care Medicine”. Con l’articolo vogliamo sottolineare l’importanza dell’uso appropriato degli antibiotici per evitare di creare resistenze antibatteriche durante la pandemia da COVID-19. Perché vede, noi per anni abbiamo portato avanti un programma di appropriatezza terapeutica, grazie al quale tutti gli ospedali italiani ed europei hanno dei programmi per usare al meglio gli antibiotici: usarli solo quando servono, per una durata limitata, alla giusta dose, etc etc. Con la “disperazione” da Covid, con il voler trattare tutto e tutti e non lasciar niente di intentato, abbiamo iniziato a usare malissimo gli antibiotici. Abbiamo impiegato 30 anni a convincere i medici e i pazienti del fatto che nell’influenza gli antibiotici non si usano, e poi li abbiamo usati per il Covid, che è comunque sempre un’infezione virale».
Anche in questo caso la “disperazione” ha rischiato di causare un danno ancora peggiore?
«Se i germi diventano resistenti, allora quella sì che è una vera pandemia sulla quale avremmo grosse difficoltà di gestione. Perché mentre la pandemia da Covid-19 è sì un disastro, ma colpisce più violentemente una determinata tipologia di soggetti, la patologia da germi multiresistenti colpisce tutti. Attenzione, perché quando i batteri diventano resistenti, non tornano indietro, e il risultato è trovarsi senza più antibiotici a nostra disposizione».
Professore, un’ultima domanda. Com’è, oggi, la situazione nel suo ospedale?
«C’è tantissimo lavoro, i PS sono in grande sollecitazione e difficoltà, arrivano soprattutto persone molto avanti con gli anni, e abbiamo focolai importanti in aeree socialmente ed economicamente disagiate. Continuiamo ad aprire reparti per poter assistere tutti, e anche in questa fase lo faremo. Ma per fortuna abbiamo meno pazienti che necessitano di cure intensive».
fonte: ilgiornale.it
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